Obstructive Sleep Apnea

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An Introduction to Sleep Apnea

Sleep Apnea is a condition in which the airway is obstructed during sleep. The body can not receive oxygen and leaves deeper levels of sleep, such as REM sleep, in an attempt to restore airflow. CPAP is the gold standard treatment for sleep apnea. We have prepared an in depth article about Sleep Apnea which covers the history, types and treatment options relating to the disease.

What is Sleep Apnea?

Sleep Apnea Defined

The definition of Sleep Apnea is an occurrence of some type of obstruction that temporarily stops the breathing during sleep. Apnea literally means "without breath" and these events can occur up to 30 or more times per hour of sleep. The scientific standard of an apneic event is the patient must stop breathing for at least 10 seconds per event and have an overall blood oxygen desaturation level of 3 to 4 percent along with certain potential changes in EEG frequencies and data. If a person has 5 or more of any type of events per hour of sleep then they can be clinically diagnosed with Sleep Apnea.

Initial Diagnosis

An overnight sleep study is usual indicated when seeking to diagnose if a patient is suffering from Sleep Apnea. This sleep test, usually conducted in a specialized sleep lab by a sleep doctor and a respiratory therapist, is called a polysomnogram or polysomnography test; also known as a PSG. For more on sleep studies, see our Introduction To The Sleep Lab video on YouTube.

Signs or Symptoms of Sleep Apnea

Often the people are unaware that they may have Sleep Apnea or they do not realize they have difficulty breathing in their sleep at all. It is usually someone else who witnesses the person sleeping and having these events or obstructions, usually gasping for air or a sudden stoppage of breathing while asleep, whereby they first become aware that they may have Sleep Apnea. Many people just think they do not sleep well, not realizing they have Sleep Apnea, and some try to self-medicate using sleeping pills, or alcohol to try and sleep better, which tends to make the problem worse.

Snoring is another big symptom but there are many people who snore who do not have Sleep Apnea. If snoring stops briefly and then resumes, that is a significant indicator of sleep apnea.

Daytime tiredness or drowsiness, difficulty or lack of concentration, headaches, impotence or decreased sex drive, moodiness or irritability, lack of energy, acid reflux (gastro-esophageal reflux disease aka GERD), restless sleep, tossing and turning, night sweats, memory problems, nighttime choking or chest pain, swelling of the legs in the obese, waking up foggy, groggy, or unrefreshed, anxiety, depression, increased urination at night; these could all be symptoms of Sleep Apnea. Some people first learn of the problem when they fall asleep at the wheel of a car, or are even involved in a car wreck or crash caused by the side effects of having untreated sleep apnea.

Of note, a score of 12 or higher on the Epworth Sleepiness Scale is indicative of someone who may potentially have Sleep Apnea.

History of Sleep Apnea

A Historical Overview of Sleep Apnea

Sir William Olser in 1918 first used a term he invented, "Pickwickian", to describe patients who were both obese and hypersomnolent. Olser was obviously a reader of Charles Dickens as the Dickens novel Pickwick Papers had a character in it that was similar to the patients he had identified with these common symptoms. Around 1956, Dr. Burwell was treating patients who often had congestive heart failure, extreme sleepiness or fatigue, as well as improper airflow to the lungs; or respiratory failure. He termed these types of patients as having Pickwickian Syndrome.

Early Diagnosis and Treatment

In 1965 a group of French and German doctors lead by Dr. Gastaut started doing research on what is now called Obstructive Sleep Apnea, and recorded breathing and sleeping patterns of a patient with Pickwickian Syndrome and discovered distinctively unique patterns of the 3 types of apneas.

Beginning in 1969 OSA (Obstructive Sleep Apnea) was often treated with a tracheostomy; bypassing the upper air passage altogether by creating an incision or opening in the trachea (windpipe) and inserting a breathing tube.

Invention of the CPAP machine

In 1981, an Australian researcher by the name of Dr. Colin Sullivan and his colleagues Berthon-Jones, Issa and Eves, introduced their findings on the treatment of OSA with something called a Continuous Positive Airway Pressure machine, or CPAP. The treatment plan started off with a reversed vacuum cleaner motor that blew air into the afflicted person's nasal passage using a Silastic tubing to keep the airway open. The initial CPAP machines were large, bulky and noisy but by the late 1980s many improvements had been made to the machine and masks and soon this became the preferred method of treatment for those who suffer from Sleep Apnea. The publishing of their research papers was a landmark development in the treatment of Sleep Apnea.

