Sleep Apnea – A Primer
April 1, 2008
Note: This is an edited transcription of a podcast recording
So what is obstructive sleep apnea? Apnea means a total cessation of breathing and this happens only when one is sleeping. So a person with sleep apnea can stop breathing from 10 to 50 to even over 100 times every hour with each episode lasting anywhere from 10 to 30 seconds. Using strict criteria, it is estimated that about 4% of men and 2% of women have this condition, but using looser criteria, it can be up to 25% in men and up to 9% in women. The scary statistic is that this condition is not diagnosed in about 80-90% of people who have it, so instead, they are being treated for the end result which can be diabetes, depression, high blood pressure, etc. It is also known that significant sleep apnea happens in about 35% of chronic snorers. It’s also important to note that you don’t need to snore to have sleep apnea, as well.
Some of the symptoms of sleep apnea include: snoring, depression or irritability, poor concentration, memory or focus problems, morning headaches, poor job performance, attention deficit disorder, and obesity. A recent study came out describing the number of car accidents in one year. It’s estimated that about 800,000 car accidents occur every year due to sleep apnea and of these, there are about 1,400 fatalities. In addition, it’s estimated that of all the commercial truck drivers in America, about 28% of them had this condition, and of this group, about one third of them have moderate to severe sleep apnea.
There are a number of medical conditions associated with sleep apnea, as well. It’s found that people with sleep apnea have up to a 50% incidence of high blood pressure and people with high blood pressure have about a 50% incidence of sleep apnea. Now the studies show that if you have had a heart attack, you are 23 times more likely to have sleep apnea and the reverse showed that if you have sleep apnea, you are about 1 ½ times as likely to have heart disease.
Another study looked at 200,000 charts retrospectively and found that patients on medicines for depression or high blood pressure were 18 times more likely to be eventually diagnosed with sleep apnea. So what they concluded was that many patients are being treated for the symptoms or complications of sleep apnea rather than the underlying cause itself.
I mentioned previously that attention deficit disorder was associated with sleep apnea. In an interesting study that came out in the Journal of Pediatrics, researchers recruited 78 children who were about to undergo a tonsillectomy for various reasons including recurrent infections or sleep apnea and compared them against 22 other children undergoing other types of surgical procedures. All these children underwent formal sleep studies and a battery of psychological tests including that for attention deficit disorder and found that 22 children, or 28% of the tonsillectomy group, were found to have ADHD by official psychiatric criteria. The control group only had 7% that were found to have sleep apnea. After surgery, one year later, 11 children or 50% of the children who originally had ADHD, no longer had by official criteria. Furthermore, after the surgery, the incidence of sleep apnea in the tonsillectomy group was equivalent to that in the control group.
I could go on and on about snoring and sleep apnea being associated with increased risk of children having memory, attention or cognitive skill problems, asthma, chronic cough, etc. but I’ll stop here. One more comment about adults and sleep apnea and ADHD: there was one study that looked at three adult patients with attention deficit disorder and sleep apnea and all three of these patients were on Ritalin. Two of these patients, after treatment for sleep apnea, were weaned off the Ritalin and the third selected weight loss and conservative regimen. This goes to show that sleep apnea and ADHD can co-exist in adults, as well.
Other medical conditions include heart disease, stroke, diabetes, erectile dysfunction and obesity, seizures, migraines, and even preeclampsia, which is a condition where pregnant women get high blood pressure at dangerous levels. All of these conditions have been associated with sleep apnea and to various degrees, respond to treatment.
So how do you diagnose sleep apnea? To diagnose sleep apnea, you have to undergo a formal sleep study, which is an overnight test where you go into a facility and they hook you up to all these monitors all over your body and they analyze all the different parameters like breathing, respirations, heart rate, brain waves, etc. while you sleep. This way they can calculate how many times you stop breathing every hour and how long for every episode. To officially get the diagnosis of obstructive sleep apnea, your apnea/hypopnea index, or the number of times you stop breathing totally or partially for greater than 10 seconds for each episode, has to be greater than 15 events every hour. Now, if you’re symptomatic – if you’re very sleepy or if you have any of the medical complications of sleep apnea such as depression, diabetes, high blood pressure, etc.—then your number can be down to 5.
