Obstructive Sleep Apnea – Research & Treatments
Obstructive sleep apnea (OSA) is the most common form of sleep apnea. It is characterized by frequent pauses 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(OSA)
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 Obstructive Sleep Apnea 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.
Sleep Apnea Oral Appliances
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
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.