Sleep Apnea | Symptoms, Causes and risk factors, Types, Treatment
1. Sleep Apnea - An overview
Before focusing on the various aspects related and relevant to sleep apnea, it seems important to highlight the meaning, benefits, and problems affecting the quality of sleep. And sleep apnea is one of such problems that adversely affect a quality sleep and in consequence the quality of life.
Veritably, sleep is a biological demand (like foods and drinks). Sleep is essential for every living being (man or animal). And Sleep is a state in which the person is less responsive to outward stimuli (as compared to a usual waking state). Sleep is necessary for work and an active and healthy life. Like work, sleep or complete uninterrupted rest is an integral part of our daily routine job. On average, about 1/3rd (8 hours) of a day is spent enjoying sleep. Quality sleep is indispensable to survive just as healthy foods and drinks are.
The benefits of sleep are many. Sleep affects every system and function of the body-- from the cardiovascular system/lungs/ breathing/blood pressure to mood/ appetite/ disease resistance/ metabolism (it is a biochemical process that functions for the growth and development of the human body) /immune system (it is a host of defense system existing in the body. The organs and the processes of the body that provide resistance to infection and toxins. The organs include the thymus, bone marrow, lymph nodes).
Sleep is also important to several brain functions (including how nerve cells or neurons communicate with each other). While one sleeps, the brain and the body stay remarkably active. Sleep plays a key role in removing toxins from the brain (that builds up while one remains awake).
Various research studies reveal the fact a chronic sleep deprivation or poor-quality sleep may invite serious health troubles like obesity/ high blood pressure/ depression/ diabetes/ kidney disease and cardiovascular disease.
Metaphorically, a sleepless night means a stressful and awful night. Again, life means “the running cycle of sleep followed by wake and work”. But death means “the sleep that never breaks” Conclusively, a sound sleep means sound health and a lively and fresh mind.
2. Sleep apnea
2.1) What it means
Sleep apnea is an involuntary cessation of breathing that occurs during sleep. Sleep apnea is a common and serious sleep disorder in which breathing repeatedly stops for a while during sleep. This causes the decreased flow of oxygen in the blood which can briefly awaken the sleeper.
2.2) Sleep apnea vs. Hypopnea
Hypopnea is a type of sleep apnea. The term, hypopnea simply means abnormally slow or shallow breathing. While sleep apnea means periods of no breathing. The difference between the 2 is explained by the degree of blockage in the patient’s air passage.
3) Normal range
For instance, if anyone naps for a ½ hour and has AHI =4 (AHI is a unit to measure the severity of sleep apnea expressed in per hour), then the implication is that the person experiences only 2 apneas within a ½ hour which is normal. (Because AHI=4 denotes the frequency occurring within an hour).
4. Sleep Apnea Symptoms
Major symptoms (such as pauses as well as snoring) are common for each and everybody. Still, to some extent, the symptoms differ depending on age and gender as stated below.
4.1) Symptoms in men
4.1.1) Sudden wake up with a very sore and dry throat (besides having sleep apnea, it may also occur while sleeping with mouth open during winter when air can get dry and cause sore throat. Again, sore throat can also occur due to a viral infection such as cold and flu).
4.1.2) Loud snoring (the tissues in the throat can relax enough so that they partially block the airway which vibrates. This increases tissue vibration, which causes snoring to grow louder.)
4.1.3) Occasionally waking up with a choking or gasping sensation (As the mucus builds up, the patient may feel as if breathing becomes difficult. During sleep the patient may wake up gasping for air).
4.1.4) The patient may feel sleepy and not energetic at all while on work during day time.
4.1.5) Morning headache :
In addition to sleep apnea, a variety of causes can invite a morning headache. Depression is the most important among them. Other causes include brain tumors (it is a tumor that develops in the brain or spinal cord. A brain tumor is a collection of a mass of abnormal cells in the brain. The skull which encloses the brain is very rigid. Any malignancy growing inside the restricted space is risky and dangerous. A brain tumor can be cancerous when it is malignant or non-cancerous when it is benign) and severe high blood pressure (it is a hyper intensive crisis that can lead to stroke. Severe high blood pressure is indicated by Systolic reading= 180 mm Hg or more / Diastolic reading =120 mm Hg or more).
4.1.6) Mood changes, decreasing interest in sex and forgetfulness (With aging, many physical problems and discomforts arrive including forgetfulness. Notably, vitamin B- 12 (the vitamin promotes nerve function and helps the body to make new cells. Additionally, it helps lower the risk of heart disease) deficiency is common among older people. Over and above, hypothyroidism i.e. an underactive thyroid may trigger the symptoms).
