What is Obstructive Sleep Apnea (Sleep Apnea)?
Obstructive sleep apnea (OSA) is a condition where a person’s upper airway repeatedly collapses either completely (apnea) or partially (hypopnea) during sleep. This results in lower levels of oxygen in the blood or awakening from sleep. The sleep is frequently interrupted, leading to a lack of restful sleep. Common symptoms include loud, heavy snoring, incidents of stopped breathing during sleep, and feeling excessively tired during the day.
OSA is more than an annoyance; it has significant impacts on heart health, mental well-being, overall quality of life, and safety while driving. This understanding of OSA including its causes, frequency, symptoms, and treatment approaches is important. We’ve also separately discussed other types of sleep and breathing disorders, including central sleep apnea, upper airway resistance, and obesity hypoventilation.
What Causes Obstructive Sleep Apnea (Sleep Apnea)?
The process that causes the throat to narrow or close during sleep is quite complex and involves several factors. This issue typically occurs when factors related to sleep, such as reduced respiratory drive and neuromuscular factors, combine with risk factors linked to a person’s anatomy. These factors contribute significantly to shutting down the upper airway during sleep.
Anatomy-related factors leading to throat narrowing include a large neck, soft tissue, bones, or vessels. All these components can put pressure surrounding the upper airway, causing the throat to collapse and limit the flow of air during sleep.
Also, the tone of the upper airway muscle matters; when this muscle tone decreases, it can cause the airway to collapse completely or partially on a recurring basis. In adults, the most common cause of Obstructive Sleep Apnea (OSA) – a condition that blocks the upper airway during sleep – is obesity, being male, and getting older. However, the severity of OSA can decrease as the person gets older, provided their weight remains stable.
Anatomy-related factors involved in this issue include:
- Micrognathia, retrognathia (small or set back jaws)
- Long face
- Underdeveloped lower jaw
- Enlarged adenoids and tonsils
- Lower position of the hyoid bone (in the neck)
Risk factors not related to anatomy, include:
- Fat distributed centrally in the body
- Obesity
- Getting older
- Being male
- Sleeping on your back
- Pregnancy
Additional factors that can contribute, include:
- Alcohol consumption
- Smoking
- Use of sedatives and sleep-inducing drugs
Medical conditions linked to this issue include:
- Endocrine disorders like diabetes, metabolic syndrome, overgrowth syndrome, and underactive thyroid
- Neurological disorders like stroke, spinal cord injury, and muscle weakness
- Prader Willi syndrome
- Down Syndrome
- Heart failure
- Irregular heartbeat
- Certain respiratory conditions related to obesity
These links between OSA and various medical conditions come mainly from observational studies and not necessarily from randomized clinical trials.
Risk Factors and Frequency for Obstructive Sleep Apnea (Sleep Apnea)
Obstructive sleep apnea is a common health issue, affecting nearly a billion people globally. This disease is particularly prevalent in adults aged 30 to 69, with around 425 million having moderate to severe obstructive sleep apnea. This signifies they experience 15 or more events of disrupted sleep per hour.
In America, the disease is prevalent among 25% to 30% of men and 9% to 17% of women. It’s more common in Hispanic, Black, and Asian communities. As people grow older, particularly from 50 and above, women are just as likely as men to develop the condition. The increasing number of people with obstructive sleep apnea is closely tied to the increasing prevalence of obesity, with rates between 14% and 55%. Notably, risk factors like obesity and the structure of upper airway soft tissue can be inherited.
Signs and Symptoms of Obstructive Sleep Apnea (Sleep Apnea)
Obstructive Sleep Apnea (OSA) is a sleep disorder that can be difficult to identify. Some common signs include feeling unusually sleepy during the day, snoring loudly, gasping or choking while sleeping, or even stopping breathing for a bit during sleep. However, not all people with OSA show these symptoms.
Often, people with this condition only complain of feeling tired in the daytime. This is why it’s important to properly understand and assess their sleepiness or fatigue level. To do this, doctors may use the Epworth Sleepiness Scale (ESS) and the Fatigue Severity Scale (FSS). The ESS measures a person’s daytime sleepiness, with scores above 9 indicating high sleepiness levels that need further analysis. In contrast, the FSS assesses how severe a person’s fatigue is.
