Snoring: ABC’s Ultimate Comprehensive Guide on Sleep Apnea
I want to thank Cara Gilmore for her updating of her article to confirm the strong position of oral appliances in treating a large proportion of patients with mild to moderate sleep apnea and as an alternative to CPAP for severe sleep apnea in patients who don’t tolerate or want CPAP therapy.
Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO
Chair, Alliance of TMD Organizations
Diplomat, American Academy of Pain Management
Diplomat, American Board of Dental Sleep Medicine
Regent & Fellow, International College of CranioMandibular Orthopedics
Board Eligible, American Academy of CranioFacial Pain
Dental Section Editor, Sleep & Health Journal
Member, American Equilibration Society
Member, Academy of Applied Myofunctional Sciences
By Cara Gilmore | Apr 11, 2016 | Blog, homepage, Sleep Apnea, Sleep Apnea Home Menu
Reprinted with permission with minimal editing.
To see in original format with excellent illustrations
Please feel free to make comments at that site.
1 About This Sleep Apnea Guide
2 What is Sleep Apnea?
2.0.1 Medical Definitions
3 Types of Sleep Apnea
4 Levels of Sleep Apnea Severity
5 Sleep Apnea Facts & Statistics Infographic
6 Causes of Obstructive Sleep Apnea (OSA)
6.2 Other Direct Causes
6.2.1 Associated Risk Factors
7 Causes of Central Sleep Apnea (CSA)
8 Is Sleep Apnea Hereditary?
9 How Do You Know If You Have Sleep Apnea?
10 Risk Factors of Obstructive Sleep Apnea
11 Risk Factors of Central Sleep Apnea
12 Symptoms of Obstructive Sleep Apnea
12.1 Direct Symptoms of OSA:
12.2 Indirect symptoms of OSA:
13 Symptoms of Central Sleep Apnea
14 How To Test For Sleep Apnea
14.1 Self Assessments
14.2 Take a Sleep Apnea Questionnaire
14.3 At Home Sleep Study
14.4 Overnight Sleep Test at a Sleep Lab
14.5 Daytime Sleep Tests
15 Dangers of Untreated Sleep Apnea
15.1 High Blood Pressure (Hypertension)
15.2 Other Major Cardiovascular Risks
15.3 Oxygen Deprivation
15.4 Weight Gain
15.5 Adult Asthma
15.6 Acid Reflux
15.7 Reduced Sex Drive
15.8 Sleep Deprivation
16 Sleep Apnea Treatment Options
16.1 Lose Weight
16.2 Oral Appliance
16.2.1 Mandibular Advancement Device
16.2.2 Tongue Retaining Device
16.2.3 Available Oral Appliances
16.3 Positive Airway Pressure
16.4.1 Nasal Surgery
16.4.2 Upper Airway Surgery
16.4.3 Jaw Repositioning
16.4.4 Creating A New Airway
16.4.5 Other Procedures
About This Sleep Apnea Guide
This powerful guide will provide you with all of the necessary information to help you gain a complete understanding about what sleep apnea is, the causes of sleep apnea, how to determine if you have sleep apnea, the various sleep apnea treatment options, and more. So whether you have just been diagnosed with sleep apnea, think you might have sleep apnea, or know someone who falls into these two categories, you have come the right place! This complete guide has all the answers to your questions regarding sleep apnea.
I was diagnosed with sleep apnea over 10 years ago. Since my diagnosis, I have performed countless hours of research and spoken with dozens of sleep specialist physicians and sleep techs. I have taken all of this information I have obtained and created this all encompassing sleep apnea guide.
Of course, if you don’t find the answer your looking for in this guide, just shoot me a question in the comment box at the bottom of the article and I will be sure to get back to you promptly with the answer.
We also have the ultimate guide on CPAP and other PAP devices including a list of solutions to the most common CPAP side effects and issues. I highly recommend you check out this complementary guide as well.
Without further delay, lets dig in and start from the top by answering the first essential question: What is Sleep Apnea?
What is Sleep Apnea?
When you sleep, all your muscles relax including those in your mouth, throat, and airways. When they get too relaxed, the muscles in the back of your throat where the airway is the narrowest can start to get in the way of your breathing. Sometimes these muscles begin to vibrate causing what is commonly known as snoring. 90 million Americans experience this presumably harmless yet agreeably annoying phenomenon known as snoring on a regular basis. Unfortunately, unbeknownst to many, millions of these snoring Americans actually have a more severe condition known as obstructive sleep apnea.
The word “apnea” literally translates to “without breath” and thus sleep apnea is the chronic cessation of breathing while sleeping. Obstructive sleep apnea is when these over relaxed muscles in the back of the throat prevent enough air from getting into the lungs or even completely closing the airway altogether and causing the person to actually stops breathing.
What is Sleep Apnea
An apnea event is when there is no respiratory effort or a complete pause in breathing for greater than 10 seconds.