4.2) Symptoms in women
4.2.1) Loud or frequent snoring
4.2.2) Silent pauses in breathing (In the case of the patients with sleep apnea, snoring is usually followed by silent pauses in breathing. On account of sleep apnea, disturbances during sleep occur when the tissue of the upper air passage/tongue/ soft palate and uvula collapse which in consequence disturb normal air inflow).
4.2.3) Choking or gasping sound
4.2.4) Daytime sleepiness (the most important cause is sleep apnea. Besides, sleep deprivation and sedating medications (Drugs are regularly taken for calming or sleep-inducing effect. These include: Alprazolam/ Diazepam/ Lorazepam/ Chloriazepoxide/ Triazolam/ Oxazepam/ Clonazepam) can aggravate the symptoms and fatigue.
4.2.5) Un-refreshing sleep (It implies poor quality sleep which is inadequate and hence ineffective to relieve fatigue).
4.2.6) Morning headache
4.2.7) Insomnia (It significant level of sleep deprivation or lack of adequate sleep which is one of the symptoms of sleep apnea. Other underlying causes are anxiety/ stress/depression and various emotional and psychological factors, such as worry/ grief/ anger/ trauma)
4.2.8) Nocturia (the term is derived from Latin “Nox” which means night and Greek “Oupa “which means urine- describing the condition with the problem of the patient while sleeping at night to wake and walk to urinate at least once)
4.3) Symptoms in adults
Varieties of symptoms arise among the adults, but the major symptoms include snoring and daytime tiredness (Snoring is a familiar and disordered condition of sleep occurring due to the interruption in the free movement of air through the nose and the throat. Day time tiredness is the outcome of the poor quality of sleep).
4.4) Symptoms in kids
- Mouth breathing: It is a symptom of sleep apnea mostly occurring in the case of the children. Also, crowded teeth (crowded teeth occur when one does not have enough space for the teeth to accommodate properly. In consequence, the teeth can bunch up/ overlap/ twist) as well as enlarged tonsils and adenoids among the children, can also cause mouth breathing.
- Breathing pauses during sleep: It occurs during sleep due to disturbances in the normal airflow through the nose and the throat.
- Day time sleepiness: It is the outcome of sleep deprivation and inadequate sleep at night.
- Difficulty in concentration: Concentration problem is found common to many people. Hormonal changes are the major causes.
Conclusively, the children with untreated sleep apnea run the risk of having behavioral, adaptive and learning problems.
5.1) Sleep apnea is a common and serious sleep disorder in which breathing repeatedly stops for 10 seconds or more during sleep. The disorder results in decreased oxygen in the blood and can awaken the sleeper throughout the night.
5.2) Pregnancy complications and risks become higher in the case of the patients having sleep apnea.
5.3) Patients suffering from sleep apnea who are undergoing any surgery, are at increased risks for developing respiratory (surgery and anesthesia are the prime causes of reparatory complications. Symptoms include: breathing problem/ labored breathing/ shallow breathing/ chest congestion/ asthma) and other complications during the period following surgery.
5.4) Patients having sleep apnea have a greater risk of sudden cardiac arrest (In this condition the heart malfunctions. In consequence, the heart suddenly and unexpectedly stops beating which can cause death).
6. Causes and risk factors
Causes are the agents directly responsible for the occurrence of a disease. On the other hand, a risk factor is not necessarily a cause. A risk factor may be anything that increases the likelihood for a patient to develop the disease (for instance, age is a vital risk factor for any malignancy. But can never be a cause).
6.1) Causes of sleep apnea
6.1.1) The most common cause of sleep apnea, occurring particularly among the adults, is overweight and obesity (an Ideal weight or otherwise, is measured by BMI implying Body Mass Index. The formula is BMI =W/ H2. Where: W= weight in kg and H2= square of height in meter. As for example, with height = 1.7 meters, BMI = 20- 25 for an ideal weight. BMI =25- 30 for an overweight. BMI= over 30 for an obese. BMI= below 18.5 for underweight)
Veritably, overweight and obesity are closely related to the soft tissue of the mouth and the throat. During sleep, when the throat and the tongue muscles are more relaxed, the soft tissue can cause the air passage to become blocked triggering the symptoms of sleep apnea.
