Sleep apnea

Sleep apnea is defined as episodes where there is a stop of breathing than last ten seconds or more while sleeping.

Episodes of apnea disrupt the normal sleep cycle impeding a proper rest. It leads to daytime drowsiness, which is a typical feature of the disorder.

While sleeping, the muscles located at the base of the throat can obstruct the airway resulting in loud snoring and difficulty breathing. If the airway is totally obstructed the breathing stops and the patient may experience partial or complete wakefulness.

Breathing obstruction prevents the patient from entering deeper stages of sleep, leading to symptoms of daytime drowsiness.

The prevalence of sleep apnea is estimated around six out of every hundred people.

The primary risk factors for developing sleep apnea in adults are:

• Male gender
• Central obesity (increased waist and neck circumference)
• Oral abnormalities: enlarged tongue (macroglossia), enlarged tonsils, very small mandible (micrognathia), or mandible placed too far back with respect to the upper jaw (retrognathia)
• Nasal obstruction diseases: nasal polyps or deviation of the nasal septum
• Heart failure
• Neurological and cerebrovascular diseases that affect breathing during sleep
• Endocrine disorders such as acromegaly and hypothyroidism
• Use of alcohol or sedatives to aid sleep
• Family history of sleep apnea

In children, in addition to a family history and oral and nasal abnormalities similar to those seen in adults, the risk factors for developing sleep apnea are:

• Congenital malformations of the nose
• Allergic rhinitis with chronic inflammation
• Presence of foreign objects in the nose
• Cystic hygroma (a tumor-like malformation in the neck)
• Palatal malformations
• Certain disorders such as Down syndrome, Crouzon syndrome, and Apert syndrome, which can affect the shape of the face and neck
• Trauma to the face
• Achondroplasia (a form of dwarfism)

The most common presentation of obstructive sleep apnea is snoring shortly after falling asleep. The snoring is typically rhythmic and may become progressively louder, but is then abruptly interrupted by periods of silence during which no breathing occurs (apnea).

The apnea is then followed by a sudden and audible gasp or snort before resuming normal breathing patterns. This pattern may occur multiple times throughout the night. Additionally, during apneic episodes, the oxygen levels in the bloodstream may decrease.

Persistent low levels of oxygen, also known as hypoxia, can result in various daytime symptoms. However, it's important to note that the affected individual may not experience dyspnea, or difficulty breathing, despite these symptoms.

The most common symptoms related to sleep apnea are:

• Loud snoring
• Snoring that is frequently interrupted by episodes of no breathing (apnea)
• Brief pauses in breathing during sleep
• Frequent awakenings throughout the night
• Daytime sleepiness or abnormal sleep patterns
• Feeling excessively tired during the day
• Morning headaches
• Increased need to urinate at night (nocturia)
• Irritability
• Difficulty with attention, memory, or judgment
• Personality changes or mood disorders
• Lethargy
• Poor school performance in children

In addition to the previously mentioned symptoms, the following may also be associated with this disease:

• Dry mouth
• Nighttime heartburn
• Increased sweating in the chest and neck area
• Hallucinations
• Decreased level of consciousness
• Confusion
• High blood pressure

Patients presenting with the described symptoms and one or more risk factors should undergo testing to rule out sleep apnea.

Additionally, individuals with chronic diseases such as hypertension, diabetes, heart disease, or a history of cerebrovascular diseases should also be considered for these studies.

To begin the evaluation process, patients and their partners (if available) should be questioned regarding symptoms such as snoring, gasping, snorting, and periods of breathing cessation during sleep.

If a physical abnormality of the mouth or throat is suspected, a thorough examination by an otorhinolaryngologist is recommended to identify any anatomical anomalies.

Other tests (usually performed by a pulmonologist) may include:

• Sleep studies (polysomnography).
• ECG (electrocardiogram) to detect possible arrhythmias while sleeping.
• Blood gas test to see the level of oxygen in the blood while sleeping.

The primary objective of treatment for sleep apnea is to establish and maintain an open airway to prevent apneic episodes during sleep.

Weight management and avoiding alcohol and sedatives at night can be effective in reducing symptoms.

If these lifestyle measures are insufficient and the obstruction persists, other treatment options are available:

• Oral devices that can be worn during sleep to position the jaw properly and prevent snoring and apnea. These devices are fitted by a dentist and their effectiveness is confirmed by a sleep specialist.
• CPAP (Continuous Positive Airway Pressure) therapy, which involves wearing a special mask over the nose and mouth that delivers a constant flow of air to keep the airway open during sleep.

Oxygen therapy may be beneficial in certain cases to improve symptoms.

When there are structural causes of sleep apnea, surgical interventions may be necessary. These can include:

• Uvulopalatopharyngoplasty (UPPP), which involves removing excess tissue from the back of the throat.
• Tonsillectomy and/or adenoidectomy, which involve removing the tonsils and/or adenoids.
• Tracheotomy, which involves creating an opening in the windpipe to facilitate breathing during sleep.

Maintaining a healthy weight and avoiding alcohol and sedatives can be effective in reducing the risk of sleep apnea.

In children, adenoiditis and tonsillar hypertrophy can cause obstructive sleep apnea, which can lead to various health problems. In such cases, the treatment options may include tonsillectomy and adenoidectomy.

Although treatment can be effective, it may not always work for everyone. Additionally, some patients may find it difficult to lose weight or may struggle to comply with the treatment due to its discomfort or inconvenience.

In severe cases where the condition is left untreated, sleep apnea can lead to the development of pulmonary hypertension, which may cause right-sided heart failure (cor pulmonale) or myocarditis.

If you experience symptoms of obstructive sleep apnea, it is important to contact your doctor for an evaluation.

You should schedule an appointment with your healthcare provider if you have this condition and your symptoms do not improve, or if you experience new symptoms.

In some cases, such as when you experience decreased consciousness, extreme drowsiness, hallucinations, personality changes, or persistent confusion, it may indicate a medical emergency and prompt medical attention is necessary.