Hypopnea is when you achieve an abnormally low respiratory rate resulting in a decrease in oxygen levels.
When either of these two events occur (apnea or hypopnea), the brain is signaled to wake up and reactivate the throat muscles to open the airway and allow enough oxygen to enter the lungs. For more severe cases, this will cause the person to wake up gasping for air, but for many, this may only take a few seconds in which then the brain will return to sleep. This can commonly occur without the individual even knowing they have awaken. Unfortunately, even though you may not be conscious of these small disturbances, their consistent occurrences throughout the night which can even occur hundreds of times, can prevent one from achieving the deep restful state of sleep that will cause a whole host of side effects and health problems
Now that we have answered the question: what is sleep apnea; lets go over the types of sleep apnea.
Types of Sleep Apnea
Obstructive Sleep Apnea (OSA): This is the most common type of sleep apnea which consists of the complete blockage or collapse of the upper respiratory track due to the over relaxing muscles of the throat or a blockage in your nasal passages.
Central Sleep Apnea (CSA): This type of sleep apnea is actually a neurological problem in which you regularly stop breathing during sleep because the brain temporarily stops sending signals to the muscles that control breathing.
Mixed Sleep Apnea: This type of sleep apnea, also know as complex sleep apnea, is the combination of both OSA and CSA. Many people diagnosed with OSA who are receiving some form of treatment such as Positive Airway Pressure will find they also are experiencing CSA symptoms as well.
Levels of Sleep Apnea Severity
Obstructive sleep apnea can be graded and is done so using 3 metrics:
AHI-GradeApnea Hypopnea Index (AHI): This measures the number of apneas and hypopneas per hour of sleep. The following table is how sleep apnea severity is classified by AHI.
Respiratory Disturbance Index (RDI): This metric is also sometimes used instead of AHI. This metric includes not only apneas and hypopneas, but also other irregular breathing events. Due to this additional inclusion, a person’s RDI can be higher than one’s AHI.
Oxygen Saturation LevelsOxygen Saturation Levels: This is the level of oxygen saturation of the blood. Normal blood oxygen level is between 96% – 97% (assuming at sea level). There is no official categorization for oxygen desaturation severity but the table to the right is a general categorization.
Sleep Apnea Facts & Statistics Infographic
Sleep Apnea Facts & Statistics:
Causes of Obstructive Sleep Apnea (OSA)
Obesity causes sleep apneaThere are many causes for obstructive sleep apnea, but the most predominant cause is obesity due to excess fat accumulation around the neck and an enlarged tongue and tonsils will apply pressure on the airway when the throat muscles relax during sleep. It is estimated that 80% of clinically obese people have sleep apnea but millions are not aware and misinterpret their symptoms as something else¹. Unfortunately this lack of appropriate diagnosis prevents so many people from receiving the appropriate treatment, thus significantly depreciating their quality of life and in many cases shortening it as well.
Other Direct Causes:
A deviated septum
Enlarged nasal turbinates
Thickened soft palate and uvula
Disproportionate size of tongue and tonsils in relation to the windpipe opening
Anatomy problems of the head and neck causing a narrower airway
Age-related muscle tone loss of the throat muscles
Associated Risk Factors
Asthma: There has been studies including the most prominent one performed by researchers at the University of Wisconsin that found people with asthma had a significantly elevated risk of developing obstructive sleep apnea. This connection was even more prominent for people who were diagnosed with asthma as children².
Other Lifestyle and Health Factors: Other risk factors associated with sleep apnea include high blood pressure, alcohol, and tobacco use.
Demographic Factors: These include being of older age, male and of African or Latino decent.
Causes of Central Sleep Apnea (CSA)
The following are specific causes of central sleep apnea:
Arthritis and degenerative changes in the cervical spine or base of the skull
Complications of cervical spine surgery
Encephalitis affecting the brainstem
Neurodegenerative illnesses such as Parkinson’s disease
Radiation of the cervical spine
Stroke affecting the brainstem
Use of certain medications such as narcotic containing painkillers
Is Sleep Apnea Hereditary?
A common question that arises when someone or a family member is diagnosed with sleep apnea: Is sleep apnea hereditary (genetic)? There have been a number of studies that have explored this question. One study in particular that was published in Sleep Medicine Review in which they were able to conclude the severity of one’s sleep apnea can be attributed to factors that are determined by one’s genetic makeup. These hereditary factors include muscle control of the upper airway, face and skull structure, and body fat distribution. All of these hereditary factors can impact a person’s risk of developing obstructive sleep apnea.
Another hereditary link that has been established through multiple studies including that of the Cleveland Family Study is that African Americans have a greater genetic predisposition to develop OSA than other races.
So is sleep apnea hereditary? Based on the conclusive scientific studies, yes, there are genetic factors that impact one’s risk of developing OSA.
Now that you know the causes and associated risk factors of the different types of sleep apnea, its time to dive into how to know if you have sleep apnea.
How do you know if you have sleep apnea?
