What is Sleep Apnea ?

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly, and you feel tired even after a full night's sleep.

The main types of sleep apnea are:

• Obstructive sleep apnea, the more common form that occurs when throat muscles relax.
• Central sleep apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing.
• Complex sleep apnea syndrome, also known as treatment-emergent central sleep apnea, occurs when someone has both obstructive sleep apnea and central sleep apnea.

If you think you might have any form of sleep apnea, see your doctor. Treatment can ease your symptoms and may help prevent heart problems and other complications.

Symptoms

The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central sleep apneas include:

• Loud snoring, which is usually more prominent in obstructive sleep apnea
• Episodes of breathing cessation during sleep witnessed by another person
• Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty staying asleep (insomnia)
• Excessive daytime sleepiness (hypersomnia)
• Attention problems
• Irritability

When to see a doctor

Consult a medical professional if you experience, or if your partner notices, the following:

• Snoring loud enough to disturb the sleep of others or yourself
• Shortness of breath, gasping for air or choking that awakens you from sleep
• Intermittent pauses in your breathing during sleep
• Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving

Many people don't think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. But be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence.

Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to sleep apnea or to other disorders, such as narcolepsy.

Causes of obstructive sleep apnea 

Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), the tonsils, the side walls of the throat and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in, and you can't get an adequate breath in. This may lower the level of oxygen in your blood.

Your brain senses this inability to breathe and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.

You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.

People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, some people with this type of sleep apnea think they sleep well all night.

Causes of central sleep apnea

Central sleep apnea is a less common form of sleep apnea that occurs when your brain fails to transmit signals to your breathing muscles. This means you make no effort to breathe for a short period of time. You may awaken with shortness of breath or have a difficult time getting to sleep or staying asleep.

Risk factors

Sleep apnea can affect anyone, even children. But certain factors increase your risk of sleep apnea:

Obstructive sleep apnea :

• Excess weight : People who are obese have four times the risk of sleep apnea that people who are a normal weight people do. Fat deposits around your upper airway may obstruct your breathing. But not everyone who has sleep apnea is overweight.
• Neck circumference : People with thicker necks may have narrower airways. For men, the risk increases if neck circumference is 17 inches (43 centimeters) and larger. In women, the risk increases if neck circumference is 15 inches (38 centimeters) or more.
• A narrowed airway : You may have inherited a naturally narrow throat. Or, tonsils or adenoids may become enlarged and block the airway, particularly in children with sleep apnea.
• Being male : Men are twice as likely to have sleep apnea. However, women increase their risk if they're overweight, and their risk also appears to rise after menopause.
• Being older : Sleep apnea occurs significantly more often in older adults.
• Family history : If you have family members with sleep apnea, you may be at increased risk.
• Use of alcohol, sedatives or tranquilizers : These substances relax the muscles in your throat.
• Smoking : Smokers are three times more likely to have obstructive sleep apnea than are people who've never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after you quit smoking.
• Nasal congestion : If you have difficulty breathing through your nose — whether it's from an anatomical problem or allergies — you're more likely to develop obstructive sleep apnea.

Central sleep apnea

• Being older : Middle-aged and older people have a higher risk of central sleep apnea.
• Heart disorders : People with congestive heart failure are more at risk of central sleep apnea.
• Using narcotic pain medications : Opioid medications, especially long-acting ones such as methadone, increase the risk of central sleep apnea.
• Stroke : People who've had a stroke are more at risk of central sleep apnea or treatment-emergent central sleep apnea.

        

What are the Complications?

Sleep apnea is considered a serious medical condition. Complications may include: 

Daytime fatigue : The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. 

• You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. People with sleep apnea have an increased risk of motor vehicle and workplace accidents.
  You may also feel quick tempered, moody or depressed. Children and adolescents with sleep apnea may do poorly in school or have behavior problems. 

• High blood pressure or heart problems : Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive sleep apnea, your risk of high blood pressure (hypertension) is greater than if you don't.
  Obstructive sleep apnea may increase the risk of recurrent heart attack, and abnormal heartbeats, such as atrial fibrillation. Obstructive sleep apnea also increases the risk of stroke. If there's underlying heart disease, these multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.

