Obstructive sleep apnea. Don’t sleep on it!

Snoring or feeling sleepy all the time, could it be sleep apnea?

We all know how important breathing freely is. We’ve all voluntarily held our breath or involuntarily lost it (i.e.: apnea). Some will remember, for example, the longest breath competitions in the pool in the summer or have lost their breath after a fall, such as slipping on a patch of winter ice. Well, sleep apnea disorder is just as breathtaking.

Day and night, breathing regularly and fully is critical to maintaining well-being and health. This may seem obvious, but sleep apnea, often minimized or unknown, passes right under our nose.

Obstructive sleep apnea (OSA) occurs when someone while sleeping involuntarily stops breathing or his breathing becomes obstructed for several seconds at a time, and it becomes repeated with chronic interruptions. The sleeper tries to breathe but the air does not pass or it passes with difficulty. This condition is the most common respiratory sleep disorder. If left untreated, sleep apnea could have a dramatic impact on one’s health since full regular breathing is a vital mechanism that provides a constant input of oxygen to our brain and body so they can function well, day and night.

As you fall asleep, muscle tone decreases as all the muscles in your body relax. They include the upper airway muscles such as muscles of the mouth, tongue and throat.

However, when these airway muscles lose too much of their muscle tone and cause the upper airways to collapse (partially or fully) repeatedly while we sleep meaning several times per hour, this is OSA. Once the involuntary obstruction or closure of the airways happens, insufficient air is flowing in and oxygen starts to diminish in the lung and in the cells. This triggers an emergency signal to restore oxygen levels urgently. Muscle tone is re-established, allowing the opening of the airways and proper breathing. This emergency reaction can create a brief awakening called a micro-arousal.

Most of the time, sleepers are not aware of these micro-arousals or that they lack air due to the apneas. Nonetheless, these symptoms have negative impacts on your health, sleep quality, and daily life.

Do you recognize yourself with the following night and daytime symptoms? Since the apnea, namely the collapse of the upper airways, goes unnoticed, people suffering from sleep apnea will instead report some of the following:

Sleep symptoms (nocturnal) Daytime symptoms (diurnal)
Apneas, obstructed or interrupted breathing repeatedly and chronically for several seconds (rarely self-reported; bed partner might report it).
Excessive sleepiness * SLEEPINESS VS FEELING FATIGUE Sleepiness is the urge or need, difficult to repress, to sleep during the day. Not to be confused with fatigue, which is feeling of exhaustion that encourages one to get some rest, but that does not translate into involuntary sleep or excessive need for it. Tired people can fight sleep without difficulty during the day. Sleepy people, on the other hand, are consumed by sleep. They can fall asleep easily in class, at work or while driving, for example. Sleepiness is not a normal state because it is related to either an acute (sleep deprivation) or chronic sleep loss or poor sleep quality. Severe sleepiness is often a crucial symptom of sleep disorders, but also of certain medical or psychological problems. Don’t sleep on it
Snoring, whistling
Unrefreshing sleep
Choking or gasping
Fatigue (lack of energy)
Bed partner complaints or worries about the snoring or breathing interruption or need to sleep in a separate room from bed partner.
Trouble concentrating or a decline in memory (cognitive symptoms).
Short awakenings/arousal
Morning headaches
Frequent need to urinate (nocturia)
Dry mouth upon waking up
Night sweating
Irritability and mood changes
Symptoms that are rare:
o Agitated sleep
o Nightmares
o Insomnia symptoms
o Bed-wetting
• Acid reflux, heartburns
• Erectile dysfunction and/or low sex drive

Snoring, on the other hand, also involves too much relaxation of the muscles surrounding the airways, but instead of making the upper airways collapse they make them vibrate, creating the typical buzz saw sounds. In itself, snoring does not induce a lack of air and oxygen and does not cause daily or chronic symptoms because it does not alter sleep quality, nor respiratory oxygen input. However, snoring can be accompanied by apneas.

