WHAT IS OSA? - download
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Obstructive Sleep Apnea (OSA) is a debilitating condition that
affects between 20 and 25 million Americans. This is a stunning
number, but the real problem is that we still have approximately
a 95% undiagnosed population of people who have treatable OSA.
The problem is twofold. First there is a large population of people
who don't even know they have the condition. Second, many primary
care physicians do not take an active or serious look at this condition,
or do not identify it when the patient complains of the common symptoms
The Technical Aspects of the Disorder
Sleep Apnea (pronounced "AP-nee-uh") is a breathing disorder
that affects people as they sleep. The word apnea comes from the
Greek prefix a ("no") and the Greek word pnoia ("breath").
People with sleep apnea stop breathing repeatedly throughout the
night. Breathing may stop ten, 20 or even 100 times per hour. This
adds up to sometimes hundreds of times per night. These breathing
cessation's are identified as "events". It is completely
variable among patients. The standard of practice is to not count
an event if it does not last at least 10 seconds. People frequently
stop breathing for a minute or longer. With these events come associated
oxygen desaturations. This can be a very serious aspect of this
condition as the brain is receiving less than optimal amounts of
oxygen during this time. The more events the patient has the more
oxygen deprived the brain is. This leads to daytime functioning
problems, as well as over time serious health concerns for the patient.
Some of the most common health hazards of untreated Sleep Apnea
· Irregular heartbeat
· High Blood Pressure
· Enlargement of the heart
· Increased risk of heart failure
· Excessive sleepiness
· Workplace and automobile accidents
· Uncontrollable weight gain
· Psychological symptoms, such as irritability and depression
· Deterioration of memory, alertness, and coordination.
There are three types of sleep apnea. They are obstructive, central
and mixed. Most clinicians and researchers believe that there are
pretty clear distinctions between obstructive apnea and central
apnea. The cause of the respective apnea determines treatment, therefore
it is important to understand the different types of apnea and what
causes each type.
Obstructive Apnea as its name indicates means that a patients upper
airway is blocked during sleep by the tissue of the soft palate,
throat, and tongue. There are many reasons why a patient may have
developed obstructive apnea. The most common is obesity, simply
too much tissue present when a patient relaxes during sleep thereby
closing off the airway in the throat during sleep. Or anatomical,
how the shape that the patients throat, jaw line and soft palate
are naturally put together. In either case, when the patient relaxes
his muscles during sleep the obstruction will occur, and oxygen
will stop being delivered. As this happens, the patient will arouse,
most of the time with a gasp, waking themselves up. This allows
the muscles to tighten up again and the patient is again able to
breathe freely. Most of the time the patient does not know that
they have woken up, nor do they acknowledge that they have not been
able to breathe during the event. They fall back to sleep, and the
whole process begins again. Remember this can happen many, many
times per hour.
Central Apnea is another matter entirely. A pure case of central
apnea is the least common of the three types. In central apnea the
cause of the breathing problem is in the brain, or central nervous
system; thus the term "central apnea". In a patient with
central apnea the respiratory center in the brain that controls
breathing, may simply stop working during sleep. It fails to signal
the chest muscles to make breathing movements. There are several
theories for why this happens. Most people believe it is related
to some disorder in the breathing reflex. The disorder may be an
inherited neurologic problem or a neuromuscular disorder that develops
later in life, such as polio or ALS.
A patient with pure central apnea has a very difficult time sleeping
and breathing at the same time. In most cases, as soon as he goes
to sleep he stops breathing, and awakens shortly after with a gasp.
This can happen many times during the night. These patients also
suffer from oxygen desaturations and are subject to the same problems
that obstructive patients may face in that regard.
Mixed Apnea is a combination of both obstructive apnea and central
apnea. Most people have some form of mixed apnea. It is thought
that most people with obstructive apnea have a central component
and that some abnormality exists in the breathing reflex in the
brain usually accompanying obstructive sleep apnea. Some believe
that when a patient with obstructive apnea has an event and gasps
to recover, a point of "overbreathing" occurs. This results
in unusually low levels of carbon dioxide (CO2) in the patients
blood, thereby stimulating a central apnea event. This then would
be the reason for the mixed apnea definition. The more severe the
patients obstructive component is, the more "overbreathing"
would occur, and a more pronounced or severe the central component
would then be expected to be seen.
