Obstructive Sleep Apnea (OSA) is defined as pauses (apneas) in breathing during sleep, due to blockage of the upper airway with a drop in oxygen saturation.
Obstructive Sleep Apnea (OSA)
The most recurrent form of sleep apnea is known as obstructive sleep apnea (OSA). This condition is marked by significant and repetitious pauses in breathing during sleep, due to some blockage of the upper airway. Despite the individual’s attempt to breathe continuously, these pauses, known as ‘apneas,’ continue to occur, typically to a point of becoming related to a loss of blood oxygen saturation. Apnea literally means ‘without breath.’ These interruptions in breathing usually last anywhere from 20 to 40 seconds, and over time can result in serious negative impacts to a person’s overall health. Obstructive Sleep Apnea can persist for years without an individual ever becoming aware of this problem. Even upon waking up, individuals usually remain incognizant of their trouble breathing. Often times, the problem is finally brought to a person’s attention when another individual observes an episode or the detrimental effects of sleep interruption finally begin to take a tole on the body. Ultimately, obstructive sleep apnea is a serious condition that requires medical treatment, so if you suspect you or a loved one suffers from this condition seek medical attention as soon as possible.
What Are The Signs And Symptoms Of Obstructive Sleep Apnea?
The most common signs and symptoms of sleep apnea in adults include but are not limited to excessive daytime sleepiness, successive awakening and disturbed sleep, loud snoring (with intervals of silence followed by gasps), repeated episodes of cessation of breathing during sleep, and jerking or restless legs during sleep. Other associated but less common symptoms include weight gain that cannot be attributed to any change in dietary habits or lifestyle, mouth breathing, nightmares, insomnia, headaches, unsatisfactory work performance, difficulty concentrating, forgetfulness, diminished sex drive, alterations in mood like grouchiness, elevated heart rate/and or blood pressure, anxiety and depression, substantial night sweats, increased urination and or nocturia (waking up in the night with the need to urinate), and habitual heartburn or gastroesophogeal reflux disease.
Typically, adults with obstructive sleep apnea suffer from obesity as well. These individuals tend to display particular heaviness in the face and neck, but this is not always the case. A large amount of adults with normal BMIs (body mass indices) suffer from sleep apnea due to diminished muscle tone, which leads to a collapse in the airway and sleep apnea.
Note however, the very most distinctive symptom of long-term obstructive sleep apnea in adults is excessive daytime sleepiness. These people commonly fall asleep for brief intervals while trying to participate in normal daytime activities, when given the chance to rest or sit. These incidences may seem quite dramatic and unforeseen, with the individual falling asleep even mid conversation at times or at social functions.
What Exactly Causes Obstructive Sleep Apnea?
Simply put, obstructive sleep apnea is caused by some blockage to the airway at one or multiple sites. In most cases, this obstruction is thought to result from either natural or premature old age, a temporary or permanent brain injury, or diminished muscle tone, which usually stems from drug or alcohol use, neurological problems, or other conditions.
Short occurrences of sleep apnea may be the outcome of an upper respiratory infection, which causes congestion that induces swelling in the throat. Tonsilitis, mononuclesosis, or the use of a drug (like alcohol) may also lead to short term OSA. Drugs cause OSA by interfering with normal sleep arousal mechanisms and tremendously relax the body tone (diminishing muscle tone in the airway).
Some individuals may experience OSA due to more than one of these problems. There is also a theory that attributes pharyngeal nerve lesions caused by long-term snoring as a reason for an increase in soft tissue around the airway and structural features that may block the airway. Structural features blocking the airway are also linked to obesity in a large amount of cases.
Pathophysiology of Obstructive Sleep Apnea
A person’s sleep/wake cycle is split into three stages: REM (rapid eye movement) sleep, non-REM (NREM) sleep, and consciousness. NREM sleep is further divided into three stages (NREM 1,2, and 3). The deepest stage of NREM sleep, NREM 3, is responsible for the physically restorative repercussions of sleep, and NREM 2 allows for mental recuperation and maintenance. During REM sleep specifically, the muscle tone in the neck and throat is almost fully narrowed, which causes the tongue and soft palate/oropharynx to relax, and in the case of sleep apnea, blocks airflow to a point where blood oxygen levels decrease. At that point, the physical effort to breath becomes so difficult that neurological mechanisms induce sudden arousal from sleep. These sudden interruptions rarely prompt a full awakening, but interrupt the stages of sleep responsible for the restorative quality of sleep, and therefore can lead to sever sleep deprivation. Interruptions in stage 3 of NREM and in REM sleep can have a negative impact on the normal functioning of the body’s immune response system, healing, and normal growth patterns, particularly in young adults and children.
Who is at Risk for Obstructive Sleep Apnea?
People who are at an increased the risk for OSA include:
- Post-menopausal women.
- Pregnant women.
- Men with supplemental mass in the neck and torso areas.
- People who smoke.
- People who have suffered a trauma to the face.
- People with a family history of OSA.
- People who exhibit unsatisfactory compliance with speech therapy and/or chemical treatments.
- People who consume sedatives, alcohol, or any medication that enhances sleepiness (usually these drugs are muscle relaxants).
Negative Health Impacts Of Obstructive Sleep Apnea
An array of health problems can arise as a result of obstructive sleep apnea. Over time, the negative effects of breathing interruptions during sleep can cause high blood pressure heart arrhythmias, pulmonary hypertension, right side heart failure, blood disorders, stroke, myocardial infarction (heart attack), carbon dioxide retention, stroke, cyanosis (a bluish coloring to the skin and/or mucous membranes), and death.
