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Sleep Apnea

Apnea during Sleep only

Sleep apnea is a common clinical condition where the breathing may suddenly stop or becomes too shallow during sleep. This apneic episodes typically lasts for a few seconds or a few minutes. The obstruction in sleep apnea could either be partial or complete.


Presentation

The following signs and symptoms are associated with either obstructive or central sleep apnea:

Leg Swelling
  • swelling (if apnea is severe) Your health care provider will take your medical history and do a physical exam.[medlineplus.gov]
Myxedema
  • Associated conditions include obesity; acromegaly; myxedema; micrognathia; myotonic dystrophy; adenotonsilar dystrophy; and neuromuscular diseases.[icd9data.com]
Fracture
  • It is unclear why the fracture only occurred on the right side. Pathologic fracture of the coronoid process due to chronic stress and secondary osteomyelitis is a rare severe complication of treatment for obstructive sleep apnea syndrome with a MRD.[ncbi.nlm.nih.gov]
Insomnia
  • Patients with complex sleep apnea syndrome had fewer maintenance-insomnia complaints (32% vs 79%; p .05) than patients with CSA but were otherwise not significantly different clinically.[web.archive.org]
  • Some of the more common include: Insomnia : The complaint of an inability to fall asleep, stay asleep, or awaking too early. This may be caused by poor sleep habits, alcohol, medications, and stress.[medstarwashington.org]
  • Common symptoms of sleep apnea include: Loud or frequent snoring Silent pauses in breathing Choking or gasping sounds Daytime sleepiness or fatigue Unrefreshing sleep Insomnia Morning headaches Nocturia (waking during the night to go to the bathroom)[sleepeducation.org]
  • […] awakening Cognitive impairment, such as trouble concentrating, forgetfulness, or irritability Mood disturbances ( depression or anxiety ) Night sweats Sexual dysfunction Headaches People with central sleep apnea more often report recurrent awakenings or insomnia[my.clevelandclinic.org]
Lethargy
  • ., an internist at the Mayo Clinic in Rochester, Minnesota, once suspected sleep apnea affected a fit ad exec based solely on the man's twin complaints of lethargy and a lackluster libido. "Sure enough," says Dr. Jaeger, "he had it.[menshealth.com]
  • Some OSA sufferers do not exhibit all of the symptoms, however they will usually experience one or more of the following: Snoring Episodes of gasping, snorting or choking during sleep Excessive daytime sleepiness, fatigue or lethargy Lack of energy and[snoreaustralia.com.au]
Grunting
  • A person with sleep apnea may be unaware of their symptoms, but another person may notice that the sleeper stops breathing, suddenly gasps or grunts, wakes up, and then goes back to sleep.[medicalnewstoday.com]
Drop Attacks
  • The patient had epileptic seizures and drop attacks only during night-time and it was not recognized during the daytime. His sleep-induced electroencephalogram was normal.[ncbi.nlm.nih.gov]

Workup

The diagnosis of sleep apnea may be effectively clinched with a detailed clinical history. Patients may still be subjected to some tests that may ascertain the diagnosis of sleep apnea. The following tests or sleep studies are implored to patients suspected of having sleep apnea:

  • Nocturnal polysomnography: This device records the lung, heart, and brain activities during sleep. Breathing patterns are graphed while nocturnal patterns of arm and leg movements are also recorded [8]. The blood oxygen levels are also measured during the test process to assess the presence of sleep apnea.
  • Home sleep test kits: These test kits are very similar to the nocturnal polysomnograph, although heart rate, breathing patterns, airflow, and blood oxygen saturation are the only parameters which are being measured.

Treatment

The milder forms of sleep apnea may only require some lifestyle modifications. However, some forms of sleep apnea like those classified under moderate and severe may need other treatment options for its resolution. The following therapy and treatment modalities are implored in the treatment of sleep apnea:

  • Continuous positive airway pressure (CPAP): This is an oxygen delivery system through a mask which is placed over the nose during sleep. The airflow through the mask creates a positive pressure slightly greater than the environmental pressure making the airways continually open during the duration of the sleep [9].
  • Adjustable airway pressure device: This system is very similar to CPAP, it only self-adjusts so that the air pressure becomes high during inhalation and subsequently drops during expiration.
  • Expiratory Positive Airway Pressure (EPAP) – This device allows airflow to freely go in during inhalation but diverts airflow through a network of smaller holes during expiration making the expiratory phase create a positive pressure to the upper airways.
  • Uvulopalatopharyngoplasty: This is a surgical procedure used to remove soft tissue structures like the tonsils and the adenoids to clear the airways and allay the symptoms of sleep apnea [10].
  • Tracheostomy: This is a surgical procedure used when all other methods fail. A hole is created through the neck and trachea for easier respiration during sleep. This procedure is indicated for patients with severe sleep apnea, with associated life threatening conditions.

