Obstructive Sleep Apnea & Snoring

Are you the target of bad jokes or middle of the night elbow thrusts? If this sounds familiar you may already know that snoring is no laughing matter.

Loud snoring can be a sign that something is seriously wrong with your breathing during sleep. Snoring indicates that the breathing passage in your throat is not fully open, and the distinctive sound of snoring comes from trying to force air through the narrowed area.

The muscles that stiffen and open the throat tend to relax during sleep in normal children and adults. This relaxation leads to slight narrowing of the throat that does not cause a problem for most people. However, in people with OSA, this narrowing of the breathing passage is so great that breathing becomes difficult, as if they were breathing through a floppy, wet straw. The sleeping brain senses that breathing is difficult and increases the effort to breath. Eventually, this increased effort awakens the brain, which signals the throat muscles to become active again and then reopens the breathing passage. With the breathing passage once more open, the effort to breath decreases and the person goes back to sleep. This cycle of falling asleep, throat narrowing, increased effort to breathe and then arousal from sleep tends to repeat itself throughout the night, and can disturb sleep dozens to hundreds of times each night. Most of these awakenings are so brief that they are not remembered the next morning. An individual with this pattern of obstructed breathing, brief awakenings from sleep, and daytime symptoms is said to have OSA.

Since the throat muscles relax during sleep to some extent in everyone, many patients with OSA have additional factors that contribute to throat closure. These include a smaller-than-normal jaw, large tongue, enlarged tonsils, or tissues that partially block the entrance to the breathing passage. OSA often occurs in overweight people, as it is thought that extra fatty tissue in the neck affects the size or shape of the breathing passage. Sometimes several of these conditions are present in the same person.

Since OSA is less frequent in younger women, a different throat structure or certain female hormones may tend to protect them from having the disease, although in later years and especially after menopause the gap between the sexes narrows.
Alcohol, sleeping pills, and tranquilizers taken at bedtime also relax these muscles and can make the breathing passage more likely to close. Some people with OSA may have worse sleep when they take a sleeping pill, or these pills can even be dangerous for them. If your health professional prescribes a sleeping pill for you, make sure that you tell him or her about any symptoms of OSA you might have.
There is more than on kind of throat closure in OSA. The breathing passage can narrow so much that no air can get through (apnea) or a bit less so that some air can pass (hypopneas). In some patients, the narrowing may be so slight that the body can keep breathing normally by increasing effort, but this may still cause repeated awakenings (respiratory effort related arousals or upper airway resistance syndrome). It is thought that all of these events lead to the same consequence: sleep deprivation. Most sufferers will have a combination of the different types of abnormal breathing. In addition, airway closure may drop the level of oxygen in the blood, which can cause additional symptoms.

If you have OSA, you may not get enough oxygen during sleep and probably don’t sleep soundly. You may suffer from sleepiness that affects your work and social activities, and that could even lead to car accidents. OSA can also put you at risk for high blood pressure, heart failure, heart attack, or stroke. If you snore loudly on most nights, you should visit your healthcare professional. He or she may suggest evaluation at a sleep disorders center. Fortunately, sleep specialists are now able to diagnose and treat these breathing disorders during sleep. Proper treatment can prevent or reverse the potentially dangerous consequences of OSA.

In Adults

• Excessively loud snoring which can be heard rooms away (or even by the neighbors).
• A pattern of snoring interrupted by pauses, then gasps, is a sign that breathing stops and restarts. Occasionally, patients will remember waking up short of breath or gasping, although the vast majority of episodes are not recalled.
• Falling asleep at the wrong times, such as at work or while driving.
• Trouble concentrating, or becoming forgetful, irritable, anxious, or depressed.
• Morning headaches or nausea, frequent trips to the bathroom to urinate at night, and loss of interest in sex. Men may complain of impotence and women may have menstrual irregularities.

These problems usually appear slowly and progress over many years, so that the patient may not recognize the symptoms. Sometimes the patient thinks the symptoms are just from getting older or are not serious. Family members, employers, or coworkers may be the first to recognize a pattern of excessive sleepiness and/or changes in mood or behavior, and should encourage a visit to a healthcare professional.

The most common complaint of people with OSA is excessive sleepiness. The sleepiness is most often felt when the person with OSA is sitting still or not active, either physically or mentally. He or she may be unable to remain awake or to concentrate while reading or watching TV, even if they are interested in the material. Driving an automobile can often be difficult because of unwanted sleep, and people with OSA have more automobile accidents due to dozing or inattention. Untreated OSA has other consequences for health and well-being besides sleepiness. A list of some of these can be found below.
Medical science is learning that treatment of OSA can reduce or eliminate these risks. In many cases, the patient feels the benefits, such as reduced sleepiness and better mood, quickly after treatment begins.

If you seek help for a sleep problem, your healthcare professional will want to know your medical history and may talk with your bedpartner or other members of your household about your sleeping and daytime behavior. A healthcare professional who suspects OSA will probably refer you to a specialist for evaluation. There you will be asked detailed questions about your sleep and daytime symptoms, and may ask you to spend a night or two in the sleep laboratory to monitor your sleep. A nighttime study will show if you have OSA and will help define the best treatment.