Diagnosing Obstructive Sleep Apnea
The diagnosis of sleep apnea is outstandingly more common among people who have a regular bed partner to inform them of their episodic symptoms. Often times, a person finally seeks medical attention when their bed partner can no longer endure the loud snoring. Typically, an individual gets diagnosed with OSA based on an amalgam of a comprehensive history of their symptoms/medical conditions and professional diagnostic tests, which span from at home self testing to full sleep studies (polysomnography) in a lab.
For initial testing, the Epworth sleepiness scale is essential. The Epworth sleepiness scale examines the probability of a person falling asleep in 8 routine situations, scaled from 0 (never) to 5 (always). A final score of above 11 is affiliated with obstructive sleep apnea.
A physician will also most likely conduct a full head and neck exam to pinpoint one or multiple sites of obstruction. The nasal cavities and oral cavity (with tongue inside the mouth) should also be examined. The tonsils will be scaled from 0 (nonexistent) to 4 (kissing). Finally , the uvula and palate should also be thoroughly inspected, as OSA patients frequently display inessential soft palate tissue or a lengthened and thick uluva. OSA patients also may present macroglossia, which obstructs the view of the palatal structures.
Home Oximetry: For individuals who are highly suspected to suffer from obstructive sleep apnea, a well-established and non-invasive home test may be sufficient for diagnosis. Home oximetry measures blood oxygenation but does not track apneic episodes (pauses in breathing) or respiratory event-related arousals. If prescribing a home oximetry test, the physician will thoroughly inform the patient of all self-testing instructions, in order to obtain the most accurate results.
Polysomnography: A lab-attended sleep test is the most accurate way of diagnosing obstructive sleep apnea. This diagnostic testing process is called polysomnography and involves and overnight study carried out in a sleep lab. This test monitors EKG, EEG, nasal and oral airflow, pulse oximetry, respiratory effort, and leg movements for further assessment. When pauses in airflow transpire for longer than 10 seconds,‘apneas’ are documented. When airflow decreases by 30% and an associated 4% decrease in oxygen saturation follows, a ‘respiratory related arousal’ is documented. When complete, the most essential recordings to evaluate are the lowest oxygen saturation levels, apneas/hypopnea index (AHI), and the respiratory disturbance index (RDI).
Treatment Options For Obstructive Sleep Apnea
There are several treatment options for OSA, and depending on a patient’s particular situation and the severity of their condition, one or a combination of multiple treatment methods may be executed. Treatments for obstructive sleep apnea include:
Behavior modifications: A patient may need to make some necessary lifestyle and behavior changes such as losing weight, quitting smoking, avoiding alcohol and sedative use, and adjusting sleeping positions.
Continuous positive airway pressure (CPAP): The very first line of treatment for OSA is continuous positive airway pressure, which eludes all the effects of obstructive sleep apnea. For this treatment, a CPAP mask, which covers the mouth and nose, carries a steady and controlled amount of air through the airways, and an additional pressure keeps the relaxed muscles held open. The individual must wear the CPAP mask at least 5 hours/night and 5 nights/week for the ideal pressure to be achieved and for the patient to be regarded compliant. This treatment is the most advantageous for increasing a patient’s quality of life as well as their Epworth sleepiness score. Additional forms of CPAP treatment include:
- Variable positive airway pressure (VPAP)/bilevel positive airway pressure (BiPAP): electronic circuit monitors breathing and distributes increasing pressure upon inhalation and decreasing pressure upon exhalation.
- Automatic positive airway pressure (APAP): newest form of CPAP treatment. A computer continuously monitors breathing.
- Nasal EPAP: patient’s own breath produces air pressure with a device that is placed over the nose. This is less affective than the traditional CPAP.
Oral appliances or splints: Sometimes this method of treatment is employed over CPAP, but it is not always as beneficial. A device much like a mouth guard is worn and slightly lowers the jaw down and forward to keep the tongue away from the back upper airways.
Surgical intervention: Patients who are non-cooperative with CPAP and find other methods of treatment insufficient may need to seek further evaluation by and Otolaryngologist (ENT surgeon) for possible surgical intervention. The most favored surgical intervention for treating OSA is uvulopalatopharygoplasty. This procedure involves removing the tonsils, clipping and rearranging the anterior and posterior tonsillar pillar, and removing the uvula, followed by the reconstruction of a smaller uvula.
For children with obstructive sleep apnea, the hallmark symptom of excessive daytime sleepiness is actually quite uncommon. In fact, toddlers and young children with OSA tend to display ‘hyperactive’ behavior instead. Interestingly enough, the typical body type of a child with OSA directly opposes the commonly overweight or obese body type seen in adults with the condition. Children with OSA may not only look extremely thin, but develop ‘failure to thrive’ as well, where growth is actually diminished.
Unlike adults, OSA in children is often the result of blocking tonsils and adenoids and can sometimes be cured with tonsillectomy and adenoidectomy. Obese or excessively overweight children may also develop OSA, however. In this instance, a child will most likely display symptoms very similar to and overweight adult with obstructive sleep apnea. Unfortunately, OSA in children has also been linked to lower IQ scores. These children may have problems with learning and experience memory trouble.
Obstructive Sleep Apnea As Post-Operative Complication
Obstructive sleep apnea can result as a complication from surgery as well. Post-operative OSA seems most commonly related to pharyngeal flap surgery. Following this operation, the pharyngeal flap may obstruct the pharynx during sleep, hindering sufficient respiration.
If you would like an obstructive sleep apnea evaluation, contact Dr. Monty Trimble at DFWSinus.com or call 817-529-6200. He has offices in Fort Worth, Keller and soon to be Southlake, Texas.