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SNORING & OBSTRUCTIVE SLEEP APNEA (OSA)

Do you snore loudly? Are you the target of bad jokes or middle-of-the-night elbow thrusts? Snoring is no laughing matter. Loud snoring can be a sign that something is seriously wrong with your breathing during sleep. Snoring indicates that the breathing passage (airway) is not fully open, and the distinctive efforts to force air through the narrowed passageway.

An estimated 10% to 30% of adults snore. In some of them, snoring may have no serious medical consequences. However, for others, loud nightly snoring may be the first indication of a potentially life-threatening disorder called obstructive sleep apnea syndrome (OSAS) or simply Obstructive Sleep Apnea.

The sleep of normal children and adults is accompanied by relaxation of the muscles that stiffen and open the air passage. This muscles relaxation leads to slight sleep-related narrowing of the throat (air passage) that is of no importance for most people. In people with OSAS, the sleep-related that narrowing is so great that breathing becomes difficult, as if they were breathing through a floppy, wet straw. The brain senses that breathing is difficult and increases the effort to breathe. Increased effort to breathe briefly awakens the brain. Once awake with a fully open throat the effort to breathe decrease. As breathing effort returns to normal, the person resumes sleep and the cycle of falling asleep, throat narrowing, raised effort to breathe and then arousal from sleep repeats itself. This cycle can disturb sleep dozens to hundreds of times each night. Most of the obstructive breathing episodes and awakenings are so brief that they are not remembered. The person with this pattern of obstructive breathing, awakening from sleep, and daytime symptoms of fatigue and sleepiness suffers from OSAS.

There is more than one pattern of abnormal breathing of OSAS. Narrowing of the throat can be complete (apnea) or partial (hypopneas and respiratory effort related arousals) but lead to the same consequence: repetitive disruption of sleep. Obstructive apnea and hypopnea may be accompanied by lack of oxygen. Most people will have a combination of the different types of abnormal breathing.

If you have OSAS, you may not get enough oxygen during sleep and probably don't sleep soundly. You may suffer daytime sleepiness that affects your work and/or social activities, and may even lead to car accidents. OSAS can also put you at risk for high blood pressure, heart failure, heat attack, or stroke. Snoring loudly every night, in all positions, calls for a visit to a sleep specialist. He or she may suggest some tests including a sleep study. Fortunately, sleep specialists are now able to detect and diagnose breathing disorders in their earlier, more treatable stages. Proper treatment can prevent or reverse the potentially life-threatening results of OSAS.

What are the Warning Signs of OSAS?
In Adults:

Snoring may be so loud that it rivals a jackhammer and can be heard rooms away.
A particular pattern of snoring interrupted by pauses, then gasps, reveals that the sleeper's breathing stops and restarts.
Adults with OSAS may fall asleep at inappropriate times, such as at work or while driving.
Adults with OSAS may have trouble concentrating, and can become unusually forgetful, irritable, anxious, or depressed.
In some cases, a person knows they have a sleep problem and seeks help. Adults with OSAS may complain about morning headaches, frequent nighttime urination, and lack of interest in sex. Men may complain of impotence and women may have menstrual irregularities.

These problems usually appear slowly over many years. Sometimes OSAS symptoms go unnoticed, or their significance is downplayed. Family members, employers, or coworkers may be the first to recognize a pattern of excessive daytime sleepiness and / or changes in mood or behavior. If they do, they should encourage a visit to a healthcare professional.

In Children:

OSAS has been linked to some cases of sudden infant death syndrome (SIDS), although the exact relationship is still uncertain. Ongoing research is evaluating the role of OSAS as a possible factor in SIDS.
OSAS may be present in children who are over-weight and those who have enlarged tonsils and adenoids.
Children with OSAS may:
Snore or squeak
Have difficulty breathing
Sleep fitfully
Have daytime hyperactivity
Older children who have OSAS may seem sluggish and may perform poorly in school. Sometimes they are labeled "slow" or "lazy". Recent research has found an association between sleep apnea and Attention Deficit disorder.

Since it is not normal for a child to snore loudly every night, parents should report their child's snoring to a healthcare professional.

