Obstructive sleep apnea is the most common form of sleep apnea. It is characterized by frequent starts and stops in breathing while asleep. This type of apnea occurs when the muscles in the back of the throat relax and block the airway. These muscles help to support oral and pharyngeal structures like the tongue, uvula, soft palate, and tonsils.
When the airway is either completely or partially blocked, there is usually 10 to 20 seconds of breathing cessation, which can lower blood oxygen levels. The brain panics when this happens and rouses the body to restart breathing. Generally, this is a very brief awakening that most people do not even notice or remember. It can happen over 30 times an hour all throughout the night, which significantly disrupts restful sleep cycles.
Symptoms of Obstructive Sleep Apnea
The most obvious and common sign of this type of apnea is loud snoring.
Other signs and symptoms that may occur during the night or in the daytime include:
- Excessive sleepiness during the day, leading to difficulty with focus and concentration
- Waking up in the middle of the night short of breath
- Breathing cessation throughout the night, which is usually observed by someone else
- Dry mouth and sore throat in the morning
- Chest pain upon waking up
- Morning headaches
- Mood instability like frequent bouts of depression, anxiety, or excessive irritability
- Insomnia, problems staying asleep, and/or restless sleep
Not everyone who snores has obstructive sleep apnea. This type of snoring is extremely loud and identifiable through the long periods of deafening silence when breathing stops.
Typically, adults and children will differ in symptoms. For example, the hallmark of OSA in adults is excessive daytime sleepiness, to the point where they may fall asleep for short periods throughout regular daily activities.
Children with OSA may suffer from hyperactivity, malnutrition, and failure to thrive, which is where their growth rates are significantly reduced.
The poorer growth can happen for one of two reasons:
- The work of breathing is burning off a lot more calories.
- There is so much nasal and airway obstruction that it is difficult to swallow food and drink.
Symptoms can be present for years without the person knowing they have the disorder. Many will have issues for only a short period, with symptoms disappearing after weight loss, surgery, or other lifestyle changes. Symptoms may also be the result of a respiratory infection, congestion, throat swelling, etc.
Causes of Obstructive Sleep Apnea
In children, enlarged tonsils or adenoids most often cause OSA. Surgical removal often leads to resolution of OSA symptoms. For adults, causes may vary and include:
- Obesity, which may cause increased soft tissue around the airway
- Structural deformities that obstruct the airways
- Decrease in muscle tone, which can be caused by alcohol, substance abuse, neurological disorders, or some other underlying health conditions.
Some scientific evidence suggests that snoring for years at a time can lead to the development of lesions in the throat, just as the vibrations from snoring can lead to nerve or neuron lesions all around the body.
Women are typically less likely to suffer from OSA than men, as men in middle years are more likely to have changing anatomy in their neck and soft tissues. Women could also be at decreased risk because of the higher levels of progesterone, but they are more likely to suffer symptoms during pregnancy and after menopause.
Furthermore, there seems to be a genetic component to OSA. Studies have shown that sufferers often have a positive family history. Lifestyle factors like drinking, smoking, and overeating increase the chances of developing the condition.
Diagnosing Obstructive Sleep Apnea
OSA is diagnosed through a series of exams and tests. A thorough history and physical is taken by the primary care physician, which includes questioning how the patient is performing in daily activities and family history. The physical exam includes examining the back of the throat for any abnormalities, checking blood pressure, and measuring neck and waistlines.
Tests used to diagnose obstructive sleep apnea are polysomnography and home sleep study sleep apnea test.
Some doctors may recommend polysomnography, or in-laboratory sleep study, to be monitored overnight by a specialist who will record oxygen levels and frequency of breathing cessation or awakenings. When breathing stops, there are fluctuations in blood oxygen levels, with a subsequent increase in carbon dioxide.
In central sleep apnea, the brain sends signals to stop breathing entirely; however, in OSA, the chest will continue to move up and down to simulate inhalation/exhalation without actually breathing.
The monitors placed during the polysomnogram show chest movements are pronounced and often exaggerated in OSA patients.
