Obstructive Sleep Apnea

More “Room” To Breathe at Night

Today’s treatments can put an end to the nocturnal choking and snoring of obstructive sleep apnea.

You’re tired all the time; you don’t feel as mentally “sharp” as you used to be; your spouse complains that your snoring has gotten worse.

Sound familiar? If so, you may have obstructive sleep apnea (OSA), a serious disorder marked by repeated interruptions of sleep due to an involuntary closure of the upper airway. OSA puts you at higher risk for a variety of medical problems, from daytime fatigue to high blood pressure and heart disease. Virtually everyone can be helped with the treatments currently available. The most important thing is to find an experienced “sleep doctor” or ear, nose, and throat specialist who can give you a proper diagnosis.

What is OSA?

In a normal airway (left), breathing is free and unobstructed during sleep. In obstructive sleep apnea, the airway narrows, causing loud snoring and interruptions in breathing (apneas).

It’s estimated that between 20 and 50 million Americans may suffer from sleep apnea to some degree, although most of them are unaware of it. OSA is progressive and may have multiple underlying causes.

“Sleep apnea is actually a spectrum of diseases,” says Eric Genden, MD, Assistant Professor of Medicine, Department of Otolaryngology, Mount Sinai School of Medicine. “It might simply start off as snoring. Then, as time passes, it gets worse, usually because they gain weight or their anatomy changes with age. Then it progresses to apnea, where they actually stop breathing.” OSA stems from anatomical abnormalities in the upper airway (the “back of the throat”). These include:

• Excess tissue, such as large tonsils
• Abnormalities in the face and neck bones
• Loss of strength, or “tone,” in the muscles that hold the airway open for breathing during sleep
• In overweight people, excess fat in the tissues of the throat
• A tendency for the tongue to flop backward during sleep and block the airway

People with OSA can stop breathing many times during the night—in some cases, hundreds of times. Each interruption is an apnea (Greek, meaning “without breath”). An interruption must last at least 10 seconds to be called an apnea, although some can last as long as two minutes. During that time, the body is starved of oxygen. An episode of apnea ends when the person awakens and automatically starts breathing again.

Sleepy snorers

People with OSA may drift in and out of consciousness, not fully aware of what’s happening to them—until the next day, when they start to feel the effects of sleep deprivation. “If you wake up, even briefly, dozens of times a night, you’re never getting enough sleep,” Dr. Genden notes.

Chronic sleep deprivation has been linked to a significantly increased risk of automobile and work-related accidents, as well as depression, mood changes, and panic attacks. And because chronic apnea reduces blood oxygen, untreated sleep apnea puts people at greater risk for heart disease, heart attack, and stroke. High blood pressure is also associated with OSA, although it’s not clear whether it is a cause or an effect.

A difficult diagnosis

Sleep apnea, depending on its severity, produces a range of symptoms. However, the most telltale signs are excessive daytime fatigue and loud snoring, pauses in breathing, or gasping or choking during sleep. To prevent the serious health consequences of OSA, it’s critical to recognize these trouble signs and see a doctor.

Diagnosis includes a physical examination and medical history. You may also be asked to keep a “sleep diary,” recording incidents of disturbed sleep, daytime fatigue, morning headaches, and other cardinal signs of OSA. You may be referred to a “sleep lab,” where patients can stay overnight while being monitored by special equipment. In a procedure called polysomnography, doctors monitor blood oxygen levels, breathing patterns, and sleep rhythms.

Treatments: CPAP and BiPAP

Some people with OSA may be helped by losing weight, developing better sleeping habits, and possibly wearing a special oral appliance to bed to help keep the airway open. But for most others, the first-line treatment is continuous positive airway pressure (CPAP). In this therapy, a bedside machine delivers a gentle flow of air to a mask that the person wears while sleeping. The slightly elevated airway pressure acts as a pneumatic “splint” to keep the airway open. For people who have trouble exhaling under CPAP, doctors can offer a similar treatment, bi-level positive airway pressure (BiPAP), which delivers slightly lower pressure during exhalation.

The good news is that CPAP works. “About 90 percent of patients who stick with it get good relief, are able to sleep normally, and start feeling better,” Dr. Genden says. The bad news is that CPAP/BiPAP may have to continue for as long as the person suffers from apnea. Not surprisingly, most people don’t enjoy wearing a mask to bed every night. “A lot of patients drop out of this treatment,” says Dr. Genden. “It’s a shame, because it’s very effective.”

When surgery can help

If non-invasive solutions such as CPAP don’t work, surgery may be an option. The type of repair possible and its chance of success will depend on the underlying cause of the airway obstruction. Medical imaging is usually required, including X-ray, computed tomography (CT, or “CAT” scanning), or magnetic resonance imaging (MRI). “Most anatomical problems are not obvious,” Dr. Genden explains. “You can’t see the problem just by looking at someone.” There are several options. “Soft tissue” surgery alters tissue in the soft palette and back of the throat, including the tonsils. More complex procedures involve changing the bone structure of the face—for example, shifting the jawbone forward. Another option is laser surgery to alter soft tissue in the airway, although its effectiveness for severe OSA is controversial.

“It all depends on a person’s specific problem,” Dr. Genden says. “The key is to find out what the problem is and then decide honestly whether it can be fixed or not.”

How to help yourself

If you suspect you have sleep apnea, you should see a physician—preferably an ear, nose, and throat doctor or sleep disorder specialist—who has the experience to diagnose your condition. In the meantime, your doctor can recommend some simple measures that can sometimes reduce your symptoms. The most important steps of all, however, are recognizing the signs of obstructive sleep apnea and seeking immediate treatment.

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