Sleep Apnea
It is not given to everybody to know when he/she suffers from a sleep apnea. A sleep history can be obtained from someone who shares your bed or your kids or anybody in the household. “He stopped breathing and scared us”: is often a sentence that we commonly hear when a patient’s family member or spouse when he/she is seen by a sleep specialist for sleep disorder during an evaluation.
During apnea, there is a cessation of breathing in which there is no movement of the muscles of inhalation and the volume of the lungs remains unchanged. Depending on what blocks the airways, there may or may not exist a flow of gas between the lungs and the environment. Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and re-starts. If you snore loudly and feel tired even after a full night’s sleep, you might suffer from sleep apnea and the quality of resting time that you should enjoy, is not adequate. There are three main types of sleep apneas:
1- An “obstructive sleep apnea” which represent the more common form when the throat muscles relax.
2- A “central sleep apnea” responding to the brain activities and the lack of signals transmitted to the muscles controlling the breathing pattern.
3- Finally, a “complex sleep apnea syndrome” when both obstructive sleep apnea and central sleep apnea are encountered together. It is also called “emergent central sleep apnea” because of the need for an emergent intervention.
To evaluate sleep, an overnight monitoring at a sleep center is nowadays a mandatory step requested by the insurance companies. When I became a patient with this medical condition a little more than 10 years ago, I was surprised to know that it was necessary to spend the night at the sleep center with a technician watching over a complicated study and adjusting head, chest and extremities electrodes, mask and tubing to follow your body all night on a monitor and perform the proper adjustments.
Rarely a home sleep study is now accepted by the insurance companies if it has not been previously approved. The test needs to be divided in two: a first part to diagnose the fact that sleep apnea in fact occurs and a second more elaborated phase to perform the study itself and fit the patient for a suitable mask. As discussed, the overnight monitoring is done at a sleep center for studying the breathing pattern and the body function during sleep. If a home sleep testing can rarely be accepted, we should expect to detect well sleep apnea by different means. Let us review the available tests:
1-Polysomnogaphy during night is a test performed while you are hooked to different monitors controlling for your heart, lungs and breathing patterns, brain activity with arms and legs movements. All are recorded while your oxygen level is constantly as well as your blood level is under observation.
2-Occasionally, you may be required to perform other simplified tests able to monitor oxygen levels, airflow and breathing pattern and even apnea. If it is found abnormal, proper therapy may be prescribed then. Remember that monitoring devices are limited in their functions and are unable to detect all cases of sleep apnea. Then the polysomnography will need to differentiate.
In the cases where you have an obstructive sleep apnea, an ear, nose and throat consultation can diagnose any obstruction at the nose or the throat level. Cardiologist or Neurologist can be used to find other systemic problem.
3- Continuous positive airway pressure (CPAP) may be recommended especially when lifestyle changes are indicated like losing weight or stopping smoking or even in presence of nasal allergies, so medications to relieve allergies will be ordered. If the symptoms persist in presence of moderate or severe apnea, particular devices can help opening the blocked airway unless surgical treatment is found necessary.
When the apnea is found moderate to severe, a machine delivering air pressure through a mask is used while sleeping. The air pressure is greater than the surrounding air but just enough to keep the airway passages open, preventing snoring and apnea. CPAP is the most common and reliable method to treat sleep apnea. Many may found it uncomfortable and cumbersome at the beginning but most often one will learn to adjust the tension of the straps holding on the mask, rendering the respiratory apparatus more comfortable to use while in bed. While being tested in the lab, a variety of masks are available for proper fitting and the appropriate mask is prescribed. If your partner believes that you are still snoring in spite of the proposed treatment, discuss with your pulmonologist or the primary care who ordered it for you. The pressure setting may be inadequate and the settings on the CPAP machine may need adjustment.
4-Whenever the CPAP machine is unable to resolve the problem, different type of air pressure device with an automatic adjustment to the pressure while sleeping (Auto-CPAP) can be used. Another kind of unit supplying rests in the use of a bi-level positive airway pressure for control where more pressure is provided when one inhales and less pressure is when you exhale.
