- What is Sleep Apnea?
Sleep apnea is a common disorder in which you stop breathing (pauses /cessation / shallowed breathing) during sleep. Pronounced as Apnea ( Ap-Nee-Ah ), it is Greek for “want of breath”. In adults, each pause in breathing is clinically significant if it is lasting at least 10 seconds or more.The most common type of Sleep Apnea is known as Obstructive Sleep Apnea (OSA). This is due to some sort of obstruction in the airway. This obstruction can be due to one or several sites of obstruction : enlarged uvula, enlarged tongue, enlarged tonsils and/or adenoids, deviated septum, small or short jaw (known as micrognathia or retrognathia, respectively). Though you may think that 10 seconds may be considered short or brief, it can have physiologic consequences.
The process of one having sleep apnea is as follows. Each pause in breathing is classified as an apnea (cessation of breathing) or shallowed /infrequent breathing known as hypopnea, pronounced as ( Hi-Pop-Nee-Ah ). These pauses can last anywhere from 10 seconds to several minutes.When breathing is ceased (or paused), carbon dioxide builds up in the blood stream. This, in turn, results in our oxygen levels dropping. Our chemoreceptors (monitoring systems) in the blood stream note the high carbon dioxide levels and send out an alarm. The brain signals us to briefly wake up (either full awakening or a partial awakening known as an arousal) with a loud snore.
This, in turn, brings our oxygen levels back to normal and normal breathing occurs. The problem is, if you have significant sleep apnea, this can occur almost every 30 seconds. Because of the brief awakenings or arousals throughout the night, the patient may experience Excessive Daytime Sleepiness and fatigue. Despite how many hours one is supposedly sleeping, the sleep apneic person feels always tired with unrefreshed sleep.
- When should Sleep Apnea be checked out?
Sleep Apnea is clinically significant if you are experiencing these events at least 6 times or more, per hour of sleep. The symptoms of sleep apnea may last for years without being diagnosed. As a result, many patients become conditioned to their daytime sleepiness and fatigue associated with significant levels of sleep disturbance.
- What are the consequences of not seeking treatment for Sleep Apnea?
If left untreated, Sleep Apnea may include daytime fatigue, a slower reaction time, and vision problems. Due to the slow reaction time, this may increase your risk of having driving or work-related accidents. Other medically related issues may occur if left untreated such as diabetes, memory loss, cardiovascular disease, stroke, even death due to the lack of oxygen to the body.Because we may experience impaired cognition, we may have difficulty paying attention, working effectively and processing information when we are awake. This may also result in memory loss, moodiness, being irritable and a decreased level of attentiveness and drive. Oftentimes, depression may develop because of lack or poor sleep.
- What kinds of physicians are knowledgeable in assessing or diagnosing Sleep Apnea?
The most physicians that are knowledgeable in diagnosing and treating sleep apnea are Pulmonologists (lung specialists), Neurologists, ENT (Ears, Nose, Throat surgeons, also known as Otolaryngologists) and Psychiatrists.Note: Not all of these specialists may be familiar with diagnosing and treating Sleep Apnea so please check their backgrounds before pursuing treatment.
- How does one get confirmation for having Sleep Apnea?
If you’ve seen a sleep physician and they suspect that you have Sleep Apnea, you may have to undergo a sleep study (also known as a Polysomnogram). There are several types of sleep studies utilized to diagnose Sleep Apnea. The most common is an in-lab Polysomnogram.This would entail you coming into a Sleep Lab in the evening (prior to your normal bed-time) where a sleep tech (known as a Polysomnographic Technologist) will greet you and show you to your bedroom. S/He will have you fill out a few forms and questionnaires have you change into your bedtime clothes, and then place several monitoring devices on you.
These monitoring devices are non-invasive (no pain, no shots). Some of these monitoring devices are EEG (Electroencephalograph) leads to record your brain wave activity. EEG leads are utilized to determine if you are awake or asleep.
When you are asleep, there are four sleep stages you go through : Stage N1 (light sleep), Stage N2 (consolidated sleep), Stage N3 (Deep sleep) and Stage R (Dream state). EOG (electro-oculogram) is recorded to monitor your eye movements. This helps the sleep technologist and physician differentiate between wake (blinking) and rapid eye movement sleep (REM).
Electromyogram (EMG) activity which are leads placed on your chin and legs to assess for any movement during your sleep such as bruxism (teeth grinding) or Periodic Limb Movements in Sleep (PLMS). Electrocardiogram (ECG) is used to monitor your heart rate and cardiac rhythm.