Types of Sleep Apnea

(OSA) Obstructive Sleep Apnea

Obstructive Sleep Apnea is the most common form of Sleep Apnea and occurs when the muscles and tissues in the throat and air passage relax while sleeping, and this impedes the flow of air into the lungs due to a blockage of the airway. This can occur many times per hour in the sleep cycle and especially during the REM sleep stages. In REM sleep all of the muscles and in fact the entire Musculo-skeletal system goes into an extremely relaxed state that causes the tongue, soft palate, tonsils, from the nose to the glottis, and the oropharynx to completely loosen up and this creates the obstruction or impedance to the air flow, thereby causing apnea (complete stoppage) and hypopnea (partial stoppage) events, as well as snoring events.

Oxygen Saturation in the blood levels drop significantly and usually this is followed by constant neurological mechanisms or arousals with each event that may not wake the person entirely from sleep but disrupt sleep constantly enough to cause many issues. A person with Obstructive Sleep Apnea rarely gets into the REM sleep stages or restorative cycle (Slow Wave Cycle) long enough or at all and the long term effects can be quite serious and numerous.

Positional Obstructive Sleep Apnea

Sleep Apnea aggravated by the person's sleeping position - usually sleeping on your back. If you have positional sleep apnea, try sewing a tennis ball onto the back of your pajama shirt. This will make sleeping on your back uncomfortable, so you learn to sleep in another position.

CPAPtalk member Autopapdude and Sleeprider say APAP is great for positional sleep apnea:

"An APAP would increase pressure to stop snores. Snoring suggests a constriction that causes soft tissues to vibrate, so increasing pressure should reduce snores. Hopefully it does not interfere with sleeping in other positions. I would only change 1/2 increment at a time."

Read a CPAPtalk thread on positional sleep apnea here.

(CSA) Central Sleep Apnea

Central Sleep Apnea is caused by the part of the brain that controls respiratory function and these centers in the brain are imbalanced and do not respond or react quickly enough to changes in oxygen or carbon-dioxide levels in the blood stream. Essentially, the brain does not respond at all to the normal triggers that would cause a person to breathe or take a breath. Pure CSA is fairly rare or uncommon. But basically the person just stops breathing for a period of time, and this can occur even when awake. A type of Central Sleep Apnea known as "Cheyne-Stokes respiration" occurs primarily in people with kidney disease, stroke, or congestive heart failure. Drops in oxygen levels (hypoxia) can cause seizures or in rare cases even death. The exact cause of Central Sleep Apnea is usually unknown and it is often partly treated with medications.

(MSA) Mixed Sleep Apnea

Also called Complex Sleep Apnea, the patient has a combination of both Central Sleep Apnea and Obstructive Sleep Apnea. Treatment is usually a combination of medication and CPAP use. Advances in technology allow recently released BiPap, BiLevel and VPAP machines to treat the special needs of those with MSA.

Who is Affected and How?

Statistics and Basic Facts

There are approximately 18 million people in the United States with Sleep Apnea and actually that number could be as high as 23 million persons. Perhaps as many as 10 million of them are undiagnosed. Most people diagnosed with Sleep Apnea are over the age of 40; however, it can affect children and people of any age, but is less common in those categories. The typical Sleep Apnea patient is a middle aged male who is obese or overweight, has a thick neck, high blood pressure, snores, and may have some physical abnormality in the breathing passage. Although that is the average person, Sleep Apnea can affect anyone, and there are plenty of atypical people who are thin or do not snore who are diagnosed with this sleeping disorder. Approximately 4 to 9 % percent of middle aged men have Sleep Apnea while about 2 to 4 percent of middle aged women suffer from Sleep Apnea.

There does seem to be strong evidence for a genetic basis or gene factors involved since often Sleep Apnea runs in families, but scientists say further research is still needed.

