The Greek word “apnea” means “without breath.” Apneas are classified as obstructive, central, and mixed. Of the three, obstructive is the most common. Despite the differences of each type, in all three people with untreated sleep apnea stop breathing repeatedly during their sleep. Obstructive sleep apnea (OSA) is caused by a blockage of the upper airway, usually when the soft tissues of the throat collapse and closes during sleep. With each apnea event, the blood oxygen level drops and the brain briefly arouses people with sleep apnea in order for them to resume breathing. It is these arousals that consequently make sleep extremely fragmented and of poor quality.
Obstructive sleep apnea is a very common disease with increasing prevalence. The estimated incidence is reported to be between 5-15% percent of the U.S. population. Yet still because of the lack of awareness by the public and healthcare professionals, the majority remain undiagnosed and untreated. The most common risk factors for OSA are overweight and obesity, and sites of upper airway obstruction (history of nasal fracture, enlarged tonsils, recessed jaw). If untreated, OSA is a serious disorder that can have significant medical consequences.
Untreated OSA is often associated with other common medical disorders, such as type-2 diabetes and gastro-esophageal reflux disorder (GERD). If untreated, OSA can cause progressive cardiovascular disease, being associated with increased risks of hypertension, heart attacks, and strokes. Other associated consequences of OSA are neurocognitive deficits (memory problems and lack of concentration), headaches, and daytime sleepiness and fatigue. Moreover, there is a 10-fold increased risk of motor vehicle collisions in OSA patients. Collectively, there has been noted to be an overall increased mortality and early death if OSA is untreated.
The most common symptoms of OSA are daytime sleepiness/fatigue and non-restorative sleep (ie, waking-up tired); these patients have a high likelihood to “doze off” in the afternoon or evening. The vast majority of these patients snore regularly, and the snoring is often noted to be very loud, often keeping the bed partner from sleeping. Typically, the snoring is the main symptom noted in pediatric patients with OSA. Many patients also note morning headaches, poor concentration, and mood disorders such as depression. These symptoms suggest a patient has OSA, but the diagnosis is made by further testing.
The most common tools used for a diagnosis of OSA include patient questionnaires and sleep studies. The gold standard for diagnosis of OSA, as well as other sleep disorders, is a polysomnogram. This test is performed in a sleep lab, where a patient is monitored overnight while asleep. Because of the lack of patient comfort with a sleep lab study, the diagnosis of OSA can now be made at home with a home sleep study.
Once the diagnosis is made, multiple treatment options, both medical and surgical, are available. Medical management should include a weight loss and exercise regimen, but the mainstay of treatment is positive airway pressure (PAP) ventilation. PAP ventilation consists of a mask and compressed air to prevent airway collapse and obstruction during sleep. Though, at first, adjusting to the PAP can be difficult, the benefits ultimately outweigh initial discomfort. Newer versions of PAP devices are easily portable and much quieter than earlier models. These new models can record the user’s breaths and deliver air only as needed. New masks that fit to the nose only and don’t require the use of straps can create a more comfortable environment for sleep. Another option for some patients with OSA is the use of oral appliances. These appliances are plastic devices that are worn in the mouth that function to protrude the jaw and prevent airway collapse during sleep.
Surgical intervention for OSA is often reserved for patients who do not tolerate medical management, such as PAP therapy. These procedures are designed to correct anatomical sites of upper airway obstruction so that patients have less obstruction during sleep. The most common surgical procedures performed for OSA include nasal and sinus surgery, tonsillectomy and palate surgery, and tongue base procedures. Others include jaw repositioning procedures and tracheostomy, which are reserved for patients with the most severe disease.
Obstructive sleep apnea, while having significant consequences if untreated, has many successful treatment options. Snoring alone does not imply OSA, but snoring coupled with other symptoms (such as daytime sleepiness) suggest OSA and that further medical evaluation is warranted. Any questions or concerns can be further discussed with your local ENT physician.
Robert Wilson, MD.