5-There are also options in wearing an oral appliance to allow the throat to remain open. Although the CPAP machines are more reliable than these oral appliances, these later units are easier to use. Other oral appliances are designed to open the throat by bringing the throat forward. A number of those devices are available through your dentist allowing the patient to try different models prior to definitive fitting. Once the fit become definitive, follow-up visits with the dentist during the first year are anticipated for any re-assessment. After all attempts at trying, if the problem is not resolved, a surgical option is still possible.
Surgery is the last option whenever all conservative treatments have failed after a three month-trial unless a structural problem with the jaw is discovered. Tissue removal in the rear of your mouth or your throat by a procedure called “Uvulopalatopharyngoplasty” involving also the removal of the tonsils and the adenoids. For many, this will prevent the throat structures from vibrating and cause snoring but it is not considered as a better treatment as the CPAAP for obstructive sleep apnea. Radiofrequency ablation is also used to perform this procedure in moderate case of sleep apnea and in the hands of some, it appears to have fewer surgical risks.
The “Maxillomandibular advancement” is another procedure consisting in a “Jaw repositioning” procedure in which the jaw is simply moved forward enlarging the space behind the tongue and the soft palate in the goal of eliminating any chance for obstruction.
Under local anesthesia, plastic rods can be surgically implanted into the soft palate. It is now the most up-to-date procedure to relieve snoring under investigation. More research is looking at the way to stimulate the hypoglossal nerve and control the tongue movement. By this way, they hope to re-direct to tongue to keep it away from obstructing the airway.
Others have looked at the way a tracheostomy can be performed as a life-threatening operation in cases of severe apnea. The patient will become dependent of this tracheostomy in which a metallic or a plastic tube can allow breathing whenever asleep. The tube can be covered during the day and uncovered at night when sleeping. Simply by-passing the upper airway.
Other types of surgery to reduce snoring have been named, notably in removing the adenoids and the tonsils. Rarely a “septoplasty” involving the bony septum may become usefull, especially if malformation is encountered or traumatic deformation following facial blows like seen in boxers or in motor vehicle accidents.
Many have benefited from lifestyle changes with Weight loss and/or bariatric surgery, a way to reduce weight and facilitate the breathing pattern. A slight weight loss might relieve constriction on the throat and resolve the problem of apnea but unfortunately can return if the weight fluctuates. An exercise program with ½ hour of moderate activity a day, can also help ease the symptoms of an obstructive apnea often without the loss of weight. A strict diet is beneficial avoiding alcohol, smoking and medications like tranquilizers and sleeping pills which paralyses the throat muscles in interfering with breathing.
The way you are sleeping may also be a problem. It is better to sleep on the stomach rather than the back to avoid blocking the airway. Some suggest to attach a tennis ball to your back to remind you that it is forbidden to lay on the back. There are also commercial devices which vibrate once you roll on your back during sleep.
There are many types of weight loss surgeries collectively called bariatric surgery on which we will superficially opiniate. This consist in making permanent changes in the digestive system to shorten the bowels or by-pass part of the gastro-intestinal tree. This is the next step when exercises or diet has not worked in the reduction of the weight in patients with serious health problems. These procedures may limit how much to eat or reduce the ability to absorb nutrients. Some may require both actions. There are some benefits in all forms of weight-loss surgery but one has to realize that such major procedures may carry significant risks and side effects. Changes in the diet and the need for exercises will assure a long-term success to the procedure.
Also, you must make permanent healthy changes to your diet and get regular exercise to help assure the long-term success of bariatric surgery. Three main surgical procedures can be offered mainly a sleeve gastrectomy, a gastric by-pass (Roux-en-Y) or a pancreatic diversion with duodenal switch (BPD/DS) to patients with life-threatening weight related health problems like High Blood Pressure, Heart disease and stroke, sleep apnea, Type 2 diabetes, nonalcoholic fatty liver disease etc. More often, bariatric surgery become an option for patients with morbid obesity with a body mass higher than 35.
The “Roux-en-Y gastric by-pass” is the most common of all the procedures done in bariatric surgery. You will need to follow the medical guidelines to become qualified through a screening process while you remain committed to live a healthier lifestyle and accept long-term follow-up to monitor your nutrition and your lifestyle as well as your behavior and your medical condition. This procedure is not reversible and it will force such patient to decrease the amount of food at one meal.
