Learning Center

SLEEP DISORDERED BREATHING

Snoring
Habitual loud snoring is the most common symptom of breathing disorders that occur during sleep. The person who snores not only sleeps restlessly, but also is at risk for serious disorders of the heart and lungs. Snoring can therefore be life-threatening because it can lead to high blood pressure, irregular heart beats, heart attacks, and sudden death.

Normal breathing must continue at all times whether awake or asleep. The act of breathing is an automatic, highly regulated mechanical function of the body. In healthy sleeping individuals, most muscular and neural activities will slow or even shut down, but respiration goes on under a neuromuscular “auto pilot.” However, if something goes wrong with the auto pilot during sleep, breathing may become erratic and inefficient.
Snoring is more common in:

elderly men and women
postmenopausal women
people who are overweight
where some physical abnormality in the nose or throat is present
abnormalities in other parts of the upper airway
night-shift workers
people who habitually drink too much alcohol
people with depression and other psychotic disorders

Symptoms of Sleep Apnea
Patients with sleep apnea have many repeated involuntary breathing pauses during sleep. The length of the breathing pause can vary within a patient, and among patients, and can last for 10 seconds to 60 seconds. Fewer than 30 such breathing pauses during a 7-hour sleep, or shorter breathing pauses, are not considered indicative of sleep apnea. Most sleep apnea patients experience 20 to 30 “apneic events” per hour, more than 200 per night. These pauses may occur in clusters.

The breathing pauses are often accompanied by choking sensations which may wake up the patient, intermittent snoring, nighttime insomnia, early morning headaches, and excessive the apneic events, a person may turn blue from low blood oxygen levels.
Other features of sleep apnea include slowing down of heart beat below 60 beats per minute (bradycardia), irregular heart beat (cardiac arrhythmias), high blood pressure (both systemic and pulmonary arterial), increase in red cells in the blood (polycythemia), and obesity. The absence of restful sleep may cause deterioration of performance, depression, irritability, sexual dysfunction, and defects in attention and concentration.

Types of Sleep Apnea
Scientists have distinguished three types of sleep apnea: obstructive, central, and mixed. However, since all three types can have the same symptoms and signs, a sleep evaluation is needed to tell the difference among them.

Obstructive Sleep Apnea (OSA) is the most common type. During OSA, efforts to breathe continue, but air cannot flow in or out of the patient’s nose or mouth. The patient may also snore heavily and have frequent arousals (abrupt changes from deep sleep to light sleep) without being aware of them.

OSA occurs when the throat muscles and tongue relax during breathing and partially block the opening of the airway. When the muscles of the soft palate at the base of the tongue and the uvula (the small conical fleshy tissue hanging from the center of the soft palate) relax, and the airway becomes obstructed making breathing labored and noisy. Airway narrowing may also occur due to being overweight, possibly because of the associated increases in the amount of tissue in the airway.

The reduction in oxygen and increase in carbon dioxide which occur during apnea cause arousals. With each arousal, a signal is sent to the upper airway muscles to open the airway; breathing is resumed with a loud snort or gasp. Although arousals serve as a rescue mechanism and are necessary for a patient with apnea, they interrupt sleep, and the patient ends up with less restorative and sleep than normal individuals.

Central Apnea occurs less frequently than obstructive apnea. There is no airflow in or out of the airway because efforts to breathe have stopped for short periods of time. In central apnea, the brain temporarily fails to send the signals to the diaphragm and the chest muscles that maintain the breathing cycle. It is present more often in the elderly than in younger people but often goes unrecognized.

In central apnea, there is periodic loss of rhythmic breathing movements. The airways remain open but air does not pass through the nose or mouth because activity of the diaphragm and the chest muscles stops. Patients with central apnea may not snore and they tend to be more aware of their frequent awakenings than those with obstructive apnea.

In Mixed Apnea, a period of central apnea is followed by a period of obstructive apnea before regular breathing resumes. People with mixed apnea frequently snore.

Snoring and Sleep Apnea
Snoring is a sign of abnormal breathing. It occurs when physical obstruction causes fluttering of the soft palate and the adjacent soft tissues between the mouth, external orifices of the nose (nares), the upper part of the windpipe (trachea), and the passage extending from the pharynx to the stomach (esophagus).

Snoring always occurs with obstructive sleep apnea. When diagnosing sleep disorders, obstructive sleep apnea is excluded if snoring is not a symptom. All snorers do not necessarily have sleep apnea; however, because they almost certainly have some physical obstruction in their airways, they may develop sleep apnea.

The prevalence of snoring is greater in the older population and apparently peaks in 60-year-old men and women, declining in older individuals. Men seem to snore more than women. Men also are more likely to develop sleep-disordered breathing. It is estimated that nearly half of all males over 40 snore habitually. Snoring is also more common in overweight people.

