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Ear, Nose & Throat Center
Specialists of the Ear, Nose and Throat / Head and Neck Surgery / Facial Plastic Surgery
Evaluation of Dizziness & Vestibular Disorders
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OBSTRUCTIVE SLEEP APNEA (OSA)
It is estimated that at any given time one-third of the United States' population suffers from sleep-related problems. The most commonly diagnosed sleeping disorder that involves otolaryngologists is obstructive sleep apnea (OSA). Obstructive sleep apnea is not a benign disease. In 1990 alone, 58,000 motor vehicle accidents involved a sleep apnea patient. These patients also have a higher incidence of stroke, right heart failure, and an increased mortality rate when there are greater than 20 apneic episodes per hour of sleep. OSA may be defined as the absence of airflow combined with persistent respiratory effort during sleep. It has been determined that the site of obstruction in these patients is within the pharynx. The exact site, however, usually cannot be determined in any given patient. The average patient is obese, middle age, male, and a loud snorer. Often the patient presents with his spouse who is keenly aware of the snoring and "pauses" in breathing (apneic episode). Other signs and symptoms include: excessive daytime somnolence, morning headaches, hypertension, personality changes, nocturnal arrhythmias (irregular heart beats), and even cor pulmonale (right heart congestive “pump” failure). The formal diagnosis of OSA requires a sleep study to document the number of apneic episodes, associated arrhythmias, and the severity of the problem.
The treatment regimen must be tailored to the individual, his symptoms, sleep study results, and physical findings. Therapeutic options may be divided into four categories: (1) identification and elimination of aggravating factors (alcohol, sedatives) coupled with sustained weight loss; (2) use of medications such as protriptyline; (3) use of mechanical devices such as continuous positive airway pressure (CPAP) or a newer modality, bilevel positive airway pressure (bipap); and (4) surgical intervention such as uvulopalatopharyngoplasty (UPPP), tracheostomy, or a newer method termed transtracheal oxygen therapy (TTO).
Sleep Apnea
General Information
Sleep Apnea is an illness which causes a person to stop breathing many times during each night's sleep. In severe cases, the number of times a person stops breathing can be over 100 times in an hour; sometimes the period of apnea (no breathing) can be up to 3 minutes long! Anyone can develop Sleep Apnea at any age. It is a serious and sometimes life-threatening illness which appears to affect males more frequently than females. In some cases, the symptoms reach maximum severity very quickly, in others the symptoms are more gradual. There are two main types of Sleep Apnea: Central Sleep Apnea (CSA) is a relatively rare nervous system disorder. When a person suffering from this type of Sleep Apnea falls asleep, the diaphragm (the muscle separating the chest and abdominal cavity which helps move air in and out of the lungs) stops moving because the brain fails to send the proper impulses through the nerves to move the diaphragm. Breathing stops! Obstructive Sleep Apnea (OSA) is far more common. In OSA, there is an abnormal loss of tone (healthy elasticity) in the muscles of the tongue, throat and larynx during sleep. As a result, the throat collapses and air flow is completely (apnea) or partially (hypopnoea) blocked. The diaphragm continues to contract with progressively more force until a partial or complete wakening occurs, and normal breathing is resumed. Some persons have a combination called Mixed Sleep Apnea. Apnea episodes cause the oxygen content of the blood to drop and carbon dioxide levels to rise. This means the heart, brain and other vital tissues are periodically deprived of oxygen. Furthermore, blood pressure rises and the heart slows. The elevated blood pressure may eventually remain elevated during the day as well. Sleep Apnea is suspect as a cause of many deaths which occur during sleep. If you suspect you might have Sleep Apnea, review the following:
One of the most obvious indicators is extremely loud, heavy snoring, often interrupted by gasps and long pauses in breathing. Just because you snore does not necessarily mean you have sleep apnea! Apnea snoring is almost always punctuated by periods of no breathing at all, or gasping for air. If you think you might have Sleep Apnea, check with your doctor! Other symptoms MAY include: Excessive daytime sleepiness, Need for frequent naps, Decrease in ability to concentrate, Loss of memory ; Decreased ability to function at work ; Irregular heartbeat during sleep ; Frequent accidents ; Loss of memory ; Irritability/short temper ; Morning headaches ; Changes in mood or behavior ; Anxiety or depression ; Decreased interest in sex ; Impotence (in men) ; Frequent wakenings/need to urinate during sleep ; Hypnogogic hallucinations occurring while awake, but very groggy ; and/ or Sudden wakening with a sense of disorientation. It is important not to ignore these symptoms as possible consequences are heart attacks and strokes. Many sufferers of Sleep Apnea think they are "champion" sleepers, able to sleep anywhere anytime, and not aware of their frequent awakenings during sleep. Make no mistake: sleep apnea can be very dangerous. There are a number of factors which appear to work together to cause Sleep Apnea. Many cases are the result of obesity - which results in excessive fatty tissue in the throat area, a short neck and heavy jaws. These factors can work together to cause a collapse of the airway. Many sufferers of Sleep Apnea have a history of chronic nasal congestion, nasal surgery, polyps, nasal deviation, enlargement of the tongue, tonsils or an abnormal jaw structure. Associated conditions include hypothyroidism and disorders of the pituitary gland. Any underlying cause or associated condition should be treated first. See your family Doctor - you may be referred to an Ear, Nose, Throat Specialist. A referral to a sleep lab must be done by a physician. Overnight testing (polysomnography) may be conducted to determine if there is a problem.
