What is obstructive sleep apnea?

What is Sleep Apnea?
Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. First described in 1965, sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. There are three types of sleep apnea: central, obstructive and mixed. Central sleep apnea, which is less common, occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations. Obstructive sleep apnea is far more common and occurs when air cannot flow into or out of the person’s nose or mouth although efforts to breathe continue.

In a given night, the number of involuntary breathing pauses or “apneic events” may be as high as 20 to 60 or more per hour. These breathing pauses are almost always accompanied by snoring between apnea episodes, although not everyone who snores has this condition. Sleep apnea can also be characterized by choking sensations. The frequent interruptions of deep, restorative sleep often leads to excessive daytime sleepiness and may be associated with an early morning headache. This common symptom may be more harmful than you think. Possible associated diagnosis: Restless leg syndrome = Sensations of tingling, crawling or burning in the legs that is usually worse at night. Accompanied by voluntary or involuntary leg movements. Cardiovascular irregularities.

Some 40 percent of American Adults say they often feel drowsy during the day. The symptom is so familiar that many people dismiss it as an unavoidable, inconsequential feature of modern life.

But drowsiness can seriously undermine your mental and physical performance and may also signal or cause danger to your health. It may be the first sign of various disorders that can sap your energy despite a good night’s rest. Or it may indicate sleep apnea, a common breathing disorder during sleep that sharply raises the risk of heart attack and stroke

Even drowsiness from a simple lack of sleep may be surprisingly hazardous. It’s a major cause of auto accidents, contributing to an estimated one out of five crashes. An insufficient sleep may harm the body and increase the risk of disease and death.

Dismissing daytime drowsiness as unimportant keeps you from raising it with your doctor and taking corrective action. That could mean improving you sleep habits or changing any drugs or dosages that are disrupting your slumber or leaving you over sedated. It may also mean getting better control over any disorders that are impairing your sleep.

Slower, Duller, Crankier
When people are isolated in a sleep lab, most end up snoozing for about seven and a half to eight hours a night. Many people say they can cut back by an hour or so and still feel fine the next day. But performance often declines when people lose just a half hour of sleep; an hour of lost sleep can be as disabling as two alcoholic drinks. Problem-solving and verbal skills, reaction time, and stamina all decline when people get less sleep than they need. And they’re more likely to become tense, moody and irritable.

You’d be much more tired if you missed an entire night’s sleep than if you lost the same total amount of shuteye over a period of several days. But sleep debt does accumulate somewhat from day to day; that’s why most people need to slumber extra long on the weekends and holidays.

Sleep apnea occurs in all age groups and both sexes but is more common in men (it may be under diagnosed in women) and possibly young African Americans. It has been estimated that as many as 18 million Americans have sleep apnea. Four percent of middle-aged men and 2 percent of middle-aged women have sleep apnea along with excessive daytime sleepiness. People most likely to have or develop sleep apnea include those who snore loudly and also are overweight, or have high blood pressure, or have some physical abnormality in the nose, throat, or other parts of the upper airway. Sleep apnea seems to run in some families, suggesting a possible genetic basis.

What causes sleep apnea?

Certain mechanical and structural problems in the airway cause the interruptions in breathing during sleep. In some people, apnea occurs when the throat muscles and tongue relax during sleep and partially block the opening of the airway. When the muscles of the soft palate at the base of the tongue and the uvula (the small fleshy tissue hanging from the center of the back of the throat) relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether. Sleep apnea also can occur in obese people when an excess amount of tissue in the airway causes it to be narrowed. With a narrowed airway, the person continues his or her efforts to breathe, but air cannot easily flow into or out of the nose or mouth. Unknown to the person, this results in heavy snoring, periods of no breathing, and frequent arousals (causing abrupt changes from deep sleep to light sleep). Ingestion of alcohol and sleeping pills increases the frequency and duration
of breathing pauses in people with sleep apnea.