Without a doubt, bed partners’ sleep quality may be quite affected. Snoring without apneas is more a social nuisance than a clinical condition, even if it raises the roof.

Anybody can snore, women and men alike, for example when they are more tired than usual, sleep on their back with their relaxed tongue falling backwards, pregnant or have consumed alcohol. Snoring during childhood is unusual though, and must be checked to make sure nothing is obstructing breathing such as enlarged tonsils. As for adults, they can be a symptom of sleep apnea in children. Sleep apnea has potential consequences on child development and health as well as on daytime functioning.

Obstructive sleep apnea is a very common and pervasive lifelong condition affecting us at all ages.

Though estimates vary, it is a major health concern worldwide, unfortunately widely under-diagnosed and under-treated (especially in women, children and young adults with a healthy weight). OSA is one of the most common sleep disorders.

Obstructive sleep apnea does not only affect men or people suffering from obesity. Older age, pregnancy, some facial physiognomy, such as receding or small jaw/chin or being overweight do increase the risk of suffering from sleep apnea.

What to do or not do with obstructive sleep apnea?​

With OSA especially, it’s better to be safe than sorry and act on it before consequences become irreversible Given that apnea influences sleep quality as well as oxygen input, it can have severe consequences on your day-to-day life and safety as well as on your health. (see next section on the consequences of OSA) Keep in mind that there are solutions and effective treatments to prevent the negative health consequences of this respiratory sleep disorder.

If this respiratory sleep disorder is left undetected and untreated, it can have irreversible consequences: cognitive decline including memory impairments, heart disease, diabetes or stroke and motor accidents due to poor alertness.

In children, the negative impacts of OSA such as poor sleep quality, sleep deprivation and poor brain oxygenation may result in physical, psychological and learning developmental impacts.

Moreover, the daily symptoms of this respiratory sleep disorder can lead to misdiagnoses in both children and adults, for example attention deficit disorder with or without hyperactivity (ADHD) or learning disabilities or mental issues such as depression. These are all good reasons to take the bull by the horn  and seek help.

Another good reason to act is that most night and daytime symptoms (see above) will quickly go away when OSA is treated properly and in a timely manner. Most daily symptoms such as fatigue, sleepiness, headaches and more will disappear within a few days whereas for others like cognitive issues efforts will usually pay off within a few months.

If you have sleep apneas, your bed partner or even people who live under the same roof are likely aware of your breathing problem and are likely also worried about it. If this is the case, please take their complaints seriously and act on them.

When severe sleepiness is experienced, it should be investigated, as it is a red flag. Severe sleepiness can indicate an underlying condition ranging from sleep disorders to psychological or medical conditions. Moreover, it dramatically increases the risk of work or car-related accidents or injuries. Long-lasting sleepiness that cannot be attributed to intentional lack of sleep (sleep deprivation) should warrant a visit to your physician or a health practitioner knowledgeable in sleep, as it is an important health and safety hazard.

Use the following guidelines  as a rule of thumb to avoid as they are known to increase snoring and sleep apnea since they worsen vibration, obstruction and closure of the upper airways:

Nasal resistance such as a stuffy nose.

Anything that decreases muscle tone around the airways, e.g. alcohol or sleeping pills.

Anything that narrows the upper airway, e.g. fat from being overweight, anatomical features such as having a small palate or small or receding jaw or chin resulting in a narrowed airways and sleeping on your back with your tongue falling backwards (because you lose muscle tone of the latter)

As you probably knew already, the sleepers’ position is a contributing factor to snoring or apneas and for some of us, it can often make the difference between having a good night’s sleep or not, but it’s not sufficient in itself to explain OSA. Getting a proper diagnosis is crucial and the first step to getting proper treatment.

Once temporary sleep deprivation has been ruled out along with other medical and psychological conditions that may be causing the symptoms, it’s time to consult a sleep expert. For suspicious snoring and sleep apneas, experts are often also specialized in respiratory function such as respiratory physician or  therapist.