6.1.2) In children, the causes of sleep apnea include: enlarged tonsils and adenoids (adenoid is a palate of tonsil lying high up in the throat and just behind the nose. The adenoids along with tonsils form part of the lymphatic system and work by trapping the germs coming in through the mouth and the nose. Adenoids usually start to shrink after age 5)
As regards the occurrence of sleep apnea among the children, other important causes are tumor (it is an abnormal growth of cells that serves no purpose. When a benign tumor spreads and deteriorates to malignancy, then it is called cancer)/ large overbite (An overbite occurs when the upper front teeth overlap with the lower front teeth. Most people have overbite to some extent) / growth in the air passage and birth defects. such as.
i) Down Syndrome :
it is a genetic disorder and is typically associated with physical growth delays, intellectual disability of mild to moderate extent and characteristics of facial features. Down syndrome causes enlargement of the tongue/adenoids/tonsils and decreased muscle in the upper air passage.
ii) PRS i.e. Pierre Robin Syndrome is also known as Pierre Robin malformation or Pierre Robin Anomaly. PRS is a sequence or chain of certain developmental malformations, one entailing in the next. PRS has a small lower jaw, and the tongue tends to fall to the back of the throat.
6.2) Sleep Apnea Risk factors
Obesity as well as overweight also plays a key role as a risk factor. Apart from that, hereditary factors play a significant role in aggravating the symptoms which include narrow throat/ hypothyroidism (it implies an underactive thyroid or low thyroid. It is a thyroid disorder in which the thyroid gland does not produce enough thyroid hormones. Hypothyroidism can invite several symptoms that include: poor ability to tolerate cold/ extreme tiredness/ constipation/ depression/ weight gain) /production of growth hormone/ acromegaly (it is a hormonal disorder that results from too much growth of hormone in the body.
The pituitary is a small gland in the brain that makes hormones. In acromegaly, the pituitary gland produces excessive amount of growth hormone) /allergens (it is a harmless substance, such as food/ pollen/ dust/ mites causing allergic reaction) and other medical conditions, such as deviated septum (it is a condition in which the nasal septum i.e. the bone and the cartilage that divide the nasal cavity of the nose is significantly off the center or crooked that makes the breathing difficult. Most people have imbalances in the size of breathing passages) that create congestion in the upper air passage. Also, excessive sedatives as well as the 2 expensive bad habits- smoking and alcohol can trigger the symptoms.
7. Sleep Apnea Diagnostic tests
The patient is likely to be referred to the sleep specialist at the sleep disorder center to evaluate and do the needful. The doctor makes an evaluation based on the signs/ symptoms/ sleep history which can be best provided by the family member, preferably sharing the bed.
7.1) Nocturnal polysomnography test
The test is conducted during sleep when the patient is hooked up with the equipment that monitors the heart/lungs/ brain activity/ breathing pattern/ arms and legs movement.
7.2) Home sleep tests
The doctor might provide simplified tests to be conducted at home to diagnose the disease. These tests usually measure the heart rate/blood oxygen level/ airflow/breathing patterns. If the results arrive abnormal, the doctor might be able to prescribe therapy (In fact, therapy and treatment are different. Medical professionals apply medicines/ surgery/ therapy/ lifestyle changes for the treatment of the disease. On the other hand, therapy is applied to cure a specific health disorder. Veritably, therapy is a part of an overall treatment procedure that helps the patient to feel better and stronger. For instance, chemotherapy and radiotherapy are applied for healing cancer).
Conclusively, if the portable monitoring devices fail to detect the root causes of sleep apnea, then the doctor might still recommend a polysomnography test, even if the initial test results are found normal. Additionally, if the sleep apnea problem is suspected, the sleep specialist will first refer to ENT (Ear Nose Throat) specialist to rule out the blockage in the nose or throat. Over and above, a cardiologist (for evaluation of heart functions) and a neurologist (for evaluating the nervous system) may be needed to identify the major causes of sleep apnea.
8. Sleep Apnea Types
The problem of sleep apnea can be categorized under 3 major heads depending on the symptoms experienced, although, they are all the same about the involuntary cessation of breathing that occurs for a while during sleep.
8.1.) Obstructive sleep apnea
It is a more common type that causes sleep to repeatedly stop and start. It is characterized by the intermittent relaxation of throat muscles/`repetitive closing of the upper air passage/repetitive oxygen disturbances and sleep fragmentation. The noticeable symptom is snoring.
8.2) Central sleep apnea
It occurs when the brain does not send proper signals to the muscles that control breathing. It is less common and differs from obstructive sleep apnea (in which case the patient can’t breathe normally because of upper air passage obstruction).