There are one of two events characterized on this study:
- Apnea, which is when airflow is completely blocked and breathing stops for at least 10 seconds
- Hypopnea, which is when airflow is 50% decreased for at least 10 seconds, or there is a 30% decrease in airflow with a subsequent awakening or serious drop in oxygen saturation levels.
Home Sleep Test
Many doctors are starting to use home sleep studies, which are much more convenient and comfortable for the patient. This is a noninvasive way of monitoring blood oxygen saturation levels during sleep.
Patients who are at higher risk of OSA are first given the STOP BANG questionnaire or other sleep apnea screening questionnaire, and a significant score means they likely have OSA rather than another sleep disorder.
Unfortunately, home oximetry does not measure apnea events or arousals, so it could be difficult to diagnose OSA with a home oximeter.
Treatments for Obstructive Sleep Apnea
The first line of treatment for OSA is always lifestyle changes. Reducing alcohol intake, losing weight, quitting smoking, and avoiding sedative medications are a starting point for treating physicians. However, lifestyle modifications do not always resolve the issues; therefore, one or more of the below options are considered in treatment plans.
Next to lifestyle changes, continuous positive airway pressure (CPAP) treatment is the frontline of treatment. It is most effective for moderate to severe symptoms. This resembles, but is different from, a ventilator. A facemask is attached to a tube that is connected to a machine, which continuously pushes positive airway pressure into the breathing passages. This helps to keep the airways open.
Variable positive airway pressure, also known as BPAP, is another type of ventilation, but instead of continuous airway pressure, the machine uses a circuit to monitor breathing and provide two different pressures: one for inhalation and one for exhalation. The inhalation pressure is higher than the exhalation pressure. This treatment is more common in patients with serious respiratory conditions.
This bandage-type device is placed over the nostrils to enhance the person’s regular breathing cycles, create positive airway pressure, and prevent obstruction. This is a device commonly used in mild cases of OSA.
Splints or other oral appliances are sometimes used in conjunction with other treatments. Patients often prefer them because they are less “invasive” than CPAP, but sometimes they do not work as well. These splints are mouth guards that keep the passages open and protect the teeth and gums. It holds the lower jaw down and forward to keep it in a more forward position, while simultaneously holding the tongue further away from the airway.
Sometimes, modifying airway anatomy is necessary to treat OSA symptoms. These types of surgeries will vary depending on the cause of the condition and the patient’s anatomy. The various operative procedures include:
- Tonsillectomy and adenoidectomy
- Nasal surgery such as turbinectomy or straightening a deviated septum
- Reduction or removal of uvula or soft palate
- Reduction of the size of the tongue base
- A procedure that surgically moves the jaw forward, pulling the tongue away from the back of the throat (genioglossus advancement)
- Hyoid suspension, where one of the neck bones is pulled forward
- Bariatric surgery for morbidly obese patients
This option is used for patients who cannot tolerate the CPAP machine. This system senses respirations and stimulates the hypoglossal nerve with electrical currents to increase muscle tone, which will help avoid the tongue collapsing to the back of the throat and blocking the airway.
What is the Prognosis for Patients with OSA
The apneic and hypopneic events associated with OSA cause a fight or flight response in the body, which further creates a hormonal reaction. Excessive use of this response can put an undue amount of stress on the body, exhausting the glands and organs that are activated during the fight or flight response. This, paired with consistently low oxygen saturation levels, can lead to long-term dangerous health consequences.
If the above symptoms become so severe that daily activities and work are affected, then it’s time to seek medical attention. Untreated obstructive sleep apnea can lead to long-term serious conditions such as:
- Cardiovascular disease
- Daytime fatigue, which can be hazardous in school or work environments and driving
- Eye and vision problems
- Mood and psychiatric disorders
One of the most serious concerns of untreated OSA is cardiovascular disease. Sleep apnea patients are at 30% higher risk of heart attack and heart-related death than those without the condition. Increased pulmonary pressures to the right side of the heart, a major concern in prolonged cases of OSA, can result in cor pulmonale, a very serious and dangerous form of congestive heart failure.
Obstructive sleep apnea and very loud snoring may seem harmless at first, but it can lead to a laundry list of daytime symptoms and more serious and extensive health concerns, so diagnosis and monitoring should be a priority.
