An in-depth report about the causes, diagnosis, treatment, and prevention of obstructive sleep apnea.
An in-depth report about the causes, diagnosis, treatment, and prevention of obstructive sleep apnea.
Obstructive sleep apnea (OSA) is a disorder in which a person temporarily stops breathing during the night, perhaps hundreds of times. These gaps in breathing are called apneas. The word apnea means "absence of breath." An obstructive apnea episode is defined as the absence of airflow for at least 10 seconds.
Sleep apnea is often accompanied by snoring, disturbed sleep, and daytime sleepiness. Many people with OSA do not even know they have the condition.
Obstructive sleep apnea (OSA) occurs when tissues in the upper throat relax and come together during sleep, temporarily blocking the passage of air. In general, OSA occurs as follows:
Obstructive sleep apnea in adults is defined as 5 or more episodes of apnea or hypopnea per hour of sleep (called apnea-hypopnea index or AHI) in individuals who have excessive daytime sleepiness. People with 5 to 15 episodes of apnea or hypopnea per hour of sleep are considered to have mild sleep apnea, 15 to 30 episodes/hour is moderate sleep apnea, and more than 30 episodes per hour indicates severe disease.
A diagnosis of OSA in children can be made when both symptoms of OSA and an abnormal sleep study are present. Any number of apneas and hypopneas in children is abnormal.
Clinical symptoms of OSA in children may include:
Abnormal sleep study (PSG) findings may include:
All of the muscles in the body relax during sleep. In people without obstructive sleep apnea, the throat muscles relax but do not block the airways. In patients with obstructive sleep apnea, the airways become temporarily blocked or narrowed during sleep, preventing air from flowing normally into the lungs.
Certain physical characteristics of the face, skull, and neck can affect the size of the airway.
A large neck (17 inches [43 centimeters] or greater in men and 16 inches [40 centimeters] or greater in women) is a risk factor for sleep apnea. While some people's necks are naturally larger than others, being overweight or obese can contribute to having a large neck.
Facial and Skull Characteristics
Structural abnormalities in the face and skull contribute to many cases of sleep apnea. These abnormalities include:
Soft Palate Characteristics
Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:
Abnormalities or weakness in the muscles that surround the airway can also contribute to obstructive sleep apnea.
Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes include:
More than 18 million Americans have sleep apnea. The incidence of obstructive sleep apnea (OSA) has been increasing, due in part to rising rates of obesity.
Obstructive sleep apnea is more common in men than in women. Men tend to have larger necks and weigh more than women. However, women tend to gain weight and develop larger necks after menopause, which increases their risk of developing sleep apnea.
Female reproductive hormones appear to play a protective role in sleep apnea. Declining estrogen levels are another reason that postmenopausal women face more risk for sleep apnea than premenopausal women.
Sleep apnea is most common in adults ages 40 to 60 years old. Middle age is also when symptoms are worse. Nevertheless, sleep apnea can affect people of all ages, including children.
African Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Hispanics.
People with a family history of OSA are at increased risk of developing the condition.
Being overweight is a major risk factor for OSA, especially when the fat distribution results in increased neck circumference. Excess weight may also contribute to sleep apnea when fat deposits increase tongue size or fill throat tissue. Even a moderate amount of weight gain can raise a child's or adult's chances of developing sleep apnea.
Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.
Alcohol use may be associated with apnea. Patients diagnosed with sleep apnea are recommended not to drink alcohol before bedtime.
Type 2 diabetes is associated with sleep apnea. It is not clear if there is an independent relationship between the two conditions or whether obesity is the common factor.
Gastroesophageal Reflux Disease (GERD)
GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. Research suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Apnea itself may also cause pressure changes that trigger GERD. Obesity is common in both conditions, and more research is needed to clarify the association.
Hypothyroidism (underactive thyroid gland) and acromegaly (overactive pituitary gland) are endocrine disorders that increase the risk for obstructive sleep apnea. Polycystic ovary syndrome (PCOS), a disorder caused by imbalances in female hormones, is also highly associated with sleep apnea. Women with PCOS are also more likely to have diabetes and obesity, which are additional risk factors for sleep apnea.
Prednisone and other corticosteroids can also lead to more fat accumulation in the neck area, increasing the likelihood of sleep apnea. Sedative medications like benzodiazepines can also lead to more OSA.