A visit to the doctor is not necessary when a person snores unless some of the other symptoms of sleep disordered breathing also occur. However, since snoring is an annoying or irritating symptom with some negative social aspects, many people have sought a “cure” for it. More than 300 devices have been patented in the U. S. which claim to control snoring. Many of these devices were developed even before medical scientists found out that heavy snoring is a potential marker of sleep apnea.

Sleep Apnea and the Heart
Sleep apnea and snoring seems to increase the likelihood of having a variety of cardiovascular diseases. These include high blood pressure, ischemic heart disease (a condition caused by reduced blood supply to the heart muscle), cardiac arrhythmias (abnormal heartbeat rhythm), and cerebral infarction (blood clot in the brain). It is not unusual for patients with sleep apnea to be mistakenly treated for primary heart disease because cardiac arrhythmias may be more prominent than the breathing disturbances.

Nearly 50 percent of sleep apnea patients have high blood pressure. Patients with the most severe sleep apnea seem to have the highest blood pressure levels and are also more likely to have trouble controlling their blood pressure than patients who do not have sleep apnea.

No one knows whether a cause and effect relationship exists between high blood pressure and sleep apnea. If it does exist, the ways these conditions interact is unknown. Snoring alone does not appear to be a risk factor for heart disease. Only when snoring occurs with sleep apnea or obesity does it seem to be associated with these conditions.

Diagnosis

What Causes Sleep Apnea?
When you are awake, throat muscles help keep your airway stiff and open so air can flow into your lungs. When you sleep, these muscles are more relaxed. Normally, the relaxed throat muscles don’t stop your airway from staying open to allow air into your lungs. But if you have obstructive sleep apnea, your airways can be blocked or narrowed during sleep because:

Your throat muscles and tongue relax more than normal.
Your tongue and tonsils (tissue masses in the back of your mouth) are large compared to the opening into your windpipe.
You’re overweight. The extra soft fat tissue can thicken the wall of the windpipe. This causes the inside opening to narrow and makes it harder to keep open.
The shape of your head and neck (bony structure) may cause a smaller airway size in the mouth and throat area.
The aging process limits the ability of brain signals to keep your throat muscles stiff during sleep. This makes it more likely that the airway will narrow or collapse.

Not enough air flows into your lungs when your airways are fully or partly blocked during sleep. This can cause loud snoring and a drop in your blood oxygen levels. When the oxygen drops to dangerous levels, it triggers your brain to disturb your sleep. This helps tighten the upper airway muscles and open your windpipe. Normal breaths then start again, often with a loud snort or choking sound.

The frequent drops in oxygen levels and reduced sleep quality trigger the release of stress hormones. These compounds raise your heart rate and increase your risk for high blood pressure, heart attack, stroke, and irregular heartbeats. The hormones also raise the risk for or worsen heart failure. Untreated sleep apnea also can lead to changes in how your body uses energy. These changes increase your risk for obesity and diabetes.

How Is Sleep Apnea Diagnosed?
When you are awake, throat muscles help keep your airway stiff and open so air can flow into your lungs. When you sleep, these muscles are more relaxed.

Normally, the relaxed throat muscles don’t stop your airway from staying open to allow air into your lungs. But if you have obstructive sleep apnea, your airway can be blocked or narrowed during sleep because:

Your throat muscles and tongue relax more than normal.
Your tongue and tonsils (tissue masses in the back of your mouth) are large compared to the opening into your windpipe.
You are overweight. The extra soft fat tissue can thicken the wall of the windpipe. This causes the inside opening to narrow and makes it harder to keep open.
The shape of your head and neck (bony structure) may cause a smaller airway size in the mouth and throat area.
The aging process limits the ability of brain signals to keep your throat muscles stiff during sleep. This makes it more likely that the airway will narrow or collapse.

Not enough air flows into your lungs when your airways are fully or partly blocked during sleep. This can cause loud snoring and a drop in your blood oxygen levels.

When the oxygen drops to dangerous levels, it triggers your brain to disturb your sleep. This helps tighten the upper airway muscles and open your windpipe. Normal breathing then starts again, often with a loud snort or choking sound.

Untreated sleep apnea also can lead to changes in how your body uses energy. These changes increase your risk for obesity and diabetes.

Doctors diagnose sleep apnea based on your medical and family histories, a physical exam, and results from sleep studies. Usually, your primary care doctor evaluates your symptoms first. He or she then decides whether you need to see a sleep specialist.

These specialists are doctors who diagnose and treat people with sleep problems. Such doctors include lung, nerve, or ear, nose, and throat specialists. Other types of doctors also can be sleep specialists.

Medical and Family Histories
Your doctor will ask you and your family questions about how you sleep and how you function during the day. To help your doctor, consider keeping a sleep diary for 1 to 2 weeks. Write down how much you sleep each night, as well as how sleepy you feel at various times during the day.

