Obstructive sleep apnea
Obstructive Sleep Apnea
Obstructive sleep apnea is a common sleep disorder. It occurs when tissues in the upper airways come too close to each other during sleep, temporarily blocking the inflow of air.
Who Is At Risk
Obstructive sleep apnea can develop in anyone at any age but most often occurs in people who are:
- Age 40 and older
Sleep Apnea Symptoms
Symptoms of sleep apnea include:
- Excessive daytime sleepiness
- Morning headaches
- Impaired emotional or mental functioning
Patients with sleep apnea may find these lifestyle changes helpful:
- Sleep on your side, not your back. Special pillows can help maintain this position.
- If you smoke, quit.
- Do not drink alcohol within 4 hours of bedtime.
- If you are overweight, reduce. Even a small amount of weight loss may improve sleep apnea symptoms.
The treatment of obstructive sleep apnea depends in part on the severity of the condition. Treatment options include:
- Breathing devices. Continuous positive airway pressure (CPAP) devices are the most common treatment for moderate-to-severe obstructive sleep apnea. Although these devices can take some time to get used to, they are a very effective treatment.
- Dental devices. Dental devices, also called oral appliances, are custom-made mouthpieces that help position the lower jaw and tongue during sleep. Dental devices may be helpful for mild cases of obstructive sleep apnea.
- Surgery. Various surgical procedures may be recommended for very severe cases of obstructive sleep apnea but there is limited evidence for their effectiveness.
Obstructive sleep apnea (OSA) is a disorder in which a person temporarily stops breathing during the night, perhaps hundreds of times. These gaps in breathing are called apneas. The word apnea means absence of breath. An obstructive apnea episode is defined as the absence of airflow for at least 10 seconds.
Sleep apnea is usually accompanied by snoring, disturbed sleep, and daytime sleepiness. People might not even know they have the condition.
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) occurs when tissues in the upper throat relax and come together during sleep, temporarily blocking the passage of air. In general, OSA occurs as follows:
- On its way to the lungs, air passes through the nose, mouth, and throat (the upper airway).
- Under normal conditions, the back of the throat is soft and tends to collapse inward as a person breathes.
- Dilator (widening) muscles work against this collapse to keep the airway open. Interference or abnormalities in this process cause air turbulence.
- If the tissues at the back of the throat collapse and become momentarily blocked, apnea occurs. Breath is temporarily stopped. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath.
- In some cases, the interference is incomplete (called obstructive hypopnea) and causes continuous but slow and shallow breathing. In response, the throat vibrates and makes the sound of snoring. Snoring can occur whether a person breathes through the mouth or the nose. (Snoring often occurs without sleep apnea.)
- Apnea decreases the amount of oxygen in the blood, and eventually this lack of oxygen triggers the lungs to suck in air.
- At this point, the patient may make a gasping or snorting sound but does not usually fully wake up.
Obstructive sleep apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep (called apnea-hypopnea index or AHI) in individuals who have excessive daytime sleepiness. Patients with 15 or more episodes of apnea or hypopnea per hour of sleep are considered to have moderate- sleep apnea.
Other Types of Apnea
- Central sleep apnea is much less common. It is caused by a problem in the central nervous system, most often a failure of the brain to signal the airway muscles to breathe. In such cases, oxygen levels drop abruptly and usually the sleeper wakes with a start. Often people with central sleep apnea recall waking up. They generally experience less sleepiness during the day than people with obstructive sleep apnea. Heart disease, and in particular heart failure, is the most common cause of central sleep apnea.
- Mixed apnea is the term used when central and obstructive sleep apneas occur together.
- Upper airway resistance syndrome (UARS) is a condition in which patients snore, wake frequently during the night, and have excessive daytime sleepiness. However, patients do not have the breathing abnormalities that characterize sleep apnea and they do not show a reduction in blood oxygen levels. Unlike apnea, UARS is more likely to occur in women than in men. Treatments are similar to those of sleep apnea.
All of the muscles in the body relax during sleep. In people without obstructive sleep apnea, the throat muscles relax but do not block the airways. In patients with obstructive sleep apnea, the airways do become temporarily blocked or narrowed during sleep, reducing air pressure and preventing air from flowing normally into the lungs.
