SLEEP APNEA
Overview
Sleep apnea is a potentially serious sleep disorder in which breathing is repeatedly interrupted during sleep. If you snore loudly and feel tired even after a full night's sleep, you might have sleep apnea.
The main types of sleep apnea are:
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Obstructive sleep apnea (OSA), which is the more common form that occurs when throat muscles relax and block the flow of air into the lungs
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Central sleep apnea (CSA), which occurs when the brain doesn't send proper signals to the muscles that control breathing
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Treatment-emergent central sleep apnea, also known as complex sleep apnea, which happens when someone has OSA — diagnosed with a sleep study — that converts to CSA when receiving therapy for OSA
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Symptoms
The symptoms of obstructive and central sleep apneas overlap, sometimes making it difficult to determine which type you have. The most common symptoms of obstructive and central sleep apneas include:
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Loud snoring (not everyone who snores has sleep apnea and not everyone with sleep apnea snores)
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Episodes in which you stop breathing during sleep — which would be reported by another person.
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Gasping for air during sleep.
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Awakening with a dry mouth.
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Morning headache.
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Difficulty staying asleep, known as insomnia.
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Excessive daytime sleepiness, known as hypersomnia.
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Difficulty paying attention while awake.
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Irritability.
Causes
Obstructive sleep apnea
Obstructive sleep apnea
This type of sleep apnea happens when the muscles in the back of the throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate called the uvula, the tonsils, the side walls of the throat and the tongue.
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When the muscles relax, your airway narrows or closes as you breathe in. You can't get enough air, which can lower the oxygen level in your blood. Your brain senses that you can't breathe, and briefly wakes you so that you can reopen your airway. This awakening is usually so brief that you don't remember it.
You might snort, choke or gasp. This pattern can repeat itself 5 to 30 times or more each hour, all night. This makes it hard to reach the deep, restful phases of sleep.
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Central sleep apnea
This less common form of sleep apnea occurs when your brain fails to send signals to your breathing muscles. This means that you make no effort to breathe for a short period. You might awaken with shortness of breath or have a difficult time getting to sleep or staying asleep.
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Risk factors
Sleep apnea can affect anyone, even children. But certain factors increase your risk.
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Obstructive sleep apnea
Factors that increase the risk of this form of sleep apnea include:
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Excess weight. Obesity greatly increases the risk of OSA. Fat deposits around your upper airway can obstruct your breathing.
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Neck circumference. People with thicker necks might have narrower airways.
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A narrowed airway. You might have inherited a narrow throat. Tonsils or adenoids also can enlarge and block the airway, particularly in children.
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Being male. Men are 2 to 3 times more likely to have sleep apnea than are women. However, women increase their risk if they're overweight or if they've gone through menopause.
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Being older. Sleep apnea occurs significantly more often in older adults.
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Family history. Having family members with sleep apnea might increase your risk.
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Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat, which can worsen obstructive sleep apnea.
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Smoking. Smokers are three times more likely to have obstructive sleep apnea than are people who've never smoked. Smoking can increase the amount of inflammation and fluid retention in the upper airway.
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Nasal congestion. If you have trouble breathing through your nose — whether from an anatomical problem or allergies — you're more likely to develop obstructive sleep apnea.
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Medical conditions. Congestive heart failure, high blood pressure and type 2 diabetes are some of the conditions that may increase the risk of obstructive sleep apnea. Polycystic ovary syndrome, hormonal disorders, prior stroke and chronic lung diseases such as asthma also can increase risk.
Central sleep apnea
Risk factors for this form of sleep apnea include:
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Being older. Middle-aged and older people have a higher risk of central sleep apnea.
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Being male. Central sleep apnea is more common in men than it is in women.
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Heart disorders. Having congestive heart failure increases the risk.
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Using narcotic pain medicines. Opioid medicines, especially long-acting ones such as methadone, increase the risk of central sleep apnea.
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Stroke. Having had a stroke increases the risk of central sleep apnea.
Complications
Sleep apnea is a serious medical condition. Complications of OSA can include:
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Daytime fatigue. The repeated awakenings associated with sleep apnea make typical, restorative sleep impossible, in turn making severe daytime drowsiness, fatigue and irritability likely.
You might have trouble 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 might also feel quick-tempered, moody or depressed. Children and adolescents with sleep apnea might perform poorly in school or have behavior problems. -
High blood pressure or heart problems. Sudden drops in blood oxygen levels that occur during OSA increase blood pressure and strain the cardiovascular system. Having OSA increases your risk of high blood pressure, also known as hypertension.