Your doctor also will want to know how loudly and often you snore or make gasping or choking sounds during sleep. Often you are not aware of such symptoms and must ask a family member or bed partner to report them.

If you are a parent of a child who may have sleep apnea, tell your child’s doctor about your child’s signs and symptoms.

Let your doctor know if anyone in your family has been diagnosed with sleep apnea or has had symptoms of the disorder.

Many people are not aware of their symptoms and therefore are not yet diagnosed with sleep apnea.

Physical Exam
Your doctor will check your mouth, nose, and throat for extra or large tissues. The tonsils often are enlarged in children with sleep apnea. A physical exam and medical history may be all that’s needed to diagnose sleep apnea in children.

Adults with this condition may have an enlarged uvula or soft palate. The uvula is the tissue that hangs from the middle of the back of your mouth. The soft palate is the roof of your mouth in the back of your throat.

Sleep Studies
A sleep study is the most accurate test for diagnosing sleep apnea. It captures what happens with your breathing while you sleep.
A sleep study is often done in a sleep center or sleep lab, which may be part of a hospital. You may stay overnight in the sleep center.

Polysomnogram (Sleep Study)
A polysomnogram (poly-SOM-no-gram), or PSG, is the most common study for diagnosing sleep apnea. This test records:

Brain activity
Eye movement and other muscle activity
Breathing and heart rate
How much air moves in and out of your lungs while you’re sleeping
The amount of oxygen in your blood

A PSG is painless. You will fall asleep just as you normally do, except you will have sensors on your scalp, face, chest, limbs, and finger. The staff at the sleep center will use the sensors to check on you throughout the night.

A sleep specialist reviews the results of your PSG to see whether you have sleep apnea and how severe it is. He or she will use the results to plan your treatment.

Treatment Options

How Is Sleep Apnea Treated?

Goals of Treatment
The goals of treating obstructive sleep apnea are to:

Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness

Treatment may help other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk for heart disease, stroke, and diabetes.

Specific Types of Treatment
Lifestyle changes, oral appliances, breathing devices, and/or surgery are used to treat sleep apnea. Currently, there are no medicines to treat sleep apnea.

If you have sleep apnea, talk to your doctor or sleep specialist about the treatment options that are most appropriate for your specific condition.

Lifestyle changes may be enough to relieve mild sleep apnea. Oral appliances may successfully treat mild to moderate sleep apnea. People who have moderate or severe sleep apnea may need breathing devices or surgery.

Lifestyle Changes
If you have mild sleep apnea, some changes in daily activities or habits may be all that you need.

Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
Lose weight if you are overweight or obese. Even a little weight loss can improve your symptoms.
Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
Keep your nasal passages open at night with nose sprays or allergy medicines, if needed. Talk to your doctor about whether these treatments might help you.
Stop smoking.

Oral Appliances
A mouthpiece, also known as an oral appliance, may help some people who have mild to moderate sleep apnea. An oral appliance may also be recommended if you snore loudly but don’t have sleep apnea.

Apnea Options dental sleep professionals can make a custom-fit plastic oral appliance for treating sleep apnea. The appliance will adjust your lower jaw and your tongue to help keep your airway open while you sleep.

If you use a oral appliance, it is important that you follow up with our office about discomfort or pain while using the device. You may need periodic office visits so that your appliance can be adjusted to fit better.

Breathing Devices
Continuous positive airway pressure (CPAP) is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your mouth and nose, or just over your nose. The machine gently blows air into your throat. The air presses on the wall of your airway. The air pressure is adjusted so that it is just enough to stop the airway from becoming narrowed or blocked during sleep.

Treating sleep apnea may help you stop snoring. But stopping snoring doesn’t mean that you no longer have sleep apnea or can stop using CPAP. Sleep apnea will return if CPAP therapy is stopped or not used correctly.

Usually, a technician will come to your home to bring the CPAP equipment. The technician will set up the CPAP machine and adjust it based on your doctor’s orders. After the initial setup, you may need to have the CPAP adjusted on occasion for the best results.

CPAP treatment may cause side effects in some people. These side effects include a dry or stuffy nose, irritated skin on your face, sore eyes, and headaches. If your CPAP isn’t properly adjusted, you may get stomach bloating and discomfort while wearing the mask.

If you are having trouble with CPAP side effects, work with your sleep specialist, his or her nursing staff, and the CPAP technician. Together, you can take steps to reduce these side effects. These steps include adjusting the CPAP settings or the size/fit of the mask, or adding moisture to the air as it flows through the mask. A nasal spray may relieve a dry, stuffy, or runny nose.

There are many different kinds of CPAP machines and masks. Be sure to tell your doctor if you’re not happy with the type you’re using. He or she may suggest switching to a different kind that may work better for you. People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP.