Certain physical characteristics of the face, skull, and neck can affect the size of the airway. They include:
Large Neck. A large neck (17 inches or greater in men and 16 inches or greater in women) is a risk factor for sleep apnea. While some people’s necks are naturally larger than others, being overweight or obese can contribute to having a large neck.
Facial and Skull Characteristics. Structural abnormalities in the face and skull contribute to many cases of sleep apnea. These include:
- Undersized or receding lower jaw or chin (micrognathia)
- Jutting lower jaw (retrognathia)
- Narrow upper jaw
- Enlarged tongue
- Enlarged tonsils
Soft Palate Characteristics. Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:
- The soft palate is stiffer, larger than normal, or both. An enlarged soft palate may be a significant risk factor for sleep apnea.
- The soft palate and the walls of the throat around it collapse easily.
Muscle Weakness. Abnormalities or weakness in the muscles that surround the airway can also contribute to obstructive sleep apnea.
Causes of Obstructive Sleep Apnea in Children
Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes include:
- Facial or skull abnormalities in infants such as brachycephaly, a birth defect in which the head tends to be shorter or wider than average.
- Overgrown tonsils, adenoids, or both in small children. (Removal of tonsils or adenoids can free the airways and may solve the problem.)
- Neuromuscular disorders that affect the muscles in the airways.
Obstructive sleep apnea is more common in men than in women. Men tend to have larger necks and weigh more than women. However, women tend to gain weight and develop larger necks after menopause, which increases their risk of developing sleep apnea.
Sleep apnea is most common in adults ages 40 - 60 years old. Middle age is also when symptoms are worse. Nevertheless, sleep apnea can affect people of all ages.
Race and Ethnicity
African-Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Mexicans.
People with a family history of obstructive sleep apnea are at increased risk of developing the condition.
Obesity is a particular risk factor for sleep apnea, even in adolescents and children. Obesity can contribute to sleep apnea when fat deposits fill throat tissue.
Smoking and Alcohol Use
Smoking. Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.
Alcohol. Alcohol use may be associated with apnea. Patients diagnosed with sleep apnea are recommended not to drink alcohol before bedtime.
Medical Conditions Related to Sleep Apnea
Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.
Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. Research suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Or, apnea itself may cause pressure changes that trigger GERD. Obesity is common in both conditions and more research is needed to clarify the association.
Polycystic Ovary Syndrome (PCOS). Obstructive sleep apnea and excessive daytime sleepiness appear to be associated with polycystic ovary syndrome (PCOS), a female endocrine disorder. About half of patients with PCOS also have diabetes. Obesity and diabetes are associated with both sleep apnea and PCOS and may be the common factors.
Sleep apnea can lead to a number of complications, ranging from daytime sleepiness to possible increased risk of death. Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.
Daytime sleepiness is the most noticeable, and one of the most serious, complications of sleep apnea. It interferes with mental alertness and quality of life. Daytime sleepiness can also increase the risk for accident-related injuries. Several studies have suggested that people with sleep apnea have two to three times as many car accidents, and five to seven times the risk for multiple accidents. Undertreated sleep apnea is a major risk factor for injury at factory and construction work sites.
Effects of Sleep Apnea on Heart and Circulation
A number of cardiovascular diseases -- including high blood pressure, heart failure, stroke, and heart arrhythmias -- have an association with obstructive sleep apnea. This link may be because both cardiovascular illnesses and sleep apnea are associated with obesity and its consequences. However, large studies have increasingly suggested that OSA itself may lead to or worsen cardiovascular disease.
At this time, however, evidence of a clear causal relationship between obstructive sleep apnea and cardiovascular events is lacking. Likewise, whether treating obstructive sleep apnea improves cardiovascular outcomes has not been demonstrated.
High Blood Pressure. A number of studies have found a strong association between moderate-to-severe sleep apnea and high blood pressure (hypertension) even when obesity is not a factor. A weak, but still higher-than-normal, association with high blood pressure has also been observed in those who snore, wake frequently during the night, or have mild sleep apnea.
Coronary Artery Disease and Heart Attack. Sleep apnea has been associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. Studies have shown that patients with moderate-to-severe obstructive sleep apnea have a higher risk for a heart attack.