- Obstructive sleep apnea. (n.d.). Retrieved July 25, 2016, from https://en.wikipedia.org/wiki/Obstructive_sleep_apnea
- Mayo Clinical Staff. (2016). Obstructive sleep apnea. Retrieved July 25, 2016, from http://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/home/ovc-20205684
Older Material Below – to be deleted or modified
What Is Sleep Apnea?
Sleep apnea is a common sleep disorder that is potentially life threatening. With sleep apnea, breathing stops or gets very shallow while the person is sleeping. Each pause in breathing typically lasts 10 to 20 seconds or more. These pauses can occur over 30 times per hour.
The most common type of sleep apnea is obstructive sleep apnea. During sleep, air cannot flow into the lungs through the mouth and nose even though there is effort to breathe. When this happens, the amount of oxygen in the blood drops. Normal breaths then start again with a loud snort or choking sound.
When sleep is fragmented throughout the night, excessive daytime sleepiness often occurs. Sleep apnea leads to disrupted sleep because:
- These brief episodes of increased airway resistance (and breathing pauses) occur many times.
- You may have many brief drops in blood oxygen levels.
- You move out of deep sleep and into light sleep several times during the night, resulting in poor sleep quality.
People with sleep apnea often have loud snoring. However, not everyone who snores has sleep apnea. Some people with sleep apnea don’t know they snore.
- Sleep apnea happens more often in people who are overweight, but even thin people can have it.
- Most people don’t know they have sleep apnea. They don’t know that they are having problems breathing while they are sleeping.
- A family member and/or bed partner may notice the signs of sleep apnea first.
Untreated sleep apnea can increase the chance of having high blood pressure and even a heart attack or stroke. Untreated sleep apnea can also increase the risk of diabetes and the risk for work-related accidents and driving accidents.
What Causes Sleep Apnea?
Sleep apnea happens when enough air cannot move into the lungs during sleep. When awake and during normal sleep, throat muscles keep the airway open and air flows into the lungs. With obstructive sleep apnea, however, the throat briefly collapses, causing pauses in breathing. With pauses in breathing, the oxygen level in the blood may drop. This happens if the following conditions occur:
- Throat muscles and tongue relax more than normal.
- Tonsils and adenoids are large.
- Being overweight. The extra soft tissue in your throat makes it harder to keep the throat area open.
- The shape of the head and neck (bony structure) results in somewhat smaller airway size in the mouth and throat area.
When the throat fully or partially blocks during sleep, air cannot flow into the lungs, even though there is effort to breathe. Breathing may become difficult and noisy and may even stop for short periods of time (apneas).
Central apnea is a subtype of sleep apnea that happens when the area of the brain that controls breathing doesn’t send the correct signals to the breathing muscles. When this occurs, there is no effort to breathe for brief periods. Snoring does not always occur with central apnea.
Who Is At Risk for Obstructive Sleep Apnea?
Anyone can have obstructive sleep apnea.
It is estimated that more than 12 million Americans have obstructive sleep apnea. More than half of people who have sleep apnea are overweight, and most snore heavily.
Sleep apnea is more common in men. One out of 25 middle-aged men and 1 out of 50 middle-aged women have sleep apnea that causes them to be very sleepy during the day. Sleep apnea is more common in African Americans, Hispanics, and Pacific Islanders than in Caucasians. If someone in your family has sleep apnea, you are more likely to develop it than someone without a family history of the condition.
Adults who are most likely to have sleep apnea include those that:
- Snore loudly.
- Are overweight.
- Have high blood pressure.
- Have a decreased size of the airways in their nose, throat, or mouth. This can be caused by the shape of these structures or by medical conditions causing congestion in these areas, such as hay fever or other allergies.
- Have a family history of sleep apnea.
Obstructive sleep apnea can also occur in children who snore. If your child snores, you should discuss it with your child’s doctor or health care provider.
Do I have Sleep Apnea?
What Are the Signs and Symptoms of Sleep Apnea?
The most common signs of sleep apnea are:
- Loud snoring
- Choking or gasping during sleep
- Fighting sleepiness during the day (even at work or while driving)
Your family members may notice the symptoms before you do. Otherwise, you will likely not be aware that you have problems breathing while you are asleep.