Behavioral interventions to promote weight loss are important. It is best that there be no alcohol intake at all. Alcohol relaxes the muscles of the throat, making it more difficult to breathe during sleep. Caution should be exercised in taking sedatives, due to the fact they depress respirations (breathing). It is important not to drive while you are sleepy.
Depending on the cause of the Apnea, certain surgical treatments may be tried - Uvulopalatoplasty (UPP) and Laser Assisted Uvulaplasty (LAUP ) being the two most common. Neither are absolute cure-all by anyone's reckoning, the best estimate of success for UPP being around 50%. While LAUP is sometimes effective in reducing snoring, its effectiveness in treating apnea is questionable. As with any surgery, careful consideration and consultation with you doctor is called for. Some people have successfully used a dental appliance, when the cause appears to be jaw structure. The most common treatment for Sleep Apnea is nasal CPAP. CPAP stands for Continuous Positive Airway Pressure. Air is supplied via a small machine, through a hose, at a prescribed pressure, into the nose via a mask fitting over the nose. This device keeps the airway open while a person sleeps, preventing it from collapsing. A newer model called BIPAP (Bi-level Positive Airway Pressure), delivers a higher pressure during inspiration and a lower one during expiration. The good news is that CPAP seems to work fairly consistently for most people. While it is not the most comfortable or appealing thing to wear while sleeping, many people swear by it and most generally agree that the benefits are worth it.
Snoring is a cry for help
Snoring is a cry for help from a person strangling for air. Yet, we tend to laugh at snoring, get angry at the snorer for keeping us from sleeping, or dismiss snoring as a sign of good sleep. Snoring may sound like a fog horn to warn sailors of danger. In fact, snoring is certainly not funny---it is a warning of danger. Unfortunately, the sleeper does not hear it, and those who do, usually don't recognize it as a danger signal.
Snoring and sleep apnea
When a person with sleep apnea syndrome falls asleep, the relaxation of the body leads to an excessive relaxation of the throat, a narrowing of the airway, and snoring. If the airway is completely blocked, even though the muscles of the diaphragm and chest are struggling to draw in air, no air can move past the blockage-apnea means without breath. The extra effort due to snoring, or partial or complete obstructions, arouses the brain. As soon as the brain awakens, the airway opens (sometimes with an explosive gasp), breathing resumes, and sleep can begin again. Usually the sleeper is not aware of the hundreds of arousals each night which keep him or her from getting normal sleep.
What is wrong with this picture?
Thanksgiving dinner, or perhaps it is Christmas dinner, or Passover. Uncle Charlie (or perhaps it is Aunt Charlene) has fallen asleep, as usual, on the overstuffed Chair in the living room. And everyone chuckles fondly to see him (or her) snug in front of the fire, his(her) arms resting gently on his (her) belly. Snoring up a storm. Familiar picture? Probably. Endearing, sweet Norman Rockwell scene? No. The association of this picture to a potentially life threatening disorder called Obstructive Sleep Apnea has been known for about a decade. It is only over the past several years, however, that there has been enough media coverage for the Disorder called sleep apnea to have reached public awareness. By this time, the message that loud snoring can be serious -- not humorous -- has been sent into the Living room by network television shows such as 20/20, 60 Minutes, the Phil Donahue Show, and even the half-time show of the Super Bowl where the players Wore Band-Aid like devices (designed to help control snoring) on their nose to help their breathing. The full picture of what to do when sleep apnea (or an incipient Sleep apnea condition such as loud snoring) is diagnosed has been less well publicized.
The signs and symptoms of apnea are described in other materials. It is more likely in men and perimenopausal or postmenopausal women than in premenopausal Women. It certainly can occur in children. If you snore you should become aware of the kinds of personal discomfort, jeopardy when driving, and decreased Function as well as possible medical jeopardy in which this places you. The treatment of obstructive sleep apnea or snoring The most important point to make about the treatment of Obstructive Sleep Apnea or Snoring Syndrome is that effective treatment requires several related Problems to be treated simultaneously. At least the following need to be addressed:
Lifestyle factors. The impression is growing that to a large extent many cases of obstructive sleep apnea and snoring may be a concomitant of Western culture. The risk of Significant obstructive sleep apnea increases with the numerous factors described below, many of which are problems endemic to our society. Correction of Obstructive sleep apnea (OSA) generally requires that these factors be eliminated. At times, elimination of these factors completely resolves the problem.
Weight. Excessive weight brought about by a sedentary life style, too many rich foods, or by medically related situations such as retention of weight after delivering a Child or thyroid problems are probably the leading factors contributing to OSA. Bed partners almost invariably make the observation that the larger their Snoring spouse became, the louder the snoring bellowed, and the more often they hear snoring pauses followed by snorts and a resumption of breathing (i.e., Apneas--episodes of obstructed breathing). Conversely, in a large percentage of patients weight loss, aided by exercise if medical conditions don't Counterindicate doing exercise, down to an ideal weight has reversed the process.
Smoking. Smoking has numerous undesirable effects on the body as Surgeon General Koop's report has by now made well known. Most pertinent to OSA are the Obstructions to the airway which cigarette smoking causes: swelling of the mucous membrane in the nose, swelling of the tissue in the throat, blockage of the Small vessels in the lung.
