Sleep Apnea

Obstructive sleep apnea (OSA) is a condition in which the flow of air pauses or decreases during breathing while you are asleep because the airway has become narrowed, blocked, or floppy.

A pause in breathing is called an apnea episode. A decrease in airflow during breathing is called a hypopnea episode. Almost everyone has brief apnea and hypopnea episodes while they sleep. OSA occurs when these episodes become more frequent.

A person who has obstructive sleep apnea often is not aware of the apnea episodes during the night. Often, family members witness the periods of snoring or apnea.

A person with obstructive sleep apnea usually begins snoring heavily soon after falling asleep. Often the snoring gets louder. The snoring is then interrupted by a long silent period during which there is no breathing. This is followed by a loud snort and gasp, as the person attempts to breathe.

In many patients this pattern repeats throughout the sleeping period.

Many people wake up unrefreshed in the morning and feel sleepy or drowsy throughout the day. This is called excessive daytime sleepiness.

People with sleep apnea may:

• Act grumpy, impatient, or irritable
• Be forgetful
• Fall asleep while working, reading, or watching TV
• Feel sleepy while driving, or even fall asleep while driving
• Have hard to treat headaches

Problems that may occur with this condition:

• Depression that becomes worse
• Hyperactive behavior, especially in children
• Leg swelling (if severe)

All of the muscles in your body become more relaxed during sleep. This includes the muscles that help keep the airway open and allow air to flow into the lungs.

Normally, the upper throat remains open enough during sleep to let air pass by. However, some people have a narrower throat area. When the muscles in the upper throat relax during sleep, the airway can become narrowed or blocked and breathing can stop for a period of time (often more than 10 seconds).

The snoring in people with obstructive sleep apnea is caused by the air trying to squeeze through the narrowed or blocked airway. However, everyone who snores does not have sleep apnea. Other factors may also increase your risk:

• Having a lower jaw that is short compared to the upper jaw (retrognathia)
• Certain shapes of the roof of your mouth (palate) or airway that cause the airway to be narrower or collapse more easily
• Large tonsils and adenoids can block the airway
• Large neck or collar size (17 inches or more in men and 16 inches or more in women)
• Large tongue, which may fall back and block the airway
• Obesity

Sleeping on the back may also increase sleep apnea episodes.

Diagnosis

Your health care provider will perform a complete history and physical exam. This will involve carefully checking your mouth, neck, and throat. You may be given a survey that asks a series of questions about daytime sleepiness, sleep quality, and bedtime habits.

A sleep study (polysomnogram) is used to confirm obstructive sleep apnea.

Other tests that may be performed include:

• Arterial blood gases
• Electrocardiogram (ECG)
• Echocardiogram
• Thyroid function studies

Treatment

The goal is to keep the airway open so that breathing does not stop during sleep

The following lifestyle changes may relieve symptoms of sleep apnea in some people:

• Avoiding alcohol or sedatives at bedtime, which can make symptoms worse
• Avoiding sleeping on the back may help with mild sleep apnea
• Losing weight may decrease the number of apnea spells during the night

Continuous positive airway pressure (CPAP) is now the first treatment for obstructive sleep apnea in most people. CPAP is delivered by a machine with a tight-fitting face mask.

Many patients have a hard time sleeping with CPAP therapy. Good follow-up and support from a sleep center can often help overcome any problems in using CPAP.

Some patients may need dental devices inserted into the mouth at night to keep the jaw forward.

Surgery may be an option in some cases. This may involve:

• Uvulopalatopharyngoplasty (UPPP) -- to remove excess tissue at the back of the throat. This surgery has not been proven to completely clear up sleep apnea. Long-term side effects are also possible.
• More invasive surgeries -- to correct problems with the face structures in rare cases when patients have severe sleep apnea and treatment has not helped
• Tracheostomy -- to create an opening in the windpipe to bypass the blocked airway if there are physical problems (rarely done)
• Surgery to remove the tonsils and adenoids often cures the condition in children. It does not seem to help most adults.

Outlook (Prognosis)

People with poorly treated obstructive sleep apnea often have:

• An increase in anxiety and depression
• A loss of interest in sex
• Poor performance at work or school

Because of daytime sleepiness, people with sleep apnea have an increased risk of:

• Motor vehicle accidents from driving while sleepy
• Industrial accidents from falling asleep on the job

With treatment, the symptoms and problems of sleep apnea should be totally corrected.

Possible Complications

Untreated obstructive sleep apnea may lead to or worsen heart disease, including:

• Heart arrhythmias
• Heart failure
• High blood pressure
• Stroke

When to Contact a Medical Professional

Call your health care provider if:

• You have excessive daytime sleepiness
• You or your family notice symptoms of obstructive sleep apnea
• You have this condition, and symptoms do not improve with treatment or new symptoms develop

Central sleep apnea is when you repeatedly stop breathing during sleep because the brain temporarily stops sending signals to the muscles that control breathing.

Central sleep apnea is not the same as obstructive sleep apnea, which is due to a blockage in the airway.

A condition called Cheyne-Stokes respiration can mimic central sleep apnea. This involves breathing to a variable depth, usually while sleeping.

Symptoms

Persons with central sleep apnea have episodes of disrupted breathing during sleep.

Symptoms may include:

• Chronic fatigue
• Daytime sleepiness
• Morning headaches
• Restless sleep

Other symptoms may occur if the apnea is due to a neurological condition. Symptoms depend on the underlying disease and what parts of the nervous system it has affected, but may include:

• Difficulty swallowing
• Voice changes
• Weakness or numbness throughout the body

Central sleep apnea often occurs in people who have congestive heart failure or CHF.

Conditions that can cause or lead to central sleep apnea include:

• CHF (congestive heart failure)
• Idiopathic (not associated with another disease and no known cause)
• Use of certain medications such as narcotic-containing painkillers

Diagnosis

The health care provider will perform a physical exam. Tests will be done to diagnose an underlying medical condition. A sleep study (polysomnogram) can confirm sleep apnea.

Other tests that may be done include:

• Echocardiogram
• Lung function studies
• MRI of the spine or neck

Treatment

1. Oxygen, continuous positive airway pressure (CPAP), or bi-level positive airway pressure (bi-level PAP) may be used for some types of central sleep apnea.
2. Some types of central sleep apnea are treated with drugs that stimulate breathing.
3. The UChicago Sleep Center Cardio-Sleep program leads diaphragmatic nerve implantation, a safe and effective treatment for CSA and alternative for PAP therapy. Sleep experts can determine if this is a treatment for you.
4. If central sleep apnea is due to heart failure, the goal is to treat the heart failure itself, diaphragmatic pacing may be considered in some cases.