John Turner MD FACP
Board Certified in Internal Medicine and Sleep Medicine

 

Sleep Apnea

Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is a disorder commonly diagnosed and treated by sleep physicians. The American Academy of Sleep Medicine states, “It is now estimated that 26 percent of adults between the ages of 30 and 70 years have sleep apnea.” Untreated OSA has significant consequences. OSA is associated with an increased occurrence of stroke, heart attack, high blood pressure, heart arrhythmias such as atrial fibrillation, diabetes, automobile accidents from falling asleep, and even sudden death during sleep.

OSA in adults usually occurs when the backmost portion of the tongue closes off and obstructs the airway, greatly diminishing (hypopnea) or stopping (apnea) breathing altogether. The oxygen levels drop, often quite low, and the patient is “bumped out” of restorative sleep in order to resume breathing. In OSA, this process repeats itself over and over during sleep. This disrupted, fragmented sleep often causes the patient to be sleepy, grumpy, and to have poor memory and concentration during the daytime.

Ironically, the patient with OSA often is the last to know that he or she has it, since even poor-quality sleep is still a state of unconsciousness. It is therefore usually quite helpful when a bed partner comes to at least the initial evaluation of a patient suspected of having OSA to give a different perspective of what is happening during sleep.

OSA is commonly associated with one or more of these symptoms or attributes:

  • Being Overweight
  • Snoring, Daytime sleepiness
  • Large neck
  • Small chin
  • Large tongue
  • Nighttime urination
  • Breathing Pauses during sleep
  • Poor memory
  • Poor concentration
  • Depression
  • Morning headaches
  • Unrefreshing sleep
  • Heartburn/GERD, Diabetes
  • Hypertension
  • Heart disease
  • Atrial fibrillation
  • Stroke

Untreated OSA is perhaps the prime cause for bed partners moving to separate bedrooms, as they can no longer tolerate sleeping next to a loud snorer, or the worry that comes when the other stops breathing. Untreated OSA is really quite unnerving to watch!

Treating OSA usually helps the patient to feel better. There is usually more refreshing sleep and less sleepiness. Concentration, mood, and memory are often improved. If present, high blood pressure, heartburn/GERD, atrial fibrillation, and diabetes may be more easily controlled.

 Sleep Apnea Diagnosis:

Sleep apnea is diagnosed by monitoring a patient during sleep. The number of times per hour that a patient stops breathing (apnea) or has a significant decrement in breathing (hypopnea) is calculated. Mild OSA is defined as 5-14 of these occurrences per hour. Moderate OSA is 15-29 per hour, and Severe is over 30 Apneas + Hypopneas per hour.

Sleep Apnea Treatment:
The “Gold Standard” treatment for obstructive sleep apnea is CPAP, which stands for Continuous Positive Airway Pressure. How this works is that air pressure in the airway is used to keep the tongue from collapsing and obstructing the airway. During a sleep study, the best pressure is determined for each individual patient. A mask which creates an airtight seal at the nostrils, over the nose, or over both the nose and mouth is used. Unless patients have a special need for oxygen, the pressure is introduced using humidified room air, and this pressure is what holds the airway open during sleep, thereby preventing the apneas and hypopneas from occurring. It is important that the company supplying the mask and CPAP find a mask that fits the patient well and is readily available to address any equipment concerns. Most patients adapt well to CPAP therapy once they start experiencing the benefits of improved sleep. The pressure needs may change over time, so retesting is recommended every 3 years – sooner for patients experiencing recurrence of sleep apnea symptoms.

Treatment of nasal obstruction is important. This often includes treating nasal allergy symptoms – especially in this part of the country. Surgical treatment of a deviated nasal septum, nasal polyps, or enlarged nasal turbinate’s, if present, by an ear, nose, and throat surgeon (ENT) should be considered.

Mandibular Advancement Devices may be used to advance the jaw forward during sleep. This is typically considered in those with mild OSA who cannot tolerate CPAP therapy. A dentist specialized in this area makes an adjustable mouthpiece, and adjusts the amount of jaw thrust during a sleep study to the point that the OSA is adequately treated.

Other ENT Surgery options include uvulopalatopharygoplasty (UPPP), lingual tonsil abatement, maxillo-mandibular advancement (MMA), tonsillar pillar procedures, and even tracheostomy.

Other Sleep Disorders:

  Restless Leg Syndrome
The sensations experienced by people with this disorder can’t be fully understood by those who don’t have it. Patients often describe a crawling feeling or pain in the legs around bedtime, and it is temporarily relieved by moving the legs or walking. It interferes with the ability to get to sleep. If it is interfering with sleep, there are treatment options which are often effective in improving or eliminating the symptoms, thus improving sleep quality.

  Periodic Limb Movements of Sleep
These are involuntary movements of the lower extremities while sleeping, and can frequently disrupt sleep, yielding less refreshing sleep. This disorder often accompanies restless leg syndrome, but can occur independently. There are medications which can help this as well.

