Sleep apnea

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Template:Sleep Apnea
ICD-10	G47.3
ICD-9	780.57
MeSH	D012891

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5]; Associate Editor(s)-In-Chief: Kashish Goel, M.D.

Keywords: Sleep apnea, obstructive sleep apnea, obesity hypoventilation, cor pulmonale

Types

There are two different type of sleep apnea. This section will focus on obstructive sleep apnea.

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is not only much more frequent than central sleep apnea, it is a common condition in many parts of the world. If studied carefully in a sleep lab by polysomnography, approximately 1 in 5 American adults has at least mild OSA. Since the muscle tone of the body ordinarily relaxes during sleep, and since, at the level of the throat, the human airway is composed of walls of soft tissue, which can collapse, it is easy to understand why breathing can be obstructed during sleep. Although many individuals experience episodes of obstructive sleep apnea at some point in life, a much smaller percentage of people are afflicted with chronic severe obstructive sleep apnea.

Normal sleep/wakefulness in adults has distinct stages numbered 1 to 4, REM sleep, and wake. The deeper stages (3 to 4) are required for the physically restorative effects of sleep and in pre-adolescents are the focus of release for human growth hormone. Stages 2 and REM, which combined are 70% of an average person's total sleep time, are more associated with mental recovery and maintenance. During REM sleep in particular, muscle tone of the throat and neck, as well as the vast majority of all skeletal muscles, is almost completely attenuated, allowing the tongue and soft palate/oropharynx to relax, and in the case of sleep apnea, to impede the flow of air to a degree ranging from light snoring to complete collapse. In the cases where airflow is reduced to a degree where blood oxygen levels fall, or the physical exertion to breathe is too great, neurological mechanisms trigger a sudden interruption of sleep, called a neurological arousal. These arousals may or may not result in complete awakening, but can have a significant negative effect on the restorative quality of sleep. In significant cases of obstructive sleep apnea, one consequence is sleep deprivation due to the repetitive disruption and recovery of sleep activity. This sleep interruption in stages 3 and 4 (also collectively called slow-wave sleep), can interfere with normal growth patterns, healing, and immune response, especially in children and young adults.

Many people experience elements of obstructive sleep apnea for only a short period of time. This can be the result of an upper respiratory infection that causes nasal congestion, along with swelling of the throat, or tonsillitis that temporarily produces very enlarged tonsils. The Epstein-Barr virus, for example, is known to be able to dramatically increase the size of lymphoid tissue during acute infection, and obstructive sleep apnea is fairly common in acute cases of severe infectious mononucleosis. Temporary spells of obstructive sleep apnea syndrome may also occur in individuals who are under the influence of a drug (such as alcohol) that may relax their body tone excessively and interfere with normal arousal from sleep mechanisms.

Diagnosis

History and Symptoms | Physical Examination | Lab Studies | Electrocardiogram | Polysomnography | Home Oximetry | Other imaging findings

Treatment

Medical Treatment | Surgical Treatment | Other Treatments

Alternative treatments

Breathing exercises, such as those used in Yoga, the Buteyko method, or didgeridoo playing can be effective. There are muscles which act to tension and open the airway during each inspiration. Exercises can, in some cases, restore sufficient function to these muscles to prevent or reduce apnea.

A program which uses specialized "singing" exercises to tone the throat, in particular, the soft palate, tongue and nasaopharynx, is 'Singing for Snorers' by Alise Ojay. Dr. Elizabeth Scott, a medical doctor living in Scotland, had experimented with singing exercises and found considerable success, as reviewed in her book The Natural Way to Stop Snoring (London: Orion 1995) but had been unable to carry out a clinical trial. Alise Ojay, a choir director singer and composer, began researching the possibility of using singing exercises to help a friend with snoring, and came across Dr. Scott's work. In 1999, as an Honorary Research Fellow with the support of the Department of Complementary Medicine at the University of Exeter, Alise conducted the first trial of singing exercises to reduce snoring which she published with Edzard Ernst, "Can singing exercises reduce snoring? A pilot study." Complement Ther Med 2000; 8(3): 151-156. The results were described by Ojay as promising and after two years of investigations, she designed the 'Singing for Snorers' program in 2002.

The independent nonprofit UK consumer advocacy group Which? reviewed Singing for Snorers. Their physician Dr. Williams "feels the company is ethical in ‘offering aims not claims’ until research is complete." and the review stated that "Combining the programme with diet and exercise, the snorer in our test couple found real improvements in the volume and frequency of his snoring after six weeks. His partner is sleeping better, too."In the case of snorers who also have sleep apnea, there is anecdotal evidence from some of the users of Ojay's program, as she reports on her page, as reported by Charley Hupp, who flew to the UK to personally thank her, on his web page and as reported by one user in the UK on the discussion forum of the British Snoring and Sleep Apnoea Association. This person, Ken, reports that sleep tests before and after the program shows a significant effect: "my apnoeas had gone down from 35 to 0.8 per hour."