Others signs of sleep apnea may include:
- Morning headaches
- Memory or learning problems
- Feeling irritable
- Not being able to concentrate on your work
- Mood swings or personality changes; perhaps feeling depressed
- Dry throat when you wake up
- Frequent urination at night
How Is Sleep Apnea Diagnosed?
Your doctor will do a physical exam and take a medical history that includes asking you and your family questions about how you sleep and how you function during the day. As part of the exam, your doctor will check your mouth, nose, and throat for extra or large tissues; for example, tonsils, uvula (the tissue that hangs from the middle of the back of the mouth), and soft palate (the roof of your mouth in the back of your throat).
Your doctor may order a sleep recording of what happens with your breathing while you sleep. A sleep recording is a test that is often done in a sleep center or sleep laboratory, which may be part of a hospital. You may stay overnight in the sleep center, although sleep studies are sometimes done in the home. The most common sleep recording used to find out if you have sleep apnea is called a polysomnogram (poly-SOM-no-gram), or PSG. This test records:
- Brain activity
- Eye movement
- Muscle activity
- Breathing and heart rate
- How much air moves in and out of your lungs while you are sleeping
- The percentage of oxygen in your blood
A PSG is painless. You will go to sleep as usual. The staff at the sleep center will monitor your sleep throughout the night. The results of your PSG will be analyzed by a sleep medicine specialist to see if you have sleep apnea, how severe it is, and what treatment may be recommended.
In certain circumstances, the PSG can be done at home. A home monitor can be used to record your heart rate, how air moves in and out of your lungs, the amount of oxygen in your blood, and your breathing effort. For this test, a technician will come to your home and help you apply the monitor that you will wear overnight. You will go to sleep as usual, and the technician will come back the next morning to get the monitor and send the results to your doctor.
Once all your tests are completed, the sleep medicine specialist will review the results and work with you and your family to develop a treatment plan. In some cases, you may also need to see another physician for evaluation of:
- Lung problems (treated by a pulmonologist)
- Problems with the brain or nerves (treated by a neurologist)
- Heart or blood pressure problems (treated by a cardiologist)
- Ear, nose, or throat problems (treated by an ENT specialist)
- Mental health, such as anxiety or depression (treated by a psychologist or psychiatrist)
How Is Sleep Apnea Treated?
Treatment is aimed at restoring regular nighttime breathing and relieving symptoms such as very loud snoring and daytime sleepiness. Treatment will also help associated medical problems, such as high blood pressure, and reduce the risk for heart attack and stroke.
Changes in Activities or Habits
If you have mild sleep apnea, some changes in daily activities or habits may be all that are needed:
- Avoid alcohol, smoking, and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
- Lose weight if you are overweight. Even a little weight loss can improve your symptoms.
- Sleep on your side instead of your back. Sleeping on your side may help keep your throat open.
People with moderate or severe sleep apnea will need to make these changes as well. They also will need other treatments, such as the following.
Continuous Positive Airway Pressure
Continuous positive airway pressure (CPAP) is the most common treatment for sleep apnea. For this treatment, you wear a mask over your nose during sleep. The mask blows air into your throat at a pressure level that is right for you. The increased airway pressure keeps the throat open while you sleep. The air pressure is adjusted so that it is just enough to stop the airways from briefly getting too small during sleep.
Treating sleep apnea may help you stop snoring. Stopping snoring does not mean that you no longer have sleep apnea or that you can stop using CPAP.
Sleep apnea will return if CPAP is stopped or if it is not used correctly. Usually, a technician comes to your home to bring the CPAP equipment. The technician will set up the CPAP machine and make adjustments based on your doctor’s orders.
CPAP treatment may cause side effects in some people. Some side effects are:
- Dry or stuffy nose
- Irritation of the skin on your face
- Bloating of your stomach
- Sore eyes
If you are having trouble with CPAP side effects, work with your sleep medicine specialist and technician. Together you can do things to reduce these side effects, such as:
- Use a nasal spray to relieve a dry, stuffy, or runny nose.
- Adjust the CPAP settings.
- Adjust the size/fit of the mask.
- Add moisture to the air as it flows through the mask.
