What is Obstructive Sleep Apnea?​

 

Obstructive sleep apnea (OSA) is the most common form of sleep apnea and is believed to affect approximately 4% of men and 2% of women. However, it is believed that only about 10% of people with OSA seek treatment leaving the majority of OSA sufferers undiagnosed.

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Symptoms

 

​Obstructive sleep apnea is caused by partial or complete blockage of the airways during sleep. During sleep, a person's throat muscles relax allowing the tongue and/or fatty tissues of the throat to fall back into the airways and block airflow. During an apnea event air is restricted from moving beyond the obstruction reducing blood flow to the brain. This in turn signals the brain to partially awaken from sleep to signal the body that it needs to breathe. This is often followed by a loud gasping, choking, or snorting sounds as the person takes a deep enough breath to fight past the obstruction.

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Once a breath is taken the brain returns to sleep, and the process begins once again. This process can occur just a few times a night or hundreds of times a night depending on the severity of the condition.

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• Mild OSA- The sufferer experiences 5-14 episodes of interruptions in breathing in an hour.

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• Moderate OSA- The sufferer experiences 15-30 episodes of interruptions in breathing in an hour.

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• Severe OSA- The sufferer experiences 30 or more interruptions in breathing in an hour.

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Other symptoms of obstructive sleep apnea include:​

 

• Snoring that is loud, disruptive, and regular is one of the most obvious signs of potential OSA.

 

• Frequent breaks in breathing caused by an obstruction. These cessations are often followed by choking or gasping noises as the body's respiratory system fights through the blockage.

 

• Excessive daytime sleepiness caused by frequent interruptions of sleep.

 

• Morning Headaches stem from the loss of oxygen in your bloodstream that flows to your brain as a result of the irregular breathing at night.

 

• Restless sleep. Sufferers of obstructive sleep apnea often have fitful sleep as their mind and body are constantly awakened throughout the night, pulling them out of the much needed stages of non-REM and REM sleep. 

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• Depression or irritability. Lack of regular quality sleep can wreak havoc on a person's mental well-being. Sufferers of obstructive sleep apnea often find themselves feeling short-tempered, and in time it can lead to more severe symptoms of depression.

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Causes and Risk Factors​

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• Weight- In many cases a person's body weight is directly linked to having obstructive sleep apnea. People who are overweight or obese are more likely to have sleep apnea than those that maintain a healthy weight. Sleep apnea can often be caused by excess fatty tissues that become built up in the neck and throat. This can lead to restrictions in airflow as the upper respiratory system's pathway is narrowed or pinched off during sleep.

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• Age- As people age their muscles begin to lose muscle tone. This is also true of the muscles in the throat. As throat muscles lose definition, they become weaker and more likely to collapse into the airways during sleep.

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• Enlarged tonsils or adenoids are the leading cause of obstructive sleep apnea in children but can also affect adults who never had a tonsillectomy when they were younger.

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• Natural causes- Some people can be genetically predisposed to having a narrower throat or may have an enlarged tongue that falls back into their airway. If your family has a history of OSA you are more likely to have it yourself.

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• Frequent alcohol use- Alcohol relaxes the muscles in the body, and this includes the throat muscles as well which may relax to the point of blocking the airway during sleep.

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• Smoking- Smoke is an irritant to the lungs, throat, and esophagus. It can cause inflammation and fluid retention in the upper airways that can impede airflow.

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Treatment​

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Positive airway pressure (PAP) Therapy

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• Continuous positive airway pressure (CPAP)

 

• Automatic positive airway pressure (APAP)

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• Bilevel positive airway pressure (BiPAP)

 

Oral Appliances

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• Mandibular advancement devices (MADs)

 

• Tongue retaining mouthpieces

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Surgery

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• Uvulopalatopharyngoplasty (UPPP) - a surgical procedure that involves removing and repositioning excess tissue in the throat to make the airway wider. The surgeon can trim down the  soft palate and uvula, remove the tonsils, and reposition some of the muscles of the soft palate. UPPP and other soft palate procedures are the most common type of surgery for sleep apnea.

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• Adenotonsillectomy - removal of the tonsils and the adenoids

 

• Nasal and Other Types of Surgery - Nasal obstruction may result from many causes including allergies, polyps, deviated septum, enlarged adenoids, and enlarged turbinates.  Multiple procedures are also available to reduce the size of the tongue base or advance it forward out of the airway.  Other procedures aim to advance and stabilize the hyoid bone which is connected to the tongue base and epiglottis. 

 

• Maxillomandibular Advancement (MMA) is a surgical procedure or Sleep Surgery which moves the upper jaw (maxilla) and the lower jaw (mandible) forward. ​​

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What is Central Sleep Apnea?

 

Central sleep apnea (CSA) occurs when the brain temporarily fails to signal the muscles responsible for controlling breathing. Unlike obstructive sleep apnea, which can be thought of as a mechanical problem, central sleep apnea is more of a communication problem.

