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Sleep Apnea Treatment Information

Although a diagnosis of sleep apnea often will be suspected on the basis of a person's medical history, there are several tests that can be used to confirm the diagnosis. The treatment of sleep apnea may be either surgical or nonsurgical.

An apnea is a period of time during which breathing stops or is markedly reduced. In simplified terms, an apnea occurs when a person stops breathing for 10 seconds or more. If you stop breathing completely or take less than 25% of a normal breath for a period that lasts 10 seconds or more, this is an apnea. This definition includes complete stoppage of airflow. Other definitions of apnea that may be used include at least a 4% drop in oxygen in the blood, a direct result of the reduction in the transfer of oxygen into the blood when breathing stops.

Apneas usually occur during sleep. When an apnea occurs, sleep usually is disrupted due to inadequate breathing and poor oxygen levels in the blood. Sometimes this means the person wakes up completely, but sometimes this can mean the person comes out of a deep level of sleep and into a more shallow level of sleep. Apneas are usually measured during sleep (preferably in all stages of sleep) over a two-hour period. An estimate of the severity of apnea is calculated by dividing the number of apneas by the number of hours of sleep, giving an apnea index (AI in apneas per hour); the greater the AI, the more severe the apnea.

A hypopnea is a decrease in breathing that is not as severe as an apnea. Hypopneas usually occur during sleep and can be defined as 69% to 26% of a normal breath. Like apneas, hypopneas also may be defined as a 4% or greater drop in oxygen in the blood. Like apneas, hypopneas usually disrupt the level of sleep. A hypopnea index (HI) can be calculated by dividing the number of hypopneas by the number of hours of sleep.

The apnea-hypopnea index (AHI) is an index of severity that combines apneas and hypopneas. Combining them gives an overall severity of sleep apnea including sleep disruptions and desaturations (a low level of oxygen in the blood). The apnea-hypopnea index, like the apnea index and hypopnea index, is calculated by dividing the number of apneas and hypopneas by the number of hours of sleep.

Another index that is used to measure sleep apnea is the respiratory disturbance index (RDI). The respiratory disturbance index is similar to the apnea-hypopnea index; however, it also includes respiratory events that do not technically meet the definitions of apneas or hypopneas, but do disrupt sleep.

Sleep apnea is formally defined as an apnea-hypopnea index of at least 15 episodes/hour in a patient if they do not have medical problems that are believed to be caused by the sleep apnea. This is the equivalent of approximately one episode of apnea or hypopnea every 4 minutes. High blood pressure, stroke, daytime sleepiness, congestive heart failure (low flow of blood to the heart), insomnia, or mood disorders can be caused or worsened by sleep apnea. In the presence of these conditions, sleep apnea is defined as an apnea-hypopnea index of at least five episodes/hour. This definition is stricter because these individuals may be already experiencing the negative medical effects of sleep apnea, and it may be important to begin treatment at a lower apnea-hypopnea index.

What are the types of sleep apnea?

There are three types of sleep apnea:

central sleep apnea (CSA),
obstructive sleep apnea (OSA), and
mixed sleep apnea (both central sleep apnea and obstructive sleep apnea).

During sleep, the brain instructs the muscles of breathing to take a breath.

Central sleep apnea (CSA) occurs when the brain does not send the signal to the muscles to take a breath, and there is no muscular effort to take a breath.
Obstructive sleep apnea (OSA) occurs when the brain sends the signal to the muscles and the muscles make an effort to take a breath, but they are unsuccessful because the airway becomes obstructed and prevents an adequate flow of air.
Mixed sleep apnea, occurs when there is both central sleep apnea and obstructive sleep apnea.

What is central sleep apnea and what causes it?

Central sleep apnea (CSA) occurs when the brain does not send the signal to breathe to the muscles of breathing. This usually occurs in infants or in adults with heart disease, cerebrovascular disease, or congenital diseases, but it also can be caused by some medications and high altitudes.

Central sleep apnea may occur in premature infants (born before 37 weeks of gestation or in full term infants. It is defined as apneas lasting more than 20 seconds, usually with a change in the heart rate, a reduction in blood oxygen, or hypotonia (general relaxation of the body's muscles). These children often will require an apnea monitor that sounds an alarm when apneas occur. Central sleep apnea in children is not the same thing as sudden infant death syndrome (SIDS).