A snore microphone is utilized to monitor any snoring. Respiratory belts are placed outside of clothing and placed around your chest and abdomen to assess your breathing. Lastly, a finger probe is placed on your finger to monitor your oxygen saturation levels throughout the night.
The normal hook-up time is anywhere from 30-45 minutes. After the hook-up is complete, the patients are encouraged to go to sleep. The Polysomnographic Technologist will be monitoring you in a separate room in which all of your monitoring devices are transmitted via computer.
The Polysomnographic Technologist will be monitoring you throughout the night assessing for any apneas, hypopneas, and/or snoring events as well as any cardiac arrhythmias, and unusual activity during sleep. You are encouraged to sleep in any position throughout the night though some time on your back is encouraged as the back will demonstrate more prominent respiratory events.
In the morning; close to your rise time, the Polysomnographic Technologist will wake you up, remove the monitoring devices, have you complete a morning questionnaire, and then you are free to change and go home or directly into work.
After the study has been completed, the study will be scored (identifying the various wake and stages of sleep as well as respiratory events, cardiac events, and any other unusual activity). The scored data will be generated in report format for the sleep physician to review and interpret. S/He will then see you in a follow-up consultation and go over the findings with you along with recommendations for treatment.
There are three main types of sleep studies :
1. Complete Diagnostic Study
2. Split-Night Study
3. All night CPAP Titration Study.
Complete diagnostic study is simply that – monitoring the patient all night long to observe for any respiratory events during sleep.
A split-night study is a combination diagnostic and treatment study. The first part of the night, the patient is monitored diagnostically to assess the level of severity. The second part of the night, the patient is placed on CPAP to treat the sleep apnea.
The third type of study is an all night CPAP or BPAP (Bi-Level) study to treat the sleep apnea. In order to have an all night CPAP or BPAP study, you must have been diagnosed (via the diagnostic or Home Sleep Test) with sleep apnea.
- What is Home Sleep Test?
Another type of study to diagnose Sleep Apnea is a Home Sleep Test (HST) also known as Ambulatory studies. Instead of a formal polysomnogram as listed above, this is a modified sleep study entailing the following parameters, airflow, respiratory effort, oxygen saturation, snoring, and body position.This is ideal if your sleep physician suspects that you have a moderate to high probability of having Sleep Apnea AND you don’t have any other underlying sleep disorders (such as Periodic Limb Movements in Sleep). This type of sleep test is one wherein your sleep physician or sleep vendors will show you how to place these devices on for single night use.
You would then drop off the equipment at the vendor’s office, physician office or the device may be picked up by the distributor depending on the prior arrangements made. The device would then be downloaded, scored and interpreted by the sleep physician. The sleep physician will then see you in a follow-up consultation and go over the results with you and make recommendations for treatment.
- What is considered clinically significant on a sleep study?
There are two types of respiratory events: apneas and hypopneas. Another type of respiratory event is known as RERA (Respiratory Effort Related Arousal). These are even mild forms of hypopneas but are clinically significant. When your physician goes over the sleep study with you, he will show you your AHI (Apnea-Hypopnea Index) or RDI (Respiratory Disturbance Index). The levels of severity are classified as follows :
0 – 5 / hr = Normal
6 – 15/ hr = Mild
16 – 30 / hr = Moderate
> 30 / hr = SevereLet’s say you have an AHI of 60/hr. There are 60 minutes to every hour. In this case, you would be demonstrating one respiratory event every minute. Any value of more than 5 / hr would be clinically significant.
- What would be my treatment options if I am diagnosed with Obstructive Sleep Apnea?
Continuous Positive Airway Pressure (CPAP) is the most common form of treatment for Obstructive Sleep Apnea. The CPAP is classified as a Durable Medical Device. It is comprised of a flow generator that has a flexible hose attached to it along with a breathing mask which comes in various types of shapes and interfaces : nasal mask, nasal pillows and full face mask.When a patient experiences an apnea, hypopnea or RERA, your airway tends to close (or partially closed). The CPAP device works like a pneumatic splint. The CPAP device comes in centimeters of water pressure from a low pressure of 4.0 cm H20 to a high pressure of 20.0 cm H20.
A manual titration in the sleep lab is performed so that the Polysomnographic Technologist will determine what pressure is ideal to keep the airway open thereby eliminating the respiratory events (apneas, hypopneas, RERAs) and the snoring.
