Definitive Guide to Obstructive Sleep Apnea

Obstructive Sleep Apnea

The Definitive Guide to

Obstructive Sleep Apnea

Obstructive Sleep Apnea is a condition caused by blockage of the upper airways during sleep. This blockage happens when the muscles controlling the tongue and the soft palate relax, causing either (1) limited airflow or (2) “apneas,” periods in which breathing actually stops for up to 10 seconds.

Here’s the thing, though: sleep apnea is scary.

Left untreated, OSA can have very serious consequences, including heart disease, stroke, and elevated blood pressure—not to mention all the serious consequences that might result indirectly: car accidents, depression, and diabetes.

Like any health condition, t hose who have it should be informed about both the disease in general and what they can do about it. That’s what this guide is for.

First, though, let’s look at some quick facts and figures.

Quick Facts about OSA

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  • OSA is relatively common. In the United States, roughly 42 people suffer from the condition—or about 13% of the total population.
  • Roughly 1 out of every 5 American adults experiences the symptoms of sleep apnea.
  • About 6% of adults in the U.S. experience severe OSA.
  • OSA is much more common in men. About 25% of middle-aged men are diagnosed with OSA, while only 9% of women suffer from it.
  • Of all the cases of OSA reported in the United States Annually, three fourths go completely undiagnosed.
  • OSA occurs at very similar rates to other breathing- and weight-related diseases, like asthma (20 million reported cases) and diabetes (24 million reported cases).

What actually happens during OSA?

Obstructive Sleep Apnea

Source: NYC Comprehensive Dentistry

It’s usually easiest to think of OSA in the context of (1) muscles and (2) sleep cycles.

The first thing we need to understand are sleep cycles. For adults, there are two basic kinds of sleep, and you’ve probably heard of them: REM (Rapid Eye Movement) sleep and non-REM (or NREM) sleep.

REM sleep is usually when the body relaxes most, and that includes the muscles of the neck, jaw, tongue and throat.

When this happens to an OSA sufferer, when the tongue and soft palate relax, they can fall into the back of the throat and restrict the airway.

Sometimes, this results in relatively harmless light snoring. Other times, though, it can block the airway completely and cause (1) a choking sensation and (2) a sense of panic.

Here's a good, detailed explanation by MedCram:

Why is it So Dangerous?

Aside from the obvious health risks, OSA is dangerous primarily because people who suffer from it sometimes don’t even know they have it.

Most of the time, cases of OSA are diagnosed because people close to the patient report snoring, the most common and obvious symptom. However, those who sleep alone may not have anyone to tell them they snore—which may seem funny but is actually really dangerous.

Those folks may also just kind of… get used to the effects of OSA—like daytime fatigue and lower sex drive—without understanding why it’s occurring (or even suspecting something is wrong). In some cases, OSA sufferers have gone decades without knowing they were experiencing sleep apnea.

What are the long-term health effects and associated risks?

Risks of sleep apnea

Source: SleepEducation.com

There are quite a few long-term health effects and risks associated with sleep apnea.

Perhaps the most dangerous of the effects of OSA is the accumulated effect of stress over several years. Specifically, in many OSA sufferers, the condition can trigger a “fight or flight” response—scaring them badly and filling their body with adrenaline. This obviously causes stress—especially over time—and, when combined with the cumulative effect of low blood oxygen levels, it can be seriously dangerous.

It can lead to strokes, hypertension, heart disease and clinical depression.

Of those, the most serious—by far—is the risk of heart disease. In fact, OSA patients have been show to be up to 30% more likely to have a heart attacks (N.A. Shah, M.D., N.A. Botros, M.D., H.K. Yaggi, M.D., M., V. Mohsenin, M.D., New Haven, Connecticut. May 20, 2007. "Sleep Apnea Increases Risk of Heart Attack or Death by 30%". American Thoracic Society).

Specifically, the continued stress can lead to increased pulmonary pressure on the right side of the heart, which can cause a condition known as cor pulmonale.

Other studies have shown that people who have Obstructive Sleep Apnea also show other characteristic signs of heart disease, such as abnormal vascular endothelial growth and low levels of nitrate-nitrate.

Finally, OSA patients also often have hypertension. However, in most cases of hypertension that are not associated with OSA, people get a bit of a break at night, and arterial pressure decreases during sleep. Of course, because with OSA, the stress actually happens at night, arterial pressure does not subside; in fact, it often increases.

What are the symptoms of OSA?