The symptoms of Sleep Apnea
There are many symptoms that can indicate a patient may have sleep
apnea. Contrary to some people's belief, sleep apnea is not just
something that happens to morbidly obese people. People with normal
body weight are also victims. You do not have to have every symptom
to have apnea. Some people present with few and are some of the
worst cases. Conversely just because a patient has all the symptoms
they may not have strict sleep apnea but another form of sleep disordered
breathing called Upper Airway Resistance Syndrome (UARS). People
have many different ways of explaining their sleep problems. If
you are in a position to take a patients history, be patient with
them and know your symptoms so you can identify what a patient is
trying to explain to you.
Loud, irregular snoring and snorts, gasps, and other unusual breathing
sounds during sleep.
This is the most common and obvious sign of sleep apnea. The snoring
will usually be very erratic and stop and start frequently, obviously
stopping when the patient stops breathing during an event. Apnea
type snoring is very loud, labored and usually indicated some struggle
or discomfort for the snorer. Not all snoring is indicative of sleep
apnea. In most cases, the patients are not that bothered at all
by this. Their bed partners however are very bothered. Many people
have slept separately from their bed partners for many years. In
many cases it is the insistence of the bed partner that the patient
Pauses in breathing during sleep.
Everyone has irregular breathing at some points in the night. All
of us while dreaming have points when our breathing speeds up or
slows down in an irregular manner. When drifting off to sleep or
when people awaken breathing also may pause. These are all very
normal changes in breathing.
People with sleep apnea frequently stops breathing completely and
may hold their breath for long periods of time. These are the times
when events are occurring. These pauses are not counted as events
in most cases unless the event lasts at least ten seconds. In most
cases, there must be at least 5 events per hour to qualify a person
as having sleep apnea. Cases are usually considered mild, moderate
or severe. This is a somewhat arbitrary scale, and where a particular
patient fits in is usually determined by the doctor interpreting
the sleep data.
Excessive daytime sleepiness (EDS) and/or Fatigue.
It is very common although very deceptive belief by many sleep
apnea sufferers that they get "too much sleep". This is
referred to by clinicians as EDS. Two thirds of patients suffer
from some sort of EDS. Often times they simply cannot identify it,
having lived with it for so long they cannot identify "normal"
any longer. It is indeed a very gradual thing. It is not normal
however to not be able to keep alert while driving, or to have to
fight to stay awake at your desk, parties, or sporting events.
EDS comes mainly from poor quality sleep. In the case of sleep
apnea, the persons sleep is interrupted so many times by having
events that the patient doesn't get enough sleep.
Fatigue is different from sleepiness. Rather than a desire to go
to sleep, fatigue is the sense of feeling exhausted, drained. Since
most patients with sleep apnea have had it for years, patients often
feel fatigue most of the time. It is common to mistake fatigue for
the normal signs of aging, or to not notice them because of gradual
Obesity is fairly common among people with sleep apnea. A strange
relationship exists between people with sleep apnea and weight.
Usually the sleep apnea makes the weight problem worse, and vise
versa. Losing weight may help the sleep apnea and other health concerns,
but usually weight loss cannot begin until the sleep apnea is treated.
Changes or loss in alertness, memory, personality or behavior.
As with most symptoms other people are the first to notice changes
in the afflicted person. Sleep apnea can mimic depression, laziness,
or personality change. These changes in behavior can include a gradual
shift in sleeping or napping habits, the level of energy the person
may have, and productivity at home or at work. A persons mood or
disposition may also be affected. Don't mistake stress for increased
irritability, shortness of temper, or "crabbiness". They
are very often caused by sleep apnea.
Other symptoms of sleep apnea are:
Continuous Positive Airway Pressure (CPAP)
The Most Effective Treatment for Sleep Apnea
There are many different treatments that have been tried over the
past several years to treat sleep apnea. Of those very few have
much affect on the actual problem, mainly only treating the symptoms.
Many of these techniques have been devised due to patient demand
for a "quick fix", which has become a mainstay in our
Some of the treatments out there that are used are:
Various types of surgery. There are three main types of surgery
done today for sleep apnea. These consist of a procedure called
UPPP, mandibular advancement, and tracheostomy. There are many drawbacks
to having surgery. Pain, excessive loss of blood, reaction to medication
or anesthesia etc.