These tests can be useful, as people with OSA could be struggling with both sleepiness and fatigue simultaneously. Other potential signs include headaches in the morning, self-reported insomnia, and frequently urinating at night. Interestingly, women with OSA often report trouble falling asleep and staying asleep.
One popular tool for screening OSA is the STOP-BANG questionnaire:
- Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
- Tired: Do you often feel tired, fatigued, or sleepy during the daytime?
- Observed: Has anyone observed you stop breathing during your sleep?
- Blood pressure: Are you having or being treated for high blood pressure?
- BMI: Is your Body Mass Index (BMI) above 35 kg/m2?
- Age: Are you over 50 years old?
- Neck circumference: Is your neck circumference greater than 40 cm?
- Sex: Are you a man?
If you answer ‘YES’ to 3 or more of these questions, there’s a high probability of you having moderate to severe OSA. Answering ‘YES’ to less than 3 items indicates a low risk.
Being obese is common in people with OSA. Other physical characteristics that often accompany this condition are having a large neck circumference, a crowded throat, a large tongue, and an undersized lower jaw among others. However, among all these characteristics, only narrowing of the throat has been found to predict OSA independently once body weight and neck size have been taken into account.
Testing for Obstructive Sleep Apnea (Sleep Apnea)
If you often feel extremely sleepy during the day, suffer from fatigue, or find your sleep unrefreshing to the point of concern, your doctor might evaluate you for a condition known as sleep apnea. However, routine screening for sleep apnea isn’t generally done unless you are symptom-free, but are engaged in occupations like driving or flying, where there could be potential risks involved.
Moreover, even without symptoms, people with specific conditions like persistent atrial fibrillation, a type of irregular heartbeat; resistant hypertension, which is high blood pressure that doesn’t respond to treatments; or those with a prior history of stroke can be screened for sleep apnea due to the high incidence of sleep apnea among these groups.
The preferred way to detect sleep apnea is a test known as polysomnography (PSG). This test, generally conducted in-lab overnight, tracks your brain waves, blood oxygen levels, heart rate, breathing, and body movement while you’re sleeping. Four key systems are assessed during PSG: nasal/oral airflow, nasal air pressure, chest movement, and oxygen levels.
Apart from PSG, at-home sleep tests or portable monitoring have become increasingly popular because of their affordability and convenience. They record airflow, respiratory effort, and blood oxygen levels. But, they don’t capture the total sleep time like PSG does, so they might underestimate the severity of a person’s sleep apnea, especially in mild cases. For this reason, people with negative or unclear test results, or a high initial suspicion of moderate to severe sleep apnea might be advised to undergo an in-lab PSG test. At-home tests are especially suitable for people who are likely to have sleep apnea and don’t have other significant medical conditions.
The extent to which sleep apnea affects a person is generally classified based on events per hour: Mild sleep apnea is defined as 5 to 15 events per hour; moderate is more than 15 to 30 events per hour; and severe is more than 30 events per hour. The severity of mild sleep apnea varies greatly, and it can be associated with daytime sleepiness, broken sleep, and cognitive issues.
Recently, there’s been debate over these traditional methods and definitions of sleep apnea. Some suggest that these methods may not capture the full impact of the condition on individual patients. To increase precision in diagnosis, researchers are exploring other factors such as the degree of oxygen deficiency, changes in heart rate at night, total sleep time with low oxygen levels, sleep disruption, and genetic influences.
Treatment Options for Obstructive Sleep Apnea (Sleep Apnea)
Treating Obstructive Sleep Apnea (OSA), a condition where patients experience interrupted breathing during sleep, requires tailored solutions for each patient. While treatments for moderate to severe OSA have been shown to improve outcomes, the impact of therapy on milder cases of OSA on areas like mental capacity, mood, and heart health, for instance, is less certain.
Firstly, lifestyle changes and treating underlying medical conditions can assist in coping with OSA. For overweight patients, weight loss is often encouraged as it can reduce the severity of OSA, although it is typically not a cure. Patients need to understand the importance of sleep to their health and aim to get at least 7 to 8 hours of sleep per night.
Patients are also advised to avoid alcohol, certain medications like benzodiazepines and opiates, and some antidepressants as they may impact their condition. Addressing any nasal obstruction can also be beneficial. Additionally, optimizing treatment strategies for conditions like asthma or heart disease can be crucial.