Under normal circumstances, the brain monitors several things to determine how often to breathe. If it senses a lack of oxygen or an excess of carbon dioxide in the blood it will speed up breathing. The increase in breathing increases the oxygen and decreases the carbon dioxide in blood. Some people with heart or lung disease have an increase in carbon dioxide in their blood at all times.

When there is a chronic (long term) increase in blood carbon dioxide, the brain starts to ignore the oxygen level and monitors the blood carbon dioxide level to determine when to take the next breath. The control of breathing also becomes slower to respond to changes in carbon dioxide levels; so when a person takes more or deeper breaths and "blows off" carbon dioxide the drive to breathe decreases and the rate of breathing decreases. As a result of slower rate of breathing, the carbon dioxide builds back up in the blood and the rate of breathing increases again. The brain, slow to adjust, continues to signal for more rapid breathing until the carbon dioxide level drops too low. Breathing then slows down or stops until the carbon dioxide level rises again. This pattern of abnormal breathing is called Cheyne-Stokes breathing (after the men who described it). It is characterized by repetitive cycles of fast breathing followed by slow breathing and apnea. This breathing pattern happens when the person is awake or asleep, but becomes more of a problem when asleep. Some patients with heart failure have central sleep apnea associated with a Cheyne-Stokes pattern of breathing.

Central sleep apnea usually occurs in adults with other medical problems. In infants, it usually occurs with prematurity or other congenital disorders. In both patient groups it is usually suspected by the primary care doctor. Central sleep apnea can be diagnosed with a sleep study or overnight monitoring while the patient is in the hospital.

In infants, central sleep apnea is treated with an apnea alarm. This alarm monitors the infant's breathing with sensors and sounds a loud noise when the infant experiences an apnea. The alarm usually wakes the infant and the parents. Most infants usually "out-grow" the central apnea episodes, so the alarm monitoring is stopped after the episodes resolve. In infants with other congenital problems, apnea monitoring may be needed for a longer period.

In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.

What is obstructive sleep apnea and what causes it?

In obstructive sleep apnea (OSA), apneas have four components.

First, the airway collapses or becomes obstructed.
Second, an effort is made to take a breath, but it is unsuccessful.
Third, the oxygen level in the blood drops as a result of unsuccessful breathing.
Finally, when the amount of oxygen reaching the brain decreases, the brain signals the body to wake up and take a breath. (This is what the bed partner hears as a silence followed by a gasp for air.)

First, it is necessary to describe a "normal breath." A normal breath of air passes through the nasal passages, behind the soft palate and uvula (part of the soft palate), then past the tongue base, through the throat muscles, and between the vocal cords into the lungs. An obstruction to the flow of air at any of these levels may lead to apnea. The following are some examples:

airflow can become diminished if a person has a deviated septum (the middle wall of the nose that separates the two nostrils). A septum can be deviated to one or both sides narrowing the air passages;
there are filters in the nose called turbinates that can obstruct airflow when they become swollen;
if the palate and uvula (the part of soft palate that hangs down in the back of the throat) are long or floppy, they can fall backwards and close the area through which air flows;
the back of the tongue can also fall backwards and obstruct breathing especially when individuals lay flat on their backs; or
the side walls of the throat can fall together to narrow or close the airway.

To break it down even further:

the muscles of breathing work to expand the chest and lower the diaphragm to degenerate a negative pressure between the airways of the lungs and outside;
this negative pressure literally sucks air into the lungs;
the nasal passages, palate, tongue, and pharyngeal tissues can all contribute to narrowing of the airway;
if during an attempt to breathe the airway collapses or is obstructed the tissues of the airway are sucked together by the negative pressure;
the harder the chest tries to pull air in the greater the negative pressure and the more the tissues of the airway are sealed together; and
finally, when the oxygen in the blood stream decreases the person wakes up or the level of sleep becomes more shallow in order to more consciously take a breath.