One of the problems with these criteria for sleep apnea is that if you stop breathing for 9 seconds at a time and you stop breathing 50 times every hour, then officially you won’t have the diagnosis of sleep apnea and then you get into the realm of upper airway resistance syndrome, which I discussed in another article. If you snore only and don’t have any significant apnea or you’re otherwise asymptomatic, then you can elect to undergo snoring treatment, which I’ll talk about in a separate article. If you snore and have significant apneas, then treating the apneas will also treat the snoring, in general.
There are a number of conservative measures that are recommended to treat snoring and sleep apnea including weight loss, positional therapy, sleeping with the mouth closed as well as a number of different snoring treatments but there’s only so much one can do with this. First of all, it’s hard to lose weight because you’re so tired and it’s hard to exercise. In terms of trying to sleep on your side or on your back, you only have so much control over that when you’re sleeping. One note about snoring treatments: over-the-counter snoring treatments have been found to work sometimes but a recent controlled study which looked at three popular snore aids, including a nasodilator strip, an oral lubricant and a pillow. All were found objectively not to have any significant benefit. However, I have many patients who swear by these over-the-counter snore aids, but in my experience, it only works sometimes for some people but in general it doesn’t work most of the time.
If you’re found to have obstructive sleep apnea, the best way to treat this condition is via what’s called a Continuous Positive Airway Pressure machine, or CPAP. This is a small device that acts as an air pump which blows some positive gentle air pressure through your nose and it stents your airway open so you don’t stop breathing at night. When used effectively, it works. You wake up feeling much more refreshed, have much more energy and all the medical problems start to get better. One of the problems with CPAP, however, is that people just don’t like to use it, but with good counseling and proper follow-up from clinic staff and the equipment people that administer the device, many people can do well with this device.
However, there are certain people who just can’t use CPAP for other reasons despite trying different kinds of masks, headgear and devices. These people end up going to different devices, one of which is a mandibular advancement device, which are oral appliances that dentists make. They make an impression of your teeth and the bottom part, the mandible, the jaw bone slowly is pushed forward. The way this works is that it pulls the tongue forward, which is one of the reasons for sleep apnea, amongst many other reasons. Again, when applied properly and when patients use it, this device does work especially for snoring and for mild to moderate sleep apnea. But compliance is also a problem due to jaw pain, dry mouth, ear pain, headaches, and bite problems.
The last major option is surgery and this is a huge topic in itself and I will discuss this in detail in another article, but just to summarize, when considering doing surgery, people have to have failed trying CPAP, or at least consider the mandibular advancement device and reject it. One has to be really motivated. Secondly, there has to be some type of anatomic reason for the collapse so when I do the examination and do the endoscopy to look inside the airway passages, I have to see is some sort of obvious collapse to address it via surgical measures.
The first and most obvious area of obstruction is actually the nose. If your nose is stuffy for whatever reason—allergies, polyps, deviated septum, or anything else—that’s the first thing that I address, whether medically or surgically. This is because if you don’t breathe well through your nose, then everything else downstream is more prone to collapse. So once the nose is taken care of and if you still have sleep apnea, then you can try going back to the CPAP. Many people with stuffy noses can’t tolerate CPAP that well, but once that problem is corrected, a certain number of people can start using the CPAP more effectively. If you go further downstream, the other two major areas are at the palatal level and the tongue level. In our field (ear, nose, throat, head & neck surgery) we’ve been focusing too much on the palate because that’s typically where the snoring sounds are coming from, but that’s not the only area. If you don’t address the tongue, as well as the palate, then your success rates aren’t going to be that great.