8.3) Complex sleep apnea
It is a type of sleep apnea having slept with disordered breathing. In such case, repetitive central apneas occur (persisting for more than 5 hours when obstructive events are extinguished with positive air passage pressure)
Conclusively, the problem of sleep apnea can again be classified into mild vs. moderate vs. severe type. Even though there is no sharp line of demarcations among them, but still, it is accepted that ODI (Oxygen De-saturation Index is defined as the number of times per hour of sleep that blood’s oxygen level drops by certain degree from baseline. The ODI is typically measured as a part of standard sleep criteria) = 90% and above denotes mild sleep apnea / ODI = 80%- 89% denotes moderate sleep apnea / ODI = below 80% denotes severe sleep apnea.
9) Sleep Apnea Treatment
Various treatment options are stated below.
9.1) Lifestyle changes and home remedies
For milder symptoms of sleep apnea, the doctor may initially recommend only lifestyle changes (such as losing weight on account of overweight and obesity/regular physical workout, notably morning walk/avoiding smoking, alcohol and unhealthy foods and drinks).
9.1.1) Losing excess weight
Even a slight loss of weight may invite a large gain (through relieving constrictions in the throat). In most cases, sleep apnea problem can be resolved in the wake of shedding excess weight. But the problem may return if excess weight is regained.
9.1.2) Physical workout
Regular physical workout is health-friendly for any age and any gender that can cure or prevent most of the diseases. Regular exercise can ease the symptoms of obstructive sleep apnea (even without weight loss). Daily moderate physical activity (preferably, at least 30 minutes morning walk) will help mitigate the problem.
9.1.3) Avoiding certain medications
Medications (such as sleeping pills and tranquilizers) should be avoided as far as possible. These medications relax the muscles in the back of the throat interfering with the natural breathing system.
9.1.4) Sleeping with proper body position
Sleeping on one side (rather than lying on the back) can reduce the symptoms of sleep apnea. Because sleeping on the back can cause the tongue and soft palate to rest against the back of the throat and thus block the air passage. So, to prevent from rolling (that may cause to lie on the back during sleep), a tennis ball can be attached to the back-top side of the sleeping trouser or pant before going to bed. Other commercial devices vibrate when the patient rolls on the back of the body during sleep.
9.1.5) Avoiding all the unhealthy and bad habits
Unhealthy junk foods and drinks (including the 2 expensive bad habits: smoking and alcohol which have no social and religious recognition) should be avoided. It needs to be mentioned that on average, 1 person dies in every10 seconds somewhere in the world only due to smoking-related diseases, (source: The World Health Organization, 2015).
Conclusively, self-care through lifestyle changes and home remedies are the best option as they involve no cost in terms of side effects and money spending. However, if the treatments do not improve the symptoms, or if the symptoms arrive in moderate or severe form, then several other options are available (one of the alternative devices is to open the blocked air passage. And in some other cases surgery may be needed). Additionally, if an allergy problem also exists in addition to sleep apnea, then allergy treatment is needed.
9.2.1) CPAP (Continuous Positive Airway Pressure)
Patients having moderate to severe sleep apnea might benefit from a machine that delivers air pressure through a mask while one sleeps. With CPAP therapies, the air pressure becomes somewhat greater (than that of the surrounding area) which is just enough to keep the upper air passages open and in consequence, prevent sleep apnea as we as snoring.
Conclusively, CPAP is the most common and reliable method of treating sleep apnea. But some patients find it cumbersome and uncomfortable and consequently, give it up. Most of the patients, with regular practice, can learn and adjust everything with time. For those who cannot adjust at all, they can meet the doctor who can make necessary changes and adjustments in the setting of the mask. Additionally, if any other problems arise in terms of snoring or any other trouble (such as, weight changes), then it is the doctor who will do the needful in the pressure setting of the CPAP device.
9.2.2) other air passage pressure devices
Still after consulting the doctor, if the CPAP machine continues to remain a problem, then a different type of air passage pressure device (which is known as Auto CPAP that automatically adjusts the pressure while the patient is asleep) can be applied. Alternatively, the BPAP (Bi-level Positive Airway Pressure) machine may also be used.
Conclusively, all these devices provide more pressure when the patient inhales and less pressure when the patient exhales.
9.2.3) OA (Oral Appliances)
I am another option to wear OA (which is designed to keep the throat open).
It is better to try different devices before use. Once the right fit is found out, then it is well advised to continue with that device. Further, it should be regularly checked so that the fit is still good and adjustable. Also, the patient should remain alert whether any new signs or symptoms are being experienced.
Conclusively, OA is easier to use, although, it is less effective (as compared to CPAP).
