Obstructive Sleep Apnea

Breathing is something people typically don’t think about. But more than 12 million Americans stop breathing-some of them hundreds of times every single night. It’s a condition called sleep apnea, and it can not only lead to disrupted sleep, but it can also increase your risk for serious conditions such as high blood pressure, heart attack, and stroke.

Three types of sleep apnea exist:

• Obstructive Sleep apnea occurs when soft tissues in your nose, mouth and throat obstruct your airway when you are sleeping.
• Central Sleep apnea occurs when the brain does not send the proper signals to control breathing
• Mixed Sleep apnea occurs when patients have components of both obstructive and central sleep apnea

Obstructive sleep apnea is the most common form.

Causes
In people with obstructive sleep apnea, soft tissue in the back of the throat collapses during sleep and partially or completely blocks the airway. As a result, not enough air flows into the lungs to deliver oxygen to the blood.

As your oxygen level drops, a signal goes to your brain, which sends out a message to wake you up so you can restart your breathing. This constant wake-up call leads to interrupted sleep. Often people with obstructive sleep apnea will emit a loud snore or choking sound each time they wake up.

Risk Factors
You are more likely to develop obstructive sleep apnea if you:

• Are overweight. More than half of people with sleep apnea are overweight, according to the National Heart, Lung, and Blood Institute. Extra fat tissue can narrow the opening to the windpipe, preventing enough air from getting in.
• Have an enlarged tongue and/or tonsils. Larger organs can block the opening to the windpipe. Having a thicker-than-normal neck can also increase the risk of developing obstructive sleep apnea.
• Are older. Changes in the bone structure that occur with age can prevent your throat muscles from remaining stiff while you sleep.
• Are male. Men are about twice as likely to develop sleep apnea as women. However, women’s risk goes up after menopause.
• Have a family history. If your mother, father, sister, or other close relative has sleep apnea, your risk goes up.
• Have heart risk factors. High blood pressure, heart failure, and stroke can both contribute to and result from sleep apnea.
• Are African American, Mexican, or Pacific Islander.
• Smoke. Smoking can lead to inflammation in the airways.

Symptoms
Snoring is probably the most common and most obvious symptom of obstructive sleep apnea. It tends to be particularly loud when lying on your back. Some people make a gasping or choking sound as their breathing restarts.

Other symptoms of obstructive sleep apnea include:

• Feeling excessively tired during the day
• Irritability and/or depression
• Difficulty learning, remembering, and concentrating
• Mouth breathing (common in children with sleep apnea)
• Dry mouth or throat when you wake up in the morning

Diagnosis
You may not be aware that you have sleep apnea, but if you snore or have any of the symptoms of sleep apnea, see your doctor for an evaluation. An ear, nose, and throat specialist (otolaryngologist) may be involved in your diagnosis.

The doctor will check your medical history, do a physical exam, and may order sleep studies. During a sleep study, you stay overnight in the hospital or a sleep laboratory while the medical staff monitors your breathing, heart rate, brain waves, and other vital signs. A sleep study can help diagnose obstructive sleep apnea, as well as other sleep-related problems.

Complications
If left untreated, obstructive sleep apnea can lead to a variety of health conditions, including:

• Fatigue
• Depression
• High blood pressure
• Heart attack
• Impotence
• Morning tiredness
• Need to use the bathroom frequently at night (nocturia)
• Stroke
• Weight gain

Because some of these complications are life-threatening, it’s important to get treated for obstructive sleep apnea as soon as possible.

Treatment
With treatment, you can reduce your risk for sleep apnea complications.

One way to treat obstructive sleep apnea is with lifestyle changes:

• Lose weight if you’re overweight.
• Avoid alcohol, sedatives, and other medications that make you feel drowsy, especially before bedtime.
• Sleep on your side, rather than on your back, to help keep your airways open. You can buy a special pillow to keep you on your side if you have a tendency to flip over onto your back.
• Stop smoking.

Devices are available to help people with obstructive sleep apnea breathe during the night. An oral appliance adjusts the position of your lower jaw and tongue to help keep your airways open. Continuous positive airway pressure (CPAP) is a breathing machine that fits over your mouth and nose and gently blows air into your throat to keep oxygen flowing while you sleep. Although CPAP is very effective, many patients find it cumbersome and uncomfortable to wear.

If these treatments do not relieve your sleep apnea, there are medical procedures that can help you breathe more easily. There are a range of surgical options to treat sleep apnea. Surgery typically involves a hospital stay, and can have risks such as bleeding and infection.

• Uvulopalatopharyngoplasty is a surgery to remove excess tissue of the uvula, soft palate and tonsils widen the airway to provide more airflow to the lungs. The amount of tissue removed in surgery will depend on your anatomy and disease severity.
• Surgery inside the nose to open up any blockages that inhibit airflow. This may include removing polyps or straightening the nasal septum.
• A nasal valve procedure to open blocked nasal passages. The doctor makes two incisions-one under the eye and one in the nostril and inserts a clip in the bone under the eye. A piece of suture attaches to the clip and loops around the sagging nasal tissue, to pull it taut and open the nasal passages.
• Maxillomandibular Advancement is a surgery to move the upper and lower jaws forward to increase the space behind the palate and tongue. This procedure may also involve an oral surgeon or orthodontist.
• A tracheostomy tube may need to be placed for severe sleep apnea that has failed to respond to other treatments and surgeries. In this procedure a plastic or metal tube is inserted into the trachea (airway) through the front of the neck. At night, you breathe through this tube, bypassing the blocked airways in the upper throat and mouth.

Minimally invasive procedures are also available, and they can be performed right in the doctor’s office. They include:

• The Pillar procedure, in which the doctor implants three small polyester implants into the palate. The implants create scar tissue, which stiffen the palate to keep it from fluttering and obstructing the airway at night.
• A radiofrequency technique to reduce an enlarged tongue or tonsils. A thin probe delivers radiofrequency energy to shrink the tissues.

Sources:
National Heart, Lung and Bone institute.  Sleep Apnea
http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html
American Sleep Apnea Association
http://www.sleepapnea.org/info/index.html
Mayo Clinic.  Sleep Apnea
http://www.mayoclinic.com/health/sleep-apnea/DS00148/DSECTION=1