Sleep apnea is a serious life threatening problem that is known to greatly increase risks of heart attacks and strokes. Patients with untreated sleep apnea have up to a six fold increase in motor vehicle accidents, short term memory loss, problems with elevated blood pressure, increased insulin resistance and many other problems. Altzheimers and Dementia can both be accelerated by sleep apnea though it is probably not a primary cause of those disorders.
The signs and symptoms associated with sleep apnea include snoring and witnessed pauses in breathing often followed by gasping that is frequently upsetting to concerned spouses and bed partners. Morning headaches, chronic fatigue and excessive daytime sleepiness are all highly correlated to untreated sleep apnea.
Sleep apnea is such a dangerous disease that it is recommended that all patients suspected of having sleep apnea should have an overnight sleep study. A sleep study or Polysomnography is a specialized test that measures breathing effort, air movement, blood oxygen, snoring, position as well as EKG (electrocardiogram), EEG or measurement of brain waves and EOG or measurement of eye movements.
These tests allow a complete understanding of what is happening to a patient during sleep. Patients are specifically evaluated for different stages of sleep, number of awakenings and body movements and finally for sleep disordered breathing.
Sleep disordered breathing can be simple snoring. This is not a simple problem, studies have shown that snorers have a 300% increase in Motor Vehicle Accidents and that heavy snorers have up to a six fold increase in Atherosclerosis of the carotid arteries. The carotid arteries supply blood flow to the brain and blockages may lead to strokes.
Obstructive Sleep Apnea is a complete blockage or collapse of the airway during sleep. In laymans turn it could be called suffocation. The apnea index is the number of times an hour the patient has a complete blockage of airflow and is suffocating.
Hypopnea is an almost complete blockage of airflow. If there is any air moving, no matter how slight then a patient does not have sleep apnea but may have hypopnea if there is a 30 second period with no breathing and at least a 4% drop in oxygen saturation. Hypopnea could be considered almost suffocation. The number of hypopneas an hour is the hypopnea index.
The AHI of apnea/hypopnea index is how many apneas plus hypopneas occur per hour of sleep. For practical purposes this is the most meaningful measure of severity of sleep apnea. An AHI under 5 is considered in the normal range but ideally an AHI of “0” is preferred. Mild Sleep Apnea is an AHI of 5-15 events per hour. Moderate sleep apnea is an index 0f 15-30 events per hour. AHI over 30 is considered to be severe sleep apnea.
While mild apnea may not seen so severe a study presented at the Academy of Chest Physicians showed that patients with mild sleep apnea and no signs of excessive daytime sleepiness or excessive tiredness had a 300% increase in motor vehicle accidents rresulting in severe injury to one or more people.
There is a final category of sleep disordered breathing caller Respiratory Effort Related Arousals or RERA which is also called Upper Airway Resistance Syndrome (UARS) or snore arousals. This is where the patient struggles to breath and their sleep is disturbed but they do not meet the criteria of hypopnea. Younger and thinner men and women in general are often underscored by AHI. The original definitions were developed studying older obese males and do not always accurately reflectthese healthier individuals. Hypopnea is marked by a 4% drop in oxygen but new digital technology is very acurate and will ignore a3.99% drop in oxygen. RDI orRespiratory Distress Index is a term used to account not just for apneas and hypopnears but also RERAs, UARS or Snore Arousals.
The Gold Standard of treatment for sleep apnea is CPAP or continuous positive air pressure. It consists of a compressor, a hose and a mask and it maintains airway patency and prevents collapse by air pressure. There are a wide variety of machines and masks for increased patient comfort. While CPAP is extremely effective it is not well tolerated by the majority of patients. Studies have shown that only 23-45% of patients use CPAP regularly and users average only 4-5 hours a night 4-5 nights a week. A recent study showed 60% of patients prescribed CPAP discontinue use all together. Medicare has recognized this low compliance as a major problem and it is no longer paying for CPAP if usage levels are too low. This will be a major savings for medicare but will still leave many patients untreated. Aprroximately 25% of CPAP users love their CPAP amchines have minimal problems and use them all night, every night.