The top of the stomach is cut leaving a pouch, the size of a walnut, then the small intestine is also cut and sewn to the stomach. The food bypasses the stomach and the first portion of the intestines (duodenum) to fall in the jejunum.
The “Sleeve gastrectomy” removes at least 80% of the stomach leaving a long pouch which will hold on smaller amount of food leaving a patient with less appetite or little desire to eat. This procedure provides significant weight loss and a shorter hospital stay.
The last operation is the “Biliopancreatic diversion with the Duodenal Switch” consisting in a two-part surgery in which a sleeve gastrectomy is done first and then the distal end portion of the intestine is hooked to the duodenum with the biliopancreatic and attached to the stomach, bypassing almost the entire small intestine. This procedure reduces the food intake as well as the absorption of the nutrients.
Bariatric surgeries pose potential health risks both in short terms and long terms. You may encounter excessive bleeding, infection, anastomotic leaks, blood clots and even death in the peri-operative perio but also bowel obstruction, dumping syndrome, gallstones. hernias, malnutrition, Hypoglycemia, acid reflux, vomiting, vitamins deficiency etc.
Although surgery may last several hours, most types of bariatric surgery can be performed laparoscopically, facilitating a faster and shorter recovery. Weight loss surgeries don’t always work but you may also lose weight and/or develop serious health problems. Combine these procedures to the proper breathing devices, will allow you to enjoy better sleeping habits.
In conclusion, people with sleep apnea problems may suffer from impaired alertness and excessive daytime sleepiness, becoming a risk for driving and working accidents. They may develop health problems like diabetes and decrease in vision. Death could occur if left untreated. They can be moody, belligerent with a lack of energy leading to depression. I just wanted to stress the need to undergo an evaluation when you know how you are deprived of sleep, when you snore and you present with symptoms we discussed above. Have a good night of sleep!
Maxime Coles MD (8-19-2020)
References:
1- M J Frumin, R M Epstein, G Cohen (Nov-Dec 1959) “Apneic Oxygenation in Man”. Anesthesiology 20 (6): 789-798.
2- “Sleep Apnea: What is Sleep Apnea?”. Department of Health and Human Resources. July 10. 2012
3- De Backer W (june 2013). Obstructive sleep apnea/Hypo-apnea syndrome” Panminerva Madica. 55 (2): 191-195.
4- Al Lawati Nabil M, Patel, Sunjay R, Ayas, Najjib T. (Jan 2009). Epidemyology, Risk Factors and Consequences of Obstructive Sleep Apnea and Short Sleep Duration”. Progress in Cardiovascular Diseases: 51 (4): 285-293.
5- aurora RN, Chowdhuri S, Bista SR, Casey KR, Lamm CI, Kristo DA, Rowley JA. Zak RS, Tracy SL (Jan 2012) “The treatment of central sleep apnea syndromes in adults practice parameters with an evidence-based literature review and meta-analyses” Sleep: 35 (1): 17-40.
6- Spicuzza L, Caruso D, Di Maria G (Sept 2015) “Obstructive sleep apnea syndrome and its management” Therapeutic Advances in Chronic Diseases 6 (5) pp 273-285.
7- Silverberg DS, Iaina A, Oksenberg A, (Jan 2002) Treating obstructive sleep apnea improves essential hypertension and quality of life”. American Family physician 65 (2): 229-236.
8- Grigg-Damberger M, (Feb 2006) “Why a polysomnogram should become part of the diagnostic evaluation of stroke and transient ischemic attack” Journal of Clinical Neurophysiology: 23 (1): 21-38.
9- Young, T (April 2004) “Risk Factors for Obstructive Sleep Apnea in Adults” JAMA 291 (16) pp 2013-2016.
10- Lasserson, Toby J, Lim Jerome, Sundaram Supriya (2005). “Surgery for obstructive sleep apnea in adults”. Cochrane Reviews (4).
11- Prinsell JR, (Nov 2002) “Maxillo-mandibular advancement surgery for obstructive sleep apnea syndrome’ Journal of the American Dental association. 133 (11); 1489-1497.