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WHAT IS OSA? - download this document in Microsoft Word format


The Problem

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 of OSA.

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 are:

· Irregular heartbeat
· High Blood Pressure
· Enlargement of the heart
· Increased risk of heart failure
· Excessive sleepiness
· Workplace and automobile accidents
· Impotence
· Uncontrollable weight gain
· Psychological symptoms, such as irritability and depression
· Deterioration of memory, alertness, and coordination.
· Death

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 seek help.

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 onset.

Obesity

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:

Impotence
Morning Headaches
Bedwetting

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 current society.

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 in 1984.

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 categories.

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 well.

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.

 

 

 

 

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