                     

• Type 2 diabetes : People with sleep apnea are more likely to develop insulin resistance and type 2 diabetes compared with people without the sleep disorder.

              

• Metabolic syndrome : This disorder is a collection of other risk factors linked to a higher risk of heart disease. The conditions that make up metabolic syndrome include high blood pressure, abnormal cholesterol, high blood sugar and an increased waist circumference.

• Complications with medications and surgery : Obstructive sleep apnea is also a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea and how it's treated.

• Liver problems. People with sleep apnea are more likely to have abnormal results on liver function tests, and their livers are more likely to show signs of scarring. This is a condition known as nonalcoholic fatty liver disease.

• Sleep-deprived partners : Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore may be sleep-deprived as well.

Preparing for your appointment

If you or your partner suspects that you have sleep apnea, you'll probably first see your primary care doctor. However, in some cases when you call to set up an appointment, you may be referred immediately to a sleep specialist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well-prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions : At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as modify your diet or keep a sleep diary.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplementsthat you're taking.
• Ask a family member or friend along, if possible. Someone who accompanies you may remember information that you missed or forgot. And because your bed partner may be more aware of your symptoms than you are, it may help to have him or her along.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your visit. For sleep apnea, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• Is my condition likely temporary or long lasting?
• What treatments are available?
• Which treatment do you think would be best for me?
• I have other health conditions. How can I best manage these conditions together?
• Should I see a specialist?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask additional questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Your doctor may ask:

• When did you begin experiencing symptoms?
• Have your symptoms been continuous, or do they come and go?
• How severe are your symptoms?
• How does your partner describe your symptoms?
• Do you know if you stop breathing during sleep? If so, how many times a night?
• Is there anything that has helped your symptoms?
• Does anything make your symptoms worse, such as sleep position or alcohol consumption?

What you can do in the meantime

• Try to sleep on your side : Most forms of sleep apnea are milder when you sleep on your side.
• Avoid alcohol close to bedtime : Alcohol worsens obstructive and complex sleep apnea. Avoid alcohol for four to six hours before bed.
• Avoid sedative medications : Drugs that relax you or make you sleepy can also worsen sleep apnea.
• If you're drowsy, avoid driving : If you have sleep apnea you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving.

Tests and diagnosis

Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help you decide on your need for further evaluation.

Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Home sleep testing may also be an option. Tests to detect sleep apnea may include:

• Nocturnal polysomnography : During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.

• Home sleep tests : In some cases, your doctor may provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually involve measuring your heart rate, blood oxygen level, airflow and breathing patterns. If you have sleep apnea, the test results will show drops in your oxygen level during apneas and subsequent rises with awakenings.
  If the results are abnormal, your doctor may be able to prescribe a therapy without further testing. Portable monitoring devices don't detect all cases of sleep apnea, so your doctor may still recommend polysomnography even if your initial results are normal.

If you have obstructive sleep apnea, your doctor may refer you to an ear, nose and throat doctor to rule out any blockage in your nose or throat. An evaluation by a heart doctor (cardiologist) or a doctor who specializes in the nervous system (neurologist) may be necessary to look for causes of central sleep apnea.

Treatments and drugs

For milder cases of sleep apnea, your doctor may recommend only lifestyle changes, such as losing weight or quitting smoking. And if you have nasal allergies, your doctor will recommend treatment for your allergies. If these measures don't improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available.

Certain devices can help open up a blocked airway. In other cases, surgery may be necessary. Treatments for obstructive sleep apnea may include:

Therapies

• Continuous positive airway pressure (CPAP) : If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and snoring.
  Although CPAP is the most common and reliable method of treating sleep apnea, some people find it cumbersome or uncomfortable. Some people give up on CPAP, but with some practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit.
  You may need to try more than one type of mask to find one that's comfortable. Some people benefit from also using a humidifier along with their CPAP systems. Don't just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable.
  Additionally, contact your doctor if you are still snoring despite treatment or begin snoring again. If your weight changes, the pressure settings of the CPAP machine may need to be adjusted.

