Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea (OSA) is the most common form of sleep apnea, with around 25 million sufferers in the U.S. It is characterized by frequent pauses in breathing while asleep.Obstructive sleep apnea occurs when the muscles in the back of the throat relax, blocking the airway. These muscles help to support oral and pharyngeal structures like the tongue, uvula, soft palate, and tonsils.

When the airway is either completely or partially blocked, there are usually 10 to 20 seconds of breathing cessation, which can lower blood oxygen levels. The brain panics when this happens and rouses the body to restart breathing. Generally, this is a very brief awakening that most people do not notice or remember. It can happen over 30 times an hour, all throughout the night, which significantly disrupts restful sleep cycles.

Obstructive Sleep Apnea Symptoms

The most obvious and common sign sleep apnea is loud snoring, however not everyone who snores has sleep apnea. People who have sleep apnea often experience extremely loud snoring which is followed by long periods of deafening silence when breathing stops.

Other signs and symptoms that may occur during the day or overnight include:

  • Excessive sleepiness during the day, leading to difficulty focusing and concentrating
  • Waking up in the middle of the night short of breath
  • Breathing cessation throughout the night, which is usually observed by someone else
  • Dry mouth and sore throat in the morning
  • Chest pain upon waking up
  • Morning headaches
  • Mood instability including frequent bouts of depression, anxiety, or excessive irritability
  • Insomnia, problems staying asleep, and/or restless sleep
  • Hypertension

Typically, adults and children will differ in symptoms. For example, the hallmark of obstructive sleep apnea in adults is excessive daytime sleepiness, to the point where the individual may fall asleep for short periods of time throughout regular daily activities.

Children with obstructive sleep apnea symptoms may suffer from significantly lower growth rates. Inattention, hyperactivity, and malnutrition are different manifestations of poor sleep quality that appear often in children. Children who experience obstructive sleep apnea often burn off more calories as they sleep because their bodies have to work harder to burn off calories. Due to excessive nasal and airway obstruction, children may also find it difficult to swallow food and drink. Pay close attention to any obstructive sleep apnea symptoms in children and bring any concerns to your primary care physician.

Obstructive sleep apnea symptoms can be present for years without the person knowing they have the disorder. Many people will experience issues for only a short period of time, with symptoms disappearing after weight loss, surgery, or other lifestyle changes. Symptoms may also be the result of a respiratory infection, congestion, throat swelling, etc.

Obstructive Sleep Apnea Causes

In children, enlarged tonsils or adenoids  are a common cause of obstructive sleep apnea.  Surgical removal often leads to resolution of obstructive sleep apnea symptoms.  For adults, causes may obstructive sleep apnea causes vary but include:

  • Age
  • Obesity, which may cause increased soft tissue around the airway
  • Structural deformities that obstruct the airways
  • Decrease in muscle tone, which can be caused by alcohol, substance abuse, neurological disorders, or some other underlying health conditions

Women are typically less likely to suffer from obstructive sleep apnea than men, because middle-aged men are more likely to have changing anatomy in their neck and soft tissues. Women could also be at a decreased risk because of the higher levels of progesterone, however they are more likely to suffer from obstructive sleep apnea symptoms during pregnancy and after menopause.

Furthermore, there seems to be a genetic component to obstructive sleep apnea. Studies have shown that sufferers often have a positive family history. Lifestyle factors like drinking, smoking, and overeating can increase the chances of developing obstructive sleep apnea.

Obstructive Sleep Apnea Diagnosis

Obstructive sleep apnea diagnosis can be determined through a series of exams and tests. Tests used for obstructive sleep apnea diagnosis are polysomnography and home sleep study sleep apnea tests.

A primary care physician will perform a  physical exam which includes examining the back of the throat for any abnormalities, checking blood pressure, and measuring neck and waistlines. They will also try to get a holistic view of the patient’s lifestyle by asking questions about how daily activities are performed and about family history.

Polysomnography

Some doctors may recommend polysomnography, or in-laboratory sleep study, to be monitored overnight by a specialist in a sleep center who will record oxygen levels and frequency of breathing cessation or awakenings. When breathing stops, there are fluctuations in blood oxygen levels, with a subsequent increase in carbon dioxide.

In central sleep apnea, the brain sends signals to stop breathing entirely; however, in obstructive sleep apnea, the chest will continue to move up and down to simulate inhalation/exhalation without actually breathing. The monitors placed during the polysomnogram show chest movements are pronounced and often exaggerated in patients who experience obstructive sleep apnea

  1. Two frequent outcomes of polysomnography include:Apnea, which is when airflow is completely blocked and breathing stops for at least 10 seconds
  2. Hypopnea, which is when airflow is 50% decreased for at least 10 seconds, or there is a 30% decrease in airflow with a subsequent awakening or serious drop in oxygen saturation levels.