People with obstructive sleep apnea have an airway that is more narrow than normal, usually at the base of the tongue and palate. When lying flat, the palate is above the air passage. When the pharyngeal muscles (muscles of the pharynx or throat ) relax the palate can fall backwards and this can obstruct the airway. The genioglossus muscle is located where the base of the tongue attaches to the jawbone in front. Most people have enough space behind the tongue to take a breath without needing to pull the tongue forward. However, when obstructive sleep apnea patients are awake, this muscle needs to be active to pull the base of the tongue forward to open the airway. During sleep, most muscles including the genioglossus relax. During the stage of rapid eye movement, the muscles completely relax. Relaxation of the genioglossus muscle during sleep allows the base of the tongue to fall backwards and the airway closes. Patients with obstructive sleep apnea often don't report waking up during the night with each episode of apnea. Frequently, during the apnea the brain only awakens from a deep sleep (stages 3, 4, or REM) to a shallow level of sleep. The genioglossus muscle then contracts and pulls the tongue forward so that a breath can be taken. The patient may remain asleep, but the deep sleep that is important to be fully rested the following day is disrupted.

How common is obstructive sleep apnea?

Obstructive sleep apnea (OSA) is estimated to affect about 4% of men and 2% of women. In one study of people over 18 years of age, obstructive sleep apnea was estimated to develop in 1.5 % of people per year over the 5 year study. It is probably more common than either of these numbers because the population is becoming more obese, and obesity worsens obstructive sleep apnea. More shocking is the estimate that only 10% of people with obstructive sleep apnea are currently receiving treatment.

Some groups are more likely to develop obstructive sleep apnea.

Men are more likely to have obstructive sleep apnea than women before age 50.
After age 50, the risk is the same in men and women.
Among obese patients, 70% have obstructive sleep apnea. Obstructive sleep apnea worsens in severity and prevalence with increasing obesity.
Among patients with heart disease 30%-50% have obstructive sleep apnea, and among patients with strokes, 60% have obstructive sleep apnea.
A recent study estimated that 14% of NFL football players and 34% of NFL linemen have obstructive sleep apnea.
African-Americans have a 2.5 times greater risk of obstructive sleep apnea than Caucasians. In India, 7.5% of males have obstructive sleep apnea. Chinese males have a 4% prevalence and Chinese females a 2% prevalence of obstructive sleep apnea. This is interesting because the prevalence is similar to American Caucasians, but the Chinese population is generally smaller and less obese than the general American population. Therefore, something besides obesity must be the explanation for obstructive sleep apnea in the Chinese population. We do not understand the reasons for these differences, but studies are ongoing to better define the risks.

How common is obstructive sleep apnea?

Some groups are more likely to develop obstructive sleep apnea.

Men are more likely to have obstructive sleep apnea than women before age 50.
After age 50, the risk is the same in men and women.
Among obese patients, 70% have obstructive sleep apnea. Obstructive sleep apnea worsens in severity and prevalence with increasing obesity.
Among patients with heart disease 30%-50% have obstructive sleep apnea, and among patients with strokes, 60% have obstructive sleep apnea.
A recent study estimated that 14% of NFL football players and 34% of NFL linemen have obstructive sleep apnea.
African-Americans have a 2.5 times greater risk of obstructive sleep apnea than Caucasians. In India, 7.5% of males have obstructive sleep apnea. Chinese males have a 4% prevalence and Chinese females a 2% prevalence of obstructive sleep apnea. This is interesting because the prevalence is similar to American Caucasians, but the Chinese population is generally smaller and less obese than the general American population. Therefore, something besides obesity must be the explanation for obstructive sleep apnea in the Chinese population. We do not understand the reasons for these differences, but studies are ongoing to better define the risks.

How is obstructive sleep apnea diagnosed and evaluated?

Obstructive sleep apnea can be diagnosed and evaluated by subjective (perceived or biased) and objective (factual, based on empirical data) methods. An example of a subjective method that measures the effects of obstructive sleep apnea on patients is the Epworth Sleepiness Scale.

The Epworth Sleepiness Scale is a self-report test that establishes the severity of sleepiness. A person rates the likelihood of falling asleep during specific activities. Using the scale from 0-3 below, the risk of dozing can be ranked from the chart below.

