Obstructive sleep apnea (OSA) is a condition which causes interruptions in breathing during sleep. It is a potentially serious sleep disorder in which breathing repeatedly stops and starts during sleep as the throat muscles intermittently relax and block the airway.
In obstructive sleep apnea, breathing is interrupted by a physical block to airflow, despite the effort to breathe. The most noticeable sign of obstructive sleep apnea is snoring. However, not everyone who has OSA snores.
According to Medilexicon’s medical dictionary, Obstructive Sleep Apnea (OSA) is:
“a disorder, first described in 1965, characterized by recurrent interruptions of breathing during sleep due to temporary obstruction of the airway by lax, excessively bulky, or malformed pharyngeal tissues (soft palate, uvula, and sometimes tonsils), with resultant hypoxemia and chronic lethargy. Sleep in the supine position predisposes apnic episodes.”
People with OSA may experience repeated episodes of apnea during the night. The lack of oxygen causes a person to come out of deep sleep into a lighter stage of sleep in order to restore their normal breathing. Once they fall back into deep sleep further episodes of apnea can occur.
The repeated interruptions to sleep that are caused by OSA can lead to the person feeling very tired during the day. A person with OSA will usually have no memory of any episodes of breathlessness.
OSA is a relatively common condition that affects men more than women. The condition is most common in people aged 40 or over, although it can affect people of all ages, including children.
It is also especially common in people who are overweight.
OSA is a serious condition
A person suffering from the condition can experience a lack of proper sleep. As a result, their risk of being involved in a life-threatening accident, such as a car crash, is increased. The lack of sleep causes impairment in judgment and reaction time.
Also, there is some evidence suggesting that people with OSA are at greater risk of developing high blood pressure (hypertension), which can lead to a heart attack or stroke.
Obstructive sleep apnea treatment may involve using a device to keep the airway open or undergoing a procedure to remove tissue from the nose, mouth or throat.
What are the signs and symptoms of sleep apnea?
A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign. Signs and symptoms of obstructive sleep apnea include:
Abrupt awakenings accompanied by shortness of breath
Awakening with a dry mouth or sore throat
Difficulty staying asleep (insomnia)
Excessive daytime sleepiness (hypersomnia)
Frequent heartburn or gastroesophageal reflux disease
Frequent urination at night
Heavy night sweats
Loud snoring (with periods of silence followed by gasps)
Mood changes such as irritability, anxiety and depression
Observed episodes of breathing cessation during sleep
Unexplained daytime sleepiness
Consult a medical professional if you experience, or if your partner observes the following:
Snoring loud enough to disturb your sleep or that of others
Shortness of breath that awakens you from sleep
Intermittent pauses in your breathing during sleep
Excessive daytime drowsiness, which may cause you to fall asleep while you’re working, watching television or even driving a vehicle
People with OSA may have no memory of their sleep being interrupted. Over time, the repeated interruptions to sleep will lead to the symptoms of sleep deprivation. These include:
feeling excessively sleepy during the day
headaches; particularly in the morning
irritability and short temper
lack of interest in sex
poor memory and concentration
in men, impotence
Some people with OSA may also find that they wake up frequently during the night in order to urinate.
Many people do not consider snoring as a sign of something potentially serious. In addition, not everyone who has sleep apnea snores. Typically, snoring is loudest when sleeping on the back. It quiets when turning on the side.
Seek medical advice about any sleep problem that leads to chronic fatigue, sleepiness and irritability.
What causes obstructive sleep apnea?
Obstructive sleep apnea occurs when the muscles in the back of the throat relax too much to allow normal breathing. These muscles support the tongue, tonsils and soft palate (a muscle at the back of the throat used in speech). Once the muscles relax, the airway in the throat can narrow or become totally blocked. This interrupts the oxygen supply to the body which triggers the brain to interrupt deep sleep so that the airway can be reopened and normal breathing is restored.
This awakening is usually so brief that the person does not remember it.
The person awakens with a temporary shortness of breath that corrects itself quickly, within one or two deep breaths. The person makes a snorting, choking or gasping sound. All night long, this pattern can repeat itself five to 30 times or more each hour. These disruptions impair the ability to reach the deep, restful phases of sleep.
Most adults require at least eight hours of sleep to function at their best and half of that time should be spent in the deepest phase of sleep.
Obstructive sleep apnea in children, unlike adults, is often caused by obstructive tonsils and adenoids and may sometimes be cured with tonsillectomy and adenoidectomy.
What are the risk factors of obstructive sleep apnea?
A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.
Anyone can develop obstructive sleep apnea. However, there are certain risk factors:
Obesity – the more obese a person is, the higher the risk. More than half of those with obstructive sleep apnea are overweight. Fat deposits around the upper airway may obstruct breathing. However, thin people can also develop the disorder.
A family history of sleep apnea – People with family members with sleep apnea, may be at increased risk.