Alcohol., It is the partial collapse of the airway (breathing tube between nose/mouth and lungs) which is the immediate cause of snoring, and its complete collapse Which is the immediate cause of apnea. Alcohol relaxes the imbiber, but also causes too great a relaxation of the airway during sleep. This, and other effects Of alcohol on the body, mean that alcohol (in patients otherwise at risk) can either cause or greatly contribute to the development of loud snoring and apnea.
Organization of sleep and wakefulness across the week There are two periods of sleep which, given the right circumstances, are especially vulnerable to the development of unstable breathing. These are Stage 1 Sleep, which should only occur when a person is first falling asleep but which can occur many times during the night if sleep is poor); and REM sleep which is The time when dreaming most frequently occurs. If a person, for instance, goes to bed at 10 PM and awakens at 5 AM each workday, but then waits until several hours later to go to sleep and wake up on On-work days, both Stage 1 sleep and REM behave oddly. This problem with REM and Stage 1 is also true if on some days of the week a person just does Not get enough sleep, and then on other days of the week s/he makes up for it by sleeping much longer. The result in both cases can be the development of very significant respiratory instability during sleep. It is not unusual in the sleep laboratory when recording The sleep of people with irregular sleeping hours to discover that all of their apnea is confined to Stage 1 and/or REM sleep. In our experience for these People correction of this problem minimally requires stabilizing bedtime hours across the week. Sometimes, this is all that is required. Other factors affecting quality of nighttime sleep can lead to apnea A disruptive bedpartner, a baby or child waking you up, aggravation from the day, sleeping during conventional hours (e.g. 11 PM - 6:30 AM) when the Body's preference is to sleep a night-owl's schedule, excessive use of caffeinated products -- all of these things can also lead to the instability of Stage 1 and REM sleep. In turn, such instability can lead to an OSA tendency. Medical problems. Anything which can lead to a blockage of the nose, the throat, or the lung potentially play a role in the development of OSA. Pertinent nasal problems include allergies to air-borne particles such as animal dander, dryness of the nose because of a wood burning stove, or a septum (structure separating the left and right sides of the nose) so deviated it completely blocks the flow of air through one side. Often in that case, other structures In the nose called turbinates grow larger on the unaffected side. The result can be almost complete blockage of nasal breathing. That, in turn, increases the Effort the sleeper must make to breathe because of increased resistance to airflow -- and it is that increased resistance which can then create OSA. Factors which can block the throat include large tonsils, large adenoids, excessive amounts of fatty tissue, at times enlargement of some of the complex tissue At the back of the throat. Pertinent lung problem range from childhood asthma through emphysema. Apnea can also be a symptom of diabetes or hypothyroidism.
Specific forms of treatment
Addressing lifestyle issues. Addressing lifestyle issues is essential no matter what other factors might be involved. The overnight sleep study. The overnight sleep study provides some clues regarding treatment. The study can reveal disturbances of Stage 1 and REM sleep. Identification of these leads to Further questions about lifestyle. We may discover that the OSA is present only when the patient is sleeping supine (on the back). Gently turning the patient onto his or her side or stomach reduces The OSA. If we are not concerned that the patient is in immediate medical jeopardy, we may try to actually train the patient to stay off of his or her back during Sleep. Please note that currently there is a debate about the safety of trusting the results of this kind of intervention. The overnight study might demonstrate that OSA develops only when the person reverts to breathing through the mouth (vs breathing through the nose), so-called Obligate mouth breathing. Otolaryngological evaluation (by an ear-nose-throat specialist) might demonstrate this to be caused by allergies (which should be Evaluated by an allergist) or other causes that may restrict air flow through the nose. One current approach to correcting this problem is the use of rings which are Placed inside the nostrils at night. Another device looks like butterfly Band-Aids that keep the nasal airway open if the problem is not too severe. There is yet Insufficient evaluation of the rings and the Breathe-Right® "Band-Aids" to know how effective these treatment approaches are for OSA.
Nasal CPAP.
CPAP (Continuous Positive Airway Pressure) is in most spheres considered to be the treatment of choice. The CPAP unit consists of an air compressor and mask Which delivers pressurized air through the nose when a person is sleeping, and which then can open up the airway from the inside almost as if the air were an internal Splint. The correct pressure for the individual is determined in what is called a titration trial in the sleep laboratory. If the nasal airway will admit the flow of air, CPAP has in many cases offered immediate relief. Some people opt to use CPAP indefinitely. Others use it to support their breathing during sleep until some of the Measures which take more time to accomplish (e.g. Weight loss, smoking cessation, correction of sleep-wake rhythms) have produced the desired effect. Not Everyone opts to follow through with CPAP either short term or long term once they've experienced it. Some find the way they look when wearing the nasal CPAP Mask to be offensive. Others feel claustrophobic with it, and yet others find that the compressed air causes dryness of their nose or -- in some cases - sinus Infections. In the majority of cases these problems can be rectified, but neither is this universally true.
Surgery.