Home Sleep Test

Many sleep doctors are starting to use home sleep studies, which are much more convenient and comfortable for the patient. This is a noninvasive way of monitoring blood oxygen saturation levels during sleep.

Patients who are at higher risk of obstructive sleep apnea are first given the STOP BANG questionnaire or other sleep apnea screening questionnaires, and a significant score means they likely have obstructive sleep apnea rather than another sleep disorder. Learn more about the various home sleep test units that are used for obstructive sleep apnea diagnosis.

Obstructive Sleep Apnea Treatments

The first line of treatment for obstructive sleep apnea is a change in lifestyle changes. Reducing alcohol intake, losing weight, quitting smoking, and avoiding sedative medications are all starting points for treating sleep apnea . However, lifestyle modifications do not always resolve the issues; therefore, one or more of the below options are considered in treatment plans.

CPAP

Next to lifestyle changes, continuous positive airway pressure (CPAP) is the frontline of obstructive sleep apnea treatment. It is most effective for moderate to severe obstructive sleep apnea symptoms. These devices resemble, but are different from  ventilators. A facemask is attached to a tube, which is connected to a machine that continuously pushes positive airway pressure into the breathing passages. This helps to keep the airways open to facilitate easier breathing.

VPAP

Variable positive airway pressure, also known as BiPAP, is another type of ventilation, but instead of continuous airway pressure, the machine uses a circuit to monitor breathing and provides two different pressures: one for inhalation and one for exhalation. The inhalation pressure is higher than the exhalation pressure. This obstructive sleep apnea treatment is more common in patients with serious respiratory conditions.

Nasal EPAP

This bandage-type device is placed over the nostrils to enhance the person’s regular breathing cycles, create positive airway pressure, and prevent obstruction. This is a device commonly used in mild cases of obstructive sleep apnea.

Sleep Apnea Oral Appliances

Splints or other oral appliances are sometimes used in conjunction with other obstructive sleep apnea treatments. Patients often prefer them because they are less “invasive” than CPAP, but sometimes they do not work as well. These splints are mouth guards that keep the passages open and protect the teeth and gums. It holds the lower jaw down and forward to keep it in a more forward position, while simultaneously holding the tongue further away from the airway.

Sleep Apnea Surgery

Sometimes, modifying airway anatomy is necessary to treat obstructive sleep apnea symptoms.  These types of surgeries will vary depending on the cause of the condition and the patient’s anatomy.  The various operative procedures include:

  • Tonsillectomy and adenoidectomy
  • Nasal surgery such as turbinectomy or straightening a deviated septum
  • Reduction or removal of uvula or soft palate
  • Reduction of the size of the tongue base
  • A procedure that surgically moves the jaw forward, pulling the tongue away from the back of the throat (genioglossus advancement)
  • Hyoid suspension, where one of the neck bones is pulled forward
  • Bariatric surgery for morbidly obese patients

 Neurostimulation

This obstructive sleep apnea treatment is used for patients who cannot tolerate the CPAP machine. This system senses respirations and stimulates the hypoglossal nerve with electrical currents to increase muscle tone, which will help avoid the tongue collapsing to the back of the throat and blocking the airway.

What is the Prognosis for Patients with Obstructive Sleep Apnea

The apneic and hypopneic events associated with obstructive sleep apnea cause a fight or flight response in the body, which further creates a hormonal reaction. Excessive use of this response can put an undue amount of stress on the body, exhausting the glands and organs that are activated during the fight or flight response. This, paired with consistently low oxygen saturation levels, can lead to long-term dangerous health consequences.

If the above obstructive sleep apnea symptoms become so severe that daily activities and work are affected, then it’s time to seek medical attention. Untreated obstructive sleep apnea can lead to long-term serious conditions such as:

  • Cardiovascular disease
  • Obesity
  • Diabetes
  • Daytime fatigue, which can be hazardous in school or work environments and driving
  • Eye and vision problems
  • Mood and psychiatric disorders

One of the most serious concerns of untreated obstructive sleep apnea is cardiovascular disease. Sleep apnea patients are at 30% higher risk of heart attack and heart-related death than those without the condition.  Increased pulmonary pressures to the right side of the heart, a major concern in prolonged cases of obstructive sleep apnea, can result in cor pulmonale, a very serious and dangerous form of congestive heart failure.

Obstructive sleep apnea and very loud snoring may seem harmless at first, but they can lead to a laundry list of symptoms as well as more serious and extensive health concerns, so diagnosis and monitoring should be a priority.