  Parasomnias
This group of sleep disorders refers to unusual things some people do while asleep. Children are more likely to have this disorder, but adults can have it as well.

  Some examples include:

  • Sleepwalking
  • Sleep talking
  • Sleep eating
  • Bruxism (grinding teeth during sleep)
  • Night terrors
  • Sleep groaning

The patient does not typically recall the activity. There are treatments available, and the patient and bed partner should take steps to create a safe sleep environment to minimize chances of injury if the behavior (such as sleep walking) recurs. Those with bruxism (teeth grinding) should seek dental evaluation for a bite guard to protect their teeth from the trauma.

  Insomnia
This is a difficult problem to have, and a difficult one to treat. It is not considered to be problematic unless there are daytime consequences from the lack of sleep over a significant period of time. The most effective long-term solution is for the patient to reinforce good sleep habits at the subconscious level. This will help ensure consistent, good quality sleep without medications. This approach is accepted by sleep physicians as the treatment of choice for insomnia, and requires both time and patience.

  Narcolepsy
Patients with this disorder often regrettably gets labeled as being lazy, and for this reason many patients don’t reach their full potential in life. Many years usually pass before it is accurately diagnosed. In this sleep disorder, patients typically have uncontrollable “sleep attacks” during the waking hours, which cause them to nod off to sleep without warning. This, of course, creates potential danger if a patient drives, and creates a significant burden for them to succeed in school or work. Sleep testing is necessary for diagnosis, and there are treatments available to help control the sleep attacks and other symptoms of this disease. It is more common than many think, with an incidence estimated to be between 2 – 16 per ten thousand Americans.

Circadian Rhythm Disorders
This group of sleep disorders involves problems with our innate circadian clock, which normally reminds us when it is time to sleep. Sometimes the circadian clock gets thrown off. These are fairly commonly seen problems, and most of us know someone who has problems in this area.

Sleep Phase Delay: This is a disorder in which the patient wants to stay awake very late at night and sleep until noon. It is commonly seen in teens and young adults, contributing to trouble with concentrating or even being able to stay awake during the morning classes.

Sleep Phase Advance: This is the opposite of sleep phase delay, and involves a patient habitually preferring to go to sleep very early, such as 6 p.m., and awakening for the day in the early hours of the morning. This is more commonly seen in the elderly population.

Jet Lag: Quickly travelling across several time zones is done frequently these days. The difficulty in the circadian clock adjusting to the “new” time is known as Jet Lag. Flying east tends to be more difficult than flying west, as we tend to be more successful in delaying sleep than advancing it. There are some treatments and sleep strategies which can help to minimize the impact of Jet Lag.

Shift Work Sleep Disorder: One unfortunate byproduct of industrialization was the creation of shift work. Jobs which rotate the times of work shifts are typically more difficult to adapt to than those with a straight night shift, as the shift times and sleep times continuously change, thoroughly confusion of the circadian clock. Chronic sleepiness, poor concentration/memory, lack of energy and motivation, mood disorders, and other health problems can result from this disorder. There is definitely no replacement for sleep, but there are treatment and sleep timing strategies which can help to minimize the negative effects of shift work.

  Insufficient Sleep Syndrome
This sleep disorder is just what it sounds like. There is no great surprise that people in our society do not allow enough time for sleep. We have cable television, computers, video games, cell phones, and many other sleep distractions. As mentioned above, there is no replacement for sleep, and it is vital and necessary for the body to flourish, or even to survive. It is not unlike eating, drinking, and breathing in that regard. On average, a 10 year old child needs about 10 hours of sleep. By the teen years, 9 hours is the average need. Adults typically need 7.5-8 hours of sleep nightly to function normally, with some variation. People create a sleep debt when they are not getting the amount of sleep their body requires – for whatever reason. This includes simply are not allowing enough time for sleep, a sleep disorder depriving restorative sleep, or a combination of these. Feeling chronically sleepy, feeling the need to take naps, or “sleeping in” on weekends are characteristic indicators that there is a sleep debt. I advise patients to correct the sleep debt so that they might realize their full potential.

The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect your chance to fall asleep if you were doing them now. Use the following scale to choose the most appropriate number for each situation:

0 = NO chance of dozing
1 = SLIGHT chance of dozing
2 = MODERATE chance of dozing
3 = HIGH chance of dozing

 

Situation Chance of dozing or sleeping
0 1 2 3
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a car for an hour
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopping for a few minutes in traffic while driving
Total Epworth score

 

UNDERSTANDING YOUR SCORE

Normal: 0-7
Borderline sleepy: 8-9
Abnormally Sleepy: 10 and above.
Higher scores are associated with more sleepiness…

 

Interview of Dr. Turner on “How to detect sleep disorders.”

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