0 = Unlikely to fall asleep
1 = Slight risk of falling asleep
2 = Moderate risk of falling asleep
3 = High likelihood of falling asleep

What are the non-surgical treatments for obstructive sleep apnea?

The non-surgical treatments for obstructive sleep apnea are similar to the non-surgical treatments for snoring with a few differences. Treatments include:

behavioral changes,
dental appliances,
CPAP (continuous positive airway pressure), and
medication.

Behavioral changes

Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep. Obesity is a known contributing factor to obstructive sleep apnea. It is estimated that a 10% weight gain will worsen the apnea-hypopnea index by 30%, and a 10% weight loss will decrease the apnea-hypopnea index by 25%. Therefore, a healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods people are able to lose weight and the obstructive sleep apnea may improve. Sleep hygiene and other behavioral modifications known to improve the overall quality of sleep are also recommended. Below are some common practices that can induce sleep and enhance its quality:

reduce lighting and noise in the bedroom;
avoid reading or watching TV in bed;
avoid eating or exercising prior to sleep;
use the bedroom only for sleeping;
keep work related activities outside of the bedroom; and
try a period of physical and mental relaxation before going to bed.

Medication

Many medications have been studied for obstructive sleep apnea; however, because obstructive sleep apnea is due to an anatomic airway narrowing it has been difficult to find a medication that helps.

In people with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays have been shown to be effective. In one study, the respiratory disturbance index (RDI) decreased from 20 to 11 with nasal sprays.
Topical nasal decongestants such as oxymetazoline and neosynephrine, also can temporarily improve nasal swelling. The problem is that they cannot be used for more than 3-5 days without decreased effectiveness and withdrawal symptoms.
People who have obstructive sleep apnea due to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications if they are effective in assisting with weight loss.
Other medications have been studied, including medroxyprogesterone (Provera, Cycrin, Amen), acetazolamide (Diamox), theophylline (Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-Phyllin), tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRIs). In these studies, they were shown to have little or no effect. There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
In cases where sleep apnea may be caused by another underlying condition, appropriate treatment of such conditions is recommended and may be beneficial. For example, treating underlying heart failure may improve sleep apnea if it is a contributing factor. In people with sinusitis and nasal congestion, the swelling and inflammation of the upper airway passages can cause snoring and sleep apnea. Therefore, medications to treat underlying sinusitis and congestion can potentially improve sleep apnea in these individuals.

Dental appliances

A dental appliance holds the jaw and tongue forward and the palate up, thus preventing closure of the airway. This small increase in airway size often is enough to control the apneas. Dental appliances are an excellent treatment for mild to moderate obstructive sleep apnea. It is reported to be about 75% effective for these groups. A dental appliance does not require surgery; it is small, portable, and does not require a machine. However, there are some disadvantages to the dental appliance. It can cause or worsen temporomandibular joint (TMJ) dysfunction. If the jaw is pulled too far forward, it can cause pain in the joint when eating. For this reason, it is best to have a dentist or oral surgeon fit and adjust the appliance. A dental appliance requires natural teeth to fit properly, it must be worn every night, and the cost is variable, as is insurance coverage.

Continuous positive airway pressure (CPAP)

Continuous positive airway pressure (CPAP) is probably the best, non-surgical treatment for any level of obstructive sleep apnea. In finding a treatment for obstructive sleep apnea, the primary goal is to hold the airway open so it does not collapse during sleep. The dental appliances and surgeries (described later) focus on moving the tissues of the airway. CPAP uses air pressure to hold the tissues open during sleep. CPAP was first used in Australia by Dr. Colin Sullivan in 1981 for obstructive sleep apnea. It delivers the air through a nasal or face-mask under pressure. As a person breathes, the gentle pressure holds the nose, palate, and throat tissues open. It feels similar to holding your head outside the window of a moving car. You can feel the pressure, but you can also breathe easily. The CPAP machine blows heated, humidified air through a short tube to a mask. The mask must be worn snugly to prevent the leakage of air. There are many different masks, including nasal pillows, nasal masks, and full-face masks. The CPAP machine is a little larger than a toaster. It is portable and can be taken on trips. Determining CPAP pressure: With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by "titration." Titration frequently is performed with the help of polysomnography. It can be performed during the same night as the initial polysomnography or on a separate night. In the sleep laboratory an adjustable CPAP machine is used. A mask is fit to the person and he or she is allowed to fall back asleep. During baseline sleep the apneas and hypopneas occur, and the the technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed. Effectiveness of CPAP: CPAP has been shown to be effective in improving subjective and objective measures of obstructive sleep apnea.