Positional therapy, where patients use a device to remain on their side while sleeping, can be a suitable option for some individuals. In terms of medical treatment, Continuous positive airway pressure (CPAP) is the most successful for adults. Even though it’s highly effective, adherence can be a challenge. To that end, recent studies are looking at telemedicine and interactive features to improve the rate of CPAP use.
Customized oral appliances that can help to relieve airway obstruction might be beneficial for patients who struggle with using CPAP or don’t have reliable access to electricity. These devices are usually recommended for patients with mild to moderate OSA and proper dental health.
Surgical treatments, such as uvulopalatopharyngoplasty (UPPP) and maxillomandibular advancement (MMA), can help create more space in the throat. However, these treatments might not be effective long-term for all patients. A newer option is a device that stimulates a muscle in the upper airway during sleep, thereby helping to prevent blockage. The use of this device can also reduce sleepiness symptoms in those suffering from moderate to severe OSA who struggle with the CPAP treatment. While there are some risks, adverse events reported after this treatment are uncommon.
In severe cases, a procedure known as tracheostomy can effectively treat OSA by bypassing obstructions in the throat. However, this method should only be used in specialty sleep centers, as it requires extensive home care and patient education. Patients requiring a tracheostomy often also have other health conditions.
What else can Obstructive Sleep Apnea (Sleep Apnea) be?
When trying to identify if a patient has Obstructive Sleep Apnea (OSA), doctors need to ensure they rule out other health conditions that can display similar symptoms. These conditions include:
- Asthma
- Central sleep apnea (another type of sleep disorder)
- Chronic obstructive pulmonary disease (a type of lung disease)
- Depression
- Gastroesophageal reflux (a digestive disorder where acid from your stomach backs up into your throat)
- Hypothyroidism (a condition where your thyroid gland doesn’t produce enough hormones)
- Narcolepsy (a sleep disorder that causes excessive sleepiness and frequent daytime sleep attacks)
- Periodic limb movement disorder (a sleep disorder where you move your limbs involuntarily during sleep)
It is crucial for the doctor to consider all these possibilities and carry out proper tests to make an accurate diagnosis.
What to expect with Obstructive Sleep Apnea (Sleep Apnea)
The short-term outlook for Obstructive Sleep Apnea (OSA) patients who receive treatment is typically good; however, the long-term outlook can be uncertain. One of the main challenges is that nearly half of the patients stop using the recommended CPAP (continuous positive airway pressure) treatment within the first month, despite being educated about its benefits.
Many of these patients have other existing health conditions or are at risk of experiencing things such as heart conditions and strokes. Therefore, those who don’t use CPAP are putting themselves at higher risk of these serious health events. They also tend to incur higher yearly healthcare costs.
Moreover, OSA is tied to numerous health issues. These include pulmonary hypertension, higher levels of carbon dioxide in the blood (hypercapnia), lower than normal oxygen levels (hypoxemia), and daytime sleepiness. People with OSA are also more likely to have motor vehicle accidents. As a result, folks with OSA generally have a shorter life expectancy than the average person.
OSA can negatively impact heart function, especially amongst obese individuals. On a more positive note, recent findings suggest that the use of CPAP can improve heart functionality in patients with OSA.
Possible Complications When Diagnosed with Obstructive Sleep Apnea (Sleep Apnea)
Obstructive Sleep Apnea (OSA) can lead to several health risks. These can include:
- High blood pressure (Hypertension)
- Heart attack (Myocardial infarction)
- Stroke (Cerebrovascular accident)
- Mental health issues like depression
- Accidents caused by inability to sleep properly (Sleeplessness-related accidents)
Preventing Obstructive Sleep Apnea (Sleep Apnea)
If a person suffers from Obstructive Sleep Apnea (OSA), it would be beneficial for them to lose some weight. They should also be advised to stay away from alcohol, certain prescription medicines like benzodiazepines and opiates, as well as some antidepressants, as these can make their sleep apnea worse. It’s very important for these patients to get enough sleep every night and maintain good sleep habits. They should also understand the dangers of driving when feeling drowsy.
Continuous Positive Airway Pressure (CPAP) can be a useful tool for managing OSA. It’s crucial that patients stick to a routine of using their CPAP devices as instructed. The patients should also be reminded of the importance of keeping the device clean and in good working order.