- Use a CPAP machine that can automatically adjust the amount of air pressure to the level that is required to keep the airway open.
- Use a CPAP machine that will start with a low air pressure and slowly increase the air pressure as you fall asleep.
People with severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP. When using CPAP, it is very important that you follow up with your doctor. If you are having side effects, talk to your doctor.
A mouthpiece (oral appliance) may be helpful in some people with mild sleep apnea. Some doctors may also recommend this if you snore loudly but do not have sleep apnea.
A custom-fit plastic mouthpiece will be made by a dentist or orthodontist. An orthodontist is a specialist in correcting teeth or jaw problems. The mouthpiece will adjust your lower jaw and your tongue to help keep the airway in your throat open while you are sleeping. Air can then flow easily into your lungs because there is less resistance to breathing.
Possible side effects of the mouthpiece include damage to your:
Follow up with your dentist or orthodontist to check for any side effects and to be sure that your mouthpiece fits.
Some people with sleep apnea may benefit from surgery. The type of surgery depends on the cause of the sleep apnea.
- Surgery may be done to remove the tonsils and adenoids if they are blocking the airway. This surgery is especially helpful for children.
- Uvulopalatopharyngoplasty (U-vu-lo-PAL-a-to-fa-RIN-go-plas-te) (UPPP) is a surgery that removes the tonsils, uvula (the tissue that hangs from the middle of the back of the roof of the mouth), and part of your soft palate (the roof of your mouth in the back of your throat). This surgery is only effective for some people with sleep apnea.
- Laser-assisted uvulopalatoplasty (U-vu-lo-PAL-a-to-plas-te) (LAUP) is a surgery that can stop snoring but is probably not helpful in treating sleep apnea. A laser device is used to remove the uvula and part of the soft palate. Because this surgery stops the main symptom of sleep apnea (snoring), it is important to have a sleep study first.
- Tracheostomy (TRA-ke-OS-to-me) is a surgery used in severe sleep apnea. A small hole is made in the windpipe and a tube is inserted. Air will flow through the tube and into the lungs. This surgery is very successful but is needed only in patients not responding to all other possible treatments.
Other possible surgeries for some people with sleep apnea include:
- Rebuilding the lower jaw
- Surgery on the nose
- Surgery to treat obesity
Currently, there are no medicines for the treatment of sleep apnea.
Living With Sleep Apnea
Getting treatment for sleep apnea and following your doctor’s advice can help you and your family members.
- Getting treatment for sleep apnea can help snoring and can improve your sleep.
- Treating sleep apnea helps you feel rested during the day.
- Many people will benefit by making healthy changes, such as stopping smoking and losing weight.
- Some people will need to wear a mask at night to help keep the throat open and improve breathing.
- A few people will need to have surgery to remove tonsils and adenoids, part of the uvula (the tissue that hangs from the middle of the back of the roof of the mouth), and/or the soft palate (the roof of your mouth in the back of your throat) that may block the airway.
- Regular and ongoing followup is needed; your sleep medicine specialist will check whether your treatment is working and whether you are having any side effects.
What Can Family Do To Help?
Often, people with sleep apnea do not know they have it. They are not aware that their breathing stops and starts many times while they are sleeping. Family members or bed partners are usually the first ones to notice that the person snores and stops breathing while sleeping.
There are many things family members can do to help a loved one who has sleep apnea, including:
- Letting the person know if he or she snores loudly during sleep or has breathing stops and starts
- Encouraging the person to get medical help
- Helping the person follow the doctor’s treatment plan, including continuous positive airway pressure (CPAP)
- Making sure the person puts on the CPAP mask before falling asleep
- Providing emotional support
- Helping with insurance paperwork
Sleep apnea can be very serious. People with sleep apnea are at higher risk for car crashes, work-related accidents, and other medical problems due to their sleepiness. It is important that people with sleep apnea see their doctor to treat and control this disorder.
Treatment may improve a person’s overall health and happiness as well as the quality of sleep for both the person and the entire family.
Above courtesy of NHLBI
Below – original contribution.