Changes in sleep schedule, sleep and health hygiene such as evening alcohol consumption, or not exercising, or poor nutritional habits and  weight gain  will be reviewed (for more on sleep hygiene, see “Why sleep?”) as they are key contributing factors.

Sleep studies are the next course of action to continuing the eliminatory diagnosis process to excluding other sleep disorders causing sleepiness (i.e. hypersomnia, narcolepsy, periodic limb movements disorder, etc).

There are a combination of subjective and objective sleep assessments, done at home or at the sleep clinic at your convenience by sleep professionals. They could include questionnaires, keeping a sleep journal and evaluating overall sleep quality using diverse physiological tests.

Your sleep quality and architecture will be recorded using a polysomnogram (PSG). This non-painful test uses multiple electrodes resting on your skin to measure electrical brain and muscle activities while you sleep. Sleep studies for OSA diagnosis mostly test your breathing and lung function. To do so, respiratory rates and oxygen levels are recorded with a nose cannula, an effort belt is placed  over your chest and an abdomen and a heart rate and oxygen sensor is placed at the tip of one of your fingers.

For more information on sleep studies, please consult the Canadian Sleep Society (CSS) patient guide: https://css-scs.ca/resources/brochures/patient-guide

Time to look at treatments for OSA. Keep in mind that their benefits far outweigh their costs and are worth the trouble and sustained efforts. Treatments reverse or correct many of the symptoms and health risks of sleep apneas such as breathing interruptions, sleepiness, fatigue, snoring, cognitive trouble as well as cerebral and cardiovascular risks. They decrease the risks of associated irreversible health conditions such as stroke, diabetes or dementia.

Here are the most common treatments to turn the ship
around before it’s too late:

1. Continuous Positive Airway Pressure devices (CPAP) (gold standard)

The use of a CPAP device while sleeping is the mainstay and most effective treatment of moderate to severe apneas.

CPAP is a small machine that gently blows air, via a mask, continuously at a given pressure that keeps the airways from collapsing.

CPAP is not complicated to use but we won’t lie: it may take persistence to get used to them. Benefits are a source of motivation since some daytime symptoms such as excessive daytime sleepiness or morning headaches disappear very quickly, sometimes after only one night of use. Other symptoms like memory problems  may take more time to resolve , but  consistent  use will help. Keep it up and you will succeed!

Take your time to choose the right mask for you, as many are customizable. To work efficiently, you need to get used to wearing the nose or face mask while sleeping and to feel comfortable. Your sleep professional will support you throughout the transition. Support groups are very useful and participants can give encouragement and suggest solutions for issues that may arise.

Noise made by the CPAP is very low and won’t disturb bed partners.

2. Oral breathing devices or other appliances (such as nasal dilators or a mouthguard)

Excellent for snoring and mild to moderate obstructive sleep apnea.

These devices keep the airways open by holding the nose or mouth in an optimal position and decreases the chance that it will collapse while you inhale. The mandibular repositioning device for example, advances the tongue and lower jaw and keeps it in a lower position, which may help adjust the facial features causing snoring or apneas.

It can be an alternative treatment to CPAP machine.

Be careful not to obstruct your respiration more by using an oral breathing device or appliance. The right option requires the assistance of sleep healthcare providers such as a dentist specialized in sleep medicine.

3. Positional therapy; not sleeping on your back

Effective for snoring and mild apnea. Can be used in conjunction with CPAP or appliances.

As the tongue may create more blockage at the back of the throat when sleeping on the back, learn to sleep on your side and stay in this position.

Side bumpers are often needed for this. Imagination has given rise to several DIY bumper ideas to prevent sleepers from rolling on their back: sew a pocket on the back of a pajama top and put tennis balls in it, wear a bra in reverse with tennis balls in it, wear a backpack or sleep next to a body pillow. Readymade devices such as snore shirts, anti-snoring belt and positional alarms are also options.