It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
It improves driving on driving simulation tests and decreases the number of accidents in the real world.

When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea. An important clinical outcome of CPAP use is in the area of prevention of the potential complications of obstructive sleep apnea. Studies have shown that the proper use of CPAP reduces hospitalization for cardiac and pulmonary causes in people with obstructive sleep apnea. More generally, treating obstructive sleep apnea with CPAP can reduce the risks of conditions related to obstructive sleep apnea, such as, ischemic heart disease, abnormal heart rhythms, stroke, hypertension, and insulin dependence.

Problems with CPAP: The first 2-4 weeks is the crucial time to become a successful CPAP user. During this time, it is important to try to sleep as many hours a night as possible with the mask on. If the mask does not fit properly or the machine is not working it is important to have it fixed immediately. It is also helpful to remember all of the increased risks of untreated obstructive sleep apnea (decreased productivity, heart attacks, strokes, car accidents, and sudden death) as an incentive to continue using CPAP. People with severe obstructive sleep apnea, never get a normal night of sleep. They often put on the CPAP mask and think it is the best thing ever. They quickly get used to it because it allows them to sleep. They take it on vacations because without it they have no energy and are always sleepy. However, CPAP is not always easy to use. People with only mild to moderate sleep apnea often have a harder time using CPAP. About 60% of people with CPAP machines report that they use them, but only 45% of them actually use them more than four hours per night when the actual use time is measured. Between 25% and 50% of people who start using CPAP, stop using it. It is not easy to sleep with a mask that is blowing air into your nose. Some people are claustrophobic and have difficulty getting used to any mask. If a patient has nasal congestion or a septal deviation; it is important to have these evaluated since they can be treated (as discussed later). Some people do not like the inconvenience of sleeping with the mask or traveling with the machine. Others do not like the image of having to sleep with a mask. The noise of the machine blowing air can also be bothersome to some people using the CPAP or their bed partners.

Bi-level positive airway pressure (BiPAP)

Bi-level positive airway pressure (BiPAP) was designed for people who do not tolerate the higher pressures of CPAP. It is similar to CPAP in that a machine delivers a positive pressure to a mask during sleep. However, the BiPAP machine delivers a higher pressure during inspiration, and a lower pressure during expiration, which allows the person not to feel like they are breathing out against such a high pressure, which can be bothersome. It is most helpful for people who require a higher pressure to keep their airway open. BiPAP was designed to improve CPAP compliance; however it is difficult to measure an increase in compliance when compared to standard CPAP. BiPAP is often only approved by insurance companies after documentation that a patient cannot tolerate CPAP.

Auto-titrating continuous positive airway pressure

The auto-titrating CPAP machine is a "smart" CPAP machine that makes pressure adjustments throughout the night. As discussed above, different pressures are needed for different levels of sleep and positions. The goal of auto-titrating CPAP is to have the lowest possible pressure for each position or sleep level. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn't need a higher pressure, the pressure is reduced. The benefit is when a lower pressure is all that is required, the machine is not stuck at the highest pressure needed. The down side is, if the machine does not adjust, a person can be stuck at a lower pressure having episodes of sleep apnea. With auto-titrating CPAP, the mean pressure throughout the night is lower and 2/3 of the night is spent below the set CPAP pressure. The machine also can adjust for the changes in pressure that are needed to overcome the effects of weight gain and alcohol or sedative use. It may also improve compliance; however, this has not been measured. The disadvantages of auto-titrating CPAP are that leaks may underestimate pressure or airflow. Each company has a different algorithm for adjusting the pressure and adjusting for leaks. It is Sleep Apnea - Effective Treatments