People at a higher risk for Sleep Apnea include the obese, cigarette smokers, alcoholics or heavy drinkers, persons with high blood pressure, diabetes, heart disease, or those who have had a stroke, as well as people with thyroid problems. Also anyone who has abnormalities in their breathing passage such as enlarged tonsils, an abnormally large tongue (macroglossia), an unusually small jaw (micrognathia), or a jaw that is set back or other craniofacial abnormalities could be at high risk.

Health Risks of Untreated Sleep Apnea

People with untreated Sleep Apnea have many health risks associated with the disorder, up to and including death. Perhaps the most famous recent example of someone who died from complications of Obstructive Sleep Apnea is the NFL football player Reggie White.

Sleep Apnea can also lead to or be a contributor to the following: hypertension (high blood pressure), heart disease, strokes, diabetes, congestive heart failure, pulmonary arrhythmias (irregular heartbeat), tachycardia (rapid increase in heartbeat), hypoxia (lack of oxygen in the bloodstream), atherosclerosis (hardening of the arteries), and myocardial infarction (lack of proper blood flow to part of the heart. Also, the statistics linking Sleep Apnea to psychological or affective disorders such as depression, anxiety, and mood or personality disorders, appears to be quite strong.

Besides these severe health issues, there are the other day to day factors and symptoms listed previously that can negatively affect a person's quality of life, overall health, personal relationships, ability to work effectively and function in the world.

Sleep Apnea Affects Drivers

A person with undiagnosed or untreated sleep apnea is six (6) times more likely to be in a car wreck or automobile crash and should be considered a danger on the road. Drowsy driving is quite a large problem and while not all of it can be attributed to those with untreated Sleep Apnea, the overall numbers on drowsy driving are quite staggering. In fact about 28 percent of commercial motor vehicle or truck drivers have some form of Sleep Apnea. Some people are first diagnosed with a sleep disorder due to an auto accident.

Famous People with Sleep Apnea

There is a very high likelihood that these people had Sleep Apnea: Napoleon Bonaparte, Grover Cleveland, Johannes Brahms, Henry VIII, Queen Victoria, Theodore (Teddy) Roosevelt, Franklin D. Roosevelt, Winston Churchill, and the comedian John Candy.

More recent celebrities who have had it come out in public that they have Sleep Apnea: Reggie White (NFL football player), Rosie O'Donnell (comedienne and talk show host), William Howard Taft (former President), Jerry Garcia (Grateful Dead Guitarist), Billy Connolly (actor), Anne Rice (writer), Johnny Grunge (professional wrestler), William Shatner (actor), George Kennedy (actor), William Tarmey (actor), Divine (aka Glen Milstead - actor), Jason Rutcofsky (musician), Hall Sutton (PGA Champion), Mark Calcavecchia (PGA Golfer), and John McEuen (founder of the Nitty Gritty Dirt Band). It is suspected that Sleep Apnea was a contributing factor in the death of actor Chris Penn; actor Sean Penn's brother.

A study in the New England Journal of Medicine of 300 NFL pro football players showed a Sleep Apnea rate of 14% which is 5 times higher compared to the general population in their same age/sex category. Linemen in particular had a very high rate with 34% having been found to suffer from Sleep Apnea.

Sleep Apnea Affects Partners and Spouses

Few people realize that not only does the patient suffer from Sleep Apnea; often their partners or spouses are adversely affected. In fact, it is often at the insistence of the spouse that the disordered person finally seeks help or becomes compliant with the sleep therapy. Partners and spouses often lose sleep due to snoring or even the use of a CPAP machine. One statistic shows spouses lose about one hour of sleep per night when they are bedmates with someone who has untreated Sleep Apnea.

While there are few actual studies done on how Sleep Apnea, treated or untreated, affects the spouse, it is not hard to imagine the problems that could occur from living with someone who snores loudly, and who may be tired all the time, possibly depressed, and moody, and who has trouble functioning or concentrating, etc. Certainly there are many hardships and even divorces that have occurred due directly or indirectly to untreated Sleep Apnea. Some spouses also have to deal with someone who is diagnosed but refuses to follow the sleep therapy or doctor's advice or treatment, which can be frustrating.

Once a person is diagnosed however, often there are vast improvements in their lives due to treatment, but sometimes it comes with a new set of issues, such as CPAP machine noise, or air blowing from the CPAP mask onto the partner, and so on. But these can be overcome and the trade-offs are certainly much better issues to have than the ones that emanate from untreated Sleep-Disordered Breathing (SDB) or OSA.

