SLEEP APNEA:BREAKING THE MYTHS – Dr Muralidhar T R
Sleep apnea is a potentially serious disorder in which breathing repeatedly stops and starts. It is due to repetitive collapse of the upper airway during sleep. Sleep apnea is generally under reported and under diagnosed. Prevalence is general adult population varies between 15 – 30%
WHY IS SLEEP APNEA IMPORTANT?
Untreated sleep apnea has many potential consequences and adverse clinical associations including excessive daytime sleepiness, impaired daytime function, metabolic dysfunction and increased risk of cardiovascular and cerebrovascular disease. Adverse outcomes include drowsy driving and accidents, neuropsychiatric dysfunction, pulmonary hypertension, type two diabetes and non-alcoholic fatty liver disease.
The most common signs and symptoms include: 1. Loud snoring 2. Gasping for air during sleep 3. Awakening with a dry mouth 4. Morning headache 5. Difficulty staying asleep(insomnia) 6. Excessive daytime sleepiness (hypersomnia) 7. Difficulty paying attention while awake 8. Irritability
Well defined risk factors include older age, male sex, obesity, facial and upper airway abnormalities. Potential risk factors include smoking, family history of sleep apnea or snoring and nasal congestion. Sleep apnea is associated with certain medical conditions like obesity hypoventilation syndrome, pregnancy and end stage kidney disease, congestive heart failure, chronic lung disease and diabetes mellitus.
Examination findings include obesity, a crowded oropharynx, craniofacial abnormalities and a large neck and or waist circumference. Patients may also present the manifestations of associated conditions and complications (E.g. Cognitive deficits, mood changes, sexual dysfunction, signs of pulmonary hypertension, motor vehicle crashes).
CONDITIONS THAT MIMIC SLEEP APNEA
Conditions which mimic sleep apnea are restless leg syndrome, narcolepsy, sedative drugs, gastroesophageal reflex disorder, swallowing disorders, nocturnal seizures, nocturnal asthma, insomnia and panic attack
Recommendations for testing patients who have excessive daytime sleepiness and 2 out of 3 of the following: – Habitual snoring – Witnessed apnea – Gasping or choking during sleep – Diagnosed hypertension Many evaluation tools and questionnaires like ESS, Berlin, Stop-bang questionnaires are not typically used for diagnostic testing since they are inaccurate and not superior to good history and physical examination.
Diagnosis is confirmed with sleep study or polysomnography (PSG). This is a single non-invasive test which can be done at home or in lab/hospital. The diagnosis of sleep apnea is based upon the presence or absence of related symptoms as well as the frequency of absence of respiratory events during sleep (i.e., apneas, hypopnea and RERAs (respiratory effort related arousals))
The management of a patient with sleep apnea begins by firmly establishing the diagnosis and its severity. The patient should be educated about the risk factors, natural history and consequences of sleep apnea. Importantly all patients should be warned about the increased risk of motor vehicle accidents associated with untreated. Treatment options are:
1. Behavior modifications
2. Weight loss and exercise
3. Sleep positions
4. Alcohol avoidance
5. Medications: the drugs that might stimulate respiratory drive directly (e.g., theophylline) or indirectly (e.g., acetazolamide), drugs that reduce upper airway collapsibility (e.g., desipramine), antimuscarinics (e.g., oxybutynin) nor adrenergic agents (e.g., atomoxetine)
6. Alternative therapies like oral appliances (e.g., mandibular advancement devices, tongue retaining devices maybe offered to patients with mild to moderate sleep apnea.
7. Upper airway surgery
8. Positive airway pressure therapy (CPAP/ BIPAP): This is the mainstay of therapy for adults with sleep apnea.CPAP/BIPAP is a mask applied over the nose or mouth and connected to machine which gives positive pressure air. The mechanism of continuous positive airway pressure (CPAP) involves maintenance of a positive pharyngeal transmural pressure so that the intraluminal pressure exceeds the surrounding pressure. CPAP also stabilizes the upper airway through increased end expiratory lung volume. Lot of studies have shown benefits from CPAP. Milder complaints with CPAP include headache, airway irritation, cough, chest pressure and sinus infection.
1.Sleep apnea is not a disease, it’s a disorder.
2.Sleep apnea is not only seen in obese patients
3.Prevalence is not rare as it is underdiagnosed.
4.Establishing the diagnosis and understanding the disorder is the key.
5.Just breaking the sleep cycle variations, many illnesses and death can be prevented.
6.No invasive testing is required.
7.Beneficial treatment option is by use of CPAP/BIPAP without medications.
8.It’s not a lifetime disease, behavioral modifications can reverse the disease and use of CPAP/BIPAP.