Surgery is the last option after all the treatment procedures have failed. Before going into surgery procedure, it is advised to apply at least a 3-month trial with various alternative treatment options. However, surgical options include the following procedures.
9.3.1) Tissue removal
During the procedure, the doctor removes the tissues from the rear of the mouth and the top of the throat. The tonsils, as well as the adenoids, are usually removed in the procedure. In general, this type of surgery becomes successful in stopping the throat structures from vibrating and causing snore.
9.3.2) Tissue shrinkage
It is another option to shrink the tissue at the rear of the mouth and back of the throat by applying radiofrequency ablation (it is a procedure to reduce pain. An electrical current produced by a radio wave is used to heat a small area of nerve tissue to reduce pain in the impacted area).
Conclusively, the procedure might be used in mild or moderate sleep apnea having fewer surgical risks.
9.3.3) Jaw repositioning
In the procedure, the jaw is moved forward from the remainder of the facial bones. The procedure enlarges the space (behind the tongue and soft palate) making the obstructive sleep apnea less likely. The procedure is known as maxillomandibular advancement (it is asleep surgery performed to move the upper jaw and the lower jaw forward)
In the procedure, the plastic rods are surgically implanted into the soft palate (after the patient receives local anesthesia).
9.3.5) Nerve stimulation
This requires surgery to insert a stimulator for the nerve that controls the tongue movement. The increased stimulator helps keep the tongue in a position that helps the air passage to remain open.
It is a surgical procedure, either temporary or permanent. The procedure involves creating a new air passage in the neck of the patient by inserting a tube (made of metal or plastic) into the windpipe through which the patient breathes. The tube is placed through a cut in the neck below the vocal cords. This allows air to enter the lungs.
During the day time, the opening is kept covered. But at night the opening is uncovered to allow air to pass in and out of the lungs (bypassing the blocked air passage in the throat)
10) Key global information
- Of all types of sleep apnea, obstructive sleep apnea is most common.
- Adult obstructive sleep apnea is increasing worldwide at an alarming rate because of rising obesity.
- All over the world, more than 100 million populations suffer from sleep apnea.
- Number of male patients with sleep apnea is much higher (1.5 times higher than the females)
- Approximately, 10% among the children who snore have sleep apnea
- Of the total 326 million populations In the USA, the percentage among the patients having sleep apnea is 10% for mild obstructive disorder/ 3.5% for moderate obstructive disorder / 4% for the severe disorder.
11) Concluding remarks
11.1) For the sleep apnea patients, it is important to share a bed with a family member, if possible. Because, the concerned family member sharing the bed, can best explain the symptoms (experienced during sleep by the patient) to the doctor.
11.2) Before consulting the doctor, the patient should get well prepared with all necessary information about the use of regular and occasional medicines/ vitamins/ supplements specifying the dose and the time since when the medicines/vitamins/supplements are used. Additionally, the patient needs to explain specific health problems, if any, such as high blood pressure/ heart disease/ diabetes (including the length of period suffered).Over and above, the personal, as well as the family history of diseases and more importantly, the lifestyle being followed (such as food habits/ physical activity/ sleep time at night mentioning the duration), should be reported to the doctor.
11.3) to conduct an effective and appropriate diagnosis for treatment, the doctor may raise many a question (such as, whether the symptoms are continuous or come and go/ how severe are the symptoms/ how many times the breathing stops during sleep at night/ is there anything that improves the symptoms/ or is there anything that worsens the symptoms, such as sleeping position by lying on the back). The patient should be well prepared in advance to accurately answer all the questions for correct diagnosis followed by the effective treatment procedure
Conclusively, if the family member or friend sharing the bed happens to be a physician, then it is all the better, as the bed sharer can best explain all the symptoms observed in the case of the patient.
- S= SLEEP (apnea is a sleep disorder with the involuntary cessation of breathing for a while)
- L= LEARNING (/behavioral/adaptive problems arise in the kids if sleep apnea is untreated)
- E= EXCESS (body weight is the major risk factor to develop sleep apnea)
- E= ENLARGED (tonsils and adenoids are a prime cause of sleep apnea among the children)
- P= PREGNANCY (complications become severe for sleep apnea patients)
- A= ADULT (obstructive sleep apnea is alarmingly increasing worldwide)
- P= PATIENTS (having sleep apnea face a greater risk of sudden cardiac arrest)
- N= NO (breathing for a while during sleep, is a major symptom of sleep apnea)
- E=EVALUATION (based on signs/symptoms/sleep history of patient help diagnose disease)
- A= ALL (over the world, more than 100 million people suffer from sleep apnea)