Sleep Apnea is a very common condition. It is estimated more than 22 million Americans have some case of sleep apnea4. Unfortunately, due the public’s lack of awareness and in many cases the awareness of health care professionals, many people remain undiagnosed. It is estimated that the percent of people with sleep apnea that remain undiagnosed may be as high as 80% – 90%4! The following section will provide you with the necessary information to know if you are at a higher risk of developing sleep apena, the symptoms related to the different types of sleep apnea, and the related test/assessments you can consider taking to determine if you have sleep apnea.
Risk Factors of Obstructive Sleep Apnea:
Obesity is Risk Factor of OSAOverweight/Obese: This is the most prevalent factor of people with sleep apnea as excess fat around the neck can put pressure on the airway. The easiest way to assess if you are overweight or obese is to calculate your Body Mass Index (BMI) which measures your body fat based on height and weight. You can easily determine your BMI with this BMI calculator here at the National Heart, Lung, and Blood Institute website which also provides a set of BMI categories so you can determine whether your underweight, normal weight, overweight, or obese.
Thicker NeckThicker Neck: If you have a thicker neck, you are more likely to have a narrower airway that is more easily blocked. You have an increased risk of sleep apnea if you have a neck circumference larger than:
Men: 17’’ (43cm)
Women: 15’’ (38cm)
As discussed in the previous section above, studies have shown hereditary factors such a narrowed airway, body fat distribution, etc. can put you at greater risk of developing sleep apnea, so if you have cases of sleep apnea within your family, you are at greater risk of developing OSA yourself.
Use of alcohol, sedatives, or tobaccoUse of alcohol, sedatives, or tobacco: Alcohol and sedatives can cause the throat muscles to over relax which results in OSA. Studies have also found smokers are three times more likely to have OSA. This is possibly due to excess fluid retention and inflammation of the upper airway caused by smoking.
Having nasal congestion, whether that be due to allergies or a anatomical issue, puts you at a greater risk of developing OSA.
Men or Older: Men are two times more likely to have sleep apnea than women. People over the age of 40 also have a greater risk of developing OSA as well.
Risk Factors of Central Sleep Apnea
Consistent with obstructive sleep apnea, older individuals are at a higher risk of central sleep apnea. Other risk factors include heart disorders, have had a stroke, or are using narcotic pain medications.
Symptoms of Obstructive Sleep Apnea
Here we will address both the direct and indirect symptoms of sleep apnea. Just in case you were wondering, the sleep apnea symptoms in women and men are consistent so the symptoms below are applicable to both sexes.
Direct Symptoms of OSA:
Loud and chronic snoringLoud and chronic snoring: As you know from the “What is Sleep Apnea” section, snoring is caused by the vibration of the tissue within the throat that has partially blocked ones airway. Hence, someone who snores may be experiencing further blockage of the airway to the point of not receiving sufficient oxygen to the lungs. As you yourself may not be capable of identifying this sign, your spouse may definitely be very aware of such a symptom. It’s important to know though that not all people with sleep apnea snore and not all people who snore, have sleep apnea.
Snoring with intermittent pauses during which the sleeper seems to have stopped breathing: This symptom is the identification of the complete blockage of the airway causing one to stop breathing. Similar to the loud chronic snoring, you may not be able to notice this issue but someone observing you sleep would be able to note this behavior.
Gasping and/or choking during sleepGasping and/or choking during sleep: Unlike the other two above, you will be able to identify this symptom yourself as the lack of air to your lungs signals your brain to become fully awake in an attempt to resume the flow of oxygen.
Indirect symptoms of OSA:
Excessive TirednessExcessive Tiredness:
If you are getting the suggested 7 to 9 hours of sleep but still are excessively sleepy during the day, have trouble getting up in the morning, have difficulty focusing, and/or experience forgetfulness, this may be a symptom of sleep apnea as this may be due to the fact that you are not receiving the deep restful type sleep necessary for your brain to recharge as your brain is constantly being woken up due to a lack of oxygen getting to your lungs.
Due to the intermittent blockage of air to the lungs, there is a lack of oxygen to your brain causing the blood vessels within the brain to widen in an attempt to deliver more oxygen. This can cause vascular headaches.
High Blood PressureHigh Blood Pressure: Similar to the cause of headaches, in reaction to the lack of oxygen you receive while sleeping, your body attempts to compensate by actually restricting the blood vessels in an attempt to get the oxygen flowing again.
Awakening with Dry Mouth or Sore ThroatAwakening with Dry Mouth or Sore Throat: If your mouth or throat is consistently dry or sore, this may be an indication of sleep apnea.
Effects of Sleep Deprivation:
Due to your brain repeatedly waking up during the night to activate your throat muscles to allow air to flow freely into the lungs again you will not be getting the necessary sleep and will become sleep deprived. This results in irritability, depression, decreased libido, weight gain, and more.
