Who is at risk for sleep apnea? The easy answer to this is, “everybody,” but some people are more at risk than others. Until recently, sleep apnea was considered to be primarily an adult disorder. However, a recent study (Tarasiuk et al., 2007) studied 156 children between the ages of three to five, who had been diagnosed with obstructive sleep apnea, and found problems of general health that echoed adult problems, including a 40% increase in hospital visits. Therefore, although less frequent in children, it is still serious and demands early treatment. However, as I said, some people are more at risk than others. Who? What is known to correlate with the disorder?
- Positive family history of the disorder.
- Obesity, especially central obesity.
- Particular bone structure that impinges on the airway; simply having a thick neck appears to be related to this.
- Being male. Men are at higher risk than females, except menopausal women.
- African Americans, Mexicans, and Pacific Islanders are all at increased risk compared to North American Caucasions.
- Age: It is more common over forty.
- A variety of medical disorders such as diabetes, hypertension, hypothyroidism, and certain vascular diseases.
- Alcohol and other depressant drug use.
- Sleep posture and habits (more about this below).
Note that of these ten risk factors, five of them are at least partly under the control of the individual. Weight, smoking, drugs, and sleep habits are obviously mutable to some extent. Moreover, treatment and control of the medical disorders, such as diabetes and hypertension also affect, materially, the likelihood of being afflicted. Under treatment strategies, these will be discussed somewhat further.
Related to the mechanical causes of airway blockage, sleep apnea sometimes comes during pregnancy, and usually resolves after delivery. However, it is of importance to treat it during the period it appears, perhaps all the more because of the demands of the pregnancy. Among other problems, this could predispose to pre-eclampsia, a potentially very serious condition. Vigilance during pregnancy is of critical importance.
What to Do
First, it is important to recognize the presence of the disorder. There are several ways to do this before the definitive diagnostic procedure that involves a sleep laboratory, which most people do not have in their homes. The most important of these involves simple observation. Snoring is the first cue. Obstructive apnea, the most common type, is virtually always associated with pretty bad snoring. If you do not live alone, you have a potential observer who probably already knows whether or not you snore. However, you must then convince the person to stay awake and watch you while you sleep, not necessarily a popular occupation.
If the observer sees even one episode of not breathing for at least ten seconds, it should be explored further. It is a very good idea for the observer to keep a notebook on the number of episodes and when they occur. In addition, noting the position in which the person is sleeping is important to obtain information to present to the sleep specialist, who is the next stop. Sleeping on one’s back exacerbates obstructive apnea simply because gravity helps collapse the soft tissue into the airway. Sometimes, just getting used to sleeping on one’s side can be enough to prevent apneic episodes. Therefore, the observer should note whether and how much position affects the breathing.
Although it is possible to have sleep apnea without the concomitant snoring (if it is central), an observer can still note the episodes easily, because the hypoxia causes sudden gasping as the individual partially awakens to get a breath. If you have symptoms of sleep apnea, such as the daytime sleepiness, and do not have anyone willing to observe you while you sleep, there are relatively simple devices that you can use to make the preliminary diagnosis. The key problem in sleep apnea, of course, is the hypoxia, the low oxygen levels in the blood. Well, this can be measured by a simple device that clips over the fingertip, called a pulse oxymeter. These measure the percentage of oxygen saturation in the blood.
While these are relatively inexpensive and simple to use, they don’t do the user any good if he can’t read them while sleeping. However, there is an advanced model of this device that will trip an alarm when the oxygen level falls below the level that the user sets (usually about 80%).This, of course, fully awakens the sleeper and that constitutes evidence of one apneic episode. Any such episode is enough to send one for a referral to a sleep specialist, who then, depending on the degree of the problem, will explain the following principles to reduce or eliminate the apnea, or recommend a more drastic treatment. The self help recommendations will be some version of the following advice:
If you are overweight, lose it.
Do not take sedatives or alcohol at night.