Obstructive sleep apnea can lead to a number of complications, ranging from daytime sleepiness to possible increased risk of death. Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.
Excessive daytime sleepiness is the most noticeable, and one of the most serious, complications of sleep apnea. It interferes with mental alertness, social relations, and quality of life. People with obstructive sleep apnea are more likely to suffer from depression and may be at risk for sexual dysfunction.
Daytime sleepiness can also increase the risk for accidents and related injuries. Many studies have shown that people with sleep apnea have a significantly increased risk for drowsy driving and car accidents. Untreated sleep apnea is a major risk factor for injury at factory and construction work sites.
Sleep-disordered breathing is very common among patients with heart problems such as high blood pressure, heart failure, pulmonary hypertension, stroke, heart attack, and atrial fibrillation. This link may be because both cardiovascular conditions and sleep apnea share a common risk factor of obesity. However, increasing evidence suggests that severe OSA is an independent risk factor that may cause or worsen a number of heart-related conditions.
High Blood Pressure
Moderate-to-severe sleep apnea definitely increases the risk for high blood pressure (hypertension) even when obesity is not a factor. Studies suggest that CPAP may help reduce blood pressure, especially when combined with weight loss in overweight patients.
Coronary Artery Disease and Heart Attack
Sleep apnea appears to be associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. Studies suggest that patients with moderate-to-severe obstructive sleep apnea have a higher risk for heart attack.
Sleep apnea may increase the risk of death in patients who have previously had a stroke.
Up to a third of patients with heart failure also have sleep apnea. Central sleep apnea often results from heart failure. Obstructive sleep apnea can cause heart damage that worsens heart failure and increases the risk for death.
Sleep apnea may be a cause of atrial fibrillation (irregular heartbeat).
Untreated obstructive sleep apnea is associated with higher incidence or complication of many medical conditions including:
Because sleep apnea often includes noisy snoring, the condition can adversely affect the sleep quality of the bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.
Failure to Thrive
Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system.
Behavior and Learning Problems
Poor sleep and sleep-related breathing disturbances can cause behavioral and cognitive issues. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.
People with sleep apnea usually do not remember their snoring, restless sleep, or sudden brief waking during the night.
Symptoms may include:
Children with obstructive sleep apnea (OSA) share certain symptoms with adults such as snoring and restless sleep, but they tend not to exhibit daytime sleepiness. Children often have symptoms that differ from adults, including:
In diagnosing OSA, the doctor will ask about your medical and sleep history, and conduct a physical exam. If symptoms suggest OSA or another sleep disorder, further diagnostic testing may be performed. Your doctor may recommend you have a sleep study (polysomnography) performed at a sleep disorders center or do a sleep study at home wearing a portable monitor.
The devices used for sleep studies can measure the number of respiratory events per hour. Events measured include apnea (stopped breathing), hypopnea (shallow or slow breathing), and respiratory disturbances (stopped or slowed breathing and near-awakenings caused by the effort to breathe). Based on these measurements, a sleep specialist doctor will evaluate the apnea-hypopnea index (AHI) or the respiratory disturbance index (RDI), to determine if you have OSA and, if so, whether it is mild, moderate, or severe.
OSA in adults is diagnosed when a patient has at least 15 events per hour with or without other symptoms of obstructive sleep apnea, or 5 events per hour with symptoms.
Symptoms or signs that may indicate sleep apnea include:
To help determine the presence of OSA, the doctor may ask the following questions:
The doctor will check for physical indications of sleep apnea, including:
The doctor will also consider conditions other than sleep apnea that may cause daytime sleepiness including:
Polysomnography (PSG) is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography is typically performed at a sleep center. The patient sleeps in a room that resembles a hotel room but is equipped with a video camera and monitoring station. Polysomnography conducted in a sleep lab is the gold standard for diagnosing sleep apnea.
The patient arrives about 2 hours before bedtime without having made any changes in daily habits. A trained technician places electrodes (similar to the sticky pads used for electrocardiograms) on the patient's face and head, a sensor on the finger, and a sensor in the nose. Special belts are placed around the waist to monitor breathing activity. These devices are all painless. They are used to collect data on eye movements, brain activity, heart rate, and oxygen levels.
Wires attached to these devices transmit data to the technician in the monitoring room. The technician will score the sleep pattern data throughout the night as the patient passes through the various sleep stages. The patient is discharged in the morning. A sleep specialist doctor will later evaluate the data that was collected and send a report to your doctor.