UPPP has about a 50% failure rate out of the chute. This is because
although it can relieve some of the main symptoms (i.e. snoring)
it cannot stop the throat from becoming obstructed while a patient
sleeps. Many people who have this surgery do not have any benefit
at all, and of those who do have some relief, see a steady decline
in even these benefits over the course of about 5 years.
Mandibular advancement requires reconstructive surgery of the jaw.
In this procedure the jaw is broken and actually moved forward.
Because of the complexity of this procedure it is very seldom done.
Many insurance companies will not even consider this unless all
other measures have been tried and have all failed.
Tracheostomy used to be performed routinely on OSA patients as
there was no other treatments available. This leaves a lot to be
desired as it affects many other systems in the patients body. Not
to mention the aesthetic problems with it.
Oral devices are another possible treatment. These are designed
by taking a mold of the patients mouth and teeth. The idea is that
the device will hold the jaw, the tongue, or both in a forward position
during sleep, thus not allowing them to fall back and cause obstruction.
These devices only are appropriate for patients whose obstructive
apnea is caused primarily in the lower throat, by the position of
their tongue or lower jaw in relation to their airway.
Positional therapy is a method by which the patient learns to sleep
in a certain position. This is accomplished in a number of ways.
A tennis ball can be used, sewn into the back of pajamas. When the
patient rolls over the will lay on the ball causing them to roll
back onto their side. Or a foam wedge may be used. These wedges
are made in many different heights. This does not allow the patient
to roll onto their back. This method is successful if the patient
exhibits apnea during their test only while on their back, or sometimes
if the patient has a very mild case of apnea.
CPAP is the most effective treatment for OSA. It was developed by
Collin Sullivan and his research group at the University of Sydney
Medical School in Australia in 1981. It was first used in this country
CPAP uses air pressure as a "splint" in the back of the
throat to hold the airway open and keep it from collapsing during
sleep. Since it is a non-invasive procedure it is recognized as
the treatment of choice by most sleep professionals in the world.
CPAP often seems like a virtual "miracle" when patients
use it as they can often see benefits from it the very first night.
It should be recognized that CPAP is not a cure for OSA as it does
nothing to change the airway, but used regularly can strengthen
muscles in the airway.
There are some things that patients must adapt to when using CPAP,
but all in all, if a patient will give it an honest try, CPAP works
in almost all cases.
This treatment is not suitable in most cases for patients with
central apnea. Introduction of positive pressure in these patients
can cause many medical problems.
Different Types of Positive Pressure Devices
There are different types of positive pressure devices that are
made to treat different types of breathing disorders. Several companies
make a complete line of devices specifically designed to treat sleep
disordered breathing. The major brands are: Sullivan by ResMed,
Respironics, Healthdyne (Recently Respironics and Healthdyne merged)
and Nellcor Puritan Bennett. Each company makes devices in the following
Static Pressure CPAP Device - The term "static" refers
to the machines ability to only create positive pressure at one
defined pressure. Each of these machines have specific features
to make them comfortable for the patients to use. Some offer a ramping
feature for comfort as the patient falls asleep, and a pressure
ranges typically of +4 to 20 cm H2O. Some static pressure devices
are capable of downloading compliance data from the unit. This data
can be downloaded directly or via modem connection.
Bi-Level and Bi-Level ST Devices - These devices deliver both an
IPAP and an EPAP pressure to the patient. The EPAP pressure "splints"
the airway open to control apnea and related disease and the IPAP
pressure provides extra ventalatory support. In Spontaneous mode
these devices sense patients breathing patterns and adjusts the
pressure accordingly. In Timed mode, IPAP and EPAP pressure are
delivered at a predetermined breathing rate. In Spontaneous/Timed
mode, IPAP/EPAP transition is triggered by the patient's respiratory
cycle. Compliance data is retrievable from some of the units as
Auto Titration Devices - These devices deliver variable pressure
in the treatment of OSA. With the ability to detect some parameters;
snore, flow limitation and open and closed airway apneas, (AutoSetâ
only) the device delivers only the pressure that is needed for the
patients current state. Pressure is adjusted on a breath by breath
basis and will maintain only as much pressure as the patient needs
keeping pressures as low as possible. This makes using the machine
much more comfortable and increases compliance.