Treatment Options

Electromechanical Devices

These xPAP machines are the standard or traditional treatments for Sleep Apnea and are also the most effective treatment available. Side effects are minimal and while they can take some getting used to and adjustment, the benefits are great.

CPAP Machines

CPAP stands for Continuous Positive Airway Pressure and these machines blow a fixed amount of air pressure, specifically set for each patient, constantly throughout the night or sleep cycle. This air pressure forces the airway or air passage open and eliminates the apneas, hypopneas, and often the snoring, almost entirely, allowing the patient to get a restorative and restful sleep. The machines used to be large in size but have become smaller with time. The newer machines are about the size of two video cassettes (VHS tapes) stacked on top of one another. The user wears some type of interface such as a nasal mask or a full face mask, one that covers the nose and mouth. This mask is connected to machine usually by a 6 foot flexible hose or tube. The CPAP machine is prescribed by the doctor and the pressure is indicated on the prescription for each patient. The pressure setting expressed in centimeters of water pressure or CM H2O is derived for each patient from their sleep study.

APAP Machines

APAP is an acronym for Automatic Positive Airway Pressure and is similar to a CPAP however instead of delivering one constant pressure set specifically for each individual patient, the APAP machines will automatically find just the amount of pressure needed to keep the airway open on a breath by breath basis and often the APAP machines have more advanced features such a data reporting or software capabilities, auto altitude adjustment, and more.

These machines have some advantages over a regular CPAP, since someone's pressure needs can change in one night or over a long period of time. Even in one night or night to night several factors could cause the pressure settings to need adjustment. For instance, things like sleep position, tiredness and fatigue, deep sleep versus light sleep, a drink or two, or other factors can all cause someone's pressure needs to change. Also, over time if someone gains or loses weight this could cause an increase or decrease in the pressure needs. The APAP machines change with the patient automatically.

BiPap, VPAP, or BiLevel Machines

VPAP is defined as Variable Positive Airway Pressure and is also known as a BiPap or BiLevel machine. These machines deliver two distinct pressures; one for inhalation and a lower pressure upon exhalation, also known as IPAP and EPAP (Inhale Positive Airway Pressure and Exhale Positive Airway Pressure, respectively). This allows total control of the sleep therapy and these machines also are capable of delivering much higher pressures than a CPAP and have more complex motors, therefore are more expensive. They are usually prescribed in severe cases or for people who need higher pressures which make it difficult to exhale and therefore need a lower pressure on exhalation to make breathing out more comfortable. Some of these machines have an ST feature which stands for Synchronous Timed and will force a breath if the patient does not take a certain number of breaths per minute, also known as a backup rate or BPM rate.

Sometimes, these machines are prescribed for something other than Sleep Apnea, such as respiratory failure due to ALS (Lou Gehrig's disease), Cystic Fibrosis, or COPD (Chronic Obstructive Pulmonary Disease); usually associated with chronic bronchitis or chronic emphysema, which can be complicated by chronic asthma as well.

Surgery or Surgical Treatments

There are several different types of surgeries available for Sleep Apnea, depending on the patient, but any surgery comes with inherent risks or possible complications, and can be painful. xPAP machines are still the most effective treatment for Sleep Apnea with very minimal risk to the end-user. Often the surgery success rate is relatively low and many people report being back on a CPAP machine, or the like, within a year, albeit often at a lower pressure.

Here are some of the more common surgeries available, although doctors are always innovating and coming up with new procedures. Not all are covered here. Talk to a sleep doctor to find out more about what the newest and best options are in your own case.

Tonsillectomy or Adenoidectomy

This is performed to increase the size or opening of the air passage in the case of Sleep Apnea treatment.

Uvulopalatopharyngoplasty

UPPP is performed to reduce or remove or reshape parts of the soft palate and the uvula. It may also involve removal of part of the soft tissue from the pharyngeal areas.

Laser-assisted Uvulopalatoplasty

LAUP is similar to the above description of Uvulopalatopharyngoplasty however it uses lasers or radiofrequency waves to remove and shape the tissue.

