Sleep Apnea is a serious, potentially life-threatening condition. It is a breathing disorder characterized by repeated collapse of the upper airway during sleep, with consequent cessation of breathing. Virtually all sleep apnea patients have a history of loud snoring. They may all unknowingly experience frequent arousal during the night, resulting in chronic daytime sleepiness or fatigue.

There are two discrete types of sleep apnea: central and obstructive. Central sleep apnea, characterized by lack of airflow in the absence of ventilatory effort, is rare. Obstructive sleep apnea is much more common and is referred to as sleep apnea hereafter. It is characterized by closure of the upper airway, resulting in the cessation of airflow despite persistent ventilatory effort. Apnea is defined as cessation of airflow for more than 10 seconds. A related event, hypopnea, is characterized by a reduction in airflow associated with a decrease in oxygen saturation. The average number of apnea-hypopnea events per hour of sleep is called the apnea-hypopnea index (AHI). Adults may experience up to five events per hour without symptoms. In general, as AHI increases, so does the severity of symptoms. An AHI of five or greater in combination with self-reported excessive, or prolonged sleep is indicative of sleep apnea syndrome.

Sufferers of sleep apnea usually experience tiredness, fatigue, sleepiness, memory and judgement problems, irritability, difficulty concentrating, and personality changes. Individuals experiencing sleep apnea are more likely to fall asleep at inappropriate times and have a higher rate of automobile crashes and work-related accidents.

The cardiovascular system is also adversely affected by sleep apnea. Systemic hypertension has been reported in up to 50 percent of patients with sleep apnea. Cardiac arrhythmia (An irregularity in the force or rhythm of the heartbeat) during sleep have also been associated with sleep apnea.

Are you at risk for Sleep Apnea?

Individuals at risk for sleep apnea are those who exhibit loud, chronic snoring. Additionally, if they are observed to have apneic events characterized by choking or gasping during sleep are definite candidates for further evaluation. Bed partners or family members will likely need to be interviewed by a physician in order to obtain accurate information about the snoring and apneic events.

Obesity, particularly upper body obesity, is a risk factor for sleep apnea and has been shown to have a significant effect on its severity. Most sleep apnea sufferers are obese, when obesity is defined as greater than 120 percent of ideal body weight. Large neck girth in both male and female snorers is highly predictive of sleep apnea. In general men with a neck circumference of 17 inches or greater and women with a neck circumference of 16 inches or greater are at a higher risk for sleep apnea.

Individuals at risk for Sleep Apnea
Sympotoms
• Chronic, loud snoring
• Gasping or choking episodes during sleep
• Excessive daytime sleepiness (especially drowsy driving)
• Automobile or work-related accidents due to fatigue
• Personality changes or cognitive difficulties related to fatigue
Signs
• Obesity, especially those with a large neck girth
• Systemic hypertension
• Throat and nasal passage narrowing

If an individual complains of sleepiness but does not have other signs and symptoms of sleep apnea, a review of sleep habits may be helpful (e.g., number of hours of sleep per night, recent changes in schedule, recent lifestyle changes). The individual may simple need to consider ways in which to increase the daily amount of sleep, then other conditions such as narcolepsy (A disorder characterized by sudden and uncontrollable, though often brief, attacks of deep sleep, sometimes accompanied by paralysis and hallucinations) or depression should be considered.

Sleep apnea is also seen in children. Children with sleep apnea may exhibit different signs and symptoms than adults. During sleep, children exhibit snoring and labored breathing. Features compatible with sleep apnea include weight loss or failure to gain weight, poor school performance, and behavioral problems.

Diagnosing Sleep Apnea

If there is a high suspicion of sleep apnea, a sleep study is indicated to establish a diagnosis. Currently, polsomnography, which requires an overnight stay in a sleep laboratory, is the optimum test for diagnosing sleep apnea. It includes evaluation of sleep staging, airflow and ventilatory effort, arterial oxygen saturation, electrocardiogram, body position, and periodic limb movements. A variety of home monitors are currently available or being developed that can record both cardiopulmonary parameters (for example airflow, ventilatory effort, heart rate, and oxygen saturation) and sleep parameters and may be useful in diagnosing sleep apnea. It is imperative that a person with expertise in sleep disorders interprets the sleep study since an accurate diagnosis is crucial to develop the best treatment.

The severity of symptoms will determine how quickly a sleep study should be obtained and therapy initiated. Sufferers who report falling asleep while driving or those with heart failure or angina are high priority for a sleep study and rapid intervention.

Treatment Options

The goals of treatment for sleep apnea patients include both physiologic and symptomatic components. Physiologic goals of treatment include eliminating sleep fragmentation, apneas and hypopneas, and oxygen desaturation (less than normal amounts of oxygen carried in the blood stream). Symptomatic goals include eliminating snoring and sleepiness and improving quality of life. Symptomatic improvements, particularly decreased snoring, do not necessarily correlate with physiologic improvements or decreased morbidity.

