Sleep Apnea- A sleeping threat!

What is it?

Apnea is a medical condition in which breathing literally stops – for a few seconds in most instances but sometimes it may actually continue for almost a minute. If this happens when the person is asleep, it may be described as Sleep Apnea, the commonest form of which is Obstructive Sleep Apnea or OSA.

So what happens?

Obstructive sleep apnea (OSA) symptoms generally begin insidiously and are often present for years before the patient is referred for evaluation.

Nocturnal symptoms may include the following:

Snoring, usually loud, habitual, and bothersome to others
Witnessed apneas, which often interrupt the snoring and end with a snort
Gasping and choking sensations that arouse the patient from sleep, though in a very low proportion relative to the number of apneas they experience
Nocturia
Insomnia
Restless sleep, with patients often experiencing frequent arousals and tossing or turning during the night.

Daytime symptoms may include the following:

Nonrestorative sleep (ie, “waking up as tired as when they went to bed”)
Morning headache, dry or sore throat
Excessive daytime sleepiness (EDS) usually begins during quiet activities (eg, reading, watching television); as the severity worsens, patients begin to feel sleepy during activities that generally require alertness (eg, school, work, driving).
Daytime fatigue/tiredness
Cognitive deficits; memory and intellectual impairment (short-term memory, concentration)
Decreased vigilance
Morning confusion
Personality and mood changes, including depression and anxiety
Sexual dysfunction, including impotence and decreased libido
Gastroesophageal reflux
Hypertension
Depression

How bad is it?

The consequences of getting inadequate sleep are many, including high blood pressure, diabetes, slowing down of reflexes while driving or working with machines, and so on. Your health may be impacted more seriously on account of chronic insufficiency of oxygen supply to the brain due to OSA over a period of several years. Sleep Apnea is thus two medical disorders rolled into one!

OSA happens because of quite a few reasons – obesity, family history of OSA, an oversized tongue that touches the top of the mouth when you are sleeping, the lower jaw being considerably smaller than normal, etc. Obesity is not only an important cause of OSA, but also affects the severity of the disorder. In India, the figure varies from 2.4% to 3.42% in men and about 1-2% in women. It increases as the people approach middle age and with increase in Body Mass Index (BMI), the March 2015 issue of Respi-Mirror (a publication of the Chest Research Foundation) reports. Thus the absolute number of people living with OSA in India is estimated at about 34 million!

The twin effects of inadequate sleep and insufficient oxygen during OSA are not difficult to imagine. Apart from the really serious consequences such as diabetes, heart disease and a higher than average of paralytic stroke, OSA shows up in several forms that could impair your daily activities to some extent. Thus people who drive a car could find themselves involved in traffic accidents oftener than expected. The same thing applies to those who use electrical appliances at home or at work. Excessive Daytime Sleepiness (EDS), a well- known feature of OSA, could at the very least cause in embarrassment if you nod off at an important meeting!

OSA is associated with an increased risk of type 2 diabetes. Whether OSA causes type 2 diabetes or whether it is associated with insulin resistance and diabetes is unclear. Use of CPAP can reverse insulin resistance. Sleep fragmentation, sleep deprivation, and hypoxemia (which all occur in OSA) are thought to play independent roles in glucose intolerance. Conflicting results show that reversal of glucose intolerance may occur when OSA is treated.

How do we set it right?

When it comes to the treatment of OSA, some surgical options may be considered in specific cases, such as a deviated Nasal Septum (the piece of cartilage that separates the two nostrils). But for the vast majority of OSA patients, the treatment of first choice is Continuous Positive Air Pressure (CPAP). However, before initiating treatment with CPAP, a thorough examination by an ENT surgeon and a proper study of Sleep Patterns is essential. Once the diagnosis of OSA is established, a device that delivers a small amount of positive pressure can be used for keeping the air passages open. The CPAP device could be placed in the nose or worn over the mouth and helps to stabilize air pressure throughout the passageway. Some patients are however uncomfortable wearing the CPAP device while sleeping. In a smaller proportion of cases, a similar procedure known as BiPAP (bi-level positive airway pressure) may prove more useful.

Surgery for obstructive sleep apnea (OSA), is a secondary therapy in patients with OSA who cannot adhere to continuous positive airway pressure (CPAP) or as adjunctive therapy along with CPAP or an oral appliance [4]. Surgery is indicated as primary therapy in children in whom adenotonsillectomy is generally considered first-line therapy for moderate-to-severe disease in the presence of adenotonsillar hypertrophy.

What we must know?

From least invasive and effective to most invasive and effective, treatments can be summarized as follows:

All patients should be offered nasal CPAP therapy first.
In patients with mild-to-severe obstructive sleep apnea who refuse or reject nasal CPAP therapy, BiPAP therapy should be tried next. If this therapy fails or is rejected, OA therapy should be considered.
OAs may be considered first-line therapy for patients with mild OSA, particularly if they are unwilling to try nasal CPAP therapy.
All interventions to improve tolerance of CPAP therapy should be attempted prior to deciding that treatment has failed in a particular patient.
Patients in whom noninvasive medical therapy (eg, CPAP, BiPAP, OAs) fails should be offered surgical options. Patients should be made aware of the success rates for each surgical procedure. They should be informed that they might require more than 1 surgical procedure, some fairly extensive, to cure OSA.