Symptoms of Central Sleep Apnea
There are multiple symptoms of central sleep apnea that are the same as obstructive sleep apnea as well as a few different ones which are italicized below:
Disrupted breathing during sleep/restless sleep
Problems with swallowing
Numbness affecting the whole body
How To Test For Sleep Apnea
There are a variety of strategies and tools you can use yourself to determine if you may have sleep apnea. These methods are not intended to be a replacement for a true sleep study performed by a physician, but are to be used to see if further steps, including an appointment with your physician is warranted.
Maintain a Sleep Diary:
As discussed above, there is many symptoms of sleep apnea that you may not be able to directly identify yourself as you are sleeping, but keeping a sleep diary can definitely help you with tracking your sleep patterns. Simply record how much time you spend in bed, any occurrences of awakenings in the night, how you feel in the morning, etc. If you have a sleep partner, you can ask them to note any of their observations as well including your snoring patterns, any unusual sounds such as gasping or lack thereof sounds (i.e. stoppage of breathing).
Record Yourself Sleeping:
Many of us don’t have a sleep partner and even if you do, they probably won’t be able to note all of your habits while sleeping as they will be attempting to get their much needed rest as well. This is why setting up an audio or video recording of you sleeping can be a great way to observe your sleep patterns and help identify any symptoms of possible sleep apnea. There are a variety of great sound-activated audio/video recorder applications for your phone, tablet, or computer. Below are links to one for android phones/tablets and one for apple products:
Android: Sound & Voice Recorder – ASR
Apple: Voice – Activate Recorder
Use a Sleep Monitoring App:
There is variety of both free and paid sleep monitoring apps for your iphone or android smartphone that you can use to monitor your sleep. Here is a link to LifeHacker’s list of best sleeping apps.
University of Washington has actually developed an app specifically designed to monitor your sleep habits and test for sleep apnea in the comfort of your own home. They have accomplished this by developing an algorithm to identify the events related to the multiple types of sleep apnea. It is currently not yet available to the public as it is presently under FDA approval, but you can email them at email@example.com to request to be notified personally once it is available. Be sure to check out the ApneaApp website here.
Sleep Apnea QuestionnaireTake a Sleep Apnea Questionnaire:
There are a variety of sleep apnea questionnaires you can complete to help you get a better idea as to your level of risk of having obstructive sleep apnea. Below are the most popular sleep apnea questionnaires ranging from the simplest to the most in depth. All of these tests can be self administered but the more complex tests may be more accurate when administered by a nurse or physician.
G.A.S.P. Questionnaire: G.A.S.P stands for “Graduated Apnea Screening Protocol”. This is the simplest of the sleep apnea questionnaires with only 5 basic questions that require no real technical knowledge. The test does ask whether you have high blood pressure or are overweight which does take some form of measurement. If you don’t know if you have high blood pressure, you can simply go to your local pharmacy, drug store, Walmart, etc. which usually has a self-testing blood pressure machine and you can check to determine if you are overweight by calculating your BMI here.
STOP-Bang QuestionnaireSTOP-Bang Questionnaire: I think this is one of the best questionnaires for someone to use to assess their risk of developing OSA. It is more in depth than the G.A.S.P. questionnaire but less complex than the Berlin questionnaire as well easier to score. It does include an additional measurement which is one’s neck size. This requires the proper tool and precision in taking the measurement correctly. I really like the specific STOPBang questionnaire at STOPBang.ca as it has a BMI calculator built into the questionnaire and will calculate your score automatically which makes it that much easier to determine your risk level.
Berlin Questionnaire:The Berlin Questionnaire is the most well-known and respected sleep apnea risk assessment questionnaire as it is the most thoroughly studied. There are no actual required physical measurements but the questions are slightly more complex as there are more answer choices and there is a segmented scoring system.
Epworth Sleepiness Scale:
This questionnaire does not directly assess one’s risk level of Obstructive Sleep Apnea like the other questionnaires referred to above. Instead, it helps to measure your general level of daytime sleepiness, which as you know, is one of the primary symptoms of sleep apnea. The self-administered questionnaire asks the individual to rate on a 4 point scale the chance of dozing off under 8 different typical scenarios (e.g. watching TV, sitting and reading). Someone taking this questionnaire may not commonly experience all 8 scenarios in their typical life so some mental judgement is required. Designed by Dr. Murray Jones, this questionnaire has become the world’s standard method for assessing one’s daytime sleepiness and can help someone get a better idea if they have excessive daytime sleepiness; a symptom of sleep apnea.
At Home Sleep Study
Home sleep tests are relatively new, but over the last couple of years, they have begun to gain recognition from the medical profession as well as the insurance companies. For many, the pros of the home test outweigh the advantages of the overnight sleep lab tests. This may be due to fiscal reasons, an inability to take time away from home (e.g. have kids), a feeling of claustrophobia with all of the sensors that are attached to the individual for an overnight sleep study at a sleep lab, etc.