If you show signs of moderate-to-severe sleep apnea during your sleep, the technician may wake you up during the night to perform split-night polysomnography. In split-night polysomnography, during the second part of the night patients are fitted with a CPAP mask and receive a CPAP titration study to adjust the amount of air flow coming through the mask. In centers that do not perform split-night polysomnography, patients may need to return for a second overnight sleep study to have CPAP titration performed.
Diagnostic testing at home with portable monitors may be an option for patients who have a high likelihood of moderate-to-severe obstructive sleep apnea, do not have access to a sleep laboratory, and do not have any other major medical disorders. Portable monitors are not appropriate for people who have serious conditions such as chronic lung disease, heart failure, or neurological disorders (such as seizures). Patients with these conditions are at higher risk for central sleep apnea. Many portable monitors cannot distinguish between central and obstructive sleep apnea. Portable monitors are also not recommended for patients who may have other sleep disorders, such as narcolepsy.
There are different types of portable home monitors. They are classified as type II, type III, or type IV. (Sleep lab-based polysomnography is classified as type 1.) Type II monitors are the most similar to an overnight PSG study conducted in a sleep center. The main difference is that there's no technician present. Type III monitors record fewer variables than type II or type I studies, but usually evaluate several respiratory channels, heart rate, and oxygen saturation. However, they cannot distinguish between sleep and wake states. Type IV monitors are the least sophisticated devices. Type III and type IV portable monitors do not measure the apnea-hypopnea index, but can provide estimates.
Portable monitors usually come with an air-flow sensor that goes under the nose, an oxygen clip that's attached to a finger, and a belt monitor that goes around the chest. The data is collected through wireless transmission. Depending on the device, the patient may pick up the monitor at a local hospital and receive instructions from a technician, or the monitor may be shipped in the mail to the patient's home.
All patients with OSA who are overweight or obese should attempt to lose weight. Weight loss reduces snoring and apnea/hypopnea episodes in many people, and may even in some cases cure OSA. Weight loss may also help improve sleep and reduce daytime sleepiness. Weight loss associated with bariatric surgery has also been shown to decrease apnea/hypopnea episodes; however, the evidence is yet limited.
Body position has some effect on obstructive sleep apnea, with at least twice as many apneas occurring in people who lie on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. Sleeping on the back also increases the chances of snoring.
Positional therapy can help relieve snoring. However, simply trying to treat snoring will not treat sleep apnea. (Remember that snoring does not necessarily indicate sleep apnea.) Changing body position may help with mild apnea but it has little effect on severe sleep apnea.
As a first step, simply try sleeping on your side. Other suggestions for maintaining a low-risk sleeping position include:
It is important for patients to treat obstructive sleep apnea (OSA) as they would any chronic disease. OSA needs to be taken seriously given its long-term complications and its association with high blood pressure, heart problems, stroke, and diabetes. Ideally, OSA should be treated by a doctor who specializes in sleep disorders.
The American College of Physicians recommends the following treatments for OSA in adults:
The American College of Physicians does not find evidence to support the use of medications for treatment of OSA. In general, drugs are not very helpful except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. For example, thyroid hormone may help improve sleep apnea in patients who have an underactive thyroid gland (hypothyroidism). Intranasal corticosteroids may be helpful in some cases for children with sleep apnea.
Modafinil (Provigil), which is also used to treat narcolepsy, is the only drug approved by the FDA to treat the sleepiness associated with obstructive sleep apnea in patients for whom CPAP does not completely eliminate excessive daytime sleepiness. However, modafinil is meant to be used in combination with -- not as a substitute for -- CPAP. Sleep doctors stress that patients who take modafinil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying cause of obstructive sleep apnea or its complications.
Patients with sleep apnea should be aware that sedatives, narcotics, and anti-anxiety drugs can actually worsen the breathing disturbances that occur with this condition. These medications may cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Patients with sleep apnea should never use sleeping pills or tranquilizers. If undergoing surgery, be sure to inform your surgeon, anesthesiologist, and other doctors of your condition so that they can determine which sedatives, anesthetics, or pain medications are safe and appropriate.
Surgery should never be used as an initial treatment for OSA in adults. Surgical treatments for sleep apnea have a number of risks, and there is limited evidence as to their benefit. However, surgery may be an appropriate option for select patients who cannot tolerate or comply with CPAP therapy. [For more information, see Surgery section in this report.]