Stroke. There is some association between the presence of sleep apnea and risk of death in patients who have previously had a stroke.
Heart Failure. Up to a third of patients with heart failure also have sleep apnea. Both central and obstructive sleep apnea are linked with heart failure. Obstructive sleep apnea can make heart failure worse, and patients with apnea have a higher mortality rate than those who do not.
Atrial Fibrillation. Sleep apnea is more common in people with atrial fibrillation (irregular heartbeat) than in patients with other heart conditions.
Other Adverse Effects on Health
Sleep apnea is associated with a higher incidence of many medical conditions, besides heart and circulation. The links between apneas and these conditions are unclear.
- Diabetes. Severe obstructive sleep apnea is associated with type 2 diabetes.
- Obesity. When it comes to sleep apnea and obesity, it is not always clear which condition is responsible for the other. For example, obesity is often a risk factor and possibly a cause of sleep apnea, but it is also likely that sleep apnea increases the risk for weight gain.
- Pulmonary hypertension (high pressure in the arteries of the lungs).
- Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
- Seizures, epilepsy, and other nerve disorders. There may be an association between seizures and obstructive sleep apnea, especially in older adults. Some studies have shown treatment of obstructive sleep apnea may help in the control of refractory seizures.
- Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder may cure the headache.
- High-risk pregnancies. Sleep apnea may increase the risk of pregnancy complications, including gestational diabetes and high blood pressure.
- Eye disorders, including glaucoma, floppy eyelid syndrome, optic neuropathy conjunctivitis, dry eye, and various other infections and irritations. Some of these latter symptoms may be associated with CPAP treatments for sleep apnea.
Studies report an association between severe apnea and psychological problems. The risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder.
Effects on Bed Partners
Because sleep apnea so often includes noisy snoring, the condition can adversely affect the sleep quality of a patient's bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.
Effects in Infants and Children
Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system.
Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. (Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.)
People with sleep apnea usually do not remember waking during the night.
Symptoms in Adults
Symptoms may include:
- Excessive daytime sleepiness. Generally, patients risk falling asleep during the day while performing routine activities such as reading, watching TV, sitting inactively, lying down, or riding in a car while a passenger or stopped for a few minutes in traffic. Usually, these brief episodes of sleep do not seem to relieve their overall sense of sleepiness.
- Morning headaches.
- Irritability and impaired mental or emotional functioning. These types of symptoms are directly related to interrupted sleep.
- Snoring. Bed partners may report very loud and interrupted snoring. Patients experience snoring associated with choking or gasps. This often occurs in a crescendo pattern with the loudest noises occurring at the very end. These findings are more likely to occur when lying on the back. Patients often suffer from frequent arousals during sleep because of snoring.
Symptoms in Children
Sleep apnea occurs in about 2% of children. They may have symptoms that differ from adults, including:
- Longer total sleep time than normal in some children, especially obese children or those with severe apnea.
- More effort in breathing (flaring nostrils, heaving chests, sweating). The chest may have an inward motion during sleep.
- Behavioral difficulties without any obvious cause, such as hyperactivity and inattention.
- Morning headaches
- Failure to grow and gain weight
The symptoms of obstructive sleep apnea are not very specific. This means that most people who snore at night or who feel tired during the day probably do not have sleep apnea. Other medical reasons for daytime sleepiness should be considered by your doctor before referral to a sleep center for diagnostic sleep tests. They include:
- Having to work excessive hours or varying shifts (nights, weekends)
- Medications (tranquilizers, sleeping pills, antihistamines beta blockers, many others)
- Alcohol abuse
- Medical conditions (such as underactive thyroid, abnormal blood sodium levels, high blood calcium levels)
- Self-imposed short sleep time
- Other sleep disorders, such as narcolepsy, insomnia, or restless legs syndrome
- Chronic fatigue syndrome
- Depression or dysthymia
Symptoms or findings that make the need for evaluation by a sleep specialist include:
- Sleepiness is affecting patient's quality of life
- Sleepiness on-the-job places the patient or others in danger
- Others have observed apnea or breath-holding episodes while asleep
- Other medical illnesses that may be worsened by obstructive sleep apnea are present.