At home sleep studies are usually prescribed to patients in which the case is straightforward. This means the patient likely has moderate to severe sleep apnea but there are no other existing or suspected issues such as congestive heart failure, lung diseases, neuromuscular diseases, or other sleep disorders.
The at home test will monitor and record your breathing and blood oxygen levels. Some sleep test systems are more expansive and will also monitor your heart rate and other information. You will then return the device to the doctor in which the data will be analyzed and the doctor will be able to make a diagnosis.
Home sleep tests are also used post diagnosis to assess the effectiveness of the prescribed treatment such as the use of a Positive Airway Pressure device such as a CPAP.
Overnight Sleep Test at a Sleep Lab
The gold standard of sleep apnea testing is an overnight sleep test at a sleep lab known as Polysomnogram (PSG). A PSG collects a vast amount of data while you sleep including brain activity, heart rate, blood pressure, amount of oxygen in your blood, your breathing, and even your eye movements.
This kind of test is performed in a specialized lab and administered by sleep technicians. These sleep techs try to make your stay as comfortable as possible while gathering the necessary information for your doctor to make an appropriate diagnosis. They monitor your sleep from a separate room and will try to interrupt your sleep as little as possible. The sleep techs want you to be as comfortable as possible so do not hesitate to ask them any questions or express any concerns you may have.
The room you will be sleeping in will be equipped with an array of monitoring devices including infrared cameras. You will go through your regular routine before going to bed and then the sleep tech will prep and apply the many sensors to your body.
If you begin to have trouble breathing during the night the sleep tech will likely wake you up and apply a sleep apnea mask on your face that is attached to a Continuous Positive Airway Pressure (CPAP) machine. After you have fallen back to deep sleep the sleep tech will adjust the pressure that is applied by the CPAP to determine the minimum amount of pressure required to keep the airway open and generally determine the effectiveness of the CPAP in controlling your sleep apnea.
After your night at the sleep lab, you will be sent home while the sleep data that was collected over the night is analyzed and a sleep specialist physician can make the appropriate diagnosis which will be communicated to you on your follow up appointment along with possible treatment options.
Daytime Sleep Tests
Your physician may also prescribe additional daytime sleep studies that are commonly performed the day after the overnight PSG sleep test. These tests include a Multiple Sleep Latency Test and a Maintenance of Wakefulness Test. These tests can help your doctor diagnosis the existence of other sleep disorders and determine if your current state of sleepiness is a safety concern (both personally and to the public), as well as assess the effectiveness of your treatment.
Dangers of Untreated Sleep Apnea
High Blood Pressure (Hypertension)
Untreated sleep apnea can cause hypertension (i.e. high blood pressure) and if you already have hypertension, sleep apnea can make it worse. Approximately 50% of people diagnosed with sleep apnea also are diagnosed with hypertension5. Constantly waking up throughout the night can cause a hyperactive hormonal system that results in an increase in blood pressure. Deprivation of oxygen in one’s blood can also magnify the problem.
Other Major Cardiovascular Risks
Untreated sleep apnea can have massive cardiovascular effects on the body. As you fall asleep and stop breathing your body reacts by slowing your heart rate in order to conserve oxygen. Eventually it hits the critical level of oxygen deprivation and your heart rate begins to speed up to signal your body to wake up and start breathing again. This cycle of slowing and speeding up your heart rate happens throughout the night as your sleep apnea causes you to intermittently stop breathing and then wake up to reopen the airway to allow air to flow back into your lungs. This puts a tremendous stress on the heart. Untreated, this side effect of sleep apnea significantly increases your likelihood of a heart attack, stroke, and/or cardiovascular disease. Additionally, this deprivation of oxygen increases the levels of certain chemicals in the blood that causes inflammation that can damage the heart and blood vessels as well.
Sleep apnea restricts and/or completely inhibits oxygen from getting into your lungs and distributed throughout your body. This can happen upwards to 60 times an hour! Long term effects of such oxygen deprivation will impair one’s cognitive abilities on a daily basis which impacts so many aspects of a person’s life and will seriously cripple a person’s quality of life overall. Among many other side effects, such oxygen deprivation will hinder a person’s productivity at work and at home and put themselves and others at risk on the road.
As stated above, one of the risk factors of obstructive sleep apnea is obesity, but it is also a side effect as well. Sleep apnea can cause one’s body to excrete more Ghrelin, which is a hormone that makes you crave sweets and carbs. Due to the lack of restorative sleep and oxygenation that someone with sleep apnea receives during the night, the individual becomes sleep deprived. In addition to other things, sleep deprivation will cause one to eat more, cause the body to excrete more cortisol (hormone correlated to weight gain), as well as hinder the person’s ability to turn food into energy efficiently, thus causing the body to store more of the calories, which consequently leads to weight gain. Additionally, a link has also been established recently between a lack of sleep and decreases in the hormone leptin which curbs hunger.