Youngsters with demonstrated apnea during sleep usually have shown signs at home of poor concentration, of either withdrawal or aggressiveness, and of generally Feeling poorly. For many of these young people, large tonsils which actually meet at the midline are the demonstrated cause. For the majority of these, a Tonsillectomy may correct the problem. In some people the lower jaw is set too far back. This also displaces the tongue backward which in turn blocks what is called the posterior air space (behind the Tongue down into the throat). During the night, the combination of normal airway relaxation with the already limited airway diameter leads to the development of OSA. New surgery has become available for repositioning the jaw. Long term results are not yet in. Repair of a previously fractured nose which has led to severe obstruction of the nasal airway is a cause which can be surgically corrected. There are some forms of surgery in use now which are more controversial since they are promoted to stop snoring, but not necessarily the underlying apnea Disorder; and since they are not necessarily for the purpose of correcting an obvious anatomic abnormality. Among these forms of surgery are: Straightening the septum in patients whose septal deviation is congenital and does not produce significant blockage of the nasal airway or induce obligate, Mouth breathing, Turbinectomy to correct enlarged turbinates, and Uvulopalatopharyngoplasty (UPPP). Called by some an internal face lift, a recent study reported a 79% success rate for UPPP treatment for an unselected group of patients with diagnosed OSA. Successful response was not defined as elimination of the apnea, but rather a decrease in apnea rate by half or more from the presurgical rate. To Provide a more concrete sense of what was meant by success, the mean apnea rate after UPPP was still an average of 30 apneas per hour of sleep (compared to a normal range of 0-5). Thus the patient would still require treatment for apnea. A post-surgery sleep study should be done after this surgery. There are therefore continued efforts to develop diagnostic strategies to fine tune decisions about which patients with diagnosed apnea are most likely to Derive significant benefit from the UPPP. We add that attention must also be paid to the numerous other factors which also must be addressed when treating Patients with obstructive sleep apnea. LAUP surgery, which involves removal or shortening of the uvula (the structure which hangs down from the roof of the mouth, toward the back), removal of Tonsils if present, and in some cases a shortening of the soft palate. It has been heavily promoted as a treatment for snoring. Success in treating snoring may, However, cause the patient to overlook obstructive sleep apnea, and this operation has not been demonstrated to be effective in treating apnea. Therefore, The possibility of apnea should be eliminated before this surgery. Tracheostomy In very severe cases, when a person's breathing during the night is so impaired that his or her heart is highly dysfunctional and blood oxygen Levels become perilously low, guaranteed immediate correction of the sleep-related breathing problem is critical. However, if s/he cannot tolerate nasal CPAP, a life-saving tracheostomy can be performed. This is the creation of an opening in the lower part of the throat, below the level where the airway Collapses. Plugged during the day so that normal speech is possible, the tracheostomy is open for breathing during the night.
Oxygen.
Oxygen is rarely used alone because of the way the brain uses information about how much oxygen is in the blood. That is, oxygen administration during sleep in Some cases can paradoxically lead to significant worsening of the apnea. This becomes especially problematic when a person with apnea also has a chronic lung Disease that requires oxygen. Oxygen at the correct flow rate when used in conjunction with nasal CPAP, however, in many cases corrects this problem. It is Essential for the appropriate oxygen flow rate and appropriate nasal CPAP pressure to be determined while the patient is being monitored during nighttime sleep in A qualified sleep disorders center or apnea laboratory.
Medical interventions.
In the case of an underactive thyroid gland, the obesity which untreated hypothyroidism can create eventually can also cause OSA. However, current data suggest That an underactive thyroid gland can lead to apnea even before the individual begins gaining weight. The mechanism is unknown. Thyroid hormone supplementation Might lead to significant correction of the apnea if this is the sole problem. Because of this finding it has become common for routine thyroid function testing to be Recommended if there is any suspicion whatever (including family history) of hypothyroidism. For unclear reasons, uncontrolled diabetes can also lead to apnea. Control of blood sugar levels has, however, in our experience had at best a moderate effect in Controlling the diagnosed obstructive sleep apnea. Certain medications which increase respiratory drive are helpful in some patients. Progesterone (often marketed as Provera in the synthetic form), a female Hormone secreted at a high rate during the third trimester of pregnancy when the growing uterus has pushed hard against the diaphragm and decreased the space Lungs have to operate in, has been used with some degree of success in men and women alike. For perimenopausal and postmenopausal women, addition of Exogenous progesterone might be the first treatment effort.
Dental appliances.
Dental appliances worn during sleep, many of which gently move the lower mandible forward, are increasingly being evaluated with respect to their efficacy in Treating obstructive sleep apnea, with positive results in at least a subset of the patients studied. More studies clearly need to be conducted, but the current findings Are promising, according to a recent consensus report by the American Sleep Disorders Association.
Conclusion. The actual cause of OSA is not known. There are many people who can violate the majority of the described lifestyle factors or who have blatant Obstruction of the upper airway, but who still do not develop obstructive apnea, or even loud snoring. However, for people with clearly diagnosed Apnea, all of the foregoing can be pertinent in developing a treatment plan. We would like to underscore that neither nasal CPAP nor surgery can be Expected to have the intended effect if too many of the other factors described above are not corrected as well. On the other hand, for some Patients, correction of these lifestyle factors may eliminate the problem without further treatment.
What is sleep apnea? Sleep apnea is defined as the cessation of breathing during sleep. Apnea specialists generally agree that there are three different types of sleep apnea: obstructive, central, and mixed. Of these three, obstructive sleep apnea (OSA) is the most common; central sleep apnea is rare; mixed sleep apnea is a combination of the previous two with treatment being the same as OSA.
Obstructive sleep apnea.