Surgery
Some people who have sleep apnea may benefit from surgery. The type of surgery and how well it works depend on the cause of the sleep apnea. Surgery is done to widen breathing passages. It usually involves removing, shrinking, or stiffening excess tissue in the mouth and throat or resetting the position of the lower jaw.

Surgery to shrink or stiffen excess tissue in the mouth or throat is done in a doctor’s office or a hospital. Shrinking tissue may involve small injections or other treatments to the tissue. A series of such treatments may be needed to shrink the excess tissue. To stiffen excess tissue, the doctor makes a small cut in the tissue and inserts a small piece of stiff plastic.

Surgery to remove excess tissue is only done in a hospital. You are given medicine that makes you sleep during the surgery. After surgery, you may have throat pain that lasts for 1 to 2 weeks.

Surgery to remove the tonsils, if they’re blocking the airway, may be very helpful for some children. Your child’s doctor may suggest waiting some time to see whether these tissues shrink on their own. This shrinking of the tonsillar tissue is common as small children grow.

Managing Apnea

Living With Sleep Apnea
Obstructive sleep apnea can be very serious. However, following an effective treatment plan can often improve your quality of life quite a bit.
Treatment can improve your sleep and relieve daytime tiredness. It also may make you less likely to develop high blood pressure, heart disease, and other health problems linked to sleep apnea. Treatment may improve your overall health and happiness as well as your quality of sleep (and possibly your family’s quality of sleep).

Ongoing Health Care Needs
Follow up with your doctor regularly to make sure your treatment is working. Tell him or her if the treatment is causing side effects that you can’t handle.

This ongoing care is especially important if you’re getting continuous positive airway pressure (CPAP) treatment. It may take a while before you adjust to using CPAP.

If you aren’t comfortable with your CPAP device or it doesn’t seem to be working, let your doctor know. You may need to switch to a different device or mask. Or, you may need treatment to relieve CPAP side effects.

Try not to gain weight. Weight gain can worsen sleep apnea and require adjustments to your CPAP device. In contrast, weight loss may relieve your sleep apnea.

Until your sleep apnea is properly treated, know the dangers of driving or operating heavy machinery while sleepy.<

If you’re having any type of surgery that requires medicine to put you to sleep, let your surgeon and doctors know you have sleep apnea. They might have to take extra steps to make sure your airway stays open during the surgery.

How Can Family Members Help?
Often, people with sleep apnea don’t know they have it. They are not aware that their breathing stops and starts many times while they’re sleeping. Family members or bed partners usually are the first to notice signs of sleep apnea.

Family members can do many things to help a loved one who has sleep apnea.
Let the person know if he or she snores loudly during sleep or has breathing stops and starts.
Encourage the person to get medical help.
Help the person follow the doctor’s treatment plan, including CPAP.
Provide emotional support.

Bed Partners

Is your sleep disturbed by the snoring of your bed partner?
Sharing a bed with a snorer can affect your quality of life and also be harmful to your physical and emotional health. In many cases, both bed partners suffer from sleep-disordered breathing and sleep deprivation although only one has clinical signs and symptoms of snoring or sleep apnea. Often, snorers do not take complaints from their bed partner seriously or act in denial – which can make the situation worse.

Research shows that people who sleep next to someone who snores also experience physical and emotional consequences. Snoring and sleep apnea is unique in that it is a condition that can affect two people, although only one person has the problem.

How Snoring and Sleep Apnea Affects Bed Partners
A bed partner who snores can deprive you of your own needed sleep. Sleep deprivation can lead to issues that affect your own quality of life. Listed below are some common side effects associated with the sleep deprivation of someone who shares the bed of a snorer.

High levels of fatigue and daytime sleepiness
Higher rate of aches and pains
Depression or poorer mental health
Irritability
Memory impairment
Increased risk for accidents

Recognizing a More Serious Problem: Sleep Apnea

Have you ever noticed that your partner regularly stops breathing or suddenly gasps or chokes when asleep?
If your answer to this question is “yes,” there is a high likelihood that your partner’s snoring is a sign of a more serious sleep disordered breathing problem. Research has shown that a bed partner’s observation of apnea (periods of no breathing) is a good predictor of obstructive sleep apnea.

How to Take an Active Role

Apnea Options Treats Bed Partners Too!
You can be proactive and help your bed partner get treated so you both get better sleep.

Apnea Options treats the spouses and sleep mates of our patients as much as we treat the snorer. Once the snoring goes away, the bed partner gets more rest and starts to feel better. Sometimes the bed partner doesn’t realize how bad the snoring was affecting his or her sleep until the snoring goes away.

Try these tips:

Suggest that you both get screened for sleep disordered breathing to see if either of you has a problem that could lead to something more serious
Discuss the negative health effects of sleep deprivation
Research different treatment options and discuss with your partner
Ask your partner to discuss his/her snoring with his/her primary care doctor