Obesity will then set off a snowball of physiological events that can cause a plethora of other health conditions including diabetes. Even though sleep apnea’s causation of type 2 diabetes has not been validated, 80% of suffers of type 2 diabetes do have obstructive sleep apnea and lack of sleep is shown to impede one’s ability to properly use insulin.
Adult Asthma and Sleep apnea
As referred to above, based on studies, Asthma is an independent risk factor of Obstructive sleep apnea and that OSA symptoms are more likely to occur in people with Asthma than people without Asthma.
This association between asthma and OSA also goes in the other direction. An article published in the Journal of Clinical Sleep Medicine stated that OSA can worsen asthma due to the direct and indirect effects of OSA. Such effects include acid reflux, diminished airflow to the lungs that strains the heart, irritation of the muscles around the airway, and inflammation throughout the body (including the lungs).
There has been no proven scientific causation between asthma and obstructive sleep apnea but a correlation has been identified and many people have reported a reduction in the number of asthma attacks they experience once they have begun receiving some form of treatment for sleep apnea. Further research is necessary to confirm the link in causality between the two conditions.
Either way, it is very important for current physicians to be aware of the link between OSA and asthma and the importance of people with asthma to be assessed, diagnosed, and treated for OSA.
Acid RefluxMany doctors suggest that sleep apnea increases your risk of gastral reflux disease, otherwise known as persistent heart burn. Physicians have reported that treatment of sleep apnea has reduced the heartburn symptoms of patients.
Reduced Sex Drive
Specifically within men, sleep apnea has been shown to decrease one’s libido and sex drive. A published scientific study made a link between low testosterone and men with sleep apnea as they found approximately 50% of the men with sleep apnea secreted unnaturally low levels of testosterone while sleeping.
Sleep Apnea causes sleep deprivation
There are 4 different phases of sleep which we cycle through about 4 to 5 times on a typical nights rest. The first 3 stages are designated as non-REM sleep and the last cycle is designated as REM (Rapid Eye Movement) sleep. REM sleep is considered to be the most restorative part of our sleep cycle and is considered crucial in learning and many other important facets such as memory. Unfortunately, people with untreated sleep apnea will not get the sufficient amount of REM sleep as their brains are constantly awaken throughout the night due to the cessation of breathing. They are consistently pulled out of the sleep cycle before they reach these deeper levels of sleep including REM sleep. Such sleep deprivation has the following effects:
Sleep deprivation impairs your cognitive abilities as well as your ability to make sound judgments. To make it even worse, sleep deprived individuals have especially poor judgement on the impact that their sleep deprivation is having on them. This causes individuals to not address the problem and thus remain sleep deprived Under these circumstances it is really only a matter of time before detrimental mistakes are made resulting in an accident.
Sleep deprivation plays a major factor in accidents on the job, in the home, and on the road. The catastrophic accidents including the nuclear incidents at Chernobyl and Three Mile Island as well as the Exxon Valdez oil spill were the result of sleep deprivation.
A survey of 2,700 medical interns across the United States revealed 1 in 5 made a fatigue related mistake that injured a patient and 1 in 20 of them made a fatigue related mistake that resulted in the death of a patient.
The National Highway Traffic Safety Administration estimates that 100,000 accidents and 1,550 crash-related deaths per year are attributable to sleep deprivation8.
As you can see, the effects of sleep deprivation not only put your personal safety at risk, but also the public’s safety as well.
Impairs Cognitive Abilities & Learning:
Getting an adequate amount of sleep is essential for one to perform at their best mentally as well as be able to learn new information and skills. Sleep deprivation is actually a double sided sword in this respect. First, it impairs your ability to learn efficiently and effectively as it diminishes your attention span, concentration, reasoning, and problem solving capabilities. Secondly, when you sleep, your brain digests, consolidates, and solidifies your memories for that day, including what you learned, whether that be a piece of information or a skill. It has been discovered that sharp wave ripples are responsible for this memory consolidation and storage which only occur at the deeper levels of sleep in which are commonly not achieved for people with untreated sleep apnea. Without sufficient sleep, what you learned the day before is essentially lost.
Serious Health Problems:
A common question asked by many is: “can sleep apnea kill you?” Sleep deprivation is linked to a host of heart problems including heart attack, stroke, sudden cardiac arrest, and high blood pressure as well as other serious medical conditions such as diabetes. A British study found a lack of sleep nearly doubles one’s risk of death from all causes including cardiovascular disease. So can sleep apnea kill you? Yes it can, in a whole lot of ways when it remains untreated.
Depression & Anxiety:
For a host of reasons, sleep deprivation can lead to symptoms of depression and anxiety. A survey concluded that people diagnosed with depression or anxiety was more likely to get an insufficient amount of sleep (less than 6 hours)9. Unfortunately, this can cause a snowball effect as not only lack of sleep causes depression and anxiety but also vice versa, as depression and anxiety causes one to sleep less.