Obstructive sleep apnea is characterized by repetitive pauses in breathing during sleep due to the obstruction and/or collapse of the upper airway (throat), usually Accompanied by a reduction in blood oxygen saturation, and followed by an awakening to breathe. This is called an apnea event. Respiratory effort continues During the episodes of apnea. An analogy might be helpful: OSA is like putting your hand over your vacuum cleaner intake nozzle. Your hand blocks all air from Getting through (upper airway collapse) even though the vacuum cleaner is still applying suction (respiratory effort continues). The vacuum cleaner is usually straining Somewhat at this time, and so does the human body.
Central Sleep Apnea.
Central Sleep Apnea is defined as a neurological condition causing cessation of all respiratory effort during sleep, usually with decreases in blood oxygen Saturation. To return to the vacuum cleaner analogy: central sleep apnea would be like pulling the plug on the vacuum cleaner. No power, no suction: if the Brainstem center controlling breathing shuts down there's no respiratory effort and no breathing. The person is aroused from sleep by an automatic breathing reflex, So may end up getting very little sleep at all. Note that CSA, which is a neurological disorder, is very different in cause than OSA, which is a physical blockage - though the effects are highly similar.
Mixed apnea.
Mixed sleep apnea, as the name suggests, is a combination of the previous two. An episode of mixed sleep apnea usually starts with a central component and Then becomes obstructive in nature. Generally the central component of the apnea becomes less troublesome once the obstructive apnea is treated.
How Severe Must apnea Be To Require Treatment?
Note that for any type of apnea to even be considered of importance it must be at least 10 seconds in duration or longer. Specialists usually consider 5 or more of Such apneas per hour to be of possible clinical significance (less than 5 per hour is normal). However, another important factor is whether the person is excessively Tired during the day.
How do I know if I have it?
One of the best people to help you answer this question is your bed partner. People with sleep apnea generally have the following symptoms:Loud, frequent snoring. The pattern of snoring is associated with episodes of silence that may last from 10 seconds to as long as a minute or more. The end of an apnea episode is Often associated with loud snores, gasps, moans, and mumblings. Not everyone who snores has apnea, by any means, and not everyone with Apnea necessarily snores (though most do). This is probably the best and most obvious indicator. Your bedmate indicates that you periodically stop breathing during your sleep, or gasp for breath Excessive daytime sleepiness/fatigue: Falling asleep when you don't intend to. This could be almost anytime you are sitting down, such as during a lecture, while watching TV, while sitting at a Desk, and even while driving a car. Ask yourself, "Did I used to be able to (read, drive, watch TV) for longer periods of time without falling asleep?" If the Answer is yes, you may have sleep apnea or another sleep disorder. Even if you don't literally fall asleep, excessive fatigue (that is, you got plenty of sleep And you're still really tired) could be an indicator. Unrefreshing sleep with feelings of grogginess, dullness, morning headaches, severe dryness of the mouth. Body movements often accompany the awakenings at the end of each apnea episode, and this, together with the loud snoring, will disrupt the bed Partner's sleep and often cause her/him to move to a separate bed or room.
If I were awakening in the night and having all these symptoms, wouldn't I be aware of it? Probably not. Most people with sleep apnea do not realize that they are awakening to breathe many times during the night. The arousal is slight, and people Become accustomed to this, but it is enough to disrupt the pattern of sleep so that they get very little deep sleep or REM sleep, and awaken feeling sleepy. A great Many (probably most) apnea sufferers go through a large part (or ALL) of their lives unaware of their condition. Likewise regarding daytime sleepiness: people with sleep apnea often are not aware of feeling tired or unusually sleepy. The disorder develops over a number of Years, and they are not aware of the increasing symptoms and believe they feel "normal". Only after treatment do they realize how much more alert and energetic "normal" feels!
What should I do if I think I may have sleep apnea? As with most medical questions, if you have any doubt, the best thing to do is see your doctor. Unfortunately, many doctors are not highly knowledgeable about Sleep disorders. You might want to contact one of the sleep disorder foundations to find out your nearest accredited sleep specialist or sleep disorders center. The only definite way to diagnose OSA is to spend a night in a sleep lab undergoing a "polysomnogram," (or "PSG" - a sleep study). This is probably What your doctor will recommend. Many doctors are not familiar with sleep disorders. Your doctor may refer you to an Otolaryngologist (ENT - "Ear, Nose, & Throat" doctor), pulmonologist, or Sleep disorders expert or you may even suggest it. On rare occasions, in the author's personal opinion, a doctor may not take apnea seriously enough. It has been Reported that some people have to actively prod their doctors a bit. If your doctor seems inclined to pass the potential of apnea off as relatively unimportant, you May want to consider getting a second opinion.
I/my bedmate snore(s). Do I have apnea? It's possible, but not definite. Some people snore who do not have OSA. It's even possible, though extremely rare, for someone who has OSA to not snore. (However, if the person has excessive daytime sleepiness, he/she may have another type of sleep disordered breathing, such as upper airway resistance syndrome,
Or a different type of sleep disorder). Pay attention to the sound and pattern of snoring: is it a steady, regular snoring, or is it loud, frequent, and occurring in periodic Bursts punctuated by periods of silence, normal breathing, and/or gasping for air? The latter is a very good indicator of OSA.
