Sleep apnea is a sleep disorder characterized by pauses in breathing during sleep. Each episode, called apneas, lasts long enough so that one or more breaths are missed, and occurs repeatedly throughout sleep. The standard definition of any apneic event includes a minimum of 10 second interval between breaths, with either a neurological arousal (a three-second or greater shift in EEG frequency, measured at C3, C4, O1 or O2), a blood oxygen desaturation of 3-4% or greater, or both arousal and desaturation. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram.Clinically significant levels of sleep apnea are defined as five or more episodes per hour of any type of apnea (from the polysomnogram).
There are three distinct forms of sleep apnea: central, obstructive and complex (complex is a combination of central and obstructive), made up of 0.4%, 84% and 15% of cases respectively. Breathing is interrupted by the lack of effort in central sleep apnea. In obstructive sleep apnea, breathing is interrupted by a physical block to airflow despite effort. In mixed sleep apnea, there is a transition from central to obstructive features during the events themselves.
Treatment of Sleep Apnea
- CPAP. The most common and arguably the most consistently effective treatment for sleep apnea is the use of a continuous positive airway pressure (CPAP) device, that ‘splints’ the patient’s airway open during sleep by means of a flow of pressurized air into the throat. In addition to CPAP, a dentist specializing in sleep disorders can prescribe Oral Appliance Therapy (OAT) as well.The oral appliance is a custom-made mouthpiece that shifts the lower jaw forward, opening up the airway. OAT is usually successful in patients with mild to moderate obstructive sleep apnea. OAT is a relatively new treatment option for sleep apnea in the United States, but it’s more common in Canada and Europe. Unfortunately, CPAP and OAT are effective only for obstructive sleep apnea, not for central or mixed cases.
- Go Lateral. For unknown reasons, possibly due to changes in pulmonary oxygen stores, sleeping in the lateral position has been found to be helpful for central sleep apnea with Cheyne Stokes respiration (CSA-CSR), where respiratory control instability plays a major pathophysiological role.
- Medications. Acetazolamide and other types of medication lower blood pH and encourage respiration. Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects.
- Didgeridoo. A 2005 study in the British Medical Journal found that learning and practicing the didgeridoo helped reduce snoring and sleep apnea, as well as daytime sleepiness. This appears to work by strengthening muscles in the upper airway, reducing their tendency to collapse during sleep.
- Drugs to Avoid. Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing. Use of analgesics and sedatives in these patients postoperatively should be minimized or avoided.
- Green Tea. Compounds found in green tea may help ward off the neurological damage that can come with the breathing disorder sleep apnea, a recent animal study hints. Researchers found that when they added green tea antioxidants to the rats’ drinking water, it appeared to protect the animals’ brains during bouts of oxygen deprivation designed to mimic the effects of obstructive sleep apnea (OSA).The findings suggest that green tea compounds should be further studied as a potential OSA therapy, the researchers report in the American Journal of Respiratory and Critical Care Medicine. OSA is a common disorder in which soft tissues in the throat temporarily collapse and block the airway during sleep, causing repeated stops and starts in breathing throughout the night.
- Lifestyle Changes. Some treatments involve lifestyle changes, such as avoiding alcohol or muscle relaxants, losing weight and quitting smoking. Many people benefit from sleeping at a 30 degree elevation of the upper body or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway.Lateral positions (sleeping on one side), as opposed to supine positions (sleeping on the back), are also recommended as a treatment for sleep apnea, largely because the gravitational component is smaller than in the lateral position.
- Other options. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more effective than oral appliances, but oral appliances may be easier for you to use. Some are designed to open your throat by bringing your jaw forward, that can sometimes relieve both snoring and mild obstructive sleep apnea.A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you’ll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms.
- Undergo Surgery. Surgery on the mouth and throat, as well as other dental procedures can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. The surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction. Swelling may negate some of the effects in the immediate postoperative period. Individuals with sleep apnea generally require more intensive monitoring after surgery for these reasons.The goal of surgery for sleep apnea is to remove excess tissue from your nose or throat that may be vibrating and causing you to snore. You may be blocking your upper air passages and causing sleep apnea. Surgical options may include:
- Uvulopalatopharyngoplasty (UPPP). During this procedure, your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids are usually removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring; however, it may be less successful in treating sleep apnea because tissue farther down your throat may still block your air passage. UPPP is usually performed in a hospital and requires a general anesthetic.
- Maxillomandibular advancement. In this procedure, the upper and lower part of your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.
- Tracheostomy. You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that doctors sometimes use to treat snoring. Although sometimes these procedures are combined with others, they aren’t usually recommended as sole treatments for obstructive sleep apnea.
- Along with these treatments, you may read or hear about different treatments for sleep apnea, such as implants. Although a number of medical devices and procedures have received Food and Drug Administration clearance, there’s limited published research regarding how useful they are, and they aren’t generally recommended as sole therapies.
Causes of Sleep Apnea
Generally, drugs that are central respiratory depressants also have sedative effects, so the individual taking a toxic dose of such a drug is likely to be asleep, or at least be in an altered state of consciousness when breathing becomes irregular. Alcohol is considered a central respiratory depressant in large doses, and so are opiates, barbiturates, benzodiazepines and many other tranquilizers.
Some individuals have abnormalities that predispose them to central sleep apnea. The treatment for the condition depends on its specific cause. Similarly, in any person who has some form of sleep apnea (including obstructive sleep apnea), breathing irregularities during sleep can be dangerously aggravated by taking one of these drugs.
Quantities that are normally considered safe may cause the person with chronic sleep apnea to stop breathing altogether. Should these individuals have general anesthesia, for example, they require prolonged monitoring after initial recovery, compared to a person with no history of sleep apnea, because apnea is likely to occur with even low levels of the drugs in their system.
Treatment for sleep apnea is aimed at restoring regular nighttime breathing and relieving symptoms such as loud snoring and daytime sleepiness. Sleep apnea treatments also help with associated medical problems such as high blood pressure and reduce the patient’s risk of heart attack and stroke. As such, armed with all this knowledge, be assured that you’ve already won half the battle against this tricky respiratory condition.
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