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Central sleep apnea is also much less common that obstructive sleep apnea. Some estimates claim that approximately 20% of sleep apnea cases are CSA, but many others believe that number to be much lower.

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Central sleep apnea is often caused by medical problems and conditions that affect the brainstem. These different causes often lead to varying symptoms and different types of central sleep apnea.

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Symptoms

 

• Stopped or irregular breathing during sleep

 

• Shortness of breath leading to awakenings

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• Excessive daytime drowsiness

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• Chronic fatigue

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• Morning headaches

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• Poor or restless sleep

 

• Difficulty concentrating

 

• Mood changes

 

• Snoring, although not as prevalent as in OSA​

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Causes or conditions that can lead to CSA

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• Parkinson's disease

 

• Medical conditions that affect the brain stem including brain infection and stroke

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• Obesity

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• Certain medications like narcotic painkillers

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• Heart failure​

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Risk Factors

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• Men are more likely to develop CSA than women

 

• More common among older adults, especially those over 65

 

• People with heart disorders such as atrial fibrilation and congestive heart failure are at greater risk

 

• People who have had a stroke or have a brain tumor

 

• People sleeping at higher altitudes than they're accustomed to. Symptoms usually go away after returning to regular altitude

 

• People who use opioid medications are at greater risk

 

• Some people with obstructive sleep apnea can develop central sleep apnea when they're being treated with positive airway pressure (PAP) devices.​

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Treatment

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Treating existing conditions that are causing CSA is often the first line in treatment options for the disorder.

 

• Continuous positive airway pressure (CPAP). Similar to OSA, one of the first treatment options for CSA is the use of CPAP therapy. A CPAP device includes a breathing mask that sleep apnea sufferers wear when sleeping. Just enough consistent air pressure is delivered via the mask to the patient's airways to keep the tissue that otherwise would collapse (and cause breathing pauses and snoring) from closing during sleep. CPAP devices are effective in treating sleep apnea but do not cure the disorder. If you discontinue using your CPAP device, your sleep apnea may return.

 

• Bilevel positive airway pressure (BPAP). Bilevel positive airway pressure is similar to CPAP except that BPAP adjusts the level of air being delivered depending on whether the patient is inhaling or exhaling. During inhalation, an electronic sensor tells the BPAP to send more air through the mask to clear the apnea-causing obstruction. When the user exhales, the air pressure is reduced. This decrease is helpful for sleep apnea sufferers who have a rough time breathing out against the constant pressure of a CPAP machine.

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• Adaptive-servo ventilation (ASV). The Adaptive-servo ventilation device monitors breathing and adjusts air flow appropriately through the mask to match how the patient would be normally breathing if awake. This adjustment can be made quickly as soon as the ASV detects that the patient is not breathing correctly (as is the case with central sleep apnea, when the brain doesn’t signal the body to take a breath). When the patient exhales or after the patient resumes a normal breathing pattern, ASV adjusts the pressure again.

 

• Medications. Certain medications, such as acetazolamide (Diamox) or theophylline (Theo-24, Theochron, others), have been used to stimulate breathing in people with central sleep apnea. Medications may be prescribed when positive airway pressure therapy fails to be efficient.​

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What is Mixed or Complex Sleep Apnea?

 

Mixed sleep apnea is a combination of both obstructive and central sleep apnea symptoms. Some patients  being treated for obstructive sleep apnea with the use of CPAP machines develop symptoms of central sleep apnea upon PAP therapy. This phenomenon had long been noticed in sleep labs, but had not been previously researched. In 2006 researchers from the Mayo Clinic conducted a study of 223 sleep apnea patients and found that 15% of sleep apnea patients who were believed to have OSA in fact had mixed sleep apnea. (source)

 

During CPAP treatment for the patients believed to have OSA, the patient's airways were successfully splinted open and free from obstructions, but the patients continued to have difficulty breathing while asleep. Their symptoms of OSA shifted to symptoms of CSA while CPAP therapy was being administered.

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Treatment

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Optimal treatment options for mixed sleep apnea still need to be refined. Currently one of the best treatments is still CPAP devices, but set at the lowest possible pressure setting that successfully keep the airways free from obstructions, but don't allow CSA symptoms to develop.

 

In some cases where CPAP fails, BiPAP machines and adaptive servo ventilation devices are then tried which can better control ventilation. Bilevel positive airway pressure devices are able to deliver pressurized air that can resolve the obstructive component as well as stabilize ventilation during central apneas by forcing breaths (timed breath) during episodes of central apneas.

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Adaptive servo ventilators have shown successful use as the machines are capable of performing a breath-to-breath analysis and altering its settings accordingly.

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However, while both BiPAP and ASV machines have shown improvement in therapy over CPAP machines for mixed sleep apnea there is still no best treatment for Mixed sleep apnea.