OK, I don't have apnea. What can I do about my snoring? There are thousands of "cures" for snoring. Most of them are old wives tales that vary from ridiculous to dangerous to both. Few of them are effective. This FAQ is Not concerned with snoring, but rather with the disorder of sleep apnea. For further information, research snoring itself. Be aware that there doesn't appear to be Any guaranteed, safe "quick fix". However, if you've been through a PSG and have been diagnosed as not having sleep apnea, there are a few things you can try: If you're overweight, lose weight. Excess weight on the throat can contribute to snoring (and, of course, is unhealthy in general) Quit smoking. Again, this is a good idea in general, needless to say, but the decreased lung capacity could possibly have an effect on snoring, too. If you sleep on your back, try sleeping on your stomach. The new procedure Laser-assisted Uvulaplasty (LAUP) could be helpful under some circumstances. Be sure to read the section below concerning LAUP. Therapies for snoring and sleep apnea
Is obstructive sleep apnea dangerous? What are the effects? Absolutely. In rare cases, apnea can be fatal. Think about it: is something that makes you stop breathing something you consider to not be dangerous? It has also Been linked to high blood pressure and to increased chances of heart disease, stroke, and irregular heart rhythms (arrhythmias). Unfortunately, not all of the
Long-term effects of untreated sleep apnea are known, but specialists generally agree that the effects are harmful. If nothing else, the continual lack of quality sleep Can affect your life in many ways including depression, irritability, loss of memory, lack of energy, a high risk of auto and workplace accidents, and many other Problems. This is not something to ignore or trifle with. While it isn't usually immediately dangerous, don't take it lightly. If you think it will go away by itself - don't. It won't.
What treatments are available? There are only a few effective treatments for OSA. They fall into several categories: weight loss, surgery, dental appliances, and a breathing-assistance device. The Most popular and most effective is the use of a device which delivers air under slight pressure to the airway by way of a nasal mask. There are several types of Positive airway pressure devices including CPAP , bi-level positive airway pressure, and responsive and "smart" airway pressure devices. They are all variations on Continuous Positive Airway Pressure, or CPAP. There is no guaranteed, permanent, device-free "cure" for apnea! The type of treatment prescribed will depend on the type and location of airway obstruction and on the person's overall health. Obstructions can occur anywhere From the nose (deviated septum; swollen nasal passages from allergies), the upper pharynx (enlarged adenoids; long soft palate; large uvula; large tonsils), or the Lower pharynx (tongue that is large or situated far back; short jaw; short, wide neck with narrow airway). The location of obstructions varies between individuals, And an individual may have more than one obstruction. Breathing-assistance devices Continuous Positive Airway Pressure (CPAP) "Nasal CPAP" is the treatment of choice for most people with obstructive and mixed apnea. It is the most reliable and effective treatment in most cases. Hundreds Of thousands of CPAP devices are now in use treating obstructive sleep apnea. It involves using a small air blower device connected via a hose to a nose mask you wear while you sleep - much like a regular oxygen mask, with straps to keep it In place. Essentially, this devices blows air into your nose to keep your airway from collapsing and creating an obstruction by increasing the air pressure in your
Airways. It isn't as unpleasant as it sounds - most people get used to the sensation fairly quickly.
Admittedly, having to wear a face mask to bed isn't the most attractive thing in the universe. All I can say about that is: you have to live with it. Also, most bed Partners are usually happy to live with that rather than snoring! And it is infinitely preferable to the effects of apnea, both the fatigue and the other physical effects (additional strain on the heart, &c.). The exact results vary, but great many people report significant changes in their lives when they start using CPAP - they feel More awake, more alive - "like a whole different person", in some cases. Bi-Level Positive Airway Pressure . Bi-level positive airway pressure (bipap™ is one such device) is a variation on CPAP. Instead of providing air at a constant, steady pressure all night, the Machines "senses" how much air a person needs, based on inspiration and expiration, and varies its level of pressure accordingly. On inspiration, a higher pressure is Needed to prevent apneas, hypopneas, or snoring. But on expiration the patient typically requires several centimeters less of pressure. What is the purpose of this? Well, some people find that they simply cannot sleep with regular CPAP due to the constant air pressure. Bi-level pressure helps this Problem by providing less pressure when you are breathing out (exhaling) , and more when you are breathing in (inspiring). I would like to comment at this point that people probably should not view bi-level pressure devices as a cure-all if you're not happy with your current CPAP. I Suggest that you spend some time getting used to regular CPAP. Don't give up on it because it feels weird for the first few nights. One gets used to it after time. Just Because CPAP is annoying at first does not necessarily mean you need bi-level pressure. Give it time. Several manufacturers make bi-level airway pressure devices. Bipap™ is a trademark of Respironics. Bi-level pressure devices are significantly more expensive than regular CPAP, and I've heard that most insurance companies will not pay for it unless your doctor Essentially demands it. Responsive and "smart" airway pressure devices(JH) In the belief that the reduction of total airway flow would provide greater comfort to the patient and encourage patients to use the airway pressure treatment on a Regular basis, several manufacturers have begun to offer a new generation of treatment devices. These devices incorporate flow and pressure sensors and automatic Regulation systems. There are three basic approaches. One approach tries to keep overall pressure requirements low by using high pressure only when there is a Specific problem, but this requires a very rapid increase in pressure when a problem is detected. The second approach (Horizon autoadjust™, Virtuoso™ )varies The pressure delivered, providing less when problems are absent, and raising the pressure gradually when problems appear. The third approach (Sullivan Autoset™) gradually raises and lowers the pressure as conditions require, but also changes the pressure within a specific breath if an emerging problem is detected. DPAP (demand positive airway pressure) uses a low base pressure and rapidly ramps up the pressure after an airway obstruction or flow limitation occurs. This Rapid ramp-up of pressure is used for each breath in which a breathing problem is detected. In the approach taken by several other manufacturers, pressure changes are designed to be smooth and gradual, although each device has unique characteristics. These include: Horizon autoadjust™ by devilbiss, the Sullivan autoset™ by resmed, and the Virtuoso™ Smart CPAP system by Respironics. In the Horizon autoadjust™ by devilbiss, pressure changes are designed to be gradual. Thus, in response to airway obstructions or flow limitation, these devices Gradually increase pressure over a period of several breaths until the problem is overcome. Then the devices gradually reduce the pressure. The Virtuoso™ Smart CPAP system by Respironics monitors the airway for vibrations which typically perched apneas and responds by increasing pressure to help Prevent airway collapse. In the absence of such vibrations, pressure is reduced. The Sullivan autoset™ by resmed uses flow information to increase pressures rapidly enough to pre-empt an emerging problem and thus prevent significant flow Limitation, while using a history of recent breaths to gradually raise and lower overall pressures.