Obstructive Sleep Apnea (OSA), also referred to simply as sleep apnea, the broader category under which it falls, is a sleeping disorder in which throat tissue collapses and obstructs the flow of air in the lungs. This is caused by the body’s natural muscle attenuation process during sleep. It is the most common form of sleep apnea, affecting as many as 20% of adults, though many cases go undiagnosed.
The degree to which airflow is disrupted, and the amount of times this occurs in a typical night varies with each patient. Some patients experience only mild symptoms, often resulting in snoring, others suffer complete blockage resulting in sleep interruption, called neurological arousals. These may or may not cause complete awakening, but invariably result in sleep deprivation.
OSA can strike anyone, regardless of age or gender, and is a common side effect of obesity. The increased throat tissue in these individuals raises the likelihood of more severe blockage upon muscle relaxation.
Contrary to adults, OSA in children is most commonly found in those with slight builds, and is usually the result of tonsils or adenoids.
Signs that you may have OSA can include restless sleep, irritability, memory loss, depression, anxiety, and sudden mood changes. Detection in children is most commonly based on extremes in energy level, be it excessive tiredness, or extreme hyper behaviour. The most universal and easily detectable sign of OSA in adults is snoring, a direct result of the decreased air circulation through the lungs. It should be noted that snoring is only a possible precursor to OSA, and some snoring may be completely unrelated to OSA.
If you think you may have OSA, you should contact a local sleep clinic and schedule an overnight sleep study to have your condition evaluated. OSA is a serious condition that can be potentially life threatening in the most serious instances, and should not be left undiagnosed.
Your overnight stay will be monitored by a sleep technician, and is conducted with a polysomnogram test, whereby sensors are attached to various parts of the body to aid in detecting any sleep abnormalities. This can be anything from snoring, apneas and arousals, to body position and leg movements.
Based on the results of this test, your doctor or the sleep technician may need to do follow-up research with you to attempt to determine the length of time you’ve been afflicted with OSA, and if any recent changes in lifestyle may have contributed to it. Weight gain and increased intake of alcohol and/or drugs are leading causes of increased levels of OSA symptoms.
Once diagnosed with OSA, there are varied methods of treatment for alleviating or eliminating its occurrence. When the OSA is being caused by lifestyle choices, a simple change in lifestyle may be recommended. Avoidance of alcohol, drugs or some types of medication, all of which excessively relax the muscles during sleep, leading to airway collapse, are vital. Weight loss in heavy set individuals, and cessation of smoking in smokers are also possible cures. Specialized pillows or other devices can also be used in an attempt to keep the patient from sleeping on their back.
If these conservative methods are not giving the desired results, or if it is suspected that they will not be adequate, a physical intervention will likely be necessary.
The first and most widely prescribed of these is continuous positive airway pressure (CPAP). A breathing machine delivers a steady supply of air through a mask worn over the nose and mouth. The air pressure from this technique forces the airways to remain open, easing the natural breathing process. The amount of air pressure varies by patient, and will be judged by your doctor following your overnight study.
In lieu of this treatment, oral appliances may be encouraged. These are cheaper forms of treatment, typically consisting of devices to hold the jaw or tongue in a set position, preventing its slide into the back of the throat during muscle relaxation.
The definitive treatment for OSA is to undergo surgery, a step that may fully eliminate the ailment in patients. There are numerous forms of surgery based on the causes at the root of the OSA, and some of these surgical options are detailed below.
Nasal surgery is effective for those suffering OSA through nasal obstruction or congestion, which can be caused by a deviated septum or allergies among other causes. This is more often for patients with smaller builds, who are in the relative minority of OSA patients.
Having parts of the soft palate reduced or removed through laser surgery or radiofrequency waves.
Increasing the size of the airway passage through tonsillectomy or adenoidectomy. This is the common procedure for children suffering with OSA.
Surgical repositioning of the lower jaw, setting it in a more forward position, forcing the tongue away from the back of the throat where it blocks the airflow during sleep. In more serious cases, a procedure similar to this, involving movement of both the upper and lower jaw may be attempted.
If you suspect you or someone you know is suffering with Obstructive Sleep Apnea OSA, it is recommended not to downplay the disorder, but to have it looked at and diagnosed by a professional. Poor sleep habits can have detrimental effects on all aspects of your life, and could be corrected with minimal steps or procedures.