OSA might also increase your risk of recurrent heart attack, stroke and irregular heartbeats, such as atrial fibrillation. If you have heart disease, multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.
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Type 2 diabetes. Having sleep apnea increases your risk of developing insulin resistance and type 2 diabetes.
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Metabolic syndrome. This disorder, which includes high blood pressure, abnormal cholesterol levels, high blood sugar and an increased waist circumference, is linked to a higher risk of heart disease.
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Complications with medicines and surgery. Obstructive sleep apnea is also a concern with certain medicines and general anesthesia. People with sleep apnea might be more likely to have complications after major surgery because they're prone to breathing problems, especially when sedated and lying on their backs.
Before you have surgery, tell your doctor about your sleep apnea and how it's being treated.
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Liver problems. People with sleep apnea are more likely to have irregular results on liver function tests, and their livers are more likely to show signs of scarring, known as nonalcoholic fatty liver disease.
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Sleep-deprived partners. Loud snoring can keep anyone who sleeps nearby from getting good rest. It's common for a partner to have to go to another room, or even to another floor of the house, to be able to sleep.
Complications of CSA can include:
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Fatigue. The repeated awakening associated with sleep apnea makes typical, restorative sleep impossible. People with central sleep apnea often have severe fatigue, daytime drowsiness and irritability.
You might have difficulty concentrating and find yourself falling asleep at work, while watching television or even while driving.
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Cardiovascular problems. Sudden drops in blood oxygen levels that occur during central sleep apnea can adversely affect heart health.
If there's underlying heart disease, these repeated multiple episodes of low blood oxygen — known as hypoxia or hypoxemia — worsen prognosis and increase the risk of irregular heart rhythms.
Diagnosis
Your health care provider may make an evaluation based on your symptoms and a sleep history, which you can provide with help from someone who shares your bed or your household, if possible.
You're likely to be referred to a sleep disorder center. There, a sleep specialist can help you determine your need for further evaluation.
An evaluation often involves overnight monitoring of your breathing and other body functions during sleep testing at a sleep center. Home sleep testing also might be an option. Tests to detect sleep apnea include:
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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.
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Home sleep tests. Your health care provider might provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually measure your heart rate, blood oxygen level, airflow and breathing patterns. Your provider is more likely to recommend polysomnography in a sleep testing facility, rather than a home sleep test, if central sleep apnea is suspected.
If the results aren't typical, your provider might be able to prescribe a therapy without further testing. Portable monitoring devices sometimes miss sleep apnea. So your health care provider might still recommend polysomnography even if your first results are within the standard range.
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If you have obstructive sleep apnea, your health care provider might refer you to an ear, nose and throat specialist to rule out a blockage in your nose or throat. An evaluation by a heart specialist, known as a cardiologist, or a doctor who specializes in the nervous system, called a neurologist, might be necessary to look for causes of central sleep apnea.
Treatment
Continuous positive airway pressure (CPAP)
For milder cases of sleep apnea, your health care provider may recommend only lifestyle changes, such as losing weight or quitting smoking. You may need to change the position in which you sleep. If you have nasal allergies, your provider may recommend treatment for your allergies.
If these measures don't improve your symptoms or if your apnea is moderate to severe, a number of other treatments are available.
Certain devices can help open a blocked airway. In other cases, surgery might be necessary.
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Therapies for OSA
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Continuous positive airway pressure (CPAP).
If you have moderate to severe obstructive sleep apnea, you might benefit from using a machine that delivers air pressure through a mask while you sleep. With CPAP, 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 the CPAP machine. But with practice, most people learn to adjust the tension of the straps on the mask to obtain a comfortable and secure fit.
You might need to try more than one type of mask to find one that's comfortable. Don't stop using the CPAP machine if you have problems. Check with your health care provider to see what changes can be made to increase your comfort.
Additionally, contact your provider if you're still snoring or begin snoring again despite treatment. If your weight changes, the pressure settings of the CPAP machine might need to be adjusted.
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Other airway pressure devices.
If using a CPAP machine continues to be a problem for you, you might 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 (BPAP) also are available. These provide more pressure when you inhale and less when you exhale.
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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 might 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 might need to try different devices before finding one that works for you.
Once you find the right fit, you'll 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 symptoms.
Surgery for OSA
Surgery may be an option for people with OSA, but usually only after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for a small number of people with certain jaw structure problems, surgery is a good first option.
Surgical options might include:
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Tissue removal. During this procedure (uvulopalatopharyngoplasty), a surgeon removes tissue from the rear of your mouth and top of the throat. Your tonsils and adenoids usually are removed as well.