Devices like the Horizon autoadjust™, the Sullivan autoset™, or the Virtuoso™ Smart CPAP system by Respironics can be used in the laboratory or home to Titrate (determine) individual pressure requirements and thus be used to determine the prescription for a CPAP device. The professional doing the titration receives Extensive data on the patient, equivalent to a home sleep study. The devices (sometimes in special configurations for long-term home use may also be used as an Alternative to CPAP or bi-level airway pressure.) Compared to CPAP, 'smart' devices may offer greater patient comfort insofar as the overall pressure is reduced, providing that the changes in pressure reduce or Eliminate apnea, snoring, or flow limitation, and also provided that the changing pressures are tolerated by the patient. They may be used for patients whose Pressure requirements may vary during the course of a night, from night-to-night, and over longer periods of time. As professionals in the field of sleep disorders gain experience with these devices and their appropriate applications, they may provide an additional path to relief for Selected patients. As with any new form of treatment, physicians and patients may need to review studies of each device before selecting the one most appropriate To the needs of the specific patient. Clinical research on these devices is being presented at professional meetings. In one study of treatment , a comparison was made among three conditions: Untreated; treated based on professionally determined pressure settings applied to a manual or traditional CPAP; and pressure determined by the 'smart' CPAP. Both the manual and auto treatments reduced obstructions to breathing, with the manual being more effective in reducing apneas or hypopneas, but the auto system Operated at a 35% lower average airway pressure than manual CPAP.
Tongue-Restraining Devices (trds).
This is a suction cup that is gripped with the teeth and which sucks the tongue forward, thus opening the airway behind the tongue. People who snore only when Lying on their back, and whose tongue is the main source of obstruction, sometimes find this device helpful.
Surgeries .
Uvulopalatopharyngoplasty (UPPP) surgery This surgery removes the uvula and tightens up the soft tissue of the palate and upper throat (pharynx). It can be done separately or in conjunction with other Treatments, depending on where in the airway the obstructions occur. There are the usual surgical risks involved with this surgery. Notable ones are general Anesthetic (depresses breathing reflex and can be risky in people with breathing problems like sleep apnea), swelling of the airway, need for pre- and Post-operative medications (may depress the breathing reflex), bleeding, and significant pain lasting up to several weeks. Is it effective? Will it free me from having to wear a CPAP machine for life? This surgery seems to have a history of being about 70% effective in patients who have it. In other words, some of the people who have UPPP will End up having to use CPAP anyway.
Laser-Assisted Uvulaplasty (LAUP).
LAUP is a relatively new laser surgery on the uvula and soft palate that is reported to diminish snoring, but no controlled studies have been done to show that it Reduces sleep apnea. Because it is less extensive than UPPP, it is unlikely to be any more effective than UPPP in treating obstructive apnea. It is usually done in Several steps, and is an outpatient procedure. For that reason it is less risky than UPPP. LAUP is a relatively new procedure, and there is little data as yet concerning its effectiveness. Since this procedure has been developed, it has been heavily advertised as a "cure for snoring" in magazines and newspapers. This is true to a degree but you need to understand more about the pro's and cons.. While the procedure may sometimes be effective in helping people who snore but do not have apnea, the main danger from LAUP is that people may eliminate their snoring and assume that their problems are solved, when in fact they may still have untreated sleep apnea which may continue to get worse but be ignored because its primary alarm signal (snoring) has been silenced. Potential patients should be careful that they don't rush into a LAUP procedure without research and consideration.
Nasal Surgery. May be done to open nasal passages, to correct a deviated septum, or to improve the ability to use CPAP.
Jaw Surgeries.
Several procedures have been used to enlarge the lower and sometimes also the upper jaw, thereby attempting to make more room for the airway. Which patients Will be helped by this type of surgery is not yet predictable except in severe cases of facial malformation, and only a few surgical teams have extensive experience And have reported their results in the medical literature. This probably should be considered semi-experimental surgery.
Is there anything I can do myself?