The best first-line treatment for OSA is a system known as continuous positive airway pressure (CPAP). It is safe and effective for people of all ages, including children.
Patients with OSA who use CPAP feel better rested, have less daytime sleepiness, and have improved concentration and memory. In addition, CPAP may potentially reduce the risks for heart problems such as high blood pressure. For maximum benefit, CPAP should be used for at least 6 to 7 hours each night.
CPAP works in the following way:
The standard CPAP machine delivers a fixed, constant flow of air. Variations on CPAP include:
CPAP works well, but it can take some time to get used to, especially for the first few nights. Here are some tips to help you adjust:
Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. Although these devices may provide some improvement in patients with moderate-to-severe sleep apnea, CPAP therapy is still needed.
Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:
Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.
Benefits of Dental Devices
Dental devices seem to offer the following benefits:
Disadvantages of Dental Devices
Dental devices are not as effective as CPAP therapy. They are often expensive, and since they are custom-made they cannot be returned. Side effects associated with dental devices include:
An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.
Surgery is sometimes recommended, usually by ear, nose, and throat specialists (otolaryngologists), for severe OSA in adults. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.
Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.
The Goal of Surgery
The goals of UPPP are to:
The American Academy of Sleep Medicine (AASM) does not endorse UPPP as a sole procedure for treating OSA. The AASM recommends that patients considering this surgery first try CPAP or dental devices.
There is limited evidence as to the effectiveness of UPPP. Studies suggest that success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Other studies indicate that UPPP may lower the risk of dementia in patients with OSA.
Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior and should always be tried first. Many or most patients with moderate or severe sleep apnea will likely still require CPAP treatment after surgery.
UPPP is among the most painful treatments for sleep apnea, and recovery takes several weeks. The procedure also has a number of potentially serious complications including:
In general, only a small percentage of patients experience serious complications. Many of these complications can be avoided with proper technique and an experienced surgeon. A patient's health status, including presence of obesity and other health conditions, may also affect outcomes.
A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates in the treatment of obstructive sleep apnea with LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.
More than half of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.
According to guidelines from the American Academy of Sleep Medicine (AASM), LAUP is not routinely recommended as treatment for OSA. According to the AASM, this surgery generally does not help improve symptoms and may actually worsen the condition.
The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. However, the main focus of the procedure is a reduction in snoring. The implant helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate.
The procedure can be performed in a doctor's office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia and has less pain and quicker recovery time. There is still not enough evidence to determine whether it is an effective treatment for OSA.
Approved in 2014, the Inspire Upper Airway Stimulator is a nerve stimulation device that is surgically implanted in a patient's chest. The device senses the patient's breathing patterns and stimulates the hypoglossal nerve, which controls tongue movement, to help keep the airways open. The patient turns the device on and off, before and after sleep, using a remote control.
The FDA approved this nerve stimulator device for a subset of adult patients with moderate-to-severe OSA who cannot tolerate CPAP therapy. The device is not appropriate for patients who have mixed and central sleep apneas, certain anatomical abnormalities of the soft palate, or certain neurological conditions.
In a small study of patients, the device helped reduce breathing pauses and drops in blood oxygen levels. However, some patients experienced a worsening of their sleep apnea. The long-term risks and benefits of this device are not yet known.
The FDA has also approved a newer version of this device which is safe for patients who need to undergo magnetic resonance imaging (MRI).
Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:
Today, this operation is performed rarely, usually only if sleep apnea is life threatening.
Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. Most are invasive and reserved for patients with severe sleep apnea who fail to respond to or comply with CPAP. Overall, there is limited evidence as to their effectiveness in treating OSA. These procedures include:
Findings such as a deviated septum can contribute to snoring and other symptoms. Surgical treatment of patients with this finding may improve snoring and sleepiness. However, it does not seem to reduce the numbers of apnea or hypopnea episodes. For patients using CPAP, nasal surgery may improve compliance with using the machine and thereby improve sleep apnea.
Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for most children and adolescents with sleep apnea proven by sleep studies. Surgery appears to improve quality of life, symptoms of sleep apnea, and behavior. Sleep studies done after surgery show improvement in the measures of sleep apnea.
This surgery does not appear to improve a child's attention span or school performance. Also, OSA may improve with watchful waiting in up to one half of students.
Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:
The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.
Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.
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