Therapy decisions must be individualized and are often accomplished in consultation with sleep apnea specialists.

Behavioral Approaches

Behavioral measures may be the only treatment needed for patients with mild sleep apnea. Behavioral interventions include losing weight, eliminating evening alcohol and sedatives, and proper positioning (avoiding lying on the back while sleeping). Although weight loss may be difficult to achieve, it can be very effective and, in some cases, even curative.

Individuals treated with behavioral techniques should be reevaluated periodically after the initiation of treatment. For patients who have improved, continued support and positive reinforcement can sustain their adherence and success. In those patients who continue to experience symptoms, other therapies are warranted

CPAP – Continuous Positive Airway Pressure

CPAP is the most effective noninvasive therapy for sleep apnea. To use CPAP, the patient must wear a sealed mask over their nose or, in some cases, over the nose and mouth during sleep. The mask is connected to a blower forcing air through the nasal passages. CPAP acts as an air splint by increasing the pressure in the oropharyngeal airway, thereby maintaining an open airway. This form of treatment is usually prescribed after a sleep test has first determined the therapeutic level of CPAP pressure required reducing or eliminating sleep apnea. When used properly CPAP produces rhythmic breathing, resulting in the patient feeling dramatically better and being able to function more efficiently.

Follow-up after the first month of CPAP treatment should include checking the status of equipment, assessing patient symptoms and adherence, and assessing the status of coexisting conditions such as hypertension. Individuals who have achieved significant weight loss may have to have their CPAP pressure adjusted.

Oral and Dental Appliances

Oral or dental appliances may be an option for patients with mild-to-moderate sleep apnea. However, they are not effect in all patients. Appliances have also been used for patients who snore but do not have sleep apnea. There are various devices that displace the tongue forward or move the lower jaw down and forward to increase the openness of the airway. A dentist or orthodontist experienced in these devices should fit the patient, and a sleep study should be done after the device is fitted to evaluate its effectiveness.

Surgical Procedures

Patients need to understand that no surgical procedure has universal success, and all are invasive and carry risk. Several procedures or a combination of procedures may need to be performed to help sleep apnea sufferers. It is important that sleep studies be repeated after each surgical procedure to confirm its effectiveness.

Uvulopalatopharyngoplasty (UPP) During UPPP, an inpatient procedure, the uvula (the small, conical, fleshy mass of tissue suspended from the back of a mouth) and portions of the soft palate (The movable fold, consisting of muscular fibers enclosed in a mucous membrane, that is suspended from the rear of the hard palate and closes off the nasal cavity from the oral cavity during swallowing or sucking) are cut-back to enlarge the airway. Although snoring is temporarily relieve in most cases, apnea may persist. The overall success rates if UPPP is reported to be about 40 percent. It is difficult to predict which patients will benefit from this procedure, and long-term side effects and benefits unknown.

Nasal Surgery Nasal surgery may be used alone or in conjunction with other procedures. Nasal surgery is rarely effective when utilized alone.

Tonsillectomy In children and adolescents a tonsillectomy may provide a cure. However, in adults it is not usually helpful when offered as the only treatment. A tonsillectomy is often done in conjunction with UPPP.

Laser-Assisted Uvlopalatoplasty (LAUP) LAUP has received much attention recently as a treatment for snoring. However, its effectiveness in treating sleep apnea is unknown. LAUP differs from traditional UPPP in both surgical technique and that it is an outpatient treatment. As with UPPP, relief of snoring may occur without improvement in apneic events. Therefore, patients who elect LAUP for snoring may risk delaying the diagnosis of sleep apnea because snoring, a primary symptom, is eliminated.

Maxillofacial Surgery (Genioglossal Advancement, Maxillary and Mandibular Advancement) These are specialized procedures that are currently not widely available, although they appear to be effective in treating sleep apnea. Genioglossal (of or relating to the chin and tongue) advancement enlarges the airway at the base of the tongue. This procedure may be combined with a UPPP. Maxillary and madibular (the lower jaw) advancement enlarges the airway at the soft palate as well as the tongue.

Tracheostomy Tracheostomy is the surgical formation of an opening into the trachea through the neck to allow the passage of air. This procedure is highly successful in eliminating sleep apnea but is very invasive, both physically and psychologically. This procedure is now only performed on patients with severe obstructive sleep apnea who cannot tolerate CPAP therapy or surgery is deemed urgent. Occasionally a Tracheostomy will be performed on patients who undergo surgical correction of the upper airway anatomy to prevent postoperative swelling.

