Getting a good night's sleep

Obstructive sleep apnea (OSA) is a debilitating and often life-threatening condition that affects 18 million people in the U.S. alone. OSA occurs when tissue in the upper airways blocks the breathing passages. There are three types of sleep apneaobstructive, central, and mixed, however, obstructive sleep apnea (OSA) is the most common. The National Institute of Health estimates that 2 percent of women and 4 percent of men over the age of 35 have sleep apnea in conjunction with excessive daytime sleepiness. In normal conditions, the muscles of the upper part of the throat allow air to flow into the lungs. However, when a person with OSA falls asleep, these muscles are not able to keep the air passage open all the time. When the airway closes, breathing stops, oxygen levels fall and sleep is disrupted in order to open the airway. The disruption of sleep usually lasts only a few seconds. However these brief arousals disrupt continuous sleep and prevent OSA sufferers from reaching the deep stages of slumber, such as rapid eye movement (REM) sleep, which the body needs in order to rest and replenish its strength. Once breathing is restored, obstructive sleep apnea sufferers fall asleep only to repeat the cycle throughout the night.

The exact cause of OSA remains unclear. Generally, sleep apnea happens when enough air cannot move into your lungs while you are sleeping. When you are awake, and normally during sleep, your throat muscles keep your throat open so that air can flow into your lungs. However, with obstructive sleep apnea, the throat briefly collapses, causing pauses in your breathing. With pauses in breathing, your oxygen level in your blood may drop. Ingestion of alcohol and sleeping pills may increase the frequency and duration of breathing pauses in people with sleep apnea.

Risk factors for OSA include obesity, family history of OSA or snoring; and having a small upper airway (large tongue, large uvula, recessed chin, excess tissue in the throat and/or soft palate). Aging may be a prominent risk factor, as the loss of muscle mass is a common consequence of the aging process. Additionally, men appear to be at greater risk.

Other predisposing factors associated with obstructive sleep apnea include: use of alcohol and sedative drugs, which relax the musculature in the surrounding upper airway; smoking, which can cause inflammation, swelling, and narrowing of the upper airway; and conditions such as hypothyroidism, acromegaly, and even nasal congestion.

It is important to note, however, that healthy men, women and children of all ages may suffer from OSA.

According to the American Sleep Disorder Association, it is estimated that 75 to 90 percent of all cases of sleep apnea are never diagnosed. This is often because OSA sufferers are unaware of whether or not their symptoms are a sign of a serious breathing disorder. As such, family members, especially spouses, most frequently witness the periods of apnea. Symptoms include:

• loud snoring
• periods of not breathing (apnea)
• awakening not rested in the morning
• abnormal daytime sleepiness, including falling asleep at inappropriate times
• morning headaches
• weight gain
• limited attention
• memory loss
• poor judgment
• personality changes
• lethargy

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Research suggests that OSA is a major contributing factor in the development of hypertension, or high blood pressure. Data from a 2003 study in The New England Journal of Medicine, reveals that, “sleep-disordered breathing is likely to be a risk factor for hypertension and consequent cardiovascular morbidity in the general population.” Although many patients with OSA have clear symptoms of hypertension, as many as 90 percent of cases are undiagnosed. In studies in which blood pressure was measured following treatment for obstructive sleep apnea, daytime and nighttime blood pressure levels were found to decrease significantly. This decrease in blood pressure may also reduce the likelihood of cardiovascular complications.

The apneas and hypopneas associated with obstructive sleep apnea decrease oxygen levels and increase carbon dioxide levels in the blood. As these levels become more extreme, sufferers begin to struggle for air – in essence suffocating which causes them to wake up briefly and start breathing again. During each apnea, the stress on the body leads to an increase or irregularity of the heart rate and increased blood pressure. According to recent medical research, the stress caused by these irregular apneas may increase the risk for developing high blood pressure, cardiac arrhythmias and heart failure. In fact, according to a 2003 study in The New England Journal of Medicine, OSA sufferers have significantly increased odds of having heart failure.

People with obstructive sleep apnea often feel very sleepy during the day, which has a negative impact on their concentration and daytime performance. Long-term effects of OSA include depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone or driving. In fact, studies show that sleep deprivation can lower a person’s quality of life and increase the risk for accidents.

Diagnosis of OSA should be made by a primary care physician, pulmonologist, neurologist or other physician with specialty training in sleep disorders. Diagnosis is not simple because there can be many different reasons for disturbed sleep. In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include a sleep history and evaluation of the upper airway.

Polysomnography is the most common test used to determine if obstructive sleep apnea is present. Sometimes, simpler portable diagnostic procedures could be used to diagnose OSA. However, if the test doesnt confirm OSA in a symptomatic patient, a full polysomnography test will need to be performed. A Polysomnography patient sleeps in a laboratory overnight. Electrodes are attached to the scalp, on the outer edge of the eyelids and to the skin on the chin. Belts are placed around the chest and abdomen. A cannula is placed in the nose to measure airflow and a probe is placed on the finger to measure the blood oxygen level. While the patient sleeps, the polysomnography records body functions such as eye movement, muscle activity, heart rate, respiration, blood oxygen levels, airflow and the electrical activity of the brain. This information is then gathered and evaluated.

The Multiple Sleep Latency Test (MSLT) measures the speed of falling asleep. In this test, patients are given several opportunities to fall asleep during the course of a day when they would normally be awake. For each opportunity, time to fall asleep is measured. Individuals who fall asleep in less than 5 minutes are likely to require some type of treatment for sleep disorders. The MSLT may be useful to measure the degree of excessive daytime sleepiness and to rule out other types of sleep disorders.

There are a number of options for OSA sufferers. Which is the best for each individual depends largely on the severity of the condition.

Nonsurgical Approaches

• Continuous Positive Airflow Pressure (CPAP) the most common treatment for obstructive sleep apnea, it involves wearing a mask that supplies a steady stream of air through the nose during sleep. The airflow keeps the nasal passages open sufficiently to prevent airway collapse and apnea.
• Weight loss a weight loss of even 10 percent can reduce sleep apnea significantly.
• Changing sleep habits for some people, sleeping on ones side instead of on ones back can reduce sleep apnea.
• Behavior modification subtle changes such as avoiding sedatives and alcohol can sometimes help.

• Surgical Approaches

• Somnoplasty a surgical procedure that uses radio frequency energy to reduce the soft tissue in the upper airway.
• Uvulopalatopharyngoplasty (UPPP) a procedure that removes soft tissue on the back of the throat and palate, thereby increasing the width of the airway at the throat opening.
• Mandibular maxillary advancement a procedure that corrects facial abnormalities or throat obstructions that contribute to sleep apnea.
• Nasal surgery procedures that correct nasal obstructions such as a deviated septum, which may play a role in sleep apnea.

To learn more about OSA, visit the many resources on this site or contact Schwartz Communications at 781-684-0770.

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