Bad For Your Complexion and Physique:
Not only does a lack of sleep have negative short term effects on your skin such as puffy eyes and pasty skin, prolonged sleep loss can also lead to more semi-permanent damage including fine lines and dark circles. This is due to the excessive excretion of the hormone cortisol which is not only linked to weight gain as mentioned before, but is also capable of breaking down the protein responsible for keeping skin smooth and elastic (Collagen). Sleep deprivation also causes the body to release an insufficient amount of human growth hormone that is responsible for increasing/maintaining muscle mass, thickening skin, and strengthening bones.
Dampens Immune System:
Insufficient rest can impair one’s immune system leaving you more vulnerable to getting sick, ranging from a pesky cold to something more serious.
Not only does sleep deprivation increase one’s risk of death, but may be linked to preventing one from bringing life into this world as well. Lack of sleep is believed to increase the difficulty in conceiving a baby due the reduction of secretion of reproductive hormones.
As you now know, the side effects / dangers of untreated sleep apnea are practically endless. Sleep deprivation alone is associated with a biblical list of issues. From a big picture, as you sum up all of these side effects, not only will untreated sleep apnea most likely shorten your life but will also significantly decrease your quality of life.
Not only should you consider the direct impact of these side effects, but you should also consider the indirect impacts of such side effects. This may include preventing you from enjoying the things you used to love and damaging the relationships you have with family, friends, and significant others.
Luckily there is a plethora of physicians who specialize in resolving sleep apnea symptoms and are more than happy to get you the help you require so you can live a full, healthy, fulfilling life. There are a variety of treatments available that you and your doctor will be able to discuss so you get the best treatment for you based on your personal circumstances. The following section will help you get a better understanding of the most prescribed treatment options.
Sleep Apnea Treatment Options
The next logical question one should have after being diagnosed with sleep apnea and learning about all of the side effects that can occur by not treating such a condition is: “How do I treat or cure sleep apnea?”
Before we go over all the various sleep apnea treatment options it is important to note that the best treatment for sleep apnea is different from person to person. There are many factors that determine the right treatment for each individual including the severity of the sleep apnea (e.g. mild, moderate, or severe), the anatomical structure of your upper airway, consideration of other medical problems, as well as personal preference. Below is a description of the most popular treatment options, who they may be best for, and some of the pros and cons of each one.
Sleep Apnea Treatment Option (Lose Weight)As discussed above, one of the primary causes of sleep apnea is obesity due to the fat around the neck as well an enlarged tongue and tonsils applying pressure that help to block the airway. Therefore, a significant reduction of weight can help reduce the severity of a person’s sleep apnea and in some cases actually eliminate the OSA completely. Losing a large amount of weight is not easy for anyone and is much harder for some than others, but it should be a priority for all who are overweight or obese. Getting regular exercise and eating fewer/healthier calories is no walk in the park but the benefits can be very significant. Not only can you reduce the severity or possibly eliminate your OSA, but you will also benefit from significant improvements in your overall health and quality of life.
For some severe cases of obesity in which traditional measures to lose weight are not successful, the option of certain types of weight loss surgery can be considered as a viable option.
No matter how the weight is loss, there is no guarantee this will fully eradicate your obstructive sleep apnea and its related symptoms. Other forms of treatment may still be necessary.
Oral Appliance Sleep Apnea Treatment Option (Mandibular Advancement Device)
Oral appliances can be a great solution for those with mild to moderate sleep apnea and who are unable or just don’t prefer the traditional treatment of a CPAP or other PAP device.
More information available at http://www.IHateCPAP.com
The American Academy of Sleep Medicine now recommends the use of oral appliances as a first line approach, equal to CPAP, for mild to moderate obstructive sleep apnea. This is especially true for patients with mild sleep apnea as per the 2015 article published in the Journal of Clinical Sleep Medicine, there was no significant difference in achieving the target AHI (number of apneas per hour of sleep) when using an oral appliance versus a CPAP for treatment.
There are a couple of different types of oral appliances available, but all of which will require the assistance of a dentist or orthodontist to achieve the appropriate fitting.
It may be a trial and error process at first in which you try out multiple oral devices in order to find the one that is best for you. Initially, you will most likely have to meet with your dentists often to make the necessary adjustments and ensure the device is effective. After this initial period, you will only have to see your dentist occasionally to reevaluate your symptoms.
Mandibular Advancement Device
This is the most popular of the two types of devices and is deemed as one of the primary treatments of mild and moderate sleep apnea10. It is essentially a mouth guard that moves the lower jaw forward (see diagram above). This also moves the tongue forward as the tongue is connected to the lower jaw. This prevents the jaw from falling back during sleep and causing the airway to collapse. A secondary effect of the MAD is that it causes the muscles in the back of the throat to stretch which then stiffens the soft palette that is responsible for over-relaxing when you fall asleep and blocking your airway. This device has been found to be able to increase the upper airway capacity by as much as 50% – 75%11.
It is is very easy to insert and remove.
You can drink water with it and you can even talk with it, but you may sound a little funny.