- Children who are snoring a lot and are irritable, not thriving or growing well, or having behavioral issues
If symptoms suggest obstructive sleep apnea or other sleep disorders, further diagnostic testing will be performed. A sleep specialist or sleep disorders center will perform an in-depth medical and sleep history and physical exam. Centers should be accredited by the American Academy of Sleep Medicine.
Medical and Sleep History
To help determine the presence of sleep apnea, the doctor will ask the following questions:
- Is the patient taking any medications?
- How many periods of sleepiness are there each day and when do they occur? (Patients with apnea often do not describe this symptom as feeling "sleepy." They are more apt to describe this feeling as "lack of energy" or "feeling tired all day.")
- How restful is sleep?
- Do headaches occur regularly in the morning?
- Is the patient taking or withdrawing from stimulants, such as coffee or tobacco?
- How much alcohol is consumed per day?
- Does the patient have any problems with mental or emotional functioning?
- Does the patient suffer from heartburn?
- What is the normal sleeping position (back, side, or stomach)?
- If there is a sleeping partner, does he or she complain about the patient's snoring, thrashing, or gasping for breath? (Many times it is useful to interview the bed partner.)
- Does the patient fall asleep almost as soon as "the head hits the pillow"? (May be a sign of sleep deprivation.)
To diagnose sleep apnea, the doctor will check for physical indications of sleep apnea, including:
- Abnormalities in the soft palate or upper airways, including enlarged tonsils
- Upper body obesity
- A wide neck measurement (over 17 inches in men or 16 inches in women)
Ruling out Other Disorders
If sleep apnea is not obvious after a physical examination and history, the doctor will need to rule out any other problems. These include sleep disorders, (such as narcolepsy, insomnia, or restless legs disorder), or any medical or psychologic conditions (chronic fatigue syndrome, depression) that may be causing daytime sleepiness.
Sleep testing is recommended for patients who are considered at high risk for complications of obstructive sleep apnea. These include people who are obese, and those who have heart failure, coronary artery disease, or disturbances in heart rhythm.
Polysomnography is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography involves many measurements and is typically performed at a sleep center.
The patient arrives about 2 hours before bedtime without having made any changes in daily habits. Polysomnography electronically monitors the patient as he or she passes, or fails to pass, through the various sleep stages.
Overnight polysomnography has been the gold standard for diagnosing obstructive sleep apnea in both adults and children. It is very labor-intensive and expensive, however, and also misses snoring-induced arousals. After the diagnosis of sleep apnea is made, the patient must come back to the sleep center for another night in order to have CPAP started (CPAP titration).
Split-night polysomnography is an alternative option to overnight polysomnography. In split-night polysomnography, patients who have been diagnosed with obstructive sleep apnea in the first part of the evening, receive titration for CPAP during the second part of the night.
Home Diagnostic Portable Monitors
Diagnostic testing at home with portable monitors may be an option for patients who appear, based on history and physical exam, to have a high likelihood of moderate-to-severe OSA but who do not have other major medical disorders or other sleep disorders such as narcolepsy.
Portable monitors should only be used if the patient receives a comprehensive sleep evaluation by a board-certified sleep specialist. The monitors use nasal and respiratory sensors to record airflow, respiratory effort, and blood oxygen levels. The patient needs to be educated in how to use them by an experienced sleep technician.
Patients are shown how to use these devices and then sent home. Many of these devices are also capable of titrating CPAP levels (see Treatment section).
Body position greatly affects the number and severity of episodes of obstructive sleep apnea, with at least twice as many apneas occurring in people who lay on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (Indeed, astronauts show a marked reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children.
As a first step in dealing with sleep apnea, the patient should simply try rolling over onto the side. Patients who sleep on their backs and have 50 - 80 apneas per hour can sometimes nearly eliminate them when they shift to one side or the other. (Changing positions is less effective the more overweight a person is, but it still helps.)
Here are some suggestions that might help a person maintain a low-risk sleeping position:
- Sew a small pocket to the back of the pajamas and place a tennis ball or other small ball into it.
- A special pillow that helps to stretch the neck may reduce snoring and improve sleep for people with mild sleep apnea.
- Sleeping in an upright position may improve oxygen levels in overweight people with sleep apnea. Elevating the head of the bed may help.