How is Sleep Apnea Diagnosed?
In addition to the primary care physician, pulmonologists, neurologists, or other physicians with specialty training in sleep disorders may be involved in making a definitive diagnosis and initiating treatment. Diagnosis of sleep apnea is not simple because there can be many different reasons for disturbed sleep. Polysomnography are available for evaluating a person for sleep apnea.

Polysomnography is a test that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, airflow, and blood oxygen levels. These tests are used both to diagnose sleep apnea and to determine its severity.

Polysomnography test are usually performed in a sleep disorders center, but new technology may allow some sleep studies to be conducted in the patient’s home.

How is sleep apnea treated?

The specific therapy for sleep apnea is tailored to the individual patient based on medical history, physical examination, and the results of polysomnography. Medications are generally not effective in the treatment of sleep apnea. Oxygen is sometimes used in patients with central apnea caused by heart failure. It is not used to treat obstructive sleep apnea.

Types of Therapy
Nasal continuous positive airway pressure (CPAP) are the most common effective treatment for sleep apnea. In this procedure, the patient wears a mask over the nose during sleep, and pressure from an air blower forces air through the nasal passages. The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. The pressure is constant and continuous. Nasal CPAP prevents airway closure while in use, but apnea episodes return when CPAP is stopped or it is used improperly.

Variations of the CPAP device attempt to minimize side effects that sometimes occur, such as nasal irritation, drying, a blood nose, facial skin irritation, abdominal bloating, mask leaks, sore eyes and headaches. Some versions of CPAP vary the pressure to coincide with the person’s breathing pattern, and other CPAPs start with low pressure, slowly increasing it to allow the person to fall asleep before the full-prescribed pressure is applied.

Surgery
Some patients with sleep apnea may need surgery. Although several surgical procedures are used to increase the size of the airway, none of them is completely successful or without risks. More than one procedure may need to be tried before the patient realizes any benefits.

Some of the more common procedures include removal of adenoids and tonsils (especially in children), nasal polyps or other growths, or other tissue in the airway and correction of structural deformities. Younger patients seem to benefit from these surgical procedures more than older patients.

Uvulopalatopharyngoplasty (UPPP) is a procedure used to remove excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate). The success of this technique may range from 30 to 60 percent. The long-term side effects and benefits are not known, and it is difficult to predict which patients will do well with this procedure.

Laser-assisted uvulopalatoplasty (LAUP) is done to eliminate snoring but has not been shown to be effective in treating sleep apnea. This procedure involves using a laser device to eliminate tissue in the back of the throat. Like UPPP, LAUP may decrease or eliminate snoring but not eliminate sleep apnea itself. Elimination of snoring, the primary symptom of sleep apnea, without influencing the condition may carry the risk of delaying the diagnosis and possible treatment of sleep apnea in patients who elect to have LAUP. To identify possible underlying sleep apnea, sleep studies are usually required before LAUP is performed.

Your Child and Sleep Apnea

Obstructive sleep apnea occurs when a child stops breathing during periods of sleep. The cessation of breathing usually occurs because of a blockage (obstruction) in the airway. Tonsils and adenoids may grow to be large relative to the size of a child’s airway (passages through the nose and mouth to the windpipe and lungs). Inflamed and infected glands may grow to be larger than normal, thus, causing more blockage. The enlarged tonsils and adenoids block the airway during sleep, for a period of time. The tonsils and adenoids are made of lymph tissue and are located at the back and to the sides of the throat.
During episodes of blockage, the child may look as if he/she is trying to breath (the chest is moving up and down), but no air is being exchanged within the lungs. Often these episodes conclude with a period of awakening and compensation for lack of breathing. Periods of blockage occur regularly throughout the night and result in a poor, interrupted sleep pattern.

Sometimes, the inability to circulate air and oxygen in and out of the lungs results in lowered blood oxygen levels. If this pattern continues, the lungs and heart may suffer permanent damage.