A narrowed airway – People who have a naturally narrow throat. Tonsils or adenoids may become enlarged, blocking the airway.
Age – Being 40 years of age or over.
Being black, Hispanic or a Pacific Islander – Among people under age 35, obstructive sleep apnea is more common in blacks, Hispanics and Pacific Islanders.
Being male – In general, men are twice as likely to have sleep apnea. The reasons why are unknown.
Being older – Sleep apnea occurs two to three times more often in adults older than 65.
Chronic nasal congestion – Obstructive sleep apnea occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways.
Diabetes – Obstructive sleep apnea is three times more common in people who have diabetes.
Having a large neck – The size of the neck may indicate whether or not there is an increased risk of obstructive sleep apnea. This is because a thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17 inches (43 centimeters) for men and 15 inches (38 centimeters) for women is associated with an increased risk of obstructive sleep apnea.
Having an unusual inner-neck structure – Such as an unusually narrow airway or unusually large tonsils or tongue or having a lower jaw that is set back further than normal.
High blood pressure (hypertension) – Obstructive sleep apnea is relatively common in people with hypertension.
Menopause – A woman’s risk appears to increase after menopause. The changes in hormone levels that occur during the menopause may cause the throat muscles to relax.
Smoking. Smokers are nearly three times more likely to have obstructive sleep apnea.
Taking medicines that have a sedative effect – Such a sleeping pills or tranquillizers.
Taking the anti-impotence medicine sildenafil (Viagra) – There is some evidence to suggest that sildenafil can cause the throat muscles to relax.
Use of alcohol, sedatives or tranquilizers – These substances relax the muscles in the throat.
What are the complications of obstructive sleep apnea?
Sleep apnea is considered a serious medical condition. Complications may include:
Cardiovascular problems. Many people with obstructive sleep apnea (OSA) develop high blood pressure (hypertension). This also increases the risk of developing a cardiovascular disease such as a stroke or heart attack. This can lead to sudden death from a cardiac event. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. The more severe the obstructive sleep apnea, the greater the risk of high blood pressure. Patients with sleep apnea are much more likely to develop abnormal heart rhythms such as atrial fibrillation.
Daytime fatigue. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work or even when driving. Children and young people with sleep apnea may do poorly in school, have reduced mental development or have behavior problems. Treatment of sleep apnea can improve these symptoms, restoring alertness and improving quality of life.
Sleeping while Driving. Experiencing significant daytime sleepiness will have an adverse impact on driving ability. One study calculated that people with severe untreated OSA are 15 times more likely to be involved in a car accident. You should avoid driving until symptoms of OSA respond to treatment
Complications with medications and surgery. Obstructive sleep apnea is a concern with certain medications and general anesthesia. People with the condition may be more likely to experience complications after major surgery. This is because they are prone to breathing problems, especially when sedated and lying on their backs. Inform your doctor before having surgery. Undiagnosed sleep apnea is especially risky in this situation. Use of analgesics and sedatives in these patients postoperatively should be minimized or avoided.
Partners or family. Loud snoring can keep those around from getting good rest. This can be eventually disruptive in relationships.
People with obstructive sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, and a need to urinate frequently at night.
How is obstructive sleep apnea diagnosed?
If experiencing the symptoms of excessive daytime sleepiness a useful first step may be to ask a partner, friend, or relative to observe you when you are asleep. They may be able to spot episodes of breathlessness that could help to confirm a diagnosis of obstructive sleep apnea (OSA).
Physical examination and tests
A physical examination and a number of tests, including a blood pressure test, may be carried out. This is in order to rule out other conditions that could explain tiredness, such as an under-active thyroid gland.
An evaluation may be made based on the signs and symptoms or there may be referral to a sleep disorder center. A sleep specialist can help decide whether there is need for further evaluation. The evaluation may involve overnight monitoring of breathing and other body functions during sleep. This can sometimes be done in sleep centers which are specialist clinics or hospital departments that help treat people with sleep disorders.
Nocturnal polysomnography. During this test, the patient is hooked up to equipment that monitors the heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while sleeping.
Oximetry. This screening method involves using a small machine that monitors and records blood oxygen level while sleeping. A simple sleeve fits painlessly over one finger to collect the information overnight at home. The results of this test will often show drops in blood oxygen level during apneas and subsequent rises with awakenings. However, oximetry does not detect all cases of sleep apnea.
Portable cardiorespiratory testing. Under certain circumstances, the patient may be provided with at-home tests to diagnose sleep apnea. These tests usually involve oximetry, measurement of airflow and measurement of breathing patterns.
The patient may also be referred to an ear, nose and throat doctor (otolaryngologist) to rule out any anatomic blockage in the nose or throat.
The severity of OSA is judged on how many episodes of apneas are experienced over the course of an hour. The number of episodes determines mild, moderate, and severe OSA:
Mild OSA – between 5 to 14 episodes an hour.
