What is sleep apnea?
Sleep apnea is a common, potentially serious sleep disorder in which your breathing slows or stops during sleep. As your brain recognizes a lack of oxygen, it stimulates respiration, causing you to wake slightly. There are three main types of sleep apnea:
- Obstructive sleep apnea: The most common form of the disorder, obstructive sleep apnea (OSA) occurs when your airway collapses or relaxes, making it difficult for air to pass through. OSA can cause you to snore or stop breathing for short periods of time. Being overweight increases the risk of obstructive sleep apnea. Having obstructive structures in your breathing channel such as deviated nasal septum (middle wall of the nose), swollen nasal membranes (aka turbinates) and large tonsils and adenoids all can contribute to narrowing of nasal and throat airway, therefore resulting in snoring as well as sleep apnea.
- Central sleep apnea: This less frequent type of sleep apnea occurs when your brain fails to send signals to the muscles that help you breathe. Snoring is not typically a side effect of central sleep apnea and nasal or throat obstruction are not the usual causes of central apnea.
- Complex sleep apnea syndrome: This form of the condition occurs when someone has both obstructive and central sleep apnea.
The correct diagnosis of sleep apnea requires a full night sleep study (aka polysomnography) under the supervision of a Board Certified Sleep Medicine Doctor who specializes in performing and interpreting the information obtained through a full night of sleep either at a sleep laboratory or at home. During such sleep study many parameters including blood oxygen levels, heart rate, number of times per hour of cessation of breathing or shallow breathing, number of awakenings during the night of sleep and other indices are measured and analysed to arrive at an accurate diagnosis of presence of absence as well as severity of sleep apnea.
What are the symptoms of sleep apnea?
Sleep apnea is a very common condition which has traditionally been under diagnosed and ignored by the medical community and family members alike. More recent convincing evidence over several decades of observation and many studies have proven detrimental consequences of sleep apnea including not only serious heart and lung disease and arrhythmias but also fatal motor vehicle accidents, workplace accidents and other injuries caused by sleepiness of the affected individual. Although chronic loud snoring is a telltale sign of sleep apnea in general, not everyone who has the condition snores all the time. Other signs and symptoms include:
- Extreme daytime fatigue and frequent dozing off behind the wheel and at work and home as well as being more prone to accidents in general but motor vehicle accidents in particular
- Abrupt awakenings as a result of cessation of breathing often accompanied by snoring, shortness of breath and gasping for air
- Mood disturbance, feeling cranky and reduced productivity as well as serious marital discord over the annoying noise of snoring
- Loss of memory or inability to focus on important tasks at school, workplace or at home
- Waking up with a sore and dry mouth and throat
Are there health risks to having sleep apnea?
Yes. If you have sleep apnea, you may have a higher risk of developing:
- Type 2 diabetes: Sleep apnea has been linked to and is associated with insulin resistance and therefore can exacerbate underlying diabetes.
- High blood pressure: Since sleep apnea directly affects the amount of oxygen you take in, your cardiovascular system, dependent on adequate supply of oxygen, needs to work harder than normal to circulate blood to different organs of the body. One of the consequences of sleep apnea is high blood pressure, one of the main causes of cardiovascular disease. All you need to do to test this is to hold your breath, while awake, for a minute or longer to sense the consequence of not breathing!
- Heart attack: Because your cardiovascular system works harder with sleep apnea on a chronic basis night after night, your risk of suffering from a heart attack also increases.
- Fatty liver: Tests show that people with chronic sleep apnea are more likely to have nonalcoholic fatty liver disease, a condition that can cause liver scarring and poor liver function.
- There has been growing evidence and interest amongst urologists linking frequent nighttime urination and urinary problems with sleep apnea and sleep disordered breathing. This curious link is under investigation at many centers of excellence.
What treatments are available?
If you are diagnosed with sleep apnea, your treatment options depend on your specific diagnosis and any identifiable areas of airway obstruction in the nose, throat and voice box. Weight loss to bring the Body Mass Index (BMI) to less than 25, significant change of lifestyle, avoidance of heavy use of alcohol and smoking as well as sleep medications and sedatives are at the center of any treatment for sleep apnea and snoring. Obstructive sleep apnea is most often treated with Continuous Positive Airway Pressure (CPAP). This therapy involves a device, which acts as an air pump and opens your airway by applying adequate amount of positive pressure, which is delivered through a nasal mask during sleep. Essentially when you stop breathing, the pum senses the cessation of airflow and kicks in by pumping equivalent of a breath with accurately measured pressure into the patient’s nasal or throat airway. Although CPAP is the primary treatment modality for moderate to severe sleep apnea, it is not a panacea and is not tolerated well by all individuals. Rate of compliance with use of CPAP drops dramatically when the patient is awakened by the device and its malfunction in delivering adequate breath into the airway and by claustrophobic individuals. Patients with deviated nasal septum and nasal obstruction generally do not tolerate CPAP well and may be helped by corrective nasal surgery to facilitate the use of the much needed CPAP apparatus. Oral appliances are another option for patients with obstructive sleep apnea. These devices are designed to move your jaw forward to keep your throat airway open. The success rate varies a great deal in curing sleep apnea and also there are problems with use of the oral prostheses such as TMJ pain caused by forced abnormal position of the jaw. For patients who have trouble sleeping with a mask or an oromandibular advancement prosthesis, there are several other treatment options the appropriateness of each depends on careful clinical evaluation, determination of area(s) of airway obstruction and review of the sleep study results. Fiberoptic nasal and laryngeal examination, a simple and noninvasive examination tool easily performed at Dr. Babajanian’s office is an important and simple method for such evaluation.
When surgery is deemed necessary due to anatomic reasons or failure of conservative therapy such as CPAP many options are available including:
- Pillar® Procedure: This quick, minimally invasive procedure involves the placement of tiny woven implants into your soft palate in order to tighten flaccid tissues of the palate. Over time, these implants add structural support to help reduce the risk of tissue collapse and airway obstruction. This procedure may be performed at the office under local anesthesia or in combination with other surgical procedures at the operating room under sedation or general anesthesia.
- Nasal septal surgery as well as nasal turbinate volumetric reduction to help optimize the nasal breathing. Frequently snoring can be alleviated or improved just by nasal surgery.
- Tonsillectomy and/or adenoidectomy in children and adults who have demonstrable enlarged tonsils and adenoids to the point that interferes with breathing by causing airway obstruction.
- Uvulopalatopharyngoplasty (UPPP) which involves removal of tonsils, trimming of uvula and edge of the soft palate in the back of the throat and rearrangement of soft tissues of the throat to open the air passage to the extent possible.
- Advancement of lower jaw or upper jaw to definitively improve the air passage in the back of the nose and throat. This type of surgery is also known as orthognathic surgery and is often performed by expert maxillofacial surgeons.
- Base of tongue procedures aimed at shrinking enlarged tissues in that anatomic region if that is the area of airway obstruction. Robotic surgery has become more popular in this area of surgical options but more experience and expertise are needed to test its utility.