Obstructive sleep apnea is most commonly found in children between 3 to 6 years of age. It occurs more commonly in children with Down syndrome and other congenital conditions affecting the upper airway (i.e., conditions causing large tongue, small jaw, etc.).

What causes obstructive sleep apnea?

In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge. Large adenoids may completely block the nasal passages and make breathing through the nose difficult or impossible.

There are many muscles in the head and neck that help to keep the airway open. When a person (child or adult) falls asleep, muscle tone tends to decrease, thus, allowing tissues to fold closer together. If the airway is partially closed (by enlarged glands) while awake, falling asleep may result in a completely closed passage.

Obesity may cause obstructive sleep apnea. While a common cause in adults, obesity is a far less common reason for obstructive sleep apnea in children.

A rare cause of obstructive sleep apnea in children is a tumor or growth in the airway. Certain syndromes or birth defects, such as Down syndrome and Pierre-Robin syndrome, can also cause obstructive sleep apnea.

What are the symptoms of obstructive sleep apnea?
The following are the most common symptoms of obstructive sleep apnea. However, each child may experience symptoms differently. Symptoms may include:

• Loud snoring or noisy breathing during sleep
• Periods of not breathing - although the chest wall is moving, no air or oxygen is moving through the nose and mouth into the lungs. The duration of these periods is variable and measured in seconds.
  
• Mouth breathing - the passage to the nose may be completely blocked by enlarged tonsils and adenoids.
  
• Restlessness during sleep (with or without periods of being awake)
  
• Excessive daytime sleepiness or irritability
  (because the quality of sleep is poor, the child may be sleepy or irritable in the daytime)
  
• Hyperactivity during the day

The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

How is obstructive sleep apnea diagnosed?
Your child’s physician should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat (ENT) physician (otolaryngologist) for further evaluation.

In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include:

• Sleep history - Report from parents or caretaker
  
• Evaluation of the upper airway
  
• Sleep study (also called polysomnography)

Polysomnography, the best test available for diagnosing obstructive sleep apnea. The test requires a high level of collaboration on the part of the child and may not be possible in younger and/or uncooperative children. Two types of tests are available. In the first type, the child will sleep in a specialized sleep laboratory. In the second type, the child has on similar monitors but sleeps in his/her own bed. During the sleep study a variety of testing occurs to evaluate the following:

• Brain activity
  
• Electrical activity of the heart
  
• Oxygen content in the blood
  
• Chest and abdominal wall movement
  
• Muscle activity
  
• Amount of air flowing through the nose and mouth

During the sleep study, episodes of apnea and hypopnea will be recorded:

• Apnea
  
• Complete airway obstruction.
  
• Hypopnea
  The partial airway obstruction combined with a 2-4% decrease in the oxygen content of the blood.

Based on the laboratory test, sleep apnea is generally considered significant in children if more than 10 apnea episodes occur per night, or one or more occur per hour. Some experts define the problem as significant if a combination of one or more episodes of apnea and/or hypopnea occur per hour of sleep.

Symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Consult your child’s physician for more information.

Treatment for obstructive sleep apnea:

Specific treatment for obstructive sleep apnea will be determined by your child’s physician based on:

• Your child’s age, overall health, and medical history .
  
• Cause of the condition .
  
• Your child’s tolerance for specific medications, procedures, or therapies.
  
• Expectations for the course of the condition .
  
• Your opinion or preference .

The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway blockage in children, the treatment is surgery and removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy). Your child's otolaryngologist will discuss the treatment options, risks, and benefits with you. This surgery requires general anesthesia. Depending on the health of the child, surgery may be performed on an outpatient basis.

If the cause of the disorder is obesity, less invasive treatments may be appropriate, including weight loss and wearing a special mask while sleeping to keep the airway open. This mask delivers continuous positive airway pressure (CPAP). The device itself is often clumsy, and it may be difficult to convince a child to wear such a mask. Surgery may be necessary.

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