All patients with obstructive sleep apnea who are overweight should attempt a weight-reducing program. Weight loss certainly reduces snoring and apnea/hypopnea episodes in many people, sometimes stopping it completely. It also improves sleep and significantly reduces daytime sleepiness.
Smoking, Alcohol, and Drugs
- Smokers should quit, since smoking worsens apnea
- Avoid alcohol within 4 hours of sleep
- Avoid sedatives and sleeping medications
Treatment for sleep apnea depends on the severity of the problem. Given the data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a doctor, ideally a sleep disorders specialist.
At this time, the most effective treatments for sleep apnea are devices that deliver slightly pressurized air to keep the throat open during the night. There are a number of such devices available.
Continuous Positive Airflow Pressure (CPAP)
The best treatment for symptomatic obstructive sleep apnea is a system known as continuous positive airflow pressure (CPAP), sometimes referred to as nasal continuous positive airflow pressure (nCPAP). It is safe and effective in sleep apnea patients of all ages, including children.
CPAP may not be recommended for patients who have mild sleep apnea as identified in sleep studies but who do not have daytime sleepiness, as they generally report little or no benefit from this treatment. Those with moderate sleep apnea are more likely to be recommended CPAP. When severe sleep apnea is present, most patients will receive CPAP. Overall, CPAP is considered first-line treatment for mild-to-moderate, or moderate-to-severe obstructive sleep apnea.
CPAP works in the following way:
- The device itself is a machine weighing about 5 pounds that fits on a bedside table.
- A mask containing a tube connects to the device and fits over just the nose.
- The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent the tissues from collapsing during sleep
Effects on Sleep and Wakefulness. CPAP improves both objective and subjective measures of sleep. After using CPAP regularly many patients report the following benefits:
- Restoration of normal sleep patterns.
- Greater alertness and less daytime sleepiness.
- Less anxiety and depression and better mood.
- Improvements in work productivity.
- Better concentration and memory.
- Patients' bed partners also often report improvement in their own sleep when their mates use CPAP.
If patients comply with the CPAP regimen but do not feel less sleepy after a period of time, or their sleep apnea symptoms do not improve, the airflow pressure may not be high enough. Patients may need to be retested. Likewise, if patients have started using an oral appliance or had a surgical procedure, their doctor probably needs to reevaluate them.
Autotitrating Positive Airway Pressure (APAP) Devices
Traditional CPAP devices provide a set pressure based on findings from polysomnography. This pressure does not fluctuate during the night or between nights unless it is reset. The initial settings are determined while at the sleep center, and changes are made only after another visit to the sleep center.
Autotitrating positive airway pressure (APAP) devices automatically customize air pressure for the individual patient. For some patients, APAP devices can be used to begin therapy at home without any supervision.
Patients with chronic lung disease, heart failure, obesity hypoventilation syndrome, who do not snore, or who have central sleep apnea syndrome are not considered candidates for APAP.
APAP devices usually use one of three methods:
- Overall pressure is kept low until a specific problem is detected. At that time the pressure is automatically increased rapidly.
- Pressure is low when there are no problems but is raised gradually when they are detected.
- Pressure is gradually raised and lowered in response to problems or their absence. In addition, the device can change depending on problems within single breaths.
APAP devices are more expensive than CPAP devices. However, APAP devices may improve compliance, particularly in patients who have needed high CPAP use. They may be especially helpful for patients who require varying levels of pressure due to other conditions, such as seasonal allergies. Patients may also be able to avoid overnight stays and extra trips to the hospital.
Side Effects and Getting Used to the Device
CPAP works well for both adults and children, but many patients have problems getting used to the device. Unfortunately, CPAP devices are often cumbersome, which can lead to patients becoming discouraged and stopping treatment. All patients should be warned that the first few nights of CPAP therapy are unnerving. The mask may cause some patients to feel anxious. Starting out with low pressure to get used to the mask may help. Patients may actually sleep less, or have different sleep quality, at the start of treatment.
Nearly all patients complain of at least one side effect. Nearly half of complaints are related to the mask. Many of these problems can be minimized with a well-fitted mask that is comfortable and reduces leakage as much as possible. In recent years many new styles have become available, giving patients more options for finding a comfortable mask. In addition, thorough education and ongoing support are essential for successful treatment with CPAP.