Symptoms can vary greatly from person to person, and they can be drastically different for adults and children. Additionally, some of the symptoms commonly appear alongside other health conditions, which makes OSA difficult to diagnose. But in general, here are the most common symptoms:

  • Loud snoring
  • Daytime fatigue that feels
  • Waking up short of breath
  • Insomnia
  • Headaches in the morning
  • Elevated blood pressure
  • Morning chest pains
  • Anxiety, depression or moodiness
  • Morning dry mouth
  • Sore throat in the morning
  • Breathing cessation at night
  • Difficulty focusing during the day

If I have these symptoms, when should I see a doctor?

Sometimes, the symptoms above may not be much to worry about, and they may not indicate you suffer from Obstructed Sleep Apnea—especially if they’re mild and infrequent. Of course, it’s better to be safe than sorry, but here’s what to look for if you’re not sure whether you should go to the doctor or not.

  • Really loud snoring. Loud snoring is usually a sign that the airway is significantly blocked—particularly if it’s louder on your back and gets quieter if you sleep on your side. If your snoring is loud enough to wake other people up, that’s usually a good sign that you need to consult a medical professional.
  • Waking up with trouble breathing. Waking up suddenly in the middle of the night with trouble breathing is one of the tell-tale signs of OSA, and you should see a doctor. This often means that your breathing has stopped completely, which can cause some of the more serious health complications associated with sleep apnea.
  • Your bed partner observes you stop breathing. Sometimes, you might not notice anything at all, but your bed partner tells you that you sometimes stop breathing. Of course, this puts you at risk for other help complications, and it’s generally a good idea to talk to your doctor.
  • Your daytime fatigue is interfering with your daily activities. Severe OSA often precedes excessive tiredness during the day. If you’re so tired that you feel as if you’re going to fall asleep during daily activities, it’s probably a good idea to see a doctor. In addition to simply being a quality of life issue, this can be dangerous, and some OSA sufferers have even been known to fall asleep at the wheel and cause car accidents.
Rob J. Our Expert

According to Resmed.com, people who suffer from moderate-to-sever sleep apnea (including OSA) are up to 15 times more likely to be involved in an automobile accident. Those with mile sleep apnea are still twice as likely to have car accidents. In fact, researchers from Sleep estimated that if we could somehow treat all drivers who suffered from sleep apnea, we could save almost 1,000 lives a year, and we could reduce related collision costs by over $11 billion.

In general, though, if you’ve got any sleep problem that makes you really tired, wakes you up, or significantly impacts your mood, ask your doctor about it.

The Profile of a Typical OSA Sufferer

Who gets Obstructive Sleep Apnea?

Most of the time, typical OSA sufferers are obese adults who carry weight in the face, shoulders and necks, which is also why men experience OSA at a higher rate than women.

Sleep apnea also occurs more frequently in older people or other people who lower muscle tone, and it often first appears in middle age, and post-menopausal women experience sleep apnea at rates very close to that of men; however, conditions that cause muscles to shrink prematurely—like traumatic brain injury or other neuromuscular disorders—also increase the risk of developing OSA.

Lastly, there appears to be a genetic component to Obstructive Sleep Apnea, so if your parents and grandparents were big snorers, you may be more likely to experience OSA at some point in your life.

SO what’s the profile of a typical sleep apnea sufferer? Older, overweight men with a genetic history of snoring. Of course, this is just one demographic, and lots of people experience sleep apnea; this is simply the “typical” patient.

What’s it cost?

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Aside from being dangerous and linked to lots of other health problems, sleep apnea is expensive.

In 1996, Sleep reported that people who suffered from sleep apnea but had not yet been diagnosed were spending $200,000 more per two years than a control group (this number is the combined total medical costs from bout the patent’s out-of-pocket expenses and the insurance company’s expenses).

Another study in Chest found that undiagnosed sleep apnea patients used an estimated 23-50% more medical resources.

Here’s something even more surprising: the total estimated cost of sleepiness in general is about $43 billion, and undiagnosed OSA sufferers may be responsible for about three and a half billion dollars in medical costs in America alone.

Can you treat Obstructive Sleep Apnea?

That’s the good news: yes you can.

And there are quite a few different options.

Lifestyle Choices

Making a few simple changes can (for some) significantly reduce the effects of OSA. If you want to exhaust your self-treatment options before you dive into some of the more serious options below, you can give these a try:

  • Reduce your alcohol intake. Drinking has been linked to OSA and has been shown to make sleep apnea symptoms worse. It can be especially dangerous because alcohol can inhibit the body’s ability to wake up during stress.
  • Avoid medications that make you drowsy before bed. Avoid these medications for the same reasons you avoid alcohol. They (1) tend to relax the muscles and make symptoms worse and (2) often make it more difficult to wake up.
  • Avoid sleeping on your back. Symptoms for OSA tend to me worse—and or some people, much worse—when sleeping on your back. So, the obvious solution is to simply not sleep on your back. Most sleep apnea sufferers tend to do best sleeping on their sides.
  • Get a good pillow. A good pillow can make quite a bit of difference, especially if you have trouble sleeping in other positions. Wedge pillows or high-loft pillows can often help to open airways and promote positive airflow.
  • Lose excess weight. Although some sleep apnea patients have normal BMIs, the majority are overweight, and excess soft tissue in the upper palate has been show to increase the risk of OSA. Losing weight in general can ameliorate lots of the symptoms associated with sleep apnea.