Position treatments

One of the best treatments is merely to sleep at a 30 degree angle or higher, as if in a recliner. Doing so helps prevent gravity from collapsing the airway. Lateral positions (sleeping on your side), as opposed to supine positions (sleeping on your back), are also recommended as a treatment for sleep apnea, largely because the effect of gravity is not as strong to collapse the airway in the lateral position. Nonetheless, sleeping at a 30 degree angle is a superior sleep position compared to either a supine or lateral position. A 30 degree position can be achieved by sleeping in a recliner, buying an adjustable bed, or buying a bed wedge to place under the mattress. This approach can easily be used in combination with other treatments and may be particularly effective in very obese people.

Prognosis

Although it takes some trial and error, most patients find a combination of treatments which reduce apnea events and improve their overall health, energy, and well-being. Without treatment, the sleep deprivation and lack of oxygen caused by sleep apnea increases health risks such as cardiovascular disease, high blood pressure, stroke, diabetes, clinical depression, weight gain and obesity.

The most serious consequence of untreated obstructive sleep apnea is to the heart. In severe and prolonged cases, there are increases in pulmonary pressures that are transmitted to the right side of the heart. This can result in a severe form of congestive heart failure (cor pulmonale).

Elevated arterial pressure (commonly called high blood pressure) can be a consequence of obstructive sleep apnea syndrome. When high blood pressure is caused by OSA, it is distinctive in that, unlike most cases of high blood pressure (so-called essential hypertension), the readings do not drop significantly when the individual is sleeping. Stroke is associated with obstructive sleep apnea. Sleep apnea sufferers also have a 30% higher risk of heart attack or death than those unaffected.

Many studies indicate that it is the effect of the "fight or flight" response on the body that happens with each apneic event that increases these risks. The fight or flight response causes many hormonal changes in the body; those changes, coupled with the low oxygen saturation level of the blood, cause damage to the body over time.

See also

• Marfan syndrome

References

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• American Academy of Sleep Medicine Task Force (1999). "Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research". Sleep. 22 (5): 667–89. PMID 10450601.
• Bell, R. B. (2001). "Skeletal advancement for the treatment of obstructive sleep apnea in children". Cleft Palate-Craniofacial Journal. 38 (2): 147–54.
• Caples S, Gami A, Somers V (2005). "Obstructive sleep apnea". Ann Intern Med. 142 (3): 187–97. PMID 15684207.CS1 maint: Multiple names: authors list (link)
• Cohen, M. M. J. (1992). "Upper and lower airway compromise in the Apert syndrome". American Journal of Medical Genetics. 44: 90–93.
• de Miguel-Díez J, Villa-Asensi J, Alvarez-Sala J (2003). "Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children" (PDF). Sleep. 26 (8): 1006–9. PMID 14746382.CS1 maint: Multiple names: authors list (link)
• Mathur R, Douglas N (1994). "Relation between sudden infant death syndrome and adult sleep apnoea/hypopnoea syndrome". Lancet. 344 (8925): 819–20. PMID 7916096.
• Mortimore I, Douglas N (1997). "Palatal muscle EMG response to negative pressure in awake sleep apneic and control subjects". Am J Respir Crit Care Med. 156 (3 Pt 1): 867–73. PMID 9310006.
• Perkins, J. A. (1997). "Airway management in children with craniofacial anomalies". Cleft Palate-Craniofacial Journal. 34 (2): 135–40.
• Sculerati N. (1998 December). "Airway management in children with major craniofacial anomalies". Laryngoscope. 108 (12): 1806–12.
• Shepard, J. W. (1990). "Localization of upper airway collapse during sleep in patients with obstructive sleep apnea". American Review of Respiratory Disorders. 141: 1350–55.
• Sher, A. (1990). Obstructive sleep apnea syndrome: a complex disorder of the upper airway. Otolaryngologic Clinics of North America, 24, 600.
• Shott S, Amin R, Chini B, Heubi C, Hotze S, Akers R (2006). "Obstructive sleep apnea: Should all children with Down syndrome be tested?". Arch Otolaryngol Head Neck Surg. 132 (4): 432–6. PMID 16618913.CS1 maint: Multiple names: authors list (link)
• Shouldice RB, O'Brien LM, O'Brien C, de Chazal P, Gozal D, Heneghan C (2004). "Detection of obstructive sleep apnea in pediatric subjects using surface lead electrocardiogram features". Sleep. 27 (4): 784–92. PMID 15283015.CS1 maint: Multiple names: authors list (link)
• Slovis B. & Brigham K. (2001). "Disordered Breathing". In ed Andreoli T. E. Cecil Essentials of Medicine. Philadelphia: W.B. Saunders. pp. pp210–211.CS1 maint: Extra text (link)
• Strollo P, Rogers R (1996). "Obstructive sleep apnea". N Engl J Med. 334 (2): 99–104. PMID 8531966.
• Sullivan C, Issa F, Berthon-Jones M, Eves L (1981). "Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares". Lancet. 1 (8225): 862–5. PMID 6112294.CS1 maint: Multiple names: authors list (link)

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