Exercise good sleep hygiene; that is go to bed and get up at the same hour every day.
Get eight or more hours of sleep. (Note, most physicians will say at least seven, but the research suggests that more is better.)
Sleep on your side.
Now, if it were easy to lose weight, stop smoking, stop drinking, and change lifestyles, most mild cases of sleep apnea could be thus controlled. However, most of the time, following all of that advice completely would be about as likely as finding my pet pig flying around the house. So, in the real world, in which this advice rarely works, or cases of more severe apnea, one of two general approaches will be recommended, surgery or CPAP. Although there is a third alternative, involving a dental appliance, it is of limited practical value in part because of the degree of specialized dental expertise, and in part because of limited success. Surgery or CPAP are the most likely recommendations, but before going for a surgery I’d recommend you trying CPAP or snoring devices look at this pure sleep review by Shanice to learn more about snoring devices, and know what options are available for you.
Surgery used for sleep apnea is usually aimed at either enlarging the airway, or reducing the excess soft tissue that occludes it during sleep. If the bony architecture is abnormal, this can, sometimes be corrected to improve breathing. There are several different procedures used, depending mostly on the particular individual problem presented. Without going into the details of these procedures, I shall only say that most of them should work well, theoretically. However, in practice, they are only successful some of the time. Defining the “some,” of course, depends on the precise case, but few procedures are fool proof, or even close. The less invasive use of a CPAP appliance is usually tried first.
CPAP stands for “continuous positive airway pressure.” What this means is that air is forced into a mask that is fitted over the patient’s nose so that instead of depending on the negative pressure from the lungs to draw in a breath, the air is pushed through the tissues into the nose and, therefore, the trachea. It simply helps the person breath, compensating for the occluded airway. It works. It works well in most cases. (If there is a severe central apnea from brain injury, ventilators might be required but that is rare.) A soft, flexible mask is either fitted or actually molded to the patient’s face, ideally so that there is no leakage of air.
Air is streamed through the mask with controlled pressure and valves for exhaling. Usually, as the name implies, the pressure is maintained, but a few people find it much more comfortable if there is a mechanism to relieve the pressure during exhalation. Some devices do this, but it is usually unnecessary. The pressure is adjusted to the minimum amount that prevents any apneic events. The machines are adjustable from a pressure of about three cm. of water up to twenty. Most patients respond to somewhere between six to twelve cm. (water) pressure. Of course the least effective amount is desirable because higher pressures can be uncomfortable and even dangerous.
The most frequent reason for failure of a CPAP is non-compliance. Some people simply do not feel comfortable wearing an appliance every night, but when it is used successfully for a few days, the improvement in every aspect of life can be so dramatic that many patients will never sleep without it. In fact, most companies that sell or rent these appliances maintain a 24 hour, seven day a week emergency service to guarantee uninterrupted service. One common issue that causes discomfort is dry air that is irritating to the mucosa. This can be effectively avoided by a heated water chamber that the air passes over between the fan and the mask. I strongly recommend that anyone who receives a CPAP machine insist on this feature. It is important to keep the water chamber clean, but it is worth the effort in the added comfort.
Snoring is often treated as a joke, or, at most, an annoyance to those who listen to it. However, it can be a sign of a serious and common malady that is anything but funny. Snoring can be a sign of obstructive sleep apnea, a disorder both more common and far more serious than most people realize. Estimates of prevalence run as high as over seven percent of the adult population in the United States, 90% of which are undiagnosed and untreated. Even mild cases of sleep apnea have potentially serious and always uncomfortable consequences. It deprives the body of the benefits of full, restful sleep, and, at the same time causes a lack of adequate oxygen. This not only makes people sleepy during the day, it increases the likelihood of severe disorders ranging from hypertension and heart attacks to strokes. There are, however, effective treatments. Everyone needs to be cognizant of the symptoms of sleep apnea and to take its presence seriously.