• High Blood Pressure
• Heart Attack
• Heart Failure
• Stroke
• Depression
• Diabetes

On the night of a sleep study, you will be asked to arrive at the laboratory about two hours before your usual bedtime. Technologists will position tiny sensors at different points on your body to record your brain waves, muscle activity, leg and arm movements, heart rhythms, and other bodily functions during sleep. Each sleep disorders center has its own system of running tests, and several devices may be used to study the different patterns of breathing during sleep. These include a flexible wire probe or small plastic prongs placed at the openings of your nose and/or mouth to measure the rate at which air enters and leaves your lungs. These tests help record whether and when breathing difficulties occur. Stretchy fabric bands may be placed around your chest and abdomen to measure the effort you make to breathe, and a device clipped to one of your earlobes or fingers would chart your oxygen level. Usually there are no needles involved in the testing is not uncomfortable.

If you are diagnosed with OSA you may benefit from both general measures and specific treatments.

• Weight loss may help in the treatment of OSA if you are overweight. Even small amounts of weight loss-20 pounds by a200-paund man who should weigh 165- may improve breathing during sleep, making sleep mare restful and lessening daytime sleepiness.
• Avoid alcohol within four hours of bedtime. Alcohol depresses breathing and makes OSA episodes more frequent and severe. Alcohol also appears to trigger OSA in people who would otherwise merely snore.
• Avoid sleeping pills, Sleeping pills may also depress breathing, relax the muscles of the throat, and generally make OSA worse, exceptions may be necessary for ~ people who are bothered by frequent awakenings that are not due to OSA episodes. Seek out a healthcare professional’s advice if you use sleeping pills and have OSA.
• Take all drugs with care. Medications prescribed for headaches, anxiety, and other common problem can affect sleep and breathing.
• Sleep lying on one side or your stomach. Some people suffer from OSA only when lying on their backs. Pillows placed behind the back or a tennis ball attached to the back of pajamas will prevent back-sleeping throughout the night.
• Medications to relieve nasal stuffiness may be helpful in reducing snoring and may help OSA slightly. Mechanical nasal dilators and similar devices available at drug stores can also be used to reduce nasal obstruction, Consult your healthcare professional for advice.

Positive Airway Pressure (PAP)
In this highly effective therapy, a light mask is worn is over the nose during sleep. A small, quiet air pump is attached to the mask with a long tube, so that air under pressure enters the throat through the nasal passages. This gentle air pressure holds the throat open and allows normal sleep and breathing. Approximately 60% to 70% of patients who try PAP are able to continue to use it, while the rest find the mask too uncomfortable for various reasons. PAP masks come in all different sizes and shapes, since everyone’s face is a little different. There are different types of PAP devices, with same made to change the pressure produced when breathing in or out (bi-level PAP) or in response to snoring and excessive narrowing of the throat. These different PAP devices were invented, in part, to help improve comfort, and may help certain patients. Below are common complaints of PAP treatment for OSA. If you experience any of these, make sure you tell your healthcare professional. In most cases, there are ways to prevent these symptoms so that you can see PAP comfortably.

Common Complaints Of PAP Treatment

• Nasal stuffiness or congestion
• Dryness of the mouth or nose
• Mask air leaks
• Noise made by PAP machine
• Sore, dry, or red eyes
• Skin irritation from the mask and /straps
• Sensation of too much air pressure
• Belching or bloated feeling

Oral Appliances
Some OSA patients are helped by oral appliances, devices that open the breathing passage by bringing the jaw or tongue forward or raising the soft palate. Patients with mild and moderate OSA may especially benefit by using an oral appliance, while severe OSA usually does not respond to this type of treatment. These devices sometimes cause excessive salivation, jaw pain, gagging, or dental problems. Oral appliances should be fitted by qualified dental personnel.

Surgery
Physical problems that interfere with breathing during sleep can sometimes be corrected surgically. These problems include: enlarged tonsils or adenoids (common in children), nasal polyps or other growths, a deviated nasal septum, or certain sizes and or shapes of the face, jaw, or soft palate.
Nasal operations alone that reduce nasal stuffiness may help snoring, but are usually not effective for OSA. However, nasal surgery may be one part of an overall plan for surgical treatment of OSA.

An operation known as uvulopalatopharyngoplasty (usually abbreviated to UPPP) consists of removing excess tissue at the back of the throat that may be blocking the airway during sleep. Studies show that UPPP benefits up to half of patients with OSA, and more research is underway to identify the patients most likely to be helped by this procedure. Patients have reported side-effects of surgery, such as a change in speech and the passage of liquids into the nose when swallowing. A modification of UPPP using a laser (Laser-assisted Uvulopalatoplasty, LAUP) is a less effective treatment for OSA but can be effective for snoring. Radio frequency ablation, or other techniques that shrink the tissue of the back of the throat or tongue using electrical currents, are being studied in hopes of improving the success of surgery at controlling OSA. So far, these are still only thought to help snoring. Other types of surgery have been developed to treat OSA. Most of them aim to increase the size of the throat at the base of the tongue. These surgeries may involve cutting into the bones of the face and jaw in order to bring the jaw and face forward. In properly selected cases they are more effective than UPPP alone but they may also carry a greater risk of complications.

Patients with very severe, life-threatening OSA may occasionally need a tracheostomy as treatment. The surgeon makes an opening in the neck and into the trachea (windpipe) and inserts a tube through which the patient breathes during the night, thus completely bypassing the breathing passage in the throat. The tube is kept closed and covered by clothing during waking hours, allowing normal speech and breathing.

Oxygen
Giving extra oxygen is not usually a good treatment for OSA. Oxygen may be added to the PAP system, however, to correct for low oxygen levels due to existing lung or heart disease.

Medication
There are currently no medications proven to prevent episodes of throat closure in OSA sufferers. Some patients treated with PAP may benefit from stimulant medication if they are still sleepy.