What Causes OSAS?
When you sleep all of your body's muscles relax more than they do during waking hours. This may not cause problems for most people, but in some people with small throats this relaxation lets the airway narrow and interferes with breathing. Sleep then becomes a time of increased health risk. A smaller-than-normal jaw, large tongue, enlarged tonsils, or tissues that partially block the entrance to the airway can be factors. Sometimes several of these conditions are present in the same person.

Alcohol, sleeping pills, and tranquilizers taken at bedtime also reduce muscle tone and can make the throat more likely to collapse. Some people with OSAS may actually sleep worse when they take a sleeping pill. While most people with OSAS have no apparent physical flaw that interferes with their breathing during sleep, some physical conditions can play a role. OSAS most often strikes overweight men. A different throat structure may protect women. In later years, the gap between the sexes narrows, although it never disappears completely.

What happens if I am not treated for OSAS?
The most common complaint of people with OSAS is excessive daytime sleepiness. The sleepiness is most often felt when the person with OSAS is still or "bored". Under these circumstances he or she may be unable to remain awake or to concentrate. Reading and driving an automobile can often be difficult because of irresistible sleep (dozing). The sleepiness produced by OSAS leads to an increased number of work related and automobile accidents in patients with the disorder.

Untreated OSAS has other consequences for health and well-being. A list of some of the known consequences of untreated OSAS can be found in the following table.

Some Consequences of Untreated OSAS Hypertension Excessive daytime sleepiness Myocardial Infarction (Heart attack) Stroke Symptoms of depression Menstrual irregularities in women Frequent nighttime urination Treatment of OSAS often alleviates or eliminates most of the adverse consequences of the disorders. In many cases, the benefits of treatment are felt quickly after treatment is started.

What is a sleep study?
There are different kinds of sleep studies:

Detailed overnight polysomnograph done in the sleep center.
Portable studies that can be done in your house, which offer limited information.
Daytime studies in some patients with excessive daytime sleepiness and suspected to have Narcolepsy.

Your sleep specialist will discuss these options and choose the one that is right for you.

If you have been asked to undergo a detailed polysomnograph in the sleep center, you would be asked to go to the center about one hour before your usual bedtime. Technicians would position some ‘wires’ and ‘sensors’ at different points on your body to continuously record your brain waves, muscle activity, leg and arm movements, heart rhythms, and other body functions during sleep.

Each sleep disorders center has its own system of running tests, and several devices may be used to study the different patterns of breathing during sleep. These include a light mask that covers the nose and mouth, small plastic prongs placed at the openings of your nose, or temperature - sensitive beads taped at points on the body to measure the rate at which air enters and leaves your lungs. These tests help record whether and when breathing difficulties occur. Stretch bands with small gauges may be placed around your chest and abdomen to measure the effort you make to breathe, and a device clipped to one of your earlobes or fingers would chart falls in levels of oxygen with each apnea episode.

If a portable, limited sleep study is ordered in your house, the technician will come to your house at night and hook up this portable recorder, which primarily records your breathing pattern and oxygen level. The technician will leave your house after hooking it up and will come back the following morning to pick it up and take it to the Sleep center for analysis.

Your sleep may be studied during the day as well, through a series of naps offered at two - hour intervals. This study, known as the multiple sleep latency test (MSLT), measures daytime sleepiness. The test may also be used to test for other causes of daytime sleepiness, such as narcolepsy, which is a neurological disorder.

What will be the likely treatment offered to me?
If you are diagnosed with OSAS you may benefit from both general measures and specific treatments. General Measures

Normalize weight. Weight loss may help in the treatment of OSAS. Even a little weight loss may improve breathing during sleep, making sleep more restful and lessening daytime sleepiness.
Avoid alcohol within four hours of bedtime. Alcohol depresses breathing and makes OSAS episodes more frequent and severe. Alcohol also appears to trigger OSAS in people who would otherwise merely snore.
Avoid sleeping pills. Sleeping pills depress breathing, relax the muscles of the throat, and generally make OSAS worse. Exceptions may be necessary for people who are bothered by frequent awakenings that are not due to OSAS episodes. Seek out a healthcare professional's advice if you use sleeping pills and have OSAS.
Take all drugs with care. Medications prescribed for headaches, anxiety, and other common problems can affect sleep and breathing.
Sleep lying on one side. Some people suffer from OSAS only when lying on their backs. Pillows placed behind the back or a tennis ball attached to the back of pajamas will encourage side - sleeping throughout the night.
Medications to relieve congestion of the nose may be helpful in reducing snoring and the likelihood of OSAS episodes.