This type of surgery might 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 the throat with radiofrequency energy (radiofrequency ablation) might be an option for those who can't tolerate CPAP or oral appliances. -
Tissue shrinkage. Another option is to shrink the tissue at the rear of the mouth and the back of the throat using radiofrequency ablation. This procedure might be used for mild to moderate sleep apnea. One study found this to have effects similar to that of tissue removal, but with fewer surgical risks.
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Jaw repositioning. In this procedure, the jaw is moved forward from the remainder of the face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure is known as maxillomandibular advancement.
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Implants. Soft rods, usually made of polyester or plastic, are surgically implanted into the soft palate after numbing with a local anesthetic. More research is needed to determine how well implants work.
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Nerve stimulation.
This requires surgery to insert a stimulator for the nerve that controls tongue movement (hypoglossal nerve). The increased stimulation helps keep the tongue in a position that keeps the airway open. More research is needed.
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Creating a new air passageway, known as 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:
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Surgery to remove enlarged tonsils or adenoids.
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Weight-loss surgery, also known as bariatric surgery.
Therapies for CSA
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Treatment for associated medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions might help. Other therapies that may be used for CSA include supplemental oxygen, CPAP, BPAP, and adaptive servo-ventilation (ASV).
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Medicine changes. You may be prescribed medicine to help manage your breathing, such as acetazolamide. If medicines are worsening your CSA, such as opioids, your health care provider may change your medicines.
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Supplemental oxygen. Using supplemental oxygen while you sleep might help if you have central sleep apnea. Various forms of oxygen are available with devices to deliver oxygen to your lungs.
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Adaptive servo-ventilation (ASV). This more recently approved airflow device learns your typical breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to regulate your breathing pattern and prevent pauses in your breathing.
ASV may be an option for some people with treatment-emergent central sleep apnea. However, it might not be a good choice for people with predominant central sleep apnea and advanced heart failure. And ASV is not recommended for those with severe heart failure.
PAP machines: Tips for avoiding 10 common problems
Positive Airway Pressure (PAP) device is an important treatment for obstructive sleep apnea, but it may be frustrating at first. Learn how to avoid uncomfortable masks and other common PAP device problems.
Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. A CPAP machine uses a hose connected to a mask or nosepiece to deliver constant and steady air pressure to help you breathe while you sleep.
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Common problems with CPAP include a leaky mask, trouble falling asleep, a stuffy nose and a dry mouth.
But if a CPAP mask or machine doesn't work for you, you have other options. And most CPAP masks can be adjusted to help make them more comfortable.
Here are 10 common CPAP problems and what you can do about them:
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1. The wrong size or style CPAP mask
Work closely with your health care provider and the CPAP supplier to make sure you have a CPAP mask that fits properly. People have different face shapes, so the right mask style and size for someone else may not work for you.
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Try a different mask. A range of CPAP masks is available. For example, some feature full face masks that cover your mouth and nose, with straps that stretch across your forehead and cheeks. These may make some people feel claustrophobic, but they work well if you prefer to breathe through your mouth during sleep. They also provide a stable fit if you move around a lot in your sleep.
Other masks feature nasal pillows that fit under your nose and straps that cover less of your face. These can feel less cumbersome.
Nasal pillows may work well if you wear glasses or read with the mask on, because some don't block your eyes as much as full face masks do. However, this mask style may not be an option if you move around a lot in your sleep or sleep on your side.
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Pay attention to size. Most masks come in different sizes. Just because you're a certain size in one mask doesn't mean you'll be the same size in another. CPAP masks are usually adjustable.Ask your doctor or CPAP supplier to show you how to adjust your mask to get the best fit. Manufacturer product instructions also can help show you how to do this. A properly fitting mask shouldn't be uncomfortable or cause pain.
2. Trouble getting used to wearing the CPAP mask
First, try wearing just the CPAP mask for short periods of time while you're awake — for example, while watching TV. Then try wearing the mask and hose with the machine turned on during the day while you're awake.
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Once you get used to how that feels, start using the CPAP machine every time you sleep — including during naps. Only using the CPAP machine every now and then may delay getting used to it. Stick with it for several weeks or more to see if your mask and pressure are right for you.
3. Difficulty tolerating forced air
You may be able to overcome this by using a machine with a "ramp" feature. This setting allows you to start with low air pressure. The machine then automatically and slowly increases the air pressure to your prescribed setting as you fall asleep. Your doctor can adjust its rate.
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If this feature doesn't help, talk with your doctor about changing to a machine that automatically and constantly adjusts the pressure while you're sleeping. An example is a bi-level positive airway pressure (BPAP) machine that delivers more pressure when you breathe in (inhale) and less when you breathe out (exhale).