If you are looking for a pillow that fits your sleeping style, here are some options:

Continuous Positive Airway Pressure (CPAP) Therapy

Continuous Positive Airway Pressure (CPAP) therapy is a treatment that keeps the airway open at night using a mask that provides positive pressure.

CPAP is mostly used for people who can’t breathe spontaneously on their own (i.e. folks with more severe sleep apnea). It’s an alternative to other therapies, such as PEEP (Positive End-Expiratory Pressure), which provides positive pressure only at the end of the breath when the patient is exhaling. CPAP, on the other hand, provides continuous positive pressure, making it the most effective treatment for OSA.

The idea is to keep the oxygen levels high to avoid rather serious conditions like stroke. At home, this kind of treatment typically requires a machine and a mask, although other (and more controversial) types of CPAP delivery systems are slowly coming onto the market.

The main benefit of CPAP is that patients don’t need to be on the ventilator as long; however, researchers have observed higher rates of pneumothorax (gas in the chest that causes the lung to disconnect from the chest wall).

Here's another good explanation of how CPAP works. 

Neurostimulation

Not everyone can (or wants to) use a CPAP machine, and lifestyle changes may not completely solve the problem. Neurostimulation is in its pre-market phase and is designed to be a pre-surgery option for patients who aren’t getting results from CPAP therapy.

It works by delivering a small electric current to the hypoglossal nerve, which increases muscle tone in the rear portion of the tongue, discouraging it from collapsing over the airway.

The current is controlled by the patient and can be switched on before bed. The actual power plant is implanted into the airway.

If you're interested in this therapy, check out this news segment: 

Surgery

If nothing else works, surgery is an option for chronic OSA sufferers.

It bears mentioning that surgery is absolutely not a frontline treatment, and that there’s not much research to support the effects of operations on OSA. Additionally, there’s no one surgery that can cure OSA, and the type of surgery used is typically based on the patient’s body, habits, and symptoms.

Here are a few of the options.

  • Nasal surgery. The main options here are turbinectomies (either taking out or removing part of the nasal concha) or septum straightening surgery.
  • Tonsillectomy. Removing the tonsils can sometimes help increase the size of the airway overall.
  • Removing the uvula or soft palate. This, again, can open the airway. Sometimes during this procedure, portions of the soft palate are also removed (or removed instead).
  • Tongue base reduction. This means making the base of the tongue smaller. This can be done one of two ways: radio frequency ablation or laser excision.
  • Genioglossus advancement. This is a procedure that actually moves a small part of the jaw forward (the part that attaches to the base of the tongue) to help prevent the tongue from falling into the airway.
  • Hyoid suspension. This procedure is similar to genioglossus advancement, except it’s the hyoid bone, another bone connected to the tongue, is moved forward instead of the jaw.

What about over-the-counter treatments?

There's no shortage of over-the-counter treatments for sleep apnea. Here are just a few:

  • Breathing strips
  • Internal nasal dialators
  • Lubricants

Generally, these are not a good idea. First, there's no good science to show these things work. Second and most importantly, though, some of these treatments mask the symptoms instead of treating the actual sleep apnea.

And that is dangerous.

Sure, no one wants to snore, but snoring can be a warning sign of other potentially serious complications. So, if you're snoring, you want to know, and you typically want to ask your doctor about it.

References

Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep.

Epstein LJ, Kristo D, Strollo PJ Jr., et al. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine: Clinical guideline for the evaluation, management, and long-term care of obstructive sleep apnea in adults.J Clin Sleep Med.

Kasai T, Bradley TD. Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications.J Am Coll Cardiol.

McArdle N, Singh B, Murphy M, et al. Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration.Thorax.

Patil SP, Schneider H, Schwartz AR, Smith PL. Adult obstructive sleep apnea: pathophysiology and diagnosis.Chest.

Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P; for the Clinical Guidelines Committee of the American College of Physicians. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians.Ann Intern Med.

Randerath WJ, Verbraecken J, Andreas S, Bettega G, Boudewyns A, Hamans E, et al. Non-CPAP therapy guidelines.Eur Respir J.

Tomfohr LM, Ancoli-Israel S, Loredo JS, Dimsdale JE. Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trila. Sleep.

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