Dr. Monty Trimble and Dr. Jonathan Wu treat Obstructive Sleep Apnea (OSA), snoring and nasal airway obstruction.
Obstructive Sleep Apnea (OSA)
Obstructive sleep apnea (OSA) is a medical condition related to a difficulty breathing properly during sleep. OSA is the most common variety of sleep apnea and negatively affects the health of tens of thousands of Americans every year. A person with obstructive sleep apnea is seldom aware of this breathing problem, even amidst waking up. Usually patients do not seek treatment until a sleeping partner or family member makes them aware of their episodic symptoms and uncharacteristic breathing issues during sleep. Overall, according to the National Heart, Lung, and Blood Institute, more than 12 million Americans suffer from sleep apnea.
What is Obstructive Sleep Apnea?
Apnea literally means “without breath.” Obstructive sleep apnea is a condition characterized by recurring pauses in breath during sleep. These continual interruptions in breathing usually last between 10 and 40 seconds and induce an incomplete arousal from the normal sleep/wake cycle. Pauses in breathing can occur hundreds of times per night for people with obstructive sleep apnea, and therefore significantly disturb healthy sleep. This transpires when a complete or even just a limited blockage exists in the upper airway while sleeping. These episodes can inhibit the body’s normal flow of oxygen to vital organs and induce problems with the regular rhythms of the heart. Generally, OSA is a serious medical condition that over time may have multiple negative effects on a person’s body and overall health, well-being, and quality of life.
What Causes Obstructive Sleep Apnea?
The majority of obstructive sleep apnea cases are thought to be caused by a temporary or permanent brain injury, the natural or sometimes premature process of aging, or (most commonly) diminished muscle tone. Muscle tone can decrease due to neurological issues, alcohol or drugs, and other disorders. Also, a long-term snoring theory exists, which attributes nerve lesions, which obstruct the pharynx, to continual snoring during sleep over a long period of time. Inordinate excess soft tissue in the upper airways can also be due to obesity. Other structural features leading to a restricted airway may be the result of craniofacial syndromes, such as down syndrome and cleft palate syndromes. Also, OSA can be seen as a critical post-operative complication, most often related to pharyngeal flap surgery.
Signs and Symptoms of Obstructive Sleep Apnea
Typical signs and symptoms of obstructive sleep apnea include loud snoring (with intervals of silence trailed by loud gasping), inordinate daytime sleepiness, and disturbed sleep. Other symptoms considered a bit less common but possibly indicative of OSA are mood alterations (like irritability), difficulty focusing, headaches in the morning, insomnia, depression and anxiety, diminished sex drive, elevated heart rate and/or blood pressure, non imputable weight gain, major night sweats, unusual absentmindedness, increased nocturia and/or urination, and recurrent gastroesophageal reflux disease. Across the board, however, the tell tale symptom of obstructive sleep apnea in adults is excessive daytime sleepiness.
OSA Adults Vs. Children
Obstructive sleep apnea can manifest itself differently in children than in adults, as well as present different symptoms. The typical adult suffering from OSA also suffers from obesity, with distinct heaviness in the neck and face, although this is not always the case. In fact, a notable amount of adults with OSA have healthy BMIs (body mass indices) and develop decreased muscle tone that induces a partial upper airway collapse and sleep apnea. An adult or adolescent with serious and long-term OSA will usually fall asleep for short periods during normal daytime activities if given the chance to rest or sit down. In young children however, this immoderate sleepiness as a symptom of OSA is rare. Toddlers and young children with OSA often display hyperactive activity instead and not only look extremely thin, but may also have “failure to thrive.” In kids, OSA can often be caused by problems with the tonsils and adenoids. This may potentially be corrected by a tonsillectomy or adenoidectomy. Children who are obese and develop obstructive sleep apnea often present the same or very similar symptoms as adults with OSA.
Risk Factors For Obstructive Sleep Apnea
Risk factors for OSA include, but are not completely limited to:
- Natural or premature aging process (old age)
- Being very overweight or obese (with specific heaviness in the neck, head, and torso)
- Regular consumption of chemical depressants (commonly alcohol and sedative medications)
- Being pregnant
- Family history of OSA (genetic component)
Diagnosing Obstructive Sleep Apnea
Depending on the case, diagnosing obstructive sleep apnea may be accomplished through a combination of either ‘at home’ or ‘in-lab’ testing and patient history.