Prognosis

The common symptoms of sleep apnea like daytime sleepiness and snoring are considered to be a benign complication with a very excellent prognosis. A cohort study, implicated severe untreated sleep apnea to increase the mortality rate of myocardial infarction and stroke among Spanish patients [6]. Australian studies on moderate to severe sleep apnea among men have suggested a significant increase in mortality rate among the respondents [7].

Etiology

The obstructive type of sleep apnea occurs when the posterior muscles of the larynx relaxe and obstruct the airways during sleep. When the airways constrict during inspiration the blood oxygen levels significantly drop during sleep. The most common causes of the central sleep apnea are heart failure and cerebrovascular diseases (stroke). People suffering from central type of apnea are more likely to remember their apneic spells than those with the obstructive type of apnea.

Epidemiology

In the United States, an estimated 18 million people are suffering from either forms of sleep apnea. Although a great majority of these people remain underdiagnosed or undiagnosed. The prevalence rate of sleep apnea is estimated to be 4% among the male population and 2% among women [2]. Recent studies have seen an increasing incidence of sleep apnea in the younger age group especially among obese children.

Internationally, sleep apnea occurs infrequently among the English population with only 3 cases per 1000 population. Higher prevalence rates of obstructive sleep apnea are observed among Australians and Israeli population which reach up to 25%. The elderly population beyond the age of 65 years has a two to three fold risk of developing sleep apnea than their middle aged counterpart [3]. The relatively high fat distribution over the neck among males make them more predisposed to sleep apnea compared to women with a prevalence ratio of up to 3:1 internationally [4].

Sex distribution
Age distribution

Pathophysiology

The upper airway is a slender and compliant tube that could collapse inward when the laryngeal muscles relax during sleep [5]. The intraluminal pressure may not be always greater than the transluminal pressure during sleep; thus, the propensity for collapse and narrowing of the airways is a frequent event. The pharyngeal space where the airway constricts is bounded by the soft palate, the back of the tongue, and the parapharyngeal fat pads. Any pathology that decreases this space consequently increases the risk of sleep apnea.

Prevention

Sleep apnea is closely associated with obesity; thus, efforts to reduce weight through regular exercise and a healthy diet may significantly lower the risk for sleep apnea. Alcohol and certain medications (tranquilizers) must be avoided to prevent the throat muscles from relaxing during sleep. Try to sleep on one side rather than full supine to prevent the tongue and soft palate from falling towards the throat causing obstruction. Smoking must be avoided for this worsens oxygen saturation in the blood.

Summary

Sleep apnea or obstructive sleep apnea (OSA) is a potentially serious sleeping disorder where the breathing intermittently stops and starts for a period of time. Patients usually snore and complain of tiredness even after a full night sleep. There are essentially two types of sleep apnea, the obstructive type of sleep apnea, and the central type of sleep apnea. The obstructive type is fairly common and is characterized by the relaxation of the throat muscle during sleep [1]. The central type is evident when the brain fails to transmit the proper signals to the muscles of respiration that gives rise to apnea. Patients suffering from sleep apnea should seek medical attention promptly to avoid untoward complications in the future.

Patient Information

Definition

Sleep apnea is a common clinical condition where the breathing may suddenly stop or become too shallow during sleep.

Cause

The causes of sleep apnea vary, and they might include the internal processes that happen in our body like relaxation of the throat muscles during sleep, any obstruction in the upper airways, and concomitant medical illness like heart problems and stroke.

Symptoms

The symptoms of sleep apnea include snoring, daytime sleepiness, difficulty in maintaining sleep at night, headaches, and difficulty in maintaining focus.

Diagnosis

The diagnosis of sleep apnea is mainly by the use of a nocturnal polysomnography and home sleep test kits.

Treatment

The treatment of sleep apnea has wider options that include CPAP, adjustable airway devices, EPAP, uvulopalatopharyngoplasty, and tracheostomy.

References

Article

  1. Guilleminault C, Tilkian A, Dement WC. The sleep apnea syndromes. Annu Rev Med. 1976; 27:465-84.
  2. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. Apr 29 1993; 328(17):1230-5.
  3. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. Jan 1998; 157(1):144-8.
  4. Redline S, Kump K, Tishler PV, Browner I, Ferrette V. Gender differences in sleep disordered breathing in a community-based sample. Am J Respir Crit Care Med. Mar 1994; 149(3 Pt 1):722-6.
  5. Downey R 3rd, Perkin RM, MacQuarrie J. Upper airway resistance syndrome: sick, symptomatic but underrecognized. Sleep. Oct 1993; 16(7):620-3.
  6. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. Mar 19-25 2005; 365(9464):1046-53.
  7. Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. Nov 1 2004; 170(9):1014-21.
  8. Anderson P. New Guideline for Sleep Apnea Diagnosis. Medscape Medical News. Accessed November 16, 2014.
  9. Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. Apr 15 2008; 4(2):157-71.
  10. Sher AE. Upper airway surgery for obstructive sleep apnea. Sleep Med Rev. Jun 2002; 6(3):195-212.

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Last updated: 2017-08-09 17:39