A Short Primer on Sleep Apnea

By Angel Rivera PA-C

Sleep Apnea is the condition of stopping breathing while asleep.

There are 2 basic types of apnea: Obstructive and Central. (There is also drug-induced central apnea from overdose of narcotic medications which can lead to death).

OSA means Obstructive Sleep Apnea. It can be caused by several physical characteristic features which can serve as clues to possible Sleep Apnea and can be observed in some people with: a small chin, a short thick neck, a small rear throat, large tonsils, a large thick tongue, a large/long or short but thick uvula (the little dangling “bell” at the back of the throat), excess soft palate tissue. Loud snoring will often be observed in folks with these features but it is still just a clue; one can snore very quietly and have profound Sleep Apnea; someone else can snore horrendously and not have Sleep Apnea. The crucial point is: does the person stop breathing in their sleep?

(CSA) Central Sleep Apnea refers to a neurologic lack of respiratory drive: the brain in these individuals doesn’t tell one when they’ve stopped breathing for too long and they may cease breathing for relatively long periods of time.

An individual can have one or the other; or can have both OSA and CSA.

Symptoms/effects of Sleep Apnea: awaken tired, daytime drowsiness, awakening choking, diminished libido, depression, grumpiness/irritability, thrashing and talking in sleep, poor memory, instantaneous dreaming on falling asleep, sleep paralysis (awaken unable to move or breath), hypnagogic hallucinations (getting “impressions” from or hearing people that aren’t there), falling asleep while driving; morning headaches (caution: awakening with headaches or being wakened out of a sound sleep by a severe headache could also mean a brain tumor or a cerebral bleed).

When one stops breathing for a prolonged period of time, the oxygen level in the blood drops. Usually the brain senses this and prompts the body to inspire and breath. That is when the Sleep Apnea sufferer will take a choking breath, a.k.a. gasping arousal. The patient will start to waken but doesn’t waken fully and is usually unaware of this happening. The patient goes back to sleep and the above happens again and again, cycling all night long…a patient can stop breathing hundreds of times during the night, up to 582 and 632 times per night (real-life numbers). That is why Sleep Apnea sufferers awaken in the morning and are so tired, feeling more tired on waking than when they went to bed the night before; they feel as if they haven’t slept all night long – that’s because they haven’t! They are never fully asleep long enough to go into deep, restful, refreshing REM sleep. Sometimes people won’t even dream much, if at all.

Dangers of Sleep Apnea: oxygen level in the blood is usually 97-98% while awake. When Sleep Apnea sufferers stop breathing, blood-oxygen level can drop to 80%, 70%, even as low as 36%. This is a dangerous state. The heart does not like to be oxygen deprived, neither does the brain. The heart can become “irritable” and develop potentially lethal dysrrhythmias (bad heart rhythms). One can develop Sick Sinus Syndrome, Tachy-Brady Syndrome where the heart can slow down to dangerously slow rates, and then suddenly speed up to dangerously rapid rates. When the body is struggling to breathe in an anoxic (no oxygen) or hypoxic (low oxygen) state, all kinds of hormones are released that contribute to and complicate the above. Sleep Apnea sufferers with coronary artery disease (CAD) and/or cerebral vascular disease can die in their sleep from bad heart rhythms, heart attack, or stroke. Memory is damaged due to the repeated periods of apnea when the brain is not getting enough oxygen.

Treatments for Sleep Apnea: a CPAP (Continuous Positive Air Pressure) machine is the mainstay of therapy. Some individuals require BiPAP (Bilevel Positive Air Pressure). One wears a mask over the nose, or an alternative called Nasal Pillows that are smaller, less bulky and more comfortable to wear. The CPAP machine is nothing more than a small air-compressor that blows air continuously at pre-set and adjustable air pressures; so that even when one stops breathing, air still gets to the lungs. The patient awakens in the morning refreshed and rejuvenated. No oxygen tank is necessary, although one can be hooked up to the mask for those patients who require oxygen.

Another treatment is UPPP (Uvulo Palato Pharyngo Plasty). This is a surgical approach using scalpel or laser excision of the uvula and excess soft palate tissue; it can include removal of the tonsils. This is a painful procedure that doesn’t always work and can be complicated by regurgitation of food particles and choking. The patient may still require CPAP/BiPAP therapy.

Just as increased body mass and weight gain can negatively impact Sleep Apnea, weight loss can help improve Sleep Apnea.

The spouse of the Sleep Apnea sufferer suffers as well from the loud snoring of their partner, as well as the preoccupation and fear that the partner will stop breathing and die in his/her sleep. A spouse, family member or friend that sees someone stop breathing in their sleep is a bonafide witness who can confirm this to a doctor (with the patient’s permission).

The doctor can order a Sleep Study. A Sleep Study can be performed in a hospital or Sleep Study Lab where the patient stays overnight and is monitored by technicians. Some hospitals will wire the patient up and send them home with a machine that monitors oxygen level, heart rate, occurrence of apneas and near-apneas (hypopneas). The patient connects the machine when they go to bed and disconnects the machine when they awake in the morning; they stick the machine in a special envelope and mail it back to the hospital. When the Sleep Study is done in a hospital or Sleep Lab, the patient can be placed on a trial of CPAP during the study. The disadvantage of the hospital/Sleep Lab approach is that you are limited to one patient to one room for one night and this can be expensive. However, you could wire up 100 patients and send them home, effectively achieving 100 Sleep Studies in one night; this is much more efficient and more economical.

Some people are claustrophobic with the mask. If one has difficulty adapting to the CPAP/BiPAP machine, mask and air pressures, I recommend that they practice using it during the day while awake. Set up the machine in front of your television, radio or book, get in your easy chair, put on the mask and turn on the CPAP/BiPAP machine and practice breathing with it for short periods of time. This is the way to get accustomed to the air pressures during the day so it won’t be as much of an issue at night-time when going to bed for the night.

On a final note, Sleep Apnea appears to run in families. If a parent or both parents have Sleep Apnea, some of their children might have Sleep Apnea as well.

If Sleep Apnea is suspected, see a doctor and address your concerns.

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