- Home oximetry: This is a way of monitoring blood oxygenation levels at home during sleep. In patients with a high likelihood of OSA, this method of testing may be sufficient for diagnosis. A home oximetry machine purely measures levels of oxygen in the blood throughout sleep and does not evaluate respiratory event-related arousals or apneic events.
- Polysomnography: This is a full in-lab sleep study that measures apneic events (pauses in breathing), blood oxygenation levels, blood carbon dioxide levels, and arousals from sleep. For this testing, a person sleeps overnight in a lab and afterwards an apnea-hypopnea index (AHI) is calculated to determine the existence and severity of sleep apnea. An AHI of 5-15 is considered mild, 15-30 is moderate, and an AHI of over 30 events an hour distinguishes severe sleep apnea.
Treating Obstructive Sleep Apnea
Several treatments exist for obstructive sleep apnea, starting with lifestyle changes like abstaining from smoking and alcohol use, along with avoiding medications like sedatives and muscle relaxants. In those who are overweight, weight loss is highly suggested.
The main treatments for OSA are a variety of continuous positive airway pressure (CPAP) and mandibular advancement devices. A CPAP machine is used at home while a person sleeps at night. This is a breathing machine that pumps a controlled flow of air through a mask worn over the mouth, nose or both. A supplemental pressure holds the airways open. CPAP is the most common and typically most effective treatment for moderate to severe OSA, but several variant continuous positive airway pressure devices exist, including variable/bilevel positive airway pressure (VPAP or BiPAP), nasal EPAP, and automatic positive airway pressure (APAP).
Other treatments that may not be as effective as CPAP but are sometimes used for patients who cannot take wearing a mask all night include:
- Oral appliances—which are designed to hold the jaw slightly down and forward to improve breathing.
- Neurostimulation—which detects respiration and remits mild electrical shocks to the hypoglossal nerve to enhance muscle tone at the back of the tongue.
- Many patients who will not use CPAP also gain from sleeping at an elevation of the upper body of 30 degrees or more. This helps keep the gravitational collapse of the airway from occurring. Also, some find sleeping on their sides instead of their backs is helpful.
OSA Health Effects And Prognosis
Overtime, OSA can have very negative health impacts on the body, which makes obtaining the correct treatment so important. OSA can cause hormonal changes in the body that, combined with low blood oxygen saturation levels, produce damage to the body. If left untreated, OSA can majorly increase the risk of heart disease, high blood pressures, stroke, weight gain, obesity, depression, and diabetes. The negative effects of OSA on the heart are the worst however, with untreated patients having a 30 percent higher risk of heart attack or death than those without OSA. With proper treatment of OSA and close management, often times these negative health effects can be avoided or majorly minimized.
The sleep/wake cycle in adults is separated into REM (rapid eye movement) sleep, non-REM (NREM) sleep, and consciousness. NREM sleep is additionally split into Stages 1, 2, and 3. For the physically restorative effects of sleep to occur, NREM stage 3 is essential. REM and NREM stage 2 are more accountable for maintenance and mental recovery. Amidst REM sleep, the muscle tone of the throat and neck is almost fully narrowed, which permits the relaxation of the tongue and soft palate/oropharynx. When a person has obstructive sleep apnea, airflow is hindered during this stage of sleep. When blood oxygen levels decrease as a result or the struggle to breathe becomes to great, neurological mechanisms elicit an immediate interruption in sleep, which is known as a neurological arousal. Neurological arousals scarcely prompt a complete awakening, but can have a critical and detrimental effect on the restorative quality of sleep. Sleep interruption during NREM stage 3 and REM can also have a negative effect on healing, immune responses, and growth patterns, particularly in young adults and children.
Two to four percent of all adults are thought to have obstructive sleep apnea, and if analyzed meticulously in a sleep lab through polysomnography (overnight lab sleep study), it is thought that an estimated one in five adult Americans would display, at minimum, mild obstructive sleep apnea. Also, OSA is most frequently diagnosed in middle-aged men.
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