Common complaints include:
- Irritation in the nose and throat. The most common complaints are nasal congestion and sore or dry mouth, which are caused by leakage that dries the airway. (This may be severe in elderly people or patients who have had uvulopalatopharyngoplasty, a surgical treatment for sleep apnea. Such patients are more likely to stop using CPAP.) Chin straps, nasal salt water sprays, or humidifiers may prevent these side effects. Heated humidification devices are also available for CPAP users.
- Excessive application of pressure making exhalation difficult.
- A feeling of claustrophobia is a major factor in noncompliance. This can be improved by a lightweight and transparent mask or with masks known as nasal pillows, which are used only around the nostrils.
- Many patients have irritation and sores over the bridge of the nose. Getting a properly fitted and cushioned mask can help reduce this problem.
- Eye irritation or conjunctivitis.
- Upper respiratory infections. It is very important to keep the unit clean.
- Patients may also feel temporary chest muscle discomfort, which is caused by an increase in lung volume.
- Severe side effects are very rare but may include heart rhythm disorders (arrhythmias), severe nose bleeding, and air pockets in the skull.
- In addition to initial difficulties with its use, the fixed CPAP needs to be periodically readjusted. Patients can be trained to adjust the CPAP at home, thereby avoiding trips to the sleep professional for machine adjustments and making the process more convenient.
Studies have reported that long-term compliance with CPAP systems is low, with about one-third of patients giving up the treatment. Compliance may be improving, however, due to better technologies and better education. Factors that may help include:
- Patient education and support groups
- A dedicated nurse to ensure close follow-up of patients (particularly in the first 2 weeks of therapy)
- Access to doctors to make adjustments as needed
Not surprisingly, patients whose symptoms are noticeably relieved by the procedure early on are more likely to continue the therapy.
Because many patients find CPAP uncomfortable and difficult, they tend not to use it for the duration of the entire night. However, while some patients’ daytime sleepiness may improve after 4 - 6 hours of CPAP use each night, maximum benefits in quality of life require at least 7.5 hours of nightly CPAP use. It appears that longer nightly duration of CPAP use is best for achieving normal daytime functioning.
Other Related Devices
Bilevel Positive Airway Pressure. Bilevel positive airway pressure (BPAP) systems may be particularly helpful for patients with coexisting lung disease and those with excessive levels of carbon dioxide. These devices have a sensing feature that helps determine and vary the appropriate pressure depending on whether a person is breathing in or out. Greater pressure is needed on inhalation and less on exhalation. These machines are more expensive than the CPAP and may not be covered by insurance.
In general, drugs have not been very beneficial except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. The following drugs may be helpful for certain patients:
- Modafinil (Provigil), which is also used to treat narcolepsy, was approved by the FDA as the first drug to treat the sleepiness associated with obstructive sleep apnea. However, modanifil is meant to be used in combination with -- not as a substitute for -- standard apnea treatments such as CPAP. Sleep doctors stress that patients who take modafinil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying obstructive sleep apnea. [Modafinil can cause rare, but serious, side effects such as life-threatening rash. For more information on this drug and its side effects, see In-Depth Report #98: Narcolepsy.]
- Thyroid hormone may help sleep apnea in those with low thyroid levels (hypothyroidism).
- Some small preliminary studies have suggested that intranasal corticosteroids may be helpful for children with obstructive sleep apnea.
Note on Sedatives. Sedatives, narcotics, antidepressants, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers. Apnea patients undergoing surgery should be sure that their surgeons, anesthesiologists, and other doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.
Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. (CPAP should be used for patients with severe sleep apnea whenever possible.)
Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:
- Mandibular advancement device (MAD). This is the most widely used dental device for sleep apnea. It is similar in appearance to a sports mouth guard. MAD forces the lower jaw forward and down slightly, which keeps the airway open.
- Tongue retraining device (TRD). This is a splint that holds the tongue in place to keep the airway as open as possible.
Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.
Benefits of Dental Devices. Dental devices seem to offer the following benefits:
- Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
- Improvement in sleep in many patients.
- Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients.
- Higher compliance rates than with CPAP.