Maxillomandibular Advancement

MMA, also known as (MMO) Maxillomandibular Osteotomy or (Bi-Max) Bimaxillary Advancement, is usually reserved for severe cases which have not responded to other surgeries or an xPAP machine well or where craniofacial syndromes or structures are suspected as the cause of the problem. It is more invasive and involves removing the top and bottom jaw and moving them forward or restructuring the chin, maxilla or mandible. Often it is performed in conjunction with Genioglossus Advancement.

Genioglossus Advancement

This procedure, commonly known as tongue advancement, is designed to move or pull the tongue forward to increase the size of the airway. It is sometimes performed along with Maxillomandibular Advancement (see description above).

Hyoid Suspension

This procedure involves pulling forward the hyoid bone in the neck to place it in front of the larynx. The hyoid bone is one of the attachment points for the tongue.

Pillar Procedure

This is one of the newer procedures whereby 3 stints are placed or injected into the soft palate offering support of the soft tissue and widening the opening in the air passage.

Medications, Prescriptions, or Pharmaceuticals

Currently there are no drugs on the market that are effective for the treatment of Obstructive Sleep Apnea.

Methylxanthine Theophylline is often used to treat those afflicted with Central Sleep Apnea and sometimes children or infants with Sleep Apnea but is not indicated for adults with OSA.

If normal treatments are not effective, sometimes a doctor may prescribe drugs that usually are reserved for narcolepsy or to help combat somnolence, such a stimulants or amphetamines. Modafinil, an anti-narcoleptic medication or wakefulness promoting drug, is sometimes used in this capacity.

Protriptiline, a tricyclic antidepressant, is helpful for a small number of Sleep Apnea patients. Sometimes acetazolamide and Medroxyprogesterone are prescribed to stimulate normal breathing. Prescription steroids or nasal decongestants can be useful in some cases to assist in widening the upper air passage.

Medication and CPAP Use

Orthodontic Treatment and Dental Appliances

Dental Devices or Oral Devices are sometimes used to treat Obstructive Sleep Apnea. There are several dental devices or procedures available and approved for use in treating Sleep Apnea. Usually one must go to a dentist to discuss which one would be the best choice based on the individual and to have the device custom made or fitted. They are often relatively expensive and have a moderate success rate, but could be a good option for some individuals. In general it seems the dental devices have an overall higher success rate than surgery but still lower than CPAP therapy. There are often some side effects that could be uncomfortable or cause other problems. Talk to a qualified dentist about these potential issues. Here are just a few:

The most popular treatment is MAD or the Mandibular Advancement Device. It forces the lower jaw down and forward which can help keep the air passage open and it looks like a mouth or tooth guard used commonly in sports.

Sometimes Sleep Splints are used that hold the tongue in a certain position increasing the size of the airway.

There is a functional magnetic system as well that places two magnets opposite of each other on the sides of the jaws to help keep the airway open.

Rapid Maxillary Expansion is an orthodontic procedure that involves inserting a temporary screw device which is applied to the upper teeth and then turned or tightened periodically over a 3 to 4 week period. It can help reduce nasal pressure and is a non-surgical procedure that may improve breathing in people with a narrow upper jaw.

Alternative Treatments and Lifestyle Changes

Usually these are things to be tried in conjunction with traditional treatments. Always consult with your doctor about any alternative treatment methods before trying them.

Some people have reported that playing a didgeridoo has helped strengthen the muscles in the pharynx and upper air passage and improved the number of apnea events or allowed them to lower their pressure.

In obese or overweight individuals, losing weight often has a profound effect on their Sleep Apnea and pressure needs for the CPAP machine. Eating a healthy diet combined with exercise, can promote loss of weight and with weight loss often comes the need for less pressure on the CPAP machine.

It is recommended to avoid alcohol or other depressants or drugs that can adversely affect those with Sleep Apnea. Avoiding cigarette smoke or quitting smoking and avoiding other pollutants can help with irritation of the mucous membranes in the nose and air passage that may cause swelling.

Trying different sleeping positions can help in some cases, especially sleeping in a somewhat upright position if one is not using a CPAP machine.

Yoga and Breathing Exercises such as those found in the Buteyko Method or in some Meditation techniques may be helpful.