Many people have found this type of treatment to be far more comfortable and convenient. This causes the patient to increase the consistency at which they use the prescribed treatment which is of the utmost importance.
Another reason people prefer oral devices is for social reasons as it is far less intrusive than the use of a CPAP device.
It provides for greater mobility as the device is much smaller than a PAP machine and mask. It also does not require a power source and can be slipped in at anytime such as when you are taking a nap on a plane.
An MAD can be more economical than other forms of treatment.
MADs can be just as effective in relieving symptoms of mild and moderate sleep apnea than a CPAP.12
Mandibular advancement can increase upper airway capacity by 50-75% with maximum mandibular protrusion.13
Possible movement of teeth or altered bite
Potential of jaw pain
May experience dry lips and/or excessive salvation.
Tongue Retaining Device
The less common of the two oral devices is a tongue retaining device that essentially holds the tongue from moving back into the throat and blocking the airway.
Pros: These do tend to have fewer complications when compared to MADs.
Cons: They may be considered less comfortable and take a longer time to be worn comfortably.
Positive Airway Pressure
Sleep Apnea Treatment Options (PAP devices)Positive airway pressure (PAP) is the most popular sleep apnea treatment option utilized as it is so effective for most cases of sleep apnea. This treatment entails applying a mask or set of tubes over your mouth and nose or possibly just your nose. The mask is connected to a machine that injects compressed air into your airway thus creating virtually a splint that prevents the airway from closing and thus ceasing the occurrence of breathing cessation.
PAP treatment is almost 100% effective in relieving symptoms of obstructive sleep apnea for all levels of severity including severe.
From the very beginning you will will begin to experience great restorative nights of sleep as it is very effective in completely alleviating all aspects of your obstructive sleep apnea immediately
Studies have even found that PAP treatment improves blood pressure and even restores brain tissue after using the device consistently for a year.
PAP device technology as well as PAP mask technology has come a long way. Advances in this area have made this treatment much more tolerable with smaller and quieter machines that have a variety of special features as well as a far larger selection of comfortable masks so you can find one that works for you.
Machine and mask can be seen as large and clunky
Not the most convenient treatment when traveling
Not the most attractive device in the bedroom which can interfere with dating and/or intimacy with your significant other.
Can make people feel claustrophobic or anxious
Be sure to check out this definitive guide on PAP devices and masks so you can get a better idea of what they are, the different types, how they differ, what you should consider when determining the best PAP machine and mask for you, as well as solutions to the most common cpap side effects and issues.
Sleep Apnea Treatment Options (Surgeries)Another category of sleep apnea treatment options is surgery. There are variety of surgeries that are available to patients with sleep apnea, but are usually only considered when other options, such as the ones referred to above have failed. This is due to the fact that for a majority of circumstances, surgery has a lower efficacy rate, the risk levels are higher, as is usually the case for any surgical option, and the factor of prolonged recovery time.
However, there are some cases in which surgery may be determined as the best first option of treatment as the condition is due to particular jaw structure problems.
The following is an overview of the various types of surgeries available:
As you now know, some of the causes of OSA are directly related to the nasal region. This includes a deviated septum or enlarged nasal turbinates. As such, the straightening of a deviated septum or the removal of the enlarged nasal turbinates may solve the problem. It is common though that this does not fully cure the OSA, but does improve breathing both during the day and at night.
Upper Airway Surgery
This is the most prevalent of the surgeries performed and is otherwise known as uvulopalatopharyngoplasty (UPPP). This surgery involves the removal of tissue in the back of the throat including the uvula that impedes the breathing when sleeping. This is an inpatient procedure that will result in several weeks of recovery. There are different variations of this operation that are outpatient procedures such as laser assisted uvulopharyngoplast (LAUP) or somnoplasty. Unfortunately , both the UPPP and outpatient procedures currently have a 40% success rate in significantly improving the OSA symptoms8. Additionally, side effects can include difficulty swallowing liquids and changes in one’s voice.
Surgical Jaw Repositioning:
The technical term for this operation is Maxillomandibular Advancement (MMA). This procedure entails the actually fracturing (i.e. breaking) of the jaw and moving it forward with the intent of enlarging the airway. There is not a significant amount of data substantiating the efficacy of this procedure but it does seem to have a greater success rate than UPPP. Unfortunately, this procedure is far more complex and intensive, thus increasing the risk of complications as well as a significant increase in recovery time.
Creating A New Airway
Known as a Tracheostomy, this procedure entails creating a new airway by actually creating an opening below the larynx (voice box) which bypasses the portion of the upper airway that causes the blockage. This opening is literally plugged up during waking hours as to allow the patient to talk and operate normally and then is removed when the individual goes to sleep. This is only used for very severe cases as a last resort when all other treatment options have failed.
There are a number of other procedures including implanting plastic rods in the soft pallet which creates a literal splint that keeps it from collapsing. This and other procedures have not historically resulted in high success rates so I will not go into further detail, but these other procedures can be effective in some rare specific cases.