Nosevent (R) nasal dilators and similar device can be used to open the nasal passage and decrease snoring. Usually treatment of OSAS solely by improving nasal airflow does not solve loud snoring or significant breathing episodes.
Specific Treatments
Positive airway pressure (PAP): In this highly effective therapy, a light mask is worn over the nose during sleep. Pressure from an air compressor forces air through nasal passages and into the throat. This gentle pressure holds the throat open and allows normal sleep and breathing. Approximately 60% to 70% of patients who try PAP are able to continue its use; the remainder finds the mask uncomfortable. PAP devices come in different sizes and some are made to change the pressure when breathing in or out (bilevel PAP) or in response to snoring and excessive narrowing of the throat (autotitrating). These modifications of the standard PAP device were made to improve comfort. In general, these newer PAP devices are tolerated as well as the standard PAP apparatus. Table below lists common complaints of PAP treatments for OSAS.

Common complaints of PAP treatments
Nasal stuffiness or congestion
Dryness of the mouth
Mask air leaks
Noise made by the PAP Machine
Sore, dry, or red eyes
Sink irritation from the mask and / or straps
Too much air

Oral appliances: Some OSAS patients are helped by devices that open the airway by bringing the jaw, tongue and soft palate forward. Patients with mild and moderate OSAS may experience benefit by using an oral appliance. Severe OSAS usually does not respond to this type of treatment. Excessive salivation, jaw pain, the loosening of teeth are some other complications encountered when using oral appliances to treat OSAS. Oral appliance should not be used in people with complete, bilateral nasal obstruction.

Surgery: Physical problems that interferer with breathing during sleep can sometimes be corrected surgically. These problems include enlarged tonsils or adenoids (common in children) nasal polyps or other growth, a deviated nasal septum, and unusually formed jaw or soft palate.

Nasal operations used to remove blockages in the nose as the only treatment of snoring and OSAS are usually not effective. However, nasal surgery may be one part of an overall plan for surgical treatment of OSAS.

Using a technique known as the uvulopalatopharyngoplasty (UPPP), a surgeon removes excess tissue at the back of the throat that may be blocking the airway during sleep. Studies show that UPP benefits about half of those people who undergo the surgery. Studies are underway to identify the patients most likely to be helped by this procedure. Some patients have reported negative side - effects of the surgery, such as nasal sounding speech and the regurgitation of liquids into the nose when swallowing. A modification of UPPP using laser techniques (Laser - assisted uvulopalatoplasty, LAUP) is less effective treatment for OSAS but is effective for snoring. Somnoplasty, a new surgical technique that uses microwave energy, is being studied in hopes of improving the success of surgery at controlling OSAS.

Other surgical procedures have been designed to treat OSAS. Most of them aim to increase the size of the throat at the base of the tongue. These surgeries may involve cutting into the bones of the face and jaw. In properly selected cases they are more effective than UPPP alone but they may also carry a greater risk of complications.

In extremely advanced cases, a tracheostomy may be required to alleviate life-threatening OSAS. This procedure involves creating an opening in the trachea (windpipe). A tube inserted into the opening stays closed during waking hours, allowing normal speech and breathing through the upper airway. The tube is opened for sleep so that air by passes the obstruction in the throat and flow directly to the lungs.

Oxygen: Supplemental oxygen is not a treatment for OSAS. Oxygen may be added to the PAP system, however, to correct for low oxygen levels due to existing lung or heart disease.

Medication: OSAS sufferers are not likely to receive benefits from medication. Certain medications may help very mild cases of OSAS.

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