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4. Dry, stuffy nose
Check to make sure your mask fits well. A leaky mask can dry out your nose. If you have to tighten the straps often to prevent air leakage, the mask does not fit properly.
A CPAP machine that features a heated humidifier, which attaches to the air pressure machine, can help. You can adjust the level of humidification. Using a nasal saline spray at bedtime also can help ease a dry, stuffy nose.
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5. Feeling claustrophobic
Practice using your mask while you're awake. First, just hold it up to your face without any of the other parts. Once you're comfortable with that, try wearing the mask with the straps.
Next, try holding the mask with the attached hose on your face, without using the straps. Turn on the CPAP machine, perhaps with the ramp feature turned on. Next, do this using the straps too. Finally, try sleeping with the mask and machine on.
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Relaxation exercises, such as progressive muscle relaxation, may help reduce anxiety related to CPAP use.
If you're still feeling claustrophobic, talk to your doctor or CPAP supplier. It may help to get a different size mask or try a different style, such as one that uses nasal pillows.
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6. Leaky mask, skin irritation or pressure sores
A leaky or an ill-fitting mask means you're not getting the full air pressure you need, and you may be irritating your skin. The mask can also direct air into your eyes, causing them to become dry or teary.
Try adjusting pads and straps to get a better fit. If the mask fits over your nose, make sure it doesn't sit too high on the bridge of your nose, which can direct air into your eyes.
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You may need to ask your CPAP supplier to help you find a different size mask, particularly if your weight has changed a lot. Or try a different style mask such as one that uses nasal pillows. If you develop skin deterioration or sores, such as on your nose, tell your doctor promptly.
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7. Difficulty falling asleep
Wearing the mask alone for some time during the day may help you get used to how it feels and make it easier to fall asleep at night.
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Machines with the ramp feature that slowly and gradually increase the air pressure to your prescribed pressure setting as you fall asleep may make you more comfortable at bedtime.
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Following good general sleep habits also is helpful. Exercise regularly and avoid caffeine and alcohol before bedtime. Try to relax. For example, take a warm bath before you go to bed. Don't go to bed until you're tired.
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8. Dry mouth
If you breathe through your mouth at night or sleep with your mouth open, some CPAP machines may worsen dry mouth. A chin strap may help keep your mouth closed and reduce the air leak if you wear a nasal mask.
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A machine with a full face mask that covers your mouth and nose also may work well for you. A CPAP-heated humidifier that attaches to the air pressure machine also may help.
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9. Unintentionally removing the CPAP mask during the night
It's not unusual to sometimes wake up to find that you've removed the mask in your sleep. If you move a lot in your sleep, you may find that a full face mask will stay on your face better. You may have removed your mask while sleeping because you were uncomfortable. Consider trying a different type of mask that may fit you better.
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You may be pulling off the mask because your nose is congested. If so, ensuring a good mask fit and adding a CPAP-heated humidifier may help. A chin strap may help keep the mask on your face.
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If this is a consistent problem, consider setting an alarm for a time during the night so you can check whether the mask is still on. You could progressively set the alarm for later in the night if you find that you're keeping the mask on longer.
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10. Machine is noisy
Most new models of CPAP machines are almost silent. But if you find that your machine's noise is bothersome, first check to make sure the machine's air filter is clean and unblocked. Something in its way may worsen noise. Ask your doctor or CPAP supplier how to properly clean your mask and hose.
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If this doesn't help, have your doctor or CPAP supplier check the machine to ensure it's working properly. If the machine is working correctly and the noise still bothers you, try wearing earplugs or using a white noise sound machine to mask the noise. Placing the CPAP machine as far away from the bed as possible also may help make any machine noise less noticeable. Ask your doctor or CPAP supplier if extra tubing is available and right for your machine.
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Time and patience are key to success
Using a CPAP machine can be frustrating as you try to get used to it, but it's important that you stick with it. The treatment is essential to avoiding complications of obstructive sleep apnea, such as heart problems and excessive daytime sleepiness.
Work with your doctor and CPAP supplier to ensure the best mask fit and device for you. Regular visits to your sleep doctor are important and can help troubleshoot any problems and adjust settings, if needed. It can take a while to find the correct settings and get used to the mask.
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With time and patience, CPAP can positively affect your quality of life and health.
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Our Sleep Medicine Treatment may be the right program for you! If you are interested in learning more about how can help you get a good nights sleep, call Optimal Sleep & Weight Loss Clinic today at
(703) 955-5355 to schedule your visit.