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Sleep Apnea, Obstructive

Definition :
More than 12 million people in the United States have obstructive sleep apnea — a potentially serious sleep disorder in which breathing repeatedly stops and starts during sleep. There are several types of sleep apnea, but the most common type is obstructive sleep apnea, which occurs when your throat muscles relax and block your airway. The most noticeable sign of obstructive sleep apnea is snoring.

Anyone can have obstructive sleep apnea, although it most commonly affects older adults, men and especially those who are overweight. Obstructive sleep apnea treatment may involve using a device to keep your airway open or undergoing a procedure to remove tissue from your nose, mouth or throat.

Causes:
Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support structures including the soft palate, the uvula — a triangular piece of tissue hanging from the soft palate — the tonsils, and the tongue.

When the muscles relax, your airway narrows or closes

as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.

You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths, although this sequence is rare. You may make a snorting, choking or gasping sound. This pattern can repeat itself 20 to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.

People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they sleep well all night.


Risk Factor
:
Anyone can have obstructive sleep apnea. However, certain factors put you at increased risk :
  • Excess weight. More than half of those with obstructive sleep apnea are overweight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people can develop the disorder too.
  • Neck circumference. The size of your neck may indicate whether or not you have an increased risk of obstructive sleep apnea. That's because a thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17 inches is associated with an increased risk of obstructive sleep apnea.
  • High blood pressure (hypertension). Obstructive sleep apnea is relatively common in people with hypertension.
  • A narrowed airway. You may inherit a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.
  • Chronic nasal congestion. Obstructive sleep apnea occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways.
  • Diabetes. Obstructive sleep apnea is three times more common in people who have diabetes than in those who don't have diabetes.
  • Being male. In general, men are twice as likely to have sleep apnea.
  • Being black, Hispanic or a Pacific Islander. Among people under age 35, obstructive sleep apnea is more common in blacks, Hispanics and Pacific Islanders.
  • Being older. Sleep apnea occurs two to three times more often in adults older than 65.
  • Menopause. A woman's risk appears to increase after menopause.
  • A family history of sleep apnea. If you have family members with sleep apnea, you may be at increased risk.
  • Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.
  • Smoking. Smokers are nearly three times more likely to have obstructive sleep apnea.
When to seek medical advice :
Consult a medical professional if you experience, or if your partner observes, the following :
  • Snoring loud enough to disturb your sleep or that of others
  • Shortness of breath that awakens you from sleep
  • Intermittent pauses in your breathing during sleep
  • Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving

Many people don't think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. But be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence. With sleep apnea, snoring typically is loudest when you sleep on your back, and it quiets when you turn on your side.

Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.

Symptoms :
Signs and symptoms of obstructive sleep apnea include :

  • Excessive daytime sleepiness (hypersomnia)
  • Loud snoring
  • Observed episodes of breathing cessation during sleep
  • Abrupt awakenings accompanied by shortness of breath
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Difficulty staying asleep (insomnia)

Diagnosis:
Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help decide whether you need further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Tests to detect sleep apnea may include :

  • Nocturnal polysomnography. During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood-oxygen levels while you sleep. This can help your doctor rule out other conditions — such as periodic limb movements or narcolepsy — that can cause excessive daytime sleepiness but require different treatment.
  • Oximetry. This screening method involves using a small machine that monitors and records your blood-oxygen level while you're asleep. A simple sleeve fits painlessly over one of your fingers to collect the information overnight at home. If you have sleep apnea, the results of this test will often show drops in your blood-oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may have you undergo polysomnography to confirm the diagnosis. Oximetry doesn't detect all cases of sleep apnea, so your doctor may still recommend a polysomnogram even if the oximetry results are normal.
  • Portable cardiorespiratory testing. Under certain circumstances, your doctor may provide you with tests to be used at home to diagnose sleep apnea. These tests usually involve oximetry, measurement of airflow and measurement of breathing patterns.
Your doctor may also refer you to an ear, nose and throat doctor (otolaryngologist) to rule out any blockage in your nose or throat.

Complications :
Sleep apnea is considered a serious medical condition. Complications may include :

  • Cardiovascular problems. Sudden drops in blood-oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. About half the people with sleep apnea develop high blood pressure (hypertension), which raises the risk of heart failure and stroke. If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event.

    The more severe the obstructive sleep apnea, the greater the risk of high blood pressure.

  • Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving. Children and young people with sleep apnea may do poorly in school, have reduced mental development or have behavior problems. Treatment of sleep apnea can improve these symptoms, restoring alertness and improving quality of life.
  • Complications with medications and surgery. Obstructive sleep apnea also is a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications after major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea. Undiagnosed sleep apnea is especially risky in this situation.
  • Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to sleep in another room. Many bed partners of people who snore are sleep deprived as well.

People with obstructive sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, and a need to urinate frequently at night (nocturia). Gastroesophageal reflux disease (GERD) may be worse in people with sleep apnea.

Treatment:
For milder cases of obstructive sleep apnea, your doctor may recommend lifestyle changes, such as losing weight or quitting smoking. If these measures don't improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.

Therapies

  • Continuous positive airway pressure (CPAP). If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and snoring.
  • Although CPAP is a preferred method of treating sleep apnea, some people find it cumbersome or uncomfortable. With some practice, most people learn to adjust the mask to obtain a comfortable and secure fit. You may need to try different types of masks to find one that's comfortable. If you're having particular difficulties tolerating pressure, there are machines that have special adaptive pressure functions to improve comfort. Some people also benefit from using a humidifier along with their CPAP system.

Don't stop using the CPAP machine just because you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. In addition, contact your doctor if you are still snoring despite treatment or begin snoring again. If your weight changes, the pressure settings may need to be adjusted.

  • Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more effective than oral appliances are, but oral appliances may be easier for you to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea. Others hold your tongue in a different position.

    A number of devices are available from your dentist. You may need to try different devices before finding one that works for you.

Surgery or other procedures
The goal of surgery for sleep apnea is to remove excess tissue from your nose or throat that may be vibrating and causing you to snore, or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include :

  • Uvulopalatopharyngoplasty (UPPP). During this procedure, your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. However, it may be less successful in treating sleep apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general anesthetic.
  • Maxillomandibular advancement. In this procedure, the upper and lower part of your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure may require an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success. Your jaw may need to be wired shut for several weeks.
  • Tracheostomy. You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.
  • Implants. The Pillar procedure is a minimally invasive treatment that involves placement of three tiny polyester rods in the soft palate. These inserts stiffen and support the tissue of the soft palate and reduce upper airway collapse and snoring. The Pillar procedure is usually performed in your doctor's office with local anesthesia and takes less than 30 minutes. This relatively new treatment is recommended only for people with mild to moderate obstructive sleep apnea. Also, it may be less effective if you are extremely overweight.

Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that doctors sometimes use to treat snoring. However, these procedures aren't recommended for treating obstructive sleep apnea.

Other types of surgery may help reduce snoring and sleep apnea by clearing or enlarging air passages :

  • Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
  • Surgery to remove enlarged tonsils or adenoids
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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