The Safety Net

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Introduction

Sleep apnea refers to a breathing disorder characterized by repeated collapse of the upper airway during sleep, with consequent cessation of breathing. These cessations must last for more than 10 seconds to be defined as apnea. The term 'apnea' is derived from the Greek word meaning 'without breath'. According to the National Institutes of Health, sleep apnea is quite common, affecting more than 12 million people in this country.

Obstructive sleep apnea (OSA) typically occurs when the soft tissue in the back of the throat collapses and closes during sleep. Central sleep apnea is a very rare condition that occurs when there is a failure in neurological signaling to the muscles used for breathing. Due to the intermittent lapses in breathing, persons who experience sleep apnea have less restorative sleep.

Untreated, sleep apnea can be associated with weight gain, impotence, headaches, hypertension, and other cardiovascular disease. Job performance and other functioning can sometimes suffer due to daytime sleepiness, fatigue, inattention, and problems with memory and judgment. The field of sleep research has also devoted attention to the role of untreated sleep apnea in vehicular accidents, i.e., circumstances in which the driver is literally 'asleep at the wheel'.

Signs and Symptoms of Persons at Risk for Obstructive Sleep Apnea

The following signs and symptoms are typically identified in people who are considered at risk for OSA:

• Chronic, loud snoring
• Gasping or choking episodes during sleep
• Excessive daytime sleepiness (especially when driving)
• Vehicular or job-related accidents due to fatigue
• Personality changes or cognitive difficulties related to fatigue
• Obesity
• Nuchal obesity (male neck size =17 inches/female neck size =16 inches)
• Systemic hypertension
• Nasopharyngeal narrowing

In children, features compatible with OSA include snoring and labored breathing during sleep, weight loss or failure to gain weight, poor school performance, secondary enuresis, and some behavioral problems.

Diagnostics

When OSA is highly suspected, sleep studies are used to confirm diagnoses. Polysomnography is the diagnostic methodology used to test for sleep apnea and other sleep disorders, such as Restless Leg Syndrome. Testing is conducted during an overnight stay at a sleep laboratory. Polysomnography includes evaluation of sleep stages, airflow and ventilatory effort, arterial oxygen saturation, electrocardiogram, body position, and periodic limb movements. The sleep study data is then prepared for analysis by a physician specializing in the treatment of sleep disorders.

Treatment Options

Treatment alternatives for people who have been diagnosed with OSA include modification of behavioral factors, nasal Continuous Positive Airway Pressure (CPAP), oral and dental devices, and certain surgical procedures.

Modification of Behavioral Factors
For many people with OSA, significant weight loss may provide a curative resolution to their problems with this sleep disorder. Avoiding alcohol and sedating medications prior to sleep can also be helpful. Paying attention to the position in which one sleeps is important as well. Sleeping in a position other than supine can alleviate problems.

Nasal CPAP
Continuous Positive Airway Pressure (CPAP) is the most effective, noninvasive intervention for OSA. A sealed mask worn by the person covers either the nose or both the nose and mouth. The mask connects to a device that forces air through the nasal passages. CPAP increases the pressure in the oropharyngeal airway so that the airway does not narrow and obstruct the passage of air.

Although highly effective when used on a consistent basis, some people have difficulty adhering to the routine use of this equipment. For some people with developmental disabilities, consumer education and behavioral support may be particularly useful in understanding the value of the treatment and in adapting to the actual look and feel of this device.

Oral and Dental Devices
For some people whose sleep apnea is diagnosed as mild to moderate in severity, oral or dental devices may be recommended. Different appliances are used to move the tongue forward or move the mandible to an anterior and forward position to enhance airflow. The effectiveness of these devices vary greatly person to person, with some affording little or no benefit in treating the condition.

Surgical Procedures
Some of the surgical interventions used for OSA include nasal surgery, tonsillectomy, maxillofacial surgery, uvulopalatoplasty (UPPP), and laser-assisted uvulopalatoplasty (LAUP). As with other types of surgery, procedures used for the treatment of OSA may not always be effective. Similarly, these interventions have risks unique to the person and to the procedure. In addition, sleep studies must be repeated after recovery from each surgery.

Summary

Obstructive sleep apnea, when unidentified and untreated, can pose great risks to a person's overall health, well-being, and safety. Appropriate diagnosis, treatment, and monitoring of the person's health status and response to apnea interventions are all significant aspects of addressing this disorder. Sleep disorder research is a growing field in health care and hopefully will yield enhanced solutions for all who wrestle with getting a good night's sleep.

Resources

To learn more about obstructive sleep apnea and the diagnosis and treatment of other sleep disorders, the following resources should prove useful.

National Center on Sleep Disorders Research (NCSDR)
www.nhlbi.nih.gov/about/ncsdr