Moderate OSA – between 15 to 30 episodes an hour.
Severe OSA – more than 30 episodes an hour.
What is the treatment for obstructive sleep apnea?
Lifestyle changes may be recommended for milder cases of obstructive sleep apnea, such as losing weight or quitting smoking. If these measures do not improve the signs and symptoms or if the apnea is moderate to severe, a number of other treatments are available:
Positive airway pressure. For moderate to severe sleep apnea, a machine that delivers air pressure through a mask placed over the nose while sleeping may be recommended. The most common type is called continuous positive airway pressure (CPAP). With this treatment, the pressure of the air breathed is continuous. The compressed air prevents the airway in the throat from closing. This prevents apnea and snoring.
CPAP is the most commonly used method of treating sleep apnea. However, some people find it awkward and uncomfortable. Most people learn to adjust the mask to obtain a comfortable and secure fit. Some people also benefit from using a humidifier along with their CPAP system.
Do not stop using the CPAP machine. Check with your doctor to see what adjustments can be made to improve its comfort. Also, after weight changes, your doctor may need to adjust the pressure settings.
Mouthpiece (oral device) or Inter-oral devices (IODs). Wearing a mouthpiece designed to keep the throat open is another option. Oral appliances are a successful alternative for some patients. Some are designed to open the throat by bringing the jaw forward. This can sometimes relieve snoring and mild obstructive sleep apnea. Others hold the tongue in a different position. Advice from a dentist experienced in dental sleep medicine appliances is required for the fitting and follow-up therapy.
Surgery or other procedures
The goal of surgery is to remove excess tissue from the nose or throat that may be vibrating and causing the snoring. The excess tissue may be blocking the upper air passages and causing sleep apnea. Surgical options may include:
Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which the tissue from the rear of the mouth and top of the throat is removed. The tonsils and adenoids are commonly removed as well. UPPP usually is performed in a hospital and requires a general anesthetic.
Jaw correction. This procedure is called maxillomandibular advancement. The upper and lower parts of the jaw are moved forward from the rest of the facial bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure may require an oral surgeon and an orthodontist
Surgical opening in the neck. This form of surgery may be needed if other treatments have failed and the patient has severe, life-threatening sleep apnea. In this procedure, called a tracheostomy, an opening in the neck is made. A metal or plastic tube is inserted for breathing. The opening is kept covered during the day. But at night it is uncovered to allow air to pass in and out of the lungs, bypassing the blocked air passage in the throat.
Implants. The Pillar procedure is a minimally invasive treatment. It involves placement of three tiny polyester rods in the soft palate. These inserts stiffen and support the tissue of the soft palate and reduce upper airway collapse and snoring. This treatment is recommended only for people with mild to moderate obstructive sleep apnea.
Removing tissues in the back of the throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that are sometimes use to treat snoring. However, these procedures are not recommended for treating obstructive sleep apnea.
Other types of surgery: They may help reduce snoring and sleep apnea by clearing or enlarging air passages:
Nasal surgery to remove polyps or straighten a crooked partition between the nostrils (deviated nasal septum)
Surgery to remove enlarged tonsils or adenoids
If symptoms of daytime sleepiness are particularly severe, a short-term dose of a medicine known as a stimulant may be recommended. Stimulants work by increasing the activity within the nervous system in order to make the patient feel more alert and awake.
A medicine called modafanil may be recommended. Side effects of modfanil can include dizziness and blurred vision. In rare situations, modafanil can cause depression and make people think suicidal thoughts. The long-term use of stimulants is not recommended because they can become addictive.
Treatment is offered by speech therapists to strengthen the muscle tone and neural pathways involved in breathing.
Breathing exercises, such as those used in Yoga, the Buteyko method, or didgeridoo playing can be effective. There are muscles which act to tension and open the airway during each inspiration. Exercises can, in some cases, restore sufficient function to these muscles to prevent or reduce apnea.
Many people benefit from sleeping at a 30 degree elevation of the upper body. It helps prevent the gravitational collapse of the airway. A 30 degree elevation of the upper body can be achieved by sleeping in a recliner, an adjustable bed, or a bed wedge placed under the mattress. This approach can easily be used in combination with other treatments and may be particularly effective in very obese people. Lateral positions (sleeping on a side) as opposed to supine positions (sleeping on the back), are also recommended.
Some cases of mild to moderate OSA can be successfully treated by making changes to lifestyle. These include:
Avoiding alcohol during the evening.
Sleeping on the side, rather than on the back, may also help to relieve symptoms of OSA.
Avoid medications such as tranquilizers and sleeping pills. These relax the muscles in the back of the throat, interfering with breathing.
Keep nasal passages open at night. If there is congestion, use a saline nasal spray to help keep the nasal passages open. Get medical advice about using nasal decongestants or antihistamines, because, unlike saline sprays, these medications are generally recommended only for short-term use.
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