When patients do not tolerate CPAP there are many alternative treatments available. One of the best treatments that is both inexpensive and extremely effective in the right patient is positional therapy. Some patients with sleep apnea have positional sleep apnea where they only have sleep apnea when they sleep on their backs and it is eliminated if they sleep only on their sides. Patients that have purely positional sleep apnea can be successfully treated by not allowing them to sleep on their backs. Their are many ways to accomplish this including using a tennis ball in a sock sewed to the back of sleeping attire. One of the best ways I have found to treat positional sleep apnea is with the Rematee patient positioner. It is comfortable and lightweight. The pads are inflatable for easy use during travel. The belt is also well deisigned to allow a patient to move partiall to their back or totally prevent any back position by the degree of inflation to the side pockets. Clicking on the following link http://www.antisnoreshirt.com/ProductDetails.asp?ProductCode=BB-9004&Click=2006 will allow you to access more information about this excellent treatment modality for positional sleep apnea.
There are many patients who cannot tolerate CPAP who have sleep annea that is not positional or only partially positional and they also need a comfortable and effective alternative to CPAP. Dental Sleep Medicine provides excellent answers for those patient. Oral Appliances are very effective in treating mild to moderate sleep apnea and have been approve by the American Academy of Sleep Medicine (AASM) as a first line approach for mild to moderate sleep apnea. The National Sleep Foundation has declared that “ORAL APPLIANCES ARE A THERAPY WHOSE TIME HAS COME”. Oral appliances have also been shown to be effective for many patients with severe sleep apnea. They are approved by the AASM as an alternative to CPAP for severe sleep apnea when patients do not tolerate CPAP. An excellent site to learn more about comfortable and convenient oral appliance therapy is at the I HATE CPAP! WEBSITE, http://www.ihatecpap.com. Patients in Northern Illinois, Southern Wisconsin and across the Chicago area interested in Oral Appliance therapy cam contact my office thru my website at http://www.chicagoland.ihatecpap.com/ or call toll free at
1-8-NO-PAP-MASK (1-866-727-6275). There is a find a dentist area on the I HATE CPAP! website to help you locate a sleep apnea dentist in other areas of the country. If no doctors are listed in your area we will assist you in locating a dentist with experience in treating sleep apnea. Dentists wishing to take my course on Dental Sleep Medicine in April 2010 can contact my office at 1-8-NO-PAP-MASK.
There are some patients with extremely severe apnea sleep apnea that cannot be treated with positional therapy or oral appliance therapy alone but the combination of the two therapies together is extremely effective when treating moderately severe to very severe sleep apnea. There are also patients who can be treated with a combination of oral appliances and CPAP. The very obese patients often have a lot of adipose tissue in their necks that cannot be treated with oral appliances and position but their pressures for CPAP alone are very high and intolerable to the patient. The use of an oral appliance in conjuction with CPAP can drastically lower CPAP pressure by advancing the mandible and maintaining the airway possible reducing pressures from 24 cm to 6cm of pressure (as an example). This can be done with a full face mask or by combining an oral appliance with an oral appliance that not only opens the airway but also secures a nasal mask without straps. The leading appliance in this area is the TAP-PAP appliance invented by Keith Thorton of airway management. The TAP appliance is the most successful oral appliance and spouses love the adjustment handle that serves as a volume control for the bed partner. Eliminating snoring improves the sleep and health of the significant other as well as the patient.
There are also numerous surgeries that can be used to treat sleep apnea that I will discuss in my next post. Surgery is not considered a first line of treatment for sleep apnea but many patients can benefit from surgical intervention. I frequently do consults with patients to determine which surgery is most likely to be successful. I stongly encourage patients planning on doing jaw advancement surgery to start treatment with an oral appliance to find out how much advancement is necessary to eliminate apneas and hypopneas prior to surgery.