Have you ever gotten out of bed thinking “I could use a little more rest”? If that is a regular occurrence or if your spouse gently suggests that you snore so loud they could not even sleep, you might have sleep apnea.
People who have excessive daytime somnolence (sleepiness) or EDS often suffer from obstructive sleep apnea, which is the most common form of sleep disorder. The problem commonly occurs when some part of the upper airway blocks the smooth flow of air through the nose and into the lungs.
This happens primarily when a person transitions from the light stages of sleep identified a N1 or N2 sleep into the deeper and more restful stage N3 or REM [rapid eye movement] sleep. The deeper sleep is necessary for one to awaken feeling refreshed.
REM sleep comes in intervals throughout the night. The first interval is usually about 15 to 30 minutes in duration initially. It Is followed by lighter N2 stage sleep then two or three more periods of increasingly longer REM sleep. The last interval usually occurs just before awakening and may last for one hour.
The problem with obstructive apnea is that when we enter the deep levels of sleep, our muscles relax even more and our air passages tend to collapse. When that happens, our lungs muscles can’t easily move air through our nose and into our lungs.
The result is that the oxygen in our body is slowly used up and an alarm deep in the brain causes us to suddenly arouse in order breath. If this happens more than 10 times per hour, we are never able to fall deep enough asleep to be refreshed.
Many times the snoring can be worrisome because the period without breathing can be several seconds long and end in a loud snort which appears to an observer as someone who has severe breathing difficulty. Sometimes a spouse may feel compelled to shake or awaken the person in order to help him breath.
That kind of breathing can be dangerous. With prolonged apnea (not breathing), the oxygen concentration in vital organs such brain, heart and kidney can drop so low that cellular damage can occur. That is called hypoxia, which may lead to stroke, cardiac arrhythmia or infarction or kidney tissue damage resulting in severe blood pressure elevations.
There are several contributing factors to obstructive sleep apnea. Overweight individuals are much more likely to develop apnea particularly if the Body Mass Index is greater than 29, or the neck circumference is more than 17 inches. Diabetics, hypertensives and heart trouble patients tend to have more sleep apnea problems. Sleep apnea also makes the above problems worse.
There is a questionnaire used to indicate the potential for sleep apnea, called the Epworth Sleepiness Scale. Borderline or abnormal results should be evaluated by sleep study, which is a recording of multiple parameters of one’s sleep.
This can be performed in a sleep lab where a technician is present to monitor and record a night’s sleep. In many cases it is possible to obtain good results from home sleep study.
The patient is fitted with a recording device to be used in the home and data is brought back to the office to be evaluated. Once the diagnosis is made, the best treatment is CPAP or Constant Positive Airway Pressure.
A CPAP machine is a very intuitive machine which actually senses, records and adjusts the small amount of pressure needed to maintain an open air passage. This happens in much the same way as a balloon develops its shape when a small amount of pressure is introduced. These are tiny amounts of pressure, not enough to prevent sleep.
Other treatments are also available, such as dental appliances or surgery. Medications, such as sleeping pills, actually make sleep Apnea worse and are contraindicated. Dental appliances are most effective when the sleep problem is related to the jaw.
Surgical treatment only affects certain causes of sleep obstruction. Surgery has not proven to be very effective even in people with obvious abnormalities such as long palate or excessive tonsil tissue because there are often many sources for the obstruction and surgery is often painful and complicated. These treatments are primarily used in patients who can’t tolerate CPAP.
Once treatment is begun, follow-up evaluation is performed on an ongoing basis with evaluation and adjustment of memory cards that constantly record data in the CPAP machine. A goal of 5-7 hours of use per night with no obstructing incidents is made. Of course, waking up feeling refreshed and not tired and fatigued is the real indication of successful treatment.
Dr. Bob Glatz is an ear, nose and throat specialist based in the Cayman Islands.