“I shall need to sleep three weeks on end to get rested from the sleep I’ve had.”  -Thomas Mann 

In Part 1 of this two-part series the reader was presented with: an overview of sleep apnea; a description of the three main types; common signs and symptoms; and, causes and risk factors.  To briefly review, Sleep apnea is a very chronic, serious and potentially dangerous sleep disorder in which the person experiences abnormal temporary halts in breathing.  Each of these breathing pauses, known as “apnea”, can last anywhere from a few seconds to minutes, and in severe cases can happen up to 30 times or more an hour.  When breathing resumes it often does so with a rather loud and abrupt choking or snorting sound.  During these periods of apnea the individual goes from a period of deep sleep into light sleep.  As a result, most sufferers feel tired throughout the day even after reporting having had a full night’s sleep.  Snoring is also common amongst individuals with sleep apnea.  Unlike most other conditions, sufferers of sleep apnea are rarely aware that they are having any sort of difficulty breathing during their sleep, or for that matter even when they awaken.  Sleep apnea is actually most often identified by a family member or bed partner observing the person struggling with their breathing during sleep, and can occur in children as well as adults.  The symptoms of sleep apnea can go on literally for decades, as there are no blood tests to check for the condition, and it is something not usually detected during a routine physical exam.  Over time the sufferer becomes accommodated to the daytime fatigue and other associated symptoms leading even further away from raising a medical “red flag”.  There are three main types of sleep apnea, obstructive sleep apnea (OSA) being by far the most common form, representing approximately 85% of reported cases.  It results from an actual physical blockage of airflow most often due to the excessive relaxation of throat muscles which are collapsible, and can actually obstruct breathing during the sleep process.

The most common signs and symptoms of sleep apnea include:

• Loud and chronic snoring (although pauses in snoring may occur).  The snoring is usually the loudest when sleeping on your back, and may be less loud when sleeping on your side.  Over time the snoring will typically get louder and more chronic.  Of course, not everyone who snores has sleep apnea.
• Intermittent choking or grasping for breath while asleep.  The choking and grasping happens while you are asleep, and as such you will likely be totally unaware it is even occurring.  It is likely that a bed partner or family member will notice the problem before you do.
• Awakening frequently to urinate
• Excessive night time sweating
• Morning headaches
• Dry mouth and/or sore throat upon awakening
• Increased irritability
• Depression and/or mood swings
• Memory and or learning problems
• Poor concentration
• Battling sleepiness throughout the day
• In children:  poor school performance; angry behavior; and, hyperactivity.

A polysomnogram, or “sleep study”, along with a thorough evaluation of the clinical symptoms by a sleep specialist physician, is the most common and effective way to diagnose sleep apnea.  The study is painless and is usually performed at a sleep center/lab.  These centers often look like a high tech hotel room having a bed, desk, and state-of-the-art monitoring equipment.  The patient sleeps as usual with the exception of having sensors attached to their head, chest, arms and legs.  The polysomnogram monitors and records: brain activity; heart rate; blood pressure; eye movements; chest movements; snoring; air flow through the nose while asleep; and, blood oxygen levels. The sleep study not only provides the doctor with objective information regarding how severe the sleep problem is, but also how your body responds to the sleep disturbance.

Another type of study, oximetry, which measures the oxygen content in the blood is a simpler alternative to the polysomnogram and is usually performed during the night at the patient’s own home.  If oxygen levels are normal the likelihood of sleep apnea is very low.  If oxygen levels are significantly decreased during an overnight study the likelihood of sleep apnea is rather high.

Treatment of obstructive sleep apnea is often multifaceted and may include such lifestyle changes as:

• Avoiding alcohol and medications that can cause sedation as they can make it more difficult to maintain an open airway during sleep.
• Using allergy medications and/or nasal sprays to help keep nasal passages open at night.
• Stop smoking.  It only further exacerbates the oxygen and body response effects of sleep apnea.
• If obese, lose weight.  Even a modicum of weight loss can go a long way in improving symptoms.

Oftentimes patients with OSA will get more efficient sleep by sleeping on their side rather than on their back, and many find that sleeping with their head and chest elevated with several pillows, or in a recliner, also helps to counteract the effects of gravity on the “collapsing” of the airway muscles.  There are actually specially designed pillows and shirts that help prevent sleeping on one’s back.

There are a variety of mouthpieces, also referred to as oral appliances, which are designed to maintain an open airway during sleep.  These are considered first line treatment approaches for mild-to-moderate obstructive sleep apnea.  Dentists and orthodontists can create customized mouthpieces, known as mandibular advancement splints, which shift the lower jaw forward thereby keeping the airway open during sleep.

By far the most common and effective treatment for moderate-to-severe OSA is continuous positive airway pressure (CPAP).  Its introduction in the early 1980’s truly revolutionized the treatment of obstructive sleep apnea.  A CPAP machine gently propels a continuous flow of air through a mask which fits over the mouth and nose, or just the nose.  This continuous pressure helps keep the airway open during sleep.  Although CPAP treatment is extremely effective in treating OSA many people find it uncomfortable to use, and therefore refuse to use it on a continuous nightly basis, or sometimes refuse to use it at all.  However, given the current availability of a wide variety of shapes and sizes of masks and “nasal pillows” finding the “right” fit should be just a matter of trying various options.  In fact, there are several models of CPAP machines that actually warm and humidify the air within the system, and can monitor and record on a digital card its use and effectiveness.  The vast majority of people with moderate-to-severe sleep apnea feel so much better after only a few days of treatment with CPAP.

There are also a number of surgical procedures used to treat sleep apnea.  However, these are typically considered a second, or third, line of treatment for those who are unwilling to continue the use of CPAP, or do not benefit from its use.  These surgical interventions are individualized based on each patient’s airway anatomy, but all are designed to widen the breathing passages by removing, tightening, and/or shrinking the excess tissue along the airway, or resetting the lower jaw.

For more information regarding sleep apnea the American Sleep Apnea Association has a highly informative website at http://www.sleepapnea.org.  If you believe you, a loved one, or a friend may have sleep apnea please seek an evaluation or referral from a primary care physician.  Sleep apnea can have wide reaching negative effects on our physical and mental wellbeing.  It is very treatable and by doing so can help assure a healthy night’s sleep, a healthy mind and healthy future.