Pharmacological Treatment

The development of a successful pharmacological therapy for sleep apnea remains undeveloped. However, a number of medications have been tested with inconsistent and variable results. Recently, Tricyclic antidepressants (TCA’s) have been proven to decrease the time spent in REM sleep, which is often the time of the longest apneas and most pronounced desaturation. However, results in human studies have not produced a consistent response. Selective Serotonin Reuptake Inhibitors (SSRI’s) have also been investigated due to their strong evidence of that serotonin may have on enlarging the upper airway.

Management Considerations

Once effective treatment has been initiated, all patients should be periodically reevaluated for recurrence of symptoms such as snoring and excessive daytime sleepiness as well as cardiopulmonary complications. Patients who are adherent to treatment for sleep apnea need positive reinforcement, and those who are not adherent may require different treatment options. Patients who are on CPAP need to have their equipment evaluated periodically to ensure that the machine and mask are functioning properly. If symptoms of sleepiness persist despite proper treatment, the patient should be evaluated for other conditions.

Some information obtained from the National Institutes of Health, National Heart, Lung, and Blood Institute Publication #95-3803

Sleep Resources and Organizations

Academy of Dental Sleep Medicine
10592 Perry Hwy., Ste. 220
Wexford, PA 15090-9244
Phone: (724) 935-0836
Fax: (724) 935-0383
www.dentalsleepmed.org

American Academy of Sleep Medicine
1 Westbrook Corporate Ctr., Ste. 920
Westchester, IL 60154
Phone: (708) 492-0930
Fax: (708) 492-0943
www.aasmnet.org

American Academy of Neurology
1080 Montreal Avenue, St. Paul, Minnesota 55116
Phone: 651.695.1940
www.aan.com

American Board of Sleep Medicine
1 Westbrook Corporate Ctr., Ste. 920
Westchester, IL 60154
Phone: (708) 492-0930
Fax: (708) 492-0943
www.absm.org

American College of Chest Physicians
3300 Dundee Rd
Northbrook, IL 60062-2348
Phone 847.498.1400
Fax 847.498.5460
www.chestnet.org

American Sleep Apnea Association/A.W.A.K.E. Network
1424 K St., N.W., Ste. 302
Washington, D.C. 20005
Phone: (202) 293-3650
Fax: (202) 293-3656
www.sleepapnea.org

American Sleep Disorders Association

Associated Professional Sleep Societies
1 Westbrook Corporate Ctr., Ste. 920
Westchester, IL 60154
Phone: (708) 492-0930
Fax: (708) 492-0943
www.apss.org

Association of Polysomnographic Technologists
P.O. Box 14861
Lenexa, KS 66285-4861
Phone: (913) 541-1991
Fax: (913) 599-5340
www.aptweb.org

Board of Registered Polysomnographic Technologists
475 Riverside Dr., 6th Floor
New York, NY 10115
Phone: (212) 367-4370
E-mail: brptinfo@proexam.org
www.brpt.org

British Snoring and Sleep Apnea Association
1 Duncroft Close,
Reigate, Surrey,
RH2 9DE, England
Phone +44 1737 245638
Fax +44 (0)1737 248744
www.britishsnoring.demon.co.uk

Divers Alert Network
Peter B. Bennett Center
6 W. Colony Pl.
Durham, NC 27705
Phone: (919) 684-2948; (800) 446-2671
Fax: (919) 490-6630
www.diversalertnetwork.org

National Center on Sleep Disorder Research
Two Rockledge Centre
Suite 7024
6701 Rockledge Drive, MSC 7920
Bethesda, MD 20892-7920
Phone 301.435.0199
Fax 301.480.3451

National Heart, Lung and Blood Institute Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
Phone 301.251.1222
Fax 301.251.1223

National Sleep Alliance
4343 Shallowford Rd., Ste. C-3A
Marietta, GA 30062
Phone: (800) 235-9830
Fax: (770) 518-8508

National Sleep Foundation
1522 K St. N.W., Ste. 500
Washington, D.C. 20005
Phone: (202) 347-3471
Fax: (202) 347-3472
www.sleepfoundation.org

Restless Legs Syndrome Foundation
819 2nd St., S.W.
Rochester, MN 55902
Phone: (507) 287-6465
Fax: (507) 287-6312
www.rls.org

Sleep Apnea Association
7059 Neri Dr.
La Mesa, CA 91941
Phone: (619) 461-6442

Sleep Net
www.sleepnet.com

Sleep Research Society
1 Westbrook Corporate Ctr., Ste. 920
Westchester, IL 60154
Phone: (708) 492-0930
Fax: (708) 492-0943
www.sleepresearchsociety.org

World Federation of Sleep Research Societies
www.wfsrs.org/homepage.html

U.S. Department of Health and Human Services
Public Health Services
National Institutes of Health
National Heart, Lung, and Blood Institute