• Other airway pressure devices : If CPAP continues to be a problem for you, you may be able to use a different type of airway pressure device that automatically adjusts the pressure while you're sleeping (Auto-CPAP). Units that supply bilevel positive airway pressure (BiPAP) are also available. These provide more pressure when you inhale and less when you exhale.

• Expiratory positive airway pressure (EPAP) : These small, single-use devices are placed over each nostril before you go to sleep. The device is a valve that allows air to move freely in, but when you exhale, air must go through small holes in the valve. This increases pressure in the airway and keeps it open.
  The device may help reduce snoring and daytime sleepiness in people with mild obstructive sleep apnea. And it may be an option for some who can't tolerate CPAP.

• Oral appliances : Another option is wearing an oral appliance designed to keep your throat open. CPAP is more reliably effective than oral appliances, but oral appliances may be easier to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea.
  A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you'll still need to follow up with your dentist repeatedly during the first year and then regularly after that to ensure that the fit is still good and to reassess your signs and symptoms.

Surgery

Surgery is usually only an option after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for those few people with certain jaw structure problems, it's a good first option.

The goal of surgery for sleep apnea is to enlarge the airway through your nose or throat that may be vibrating and causing you to snore or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include:

• Tissue removal : During this procedure, which is called uvulopalatopharyngoplasty, your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. It's less effective than CPAP, and isn't considered a reliable treatment for obstructive sleep apnea.
  Removing tissues in the back of your throat with radiofrequency energy (radiofrequency ablation) may be an option for people who can't tolerate CPAP or oral appliances.

• Jaw repositioning : In this procedure, your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure is known as maxillomandibular advancement.

• Implants : Plastic rods are surgically implanted into the soft palate after you've received local anesthetic.

• Creating a new air passageway (tracheostomy) : You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe.
  You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.

Other types of surgery may help reduce snoring and contribute to the treatment of sleep apnea by clearing or enlarging air passages:

• Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
• Surgery to remove enlarged tonsils or adenoids
• Weight-loss surgery

Treatments for central and complex sleep apnea may include:

Therapies

• Treatment for associated medical problems : Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions may help. For example, optimizing therapy for heart failure may eliminate central sleep apnea.

• Supplemental oxygen : Using supplemental oxygen while you sleep may help if you have central sleep apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs.

• Adaptive servo-ventilation (ASV) : This more recently approved airflow device learns your normal breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to normalize your breathing pattern and prevent pauses in your breathing. ASV appears to be more successful than other forms of positive airway pressure at treating complex sleep apnea in some people.

• Continuous positive airway pressure (CPAP) : This method, also used in obstructive sleep apnea, involves wearing a pressurized mask over your nose while you sleep. CPAP may eliminate snoring and prevent sleep apnea. As with obstructive sleep apnea, it's important that you use the device as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made.

• Bilevel positive airway pressure (BiPAP) : Unlike CPAP, which supplies steady, constant pressure to your upper airway as you breathe in and out, BiPAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale.
  The goal of this treatment is to assist the weak breathing pattern of central sleep apnea. Some BiPAP devices can be set to automatically deliver a breath if the device detects you haven't taken one after so many seconds.

        

Along with these treatments, you may read, hear or see TV ads about different treatments for sleep apnea. Talk with your doctor about any treatment before you try it to find out how useful it might be.

Lifestyle and home remedies

In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea and possibly central sleep apnea. Try these tips:

   

• Lose excess weight : Even a slight loss in excess weight may help relieve constriction of your throat. Sleep apnea may go into complete remission in some cases if you return to a healthy weight. But sleep apnea will likely come back if you regain the weight.

• Exercise : Regular exercise can help ease the symptoms of obstructive sleep apnea even without weight loss. A good goal is to try to get 30 minutes of moderate activity, such as a brisk walk, most days of the week.

• Avoid alcohol and certain medications such as tranquilizers and sleeping pills : These relax the muscles in the back of your throat, interfering with breathing.

• Sleep on your side or abdomen rather than on your back : Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.

• Keep your nasal passages open at night : Use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using any nasal decongestants or antihistamines because these medications are generally recommended only for short-term use.

• Stop smoking, if you're a smoker : Smoking worsens obstructive sleep apnea.

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