Auto-PAP is an auto-adjusting CPAP device. This utilizes an algorithm to increase pressures if it senses flow limitations such as apneas, hypopneas or RERAs and/or snoring. Just like CPAP, the APAP comes in a range from 4.0 to 20.0 cm H20.
Bi-Level Positive Airway Pressure (BPAP) is utilized whenever patients cannot tolerate CPAP especially at high pressures. BPAP is comprised of two level pressures called Inspiratory Positive Airway Pressure (IPAP) and Expiratory Positive Airway pressure (EPAP). It is ideal for patients who have difficulty exhaling on CPAP.
Oral Appliance (OA) is a device that looks like a mouth guard. It is used primarily to treat for Primary Snoring Disorder (wherein the diagnosis is only snoring with no respiratory events) or Mild to Moderate Obstructive Sleep Apnea.
The oral appliance is worn in the mouth only when sleeping. Most of these oral appliances work by advancing the lower jaw slightly forward of its usual resting position. The oral appliance gradually advances the lower mandible by a few millimeters; enough to open up the airway to eliminate/reduce the snoring as well as respiratory events.
There are many oral appliances out there in the market. Some of these are simply “boil and bite” devices which aren’t as effective as custom-fitted devices. One particular advice utilized is the SomnoDent Oral Appliance. A Sleep Dentist or Sleep Physician fits the tray and records the mandibular measurements needed to conduct a proper fit. This device fits over the upper and lower teeth, much like a sports mouthguard.
However, unlike sports mouthguard, it is a discreet, precision-made and clinically tested medical device that is recognized for its clinical validity. It is highly effective for mild to moderate obstructive sleep apnea and snoring.The other options will be surgical intervention. ENT Referral is recommended for surgical options in cases of mild to moderate OSA.
About 70% of patients who have OSA are overweight or obese. Obesity is defined as having a Body Mass Index > 30. Losing a significant amount of weight is clinically significant in reducing/eliminating the snoring as well as reducing the respiratory events
- Is Sleep Apnea related to Heart Disease?
Heart Disease is the leading cause of death in America and stroke is the No. 4 cause and a leading cause of disability. High blood pressure is a major risk factor for both. There is a strong relationship between sleep apnea and hypertension and cardiovascular disease.
Obstructive Sleep Apnea, is the most common type of sleep apnea in which weight on the upper chest and neck contributes to blocking the flow of air. Obstructive Sleep Apnea is associated with obesity, which is a major risk factor for heart disease and stroke. Being deprived of sleep due to sleep apnea can lead to obesity.
- What is the link between Sleep Apnea and Type 2 Diabetes?
There is a high relationship between Type 2 Diabetes and Obstructive Sleep Apnea (OSA). Obstructive Sleep Apnea is the most common form of sleep disordered breathing, accounting for over 80% of cases. Up to 40% of people with OSA will have diabetes, but the incidence of new diabetes in people with OSA is unknown. OSA may have effects on glycemic control in people with Type 2 Diabetes. Being overweight or obese may play a role.
- What is Good Sleep Hygiene?
Just like personal hygiene, we have sleep hygiene which corresponds to getting a good night’s sleep. Here are some tips for obtaining good sleep hygiene:
a. Maintain a regular bed time and wake time. This should not vary even on the weekends.
b. Avoid alcohol close to bed time. Alcohol interferes with sleep and suppresses your respiratory system. If you have sleep apnea and consume alcohol, this will slow down your respiratory system thereby resulting in longer (prolonged) apneas.
c. Use the bed only for sleeping and sex.
d. Abstain from any caffeinated beverages about 6 hours before bedtime.
e. Develop a routine bed-time ritual (i.e., taking a warm bath, changing into your bedtime clothes, etc.) before going to bed.
f. Avoid heavy exercise prior to bedtime.
g. Avoid eating a heavy meal prior to bedtime.
h. If awake for more than 20 minutes, get out of bed and into another room until the urge to sleep comes about. Many people tend to go on their smartphones or watch TV to will tend to keep one awake. Try to establish a downtime for relaxing.
i. Avoid looking at the clock. If you’ve set your alarm, it will wake you up. Constantly watching the clock will result in further stress in not being able to sleep.
Easmed would like to dedicate special thanks to Mr.Glenn Roldan, RPSGT, RST, CSE, CCSH – Clinical Director from United Sleep Centers, LLC for his invaluable inputs in this Frequently Asked Questions section.