You can try! While you can't "cure" your apnea, there are several things doctors suggest you do that have greatly alleviate it: Weight loss. If you're overweight, do it! Excess weight contributes to obstructive sleep apnea in two ways: 1. Fat deposits in the neck tissue compress the airway and Make it more likely to collapse. 2. Excess weight in the abdomen makes the breathing muscles operate inefficiently, which contributes to breathing difficulty When sleeping. Weight loss by itself is very difficult (as many of us know). Sometimes people are only able, or much better able, to lose their excess weight after treatment
For sleep apnea has begun, they are able to be more awake and vigorous, and increase their energy use. Naturally, weight loss is just a generally very healthy thing (if you're overweight - if your weight is normal, don't starve yourself!). Smoking . As with the loss of excess weight, this is, of course, just a good idea in general. However, quitting might also help your sleep apnea in addition to its Countless other health benefits, by returning lung capacity to normal. The author has personally found the nicotine patches now available to be of great assistance when trying to quit smoking. But be warned - they don't do it For you - it still requires an effort on your part. They don't make it easy, but they make it easier. Alcohol . Eliminate alcohol in the evening. Alcohol depresses your breathing reflexes and significantly worsens sleep apnea. Apnea sufferers should be very careful about excessive drunkenness. It's possible that if you depress your reflexes enough, you might not wake up at all. The same thing goes for sleeping pills, drugs, or anything that might affect your breathing. Allergies and respiratory infections: These cause nasal congestion, which narrows the airway and contributes to apnea. Consult your physician for medications to treat these which will not Interfere with sleep. Medications: Many common medications interfere with either the breathing reflex or sleep or both. Some of the most common are "sleeping pills", tranquilizers, and Short-acting beta blockers. Consult your sleep specialist about seeking alternative medications.
I hate CPAP! It's uncomfortable. What can I do? The answer to this varies, but generally there are things you can do, depending on your individual situation: First, read the darn manual to your CPAP unit! Adjustment of headgear This is probably the easiest and most effective thing you can do: spend time learning how to adjust your headgear and mask. Many people struggle with it and Call it uncomfortable when they haven't really tried to adjust it properly. It's especially tough when you're sleepy and fumbling with it in the dark. Take some time. Sit down at the table during the day with the headgear. Take it apart. See where all the straps, buckles, and Velcro seams are. Figure out What each one does. Generally familiarize yourself with it. Put it on. Adjust it so it's the most comfortable, and note what each strap has to be like to achieve This. Ask someone to help you, if necessary One thing I have found is that a lot of people mistakenly think that the solution to all problems with air leakage is to adjust the straps more tightly. That Frequently doesn't help. Usually air leakage problems are due to positioning, not pressure. The author's arrangement leaks no air and is adjusted rather Loosely. Naturally, there has to be enough pressure to keep a seal, but make sure you have everything positioned just right before you start tightening the Straps greatly. Only you can tell what works best and you'll have to experiment a bit to find out. Some people have found that putting a hook in the wall over the bed, and hanging the hose over that helps to keep it from "tugging" on the mask and Headgear by removing the weight of the hose. If you use a mask, try using nasal pillows (below).
Humidifiers
If you find the incoming air to be too dry, and your sinuses are drying out, many manufacturers offer a humidifier as an option. Essentially, this is a (rather Expensive, for what it is) piece of plastic which you fill with water and place in between the machine and your mask. The air flows over the water and picks Up moisture, just like a regular house humidifier. A heated humidifier in line with the CPAP can make a significant difference in comfort. Noise Most CPAP machines are quite quiet. Most people don't mind it, and some even find the soft "white noise" of rushing air to be relaxing. Some, however, find The noise of the machine disturbing. The only two things you can do are 1) block the noise somehow, or 2) put the machine further away. To block the noise, try putting the machine behind something - a dresser or board, perhaps. However, DO NOT PLACE ANYTHING OVER THE CPAP UNIT OR BLOCK THE FLOW OF AIR IN ANY WAY! Remember, this machine pumps air - if you cut off the air flow, you could damage it or Even start a fire. It must have plenty of space around it so air can circulate. Appearance. Unfortunately, there's really nothing you can do about this. Even if you bought Gucci headgear and mask, there's no hiding the fact that you're wearing Headgear and a mask. If you think your bed partner doesn't like it, ask them if they find snoring more attractive. Try these things at your own risk - I am not responsible for any problems that might arise from attempting any of these solutions!
I don't want to use CPAP for the rest of my life!
I didn't really want to include this one, but so many "questions" boil down to this, I had to. No matter how much you want a quick, easy solution - there isn't one. Surgery offers a significant chance of cure but in 25 to 30 % of patients CPAP may still be required after recovering from the surgery. Now, It's true that there are treatments other than CPAP, and some of them work for some people. It's true that you might be able to alleviate the severity of your apnea. Yeah, I know CPAP can be a pain sometimes. I know it isn't the snuggliest thing in the world when you're trying to get romantic with your bedfellow.
What are "nasal pillows" and "Adam circuits"?
Nasal pillows ("Adam circuit" is another name for the same thing) refers to a different method of delivering air with a CPAP machine. Basically, these are nose plugs That you use in place of a traditional mask over your nose (you still connect it to the hose to CPAP machine, like a mask). It is less bulky than a mask, and there Aren't as many problems with air leaking out. The author greatly prefers this option, though of course it's a matter of personal preference. Nasal pillows are also a nice option for people who find the mask irritates their skin and/or leaves them with pressure marks or blemishes due to skin oil. To acquire nasal pillows, ask the health equipment provider where you got your CPAP.
Which CPAP machine is the best? There are several different manufacturers of CPAP machines, each with different models. They all perform the same function; the major differences are in price, Weight, and options. Some are "bare bones" while some have many options including such things as voltage converters (handy for people who travel to foreign Countries) and even remote controls!
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