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 it is to breathe freely. 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 thoroughly is critical to maintaining well-being and health. This may seem obvious, but as people has sleep apnea when they sleep, it is often unknown or barely noticed, it passes right under our nose.
Obstructive sleep apnea (OSA) occurs during sleep when someone involuntarily stops breathing or when his/her breathing becomes obstructed for several seconds at a time, in a repeated and chronic way. 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 contraction and stiffness decrease 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 tension, it causes the upper airways to collapse (partially or fully) repeatedly while we sleep. This can go on for 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 tension is re-established, allowing the opening of the airways and proper breathing. This emergency reaction can create a brief awakening called arousal.
Most of the time, sleepers are not aware of these 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 or 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 a minimum of 10 seconds (rarely self-reported; a bed partner might report it or report the gasping after).
Excessive sleepiness * SLEEPINESS VERSUS FEELING FATIGUESleepiness 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!
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 during the night
Frequent need to urinate (nocturia)
Dry mouth upon waking up
Irritability and mood changes
Symptoms that are rare:
o Agitated sleep
o Insomnia symptoms
• 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. It happens when the airways are smaller and the air has to pass faster through them. This is like the wind blowing between two buildings: the wind will funnel through and increase its speed. With fast air moving through the airways, the surrounding tissues tend to vibrate, creating the typical buzz saw sounds. In itself, snoring does not induce a lack of air and oxygen as your body can breathe the same amount of air, by increasing the speed of the in and outflow of air; and does not cause daily or chronic symptoms because it does not alter sleep quality, nor respiratory oxygen input. However, snoring is a sign of a smaller airway and 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. Similar to adults, loud and repetitive snoring 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 underdiagnosed 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 characteristics, 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 problems.
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 nights 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 the decrease in airway size, obstruction and closure of the upper airways. Please note that having some or many of the following conditions does not necessarily mean you have sleep apnea. These conditions only increase the chances of having or developing the problem.
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 or receding jaw or chin resulting in a narrowed airways and sleeping on your back with your tongue falling backwards (some people only have sleep apnea on their back, while for others it doesn’t matter)
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 lack of sleep or 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 hygiene such as evening alcohol consumption, not exercising, or 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 is 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 oxygen level over an entire night of sleep. 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.
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 appliances or mandibular advancement devices
Excellent for snoring and mild to moderate obstructive sleep apnea.
These devices keep the airways open by holding the lower jaw and/or the tongue forward in an optimal position and decreases the chance that it will close while you are asleep. The mandibular advancement device, for example, advances the lower jaw and keeps it in a forward position, which will increase the size of the airway and decrease chances of closure which causes snoring or apneas.
It can be an alternative treatment to CPAP machine.
Be careful not to obstruct your respiration more by using an off-the-shelf appliance without supervision. The right option requires the assistance of a dentist specialized in sleep medicine together with an assessment from a physician.
3. Positional therapy; not sleeping on your back
Effective for snoring and mild apnea for some people. Can also be effective in people with positional dependent sleep apnea, even if moderate to severe. Can be used in conjunction with CPAP or oral 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.
Belt 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. Remember to have good pillows that allow you to sleep comfortably on your side. It is often recommended to have a slightly elevated pillow, and to hold a pillow between the arms and between the legs.
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 surgeries are complex but when properly indicated can have very good results. The main idea is to surgically position the upper and lower jaws more forward.
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 craniofacial 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 causes 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 reversed when sleep apneas are diagnosed on time 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 as 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 VERSUS 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!