Dental devices have shown better long-term control of sleep apnea when compared to uvulopalatopharyngoplasty (UPPP), the standard surgical treatment. There are also few complications with a dental device.
Disadvantages of Dental Devices. Dental devices are not as effective as CPAP therapy. The cost of these devices tends to be high. Side effects associated with dental devices include:
- Nighttime pain, dry lips, tooth discomfort, and excessive salivation. In general, these side effects are mild, although over the long term they cause nearly half of patients to stop using dental devices. Devices made of softer materials may produce fewer side effects.
- Permanent changes in the position of the teeth or jaw have occurred in some cases of long-term use. Patients should have regular visits with a health professional to check the devices and make adjustments.
- In a small percentage of patients, the treatment may worsen apnea.
An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.
Surgery is sometimes recommended, usually by ear, nose, and throat specialists, for severe obstructive sleep apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.
The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.
The Goal of Surgery. The goal of UPPP is threefold:
- Increase the width of the airway at the throat's opening
- Block some of the muscle action in order to improve the ability of the airway to remain open
- Improve the movement and closure of the soft palate
Success Rates. The American Academy of Sleep Medicine does not endorse UPPP as a sole procedure for treating OSA. The AASM recommends that patients considering this surgery first try CPAP or dental devices.
There is limited evidence as to the effectiveness of UPPP. Studies suggest that success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior and should always be tried first. Many or most patients with moderate or severe sleep apnea will likely still require CPAP treatment after surgery.
Complications. Uvulopalatopharyngoplasty is among the most painful treatments for sleep apnea, and recovery takes several weeks. The procedure also has a number of potentially serious complications including:
- Impaired function in the soft palate and muscles of the throat (called velopharyngeal insufficiency), which can make it difficult to keep liquids out of the airway
- Mucus in the throat
- Changes in voice frequency
- Swallowing problems
- Regurgitation of fluids through the nose or mouth
- Impaired sense of smell
- Failure and recurrence of apnea. In such cases, CPAP is often less effective afterward.
In general, only a small percentage of patients experience serious complications. Many of these complications can be avoided with proper technique and experienced surgeon. A patient's health status, including presence of obesity and other health conditions, may also affect outcomes.
Laser-Assisted Uvulopalatoplasty (LAUP)
A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates in the treatment of obstructive sleep apnea with LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.
More than half of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.
According to recent guidelines from the American Academy of Sleep Medicine (AASM), LAUP is not routinely recommended as treatment for obstructive sleep apnea. According to the AASM, this surgery generally does not help improve symptoms and may actually worsen the condition.
Pillar Palatal Implant
The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. However, the main focus of the procedure is a reduction in snoring. The implant helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate. The procedure can be performed in a doctor’s office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia and has less pain and quicker recovery time. There is still not enough evidence to determine whether it is an effective treatment for obstructive sleep apnea.
Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:
- The surgeon makes an opening through the neck into the windpipe and inserts a tube.
- It is almost 100% successful, but it requires a quarter-size opening in the throat. This produces a number of medical and psychological problems associated with recovery.
Today, this operation is performed rarely, usually only if sleep apnea is life threatening.
Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. Most are invasive and reserved for patients with severe sleep apnea who fail to respond to or comply with CPAP. Overall, there is limited evidence as to their effectiveness in treating OSA. These procedures include:
- Radiofrequency ablation (RFA) for tongue or palate reduction.
- Maxillomandibular advancement (MMA), which moves the upper (maxilla) or lower (mandible) jawbone forward.
- Genioglossus (tongue advancement), in which an opening is cut where the tongue joins the jawbone and the area is pulled forward.
- Genioplasty, which is plastic surgery on the chin.
- Hyoid advancement surgery, in which the movable bone underneath the chin is moved forward, pulling the tongue muscle along with it.
- Surgery for nasal obstructions (such as a deviated septum) that contribute to snoring and other symptoms.
Removing Adenoids and Tonsils in Children
Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea proven by sleep studies. It cures or improves the condition in most patients.
Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:
- Age under 3 years old
- Severe sleep apnea
- Heart complications
- Failure to thrive
- Recent lung infections
- Certain facial structures
- Neuromuscular disease
The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.
Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.
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Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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