Sleep Apnea

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What is Sleep Apnea?

Sleep apnea, also known as Sleep Apnoea,  is a medical condition in which there is either repeated stopping or extended periods of shallow breathing during sleep. It is characterized by repeated episodes of collapse of the upper airways during sleep along with frequent episodes of arousal from sleep.

Is Sleep Apnea condition a Medical emergency?

Sleep apnea is not a medical emergency but early diagnosis and treatment are essential.

Types

Sleep apnea may be of the following types:

  • Obstructive Sleep Apnea: The most common type; caused due to obstruction at the level of the soft palate or the tongue due to the collapse and excessive relaxation of the throat muscles
  • Central Sleep Apnea (Cheyne Stokes Respiration): Due to defects in the respiratory control centres of the brain, that affect breathing during sleep, resulting from an abnormal response of the neurological feedback mechanisms that react to blood oxygen and CO2 levels, and the respiratory rate.
  • Mixed Sleep Apnea/Complex Sleep Apnea: There is a combination of obstructive and central sleep apnea mechanisms

Causes

The cause of sleep apnea depends on the type of condition that is present and may include the following:

  • Obstructive sleep apnea: It can have structural and non-structural factors contributing to the condition and may include
    • Structural Factors:
      • Defects in the jaw structure such as a small lower jaw
      • Facial elongation
      • Down Syndrome
      • Marfan Syndrome
      • High arched palate (more common in women)
      • Adenotonsillar hypertrophy (more common in children and adolescents)
      • Nasal obstruction due to polyps deviated septum, trauma
    • Non-Structural:
      • Obesity
      • Hypothyroidism
      • Stroke
      • Acromegaly
      • Alcohol consumption
      • Postmenopausal state
      • Sedative use
      • Smoking
    • Central Sleep Apnea:
      • Stroke
      • Diabetes
      • Hypothyroidism
      • Parkinson Disease
      • Myasthenia gravis
      • Acromegaly
      • Prader Willi syndrome
      • Cardiomyopathy
      • Heart failure
    • Complex Sleep Apnea: It is usually seen during CPAP treatment of individuals with obstructive sleep apnea

Risk factors

Factors that increase the risk of sleep apnea include the following:

  • Obesity
  • Gender: Males are more affected
  • Age: More common in the elderly age group
  • Smoking
  • Diabetes
  • Congestive heart failure
  • Hypertension
  • Parkinson disease
  • Use of sedatives and narcotics
  • History of stroke
  • Family history of the condition

Symptoms & signs

The signs and symptoms of sleep apnea may include:

  • Habitual loud snoring
  • Episodes of stopping of breathing which end the snoring with a snort
  • Gasping or choking sensation leading to awakening from sleep
  • Increased frequency of urination at night
  • Disturbed sleep
  • Fatigue
  • Morning headache
  • Dry and sore throat
  • Daytime sleepiness
  • Memory deficits
  • Mood changes
  • Sexual dysfunction and decreased libido
  • High blood pressure

Investigations

Some investigations that are advised for the evaluation of the condition include:

  • Laboratory tests:
    • CBP & ESR
    • Thyroid profile
    • Serum Cysteine levels
  • Polysomnography:
    • Sleep stages are recorded via an EEG (electroencephalogram) and chin electromyogram
    • Single lead ECG
    • Leg movements are recorded via lower leg muscle EMG
    • Breathing is monitored and
    • Breathing pattern analysis
  • Home sleep tests

Diagnosis

A diagnosis of sleep apnea and the underlying causes is established based on medical history, clinical evaluation, and results of the investigations done.

Treatment options

The treatment depends on the type of condition present, the underlying cause, and the general health of the individual. Mild forms are managed conservatively with lifestyle changes, while moderate to severe types are managed with medical or surgical interventions and the underlying medical cause is also treated.

Medical management

Medical management may include:

  • Obstructive Sleep Apnea:
    • Central Nervous System (CNS) stimulants: Such as Modafinil, or Armodafinil for the management of daytime sleepiness
    • Dopamine/Norepinephrine Reuptake Inhibitors: Such as Solriamfetol for the management of excessive daytime sleepiness
  • Central Sleep Apnea:
    • Acetazolamide: It is useful in individuals with heart failure
    • Theophylline: It is useful in individuals with heart failure
    • Sedative Hypnotics: It helps with the consolidation of sleep patterns and minimizing instability during sleep-wake transitions

Interventional including surgery and indications for surgery

Interventions for the management of sleep apnea include:

  • Continuous Positive Airway Pressure (CPAP) therapy: It is useful in both obstructive and central sleep apnea; it helps to keep the upper airways open during sleep
  • Bilevel Positive Airway Pressure (BPAP) Therapy: It provides more pressure during inhalation than exhalation
  • Adaptive Servo Ventilation (ASV)
  • Oral Appliances: Act by moving the tongue forward, the lower jaw downwards and increasing airspace to prevent it from complete closure during sleep
  • Supplemental Oxygen

Surgical procedures that may be done for its management include:

  • Uvulopalatopharyngoplasty (UPPP): Resection of the soft palate and uvula
  • Craniofacial Reconstruction Surgeries: Done by the advancement of the tongue or the upper and lower jawbones
  • Tracheostomy: Done in individuals with very severe obstructive sleep apnea
  • Radiofrequency tissue reduction of the soft palate
  • Bariatric surgery: For the management of obesity
  • Overdrive Atrial Pacing: In individuals with dual pacemakers

 Role of diet/ Exercise/ Lifestyle changes/ Preventive

Some measure that can be taken to manage and prevent sleep apnea include:

  • Change of sleeping position: Avoid sleeping face down, and practice sleeping on the side
  • Losing excessive weight
  • Eating a healthy diet and maintaining an ideal body weight
  • Getting regular exercise
  • Avoiding smoking
  • Avoiding consumption of alcohol
  • Avoiding narcotic sedatives

Complications

Some complications associated with sleep apnea include:

  • Increased risk of atrial fibrillation and heart rhythm disorders
  • Complications due to surgical interventions
  • Reduced quality of life due to daytime sleepiness and fatigue

Prognosis

The prognosis depends on the underlying cause, and the general health of the individual. People with heart disorders along with sleep apnea have an increased risk of morbidity and mortality.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if the signs and symptoms of sleep apnea are noticed.

Indications for hospitalization if required

Hospitalization is usually not required, however, brief hospitalization may be required if surgical interventions are advised.

Suggested clinical specialist/ Departments to consult for this condition

  • Sleep Medicine
  • General Medicine
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