4. Surgical treatment airways anomalies

Surgery becomes an effective treatment when a throat structural malformation or jaw position is causing the snoring or apneas. These can be natural features or secondary to an accident causing cervical damages such as a car accident involving whiplash for example.

5. Weight management

If snoring or sleep apnea is related to weight, measures should be taken to reduce fat accumulation, as neck fat accumulation due to being overweight or obese may be the cause of the airway collapse. Although easier said than done, weight loss is an extremely effective treatment, which makes it worth the sustained efforts. Again support groups and therapeutic guidance are very helpful to remain goal-oriented and remember to talk about issues as they arise.

What are the causes of obstructive sleep apnea?

Snoring and obstructive sleep apnea (OSA) often depend on a combination of contributing factors such as an individual’s anatomy such as face, neck and throat parameters, body weight, age, abnormal airways due to a car accident for example and lifestyle such as alcohol consumption.

More precisely, for children and adults alike, physiognomy risk factors include:

  • Larger than average tonsils and/or adenoids (lymph nodes in the throat behind the nose)
  • Being overweight or having a large neck circumference
  • Having a small or receding jaw or midface,
  • Larger-than-usual tongue,
  • Less muscle tone than normal (such as in people with Down syndrome, cerebral palsy, and/or neuromuscular disorders).

These at risk profiles may be innate or acquired after an injury such as a car accident-involving whiplash. Sleepiness and fatigue following an accident involving injuries around the airways may be causing apnea symptoms and preventing full recovery. Healthcare professionals may be trained to recognize silhouettes (airways, face, neck and body) that are more at risk than others. Respiratory physicians, therapists and sleep medicine specialists have a trained eye on this matter.

OSA may be family-related but it is not a genetic disease per se. The hereditary characteristic of sleep apnea is in fact related to the common morphology of the cranio-facial features and the upper respiratory tract or adipose tissue, for example.

What are the consequences of obstructive sleep apnea?​

When people are snoring, with no sleep apnea associated, there are no health consequences aside from potentially disrupting their bed partner’s sleep.

However, OSA is a serious condition that cause  harm.  These negative effects are all caused by chronic insufficient oxygen input, poor sleep quality and accumulated lack of sleep, especially deep sleep due to apnea.

Many symptoms are temporary and can be reverse when sleep apneas are diagnosed  ontime and effective treatment is applied.. Within a day to several months of proper treatment, the night and daytime symptoms and health conditions, described  above, can resorb or be mitigated  significantly.

Irreversible consequences also exist and can have a lifelong impact. Undetected or untreated OSA can lead to serious chronic medical conditions such diabetes, stroke, ischemic heart disease, permanent memory loss and cognitive troubles.

Poor sleep affects every aspect of life, including one’s vitality, general outlook and productivity. Sleep apnea symptoms such as sleepiness may have dangerous consequences as they result in more frequent traffic or work accidents.

OSA is a major public health issue. It is also a significant economic burden. The costs of undetected and untreated sleep apnea are higher for society and for you personally than the cost of getting help and acting on this treatable sleep condition. Remember, eyes on the ball to turn this ship around once and for all.

* SLEEPINESS VS FEELING FATIGUE
Sleepiness is the urge or need, difficult to repress, to sleep during the day. Not to be confused with fatigue, which is a feeling of exhaustion that requires one to rest, but that does not translate into involuntary sleep or an excessive need for it. Tired people can fight sleep without difficulty during the day. Sleepy people, on the other hand, are consumed by sleep. They can fall asleep easily in class, at work or while driving, for example. Sleepiness is not a normal state because it is related to either an acute (sleep deprivation) or chronic sleep loss or poor sleep quality. Severe sleepiness is often a critical symptom of sleep disorders, but also of certain medical or psychological problems. Don’t sleep on it