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?

Sleep apnea occurs in two main types: obstructive sleep apnea, the more common form that occurs when throat muscles relax, and central sleep apnea, which occurs when your brain doesn’t send proper signals to the muscles that control breathing. Additionally, some people have complex sleep apnea, which is a combination of both.

If you think you might have sleep apnea, see your doctor. Treatment is necessary to avoid heart problems and other complications.

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:

* Excessive daytime sleepiness (hypersomnia)
* Loud snoring, which is usually more prominent in obstructive sleep apnea
* Observed episodes of breathing cessation during sleep
* 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)

When to see a doctor
Consult a medical professional if you experience, or if your partner observes, the following:

* Snoring loud enough to disturb the sleep of others or yourself
* Shortness of breath 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 other disorders, such as narcolepsy.

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. 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.
  • Oximetry. This screening method involves using a small machine that monitors and records the oxygen level in your blood while you’re asleep. A simple sleeve fits painlessly over one of your fingers to collect the information overnight at home. If you have sleep apnea, the results of this test will show drops in your oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may have you undergo polysomnography to confirm the diagnosis. Oximetry doesn’t detect all cases of sleep apnea, so your doctor may still recommend a polysomnogram even if the oximetry results are normal.
  • Portable cardiorespiratory testing. Under certain circumstances, your doctor may provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually involve oximetry, measurement of airflow and measurement of breathing patterns.

If you have obstructive sleep apnea, your doctor may refer you to an ear, nose and throat doctor (otolaryngologist) 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.

Treatment

For milder cases of sleep apnea, your doctor may recommend lifestyle changes such as losing weight or quitting smoking. 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 a preferred method of treating sleep apnea, some people find it cumbersome or uncomfortable. 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 system.

    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 may need to be adjusted.

  • Adjustable 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. For example, units that supply bilevel positive airway pressure (BiPAP) are available. These provide more pressure when you inhale and less when you exhale.
  • Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more effective than oral appliances, but oral appliances may be easier for you 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 at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms.

Surgery
The goal of surgery for sleep apnea is to remove excess tissue from 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:

  • Uvulopalatopharyngoplasty (UPPP). During this procedure, 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. However, it may be less successful in treating sleep apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general anesthetic.
  • Maxillomandibular advancement. In this procedure, the upper and lower part of 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 may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.
  • 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.

Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that doctors sometimes use to treat snoring. Although sometimes these procedures are combined with others, they aren’t usually recommended as sole treatments for obstructive sleep apnea.

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

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.
  • Continuous positive airway pressure. This method, also used in obstructive sleep apnea, involves wearing a pressurized mask over your nose while you sleep. The mask is attached to a small pump that forces air through your airway to keep it from collapsing. 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.
  • 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 may be more successful than CPAP at treating central sleep apnea. However, more study is needed.

Along with these treatments, you may read or hear about different treatments for sleep apnea, such as implants. Although a number of medical devices and procedures have received Food and Drug Administration clearance, there’s limited published research regarding how useful they are, and they aren’t generally recommended as sole therapies.

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 and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in, and breathing momentarily stops. 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 can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths, although this is rare. 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, many people with this type of sleep apnea think they sleep well all night.

Causes of central sleep apnea
Central sleep apnea, which is far less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or have a difficult time getting or staying asleep. Like obstructive sleep apnea, snoring and daytime sleepiness can occur. The most common cause of central sleep apnea is heart disease, and less commonly, stroke. People with central sleep apnea may be more likely to remember awakening than people with obstructive sleep apnea are.

Causes of complex sleep apnea
People with complex sleep apnea have upper airway obstruction just like those with obstructive sleep apnea, but they also have a problem with the rhythm of breathing and occasional lapses of breathing effort.

Most alternative medicines for sleep apnea have not been well studied. Acupuncture has shown some benefit, but also needs more study. Although it may be used in conjunction with standard treatments, acupuncture should not replace them. Talk to your doctor about any alternative treatment approaches you’re considering.