Obstructive Sleep Apnea

Dr. Joseph Libermann III

Sleep is a vital cog in the life of every American. We need a certain amount of it, but beyond that we gain a great deal of satisfaction out of finally resting our heads and waking up refreshed on the other side of a good night’s rest. Obstructive sleep apnea (OSA) is a dangerous and debilitating condition that disrupts this precious cycle. Most commonly caused by upper airway collapse during inspiration while sleeping, it usually results in at least a whistling sound, or more typically, loud snoring. More disruptively, OSA also causes patients’ breathing to stop for short periods of time during sleep. When this happens your brain senses the impairment and rouses you from sleep to reopen the airway. Although a person may not even be aware of it, this can occur hundreds of times a night, not allowing the brain and body to get enough oxygen. Thus, people with OSA often wake up with a headache, feel tired or irritable, have trouble concentrating, and may gain weight. They frequently don’t find their sleep very refreshing, and have excessive daytime sleepiness (ES). Despite the seriousness of this disorder, there is currently widespread underdiagnosis and, consequently, undertreatment, a problem reflected in estimates stating that approximately 80 to 90% of cases are undiagnosed. This can be explained in part by the very nature of the condition— it occurs while one sleeps, the prominent pathological event, airway collapse on inspiration, is not appreciated by the patient and symptoms associated with the disorder are typically vague (morning headache, sluggishness, etc.) and can readily be ascribed to other things.

Lack of restful sleep can lead to other serious health issues that may not even appear related to sleep, leaving many real risks of sleep apnea hidden from the patient. For example, left undiagnosed and untreated, OSA can have such detrimental consequences as cardiovascular disease (including hypertension or elevated blood pressure), depression, decreased health-related quality of life, and an increased incidence of motor vehicle accidents. Lack of restorative sleep with consequent ES is considered to be the cause of this latter problem. In addition, intermittent disruption to the flow of oxygen to the brain may further contribute to ES by causing irreversible damage to wake-promoting areas of the brain. Snoring is not only an inconvenience to a bed partner, but could be signaling the presence of a significant health problem that needs attention to avoid potentially dire consequences.

Beyond individual patients, the pervasiveness of OSA and ES has put the general public at risk. Accidents resulting from drivers falling asleep at the wheel have become an all too familiar tragedy.  Medical bills, potential rehabilitation costs, and, in some cases, lifetime care of a disabled accident victim further impose a strain on society. Another cost of OSA, not frequently considered, is the cost of caring for the medical consequences of this condition. Patients may require extensive and expensive remediation that could include heart surgery as a result of cardiovascular disease. We need to be aware that OSA is not a trivial disorder!

A Closer Look

OSA’s severity is most often defined by the apnea-hypopnea index (AHI), a measure reflecting the number of times a patient has hypopnea, or apnea (stops breathing), during an hour of sleep.

  • Mild OSA corresponds to an AHI score of 5 to 15
  • Moderate OSA to a score of 16 to 30
  • Severe OSO to a score greater than 30

Prevalence studies indicate that 1 in 5 US adults defined as overweight by the body mass index has mild OSA.  1 in 15 has an AHI above 15—meaning up to 5% of adults in Western countries has OSA, as well as ES. Population-based studies suggest that prevalence is higher in blacks than in whites, men are at a 2- to 3-fold greater risk than women, and the rate increases steadily with age starting in midlife.  For example, in the Sleep Heart Health study—a prospective cohort study designed to investigate the link between OSA and CV disease—the proportion of individuals with moderate OSA was 1.7-times higher among older (60-99 years) versus younger (40-60 years) participants. However, there is also evidence that the prevalence may stabilize after 65 years of age. OSA can also develop rather rapidly. AHI event increases in the range of  4 per hour over a period of 5 years and 2.6 events per hour over 8 years were observed in The Cleveland Family Study  and The Wisconsin Sleep Cohort Study respectively. In both studies significant predictors of progression included excess body weight, central obesity, cardiovascular disease, diabetes, increased age, and habitual snoring.

Risk Factors

Being overweight, and thus at risk for OSA, is an issue with many dimensions. One troubling aspect is the reality that, as a society, we are becoming more obese, thus we will see more OSA. Excess body weight alters the structure and functioning of the upper airway, changes the relationship between respiratory drive and compensation, reduces functional capacity, and increases oxygen demand. Unfortunately, although weight loss would be the least invasive medical intervention, it is not easily accomplished.  Dieting and exercise are difficult for most people, and results are laboriously slow, giving minimal positive reinforcement.  The benefits of maintaining a normal weight as we age are well documented, but lack of instant gratification is discouraging.

It is important to avoid tunnel vision by not focusing solely on the issue of weight, while also recognizing that not all snoring is a symptom of sleep apnea, but if you have one or more risk factors, and your bed partner has heard the snoring and/or witnessed the apnea, you need to be evaluated, or run the risk very serious illness. It can affect both adults and children, but you are more likely to have the condition if you:

  1. Have a large neck (for men: 17 inches around, or more; for women: 16 inches or more)
  2. Have a large tongue or tonsils
  3. Have a small jawbone
  4. Have family members with sleep apnea
  5. Have gastroesophageal reflux disease (GERD)
  6. Have sinus issues, allergies, or other nasal conditions
  7. Consume alcohol
  8. Use sedatives
  9. Are menopausal

Testing and Diagnosis

Though OSA’s presence should be suspected in those who snore loudly and have any of the risk factors, or co-morbidities, the diagnosis can be confirmed only by a professional. Reality is this diagnosis can only be established with absolute certainty through the use of polysomnography, a rather elegant study performed by a sleep specialist. The test takes place in a sleep laboratory where you would spend the night in a quiet, private room where a specially trained staff member monitors the measurements of your sleep patterns, along with your breathing and heart rate. In consultation with your primary care provider the sleep doctor can decide what, if any, treatment you may need.

Because polysomnography is cumbersome and expensive, many patients shy away from it. In-home, unattended, portable recording may be used in situations where the inconvenience or expense of a formal polysomnograph precludes its use, though the American Academy of Sleep Medicine (AASM) condones it only for a selected group of adults aged 18 to 65, who have a high pretest probability of moderate-to-severe OSA and no comorbid medical conditions.  Home assessment must also be overseen by a sleep specialist. The Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT) are less intrusive, but typically less reliable assessments that may also be considered.

Your personal doctor is best positioned to guide you through the maze of available diagnostic options. He or she may recommend additional tests such as upper airway imaging, measurement of thyroid-stimulating hormone, and other tests as appropriate to assess chronic medical conditions associated with OSA. Regardless, if you suspect that you or a loved one has this potentially devastating disorder, you’d be well advised to pursue this, as ignoring it may result in a very unwelcomed outcome. A thorough evaluation by a professional to explore all of the factors that could contribute to a person’s OSA, is the best way to approach this problem. Many of the problems contributing to OSA can be as subtle as many of the symptoms of OSA, and it takes a trained eye to sort them out. Moreover the price of not sorting them out could far outweigh any cost incurred in the sorting out process.

Treatment Options and Lifestyle Changes

Once the diagnosis is established, it’s time to consider what can be done about it. The first step in this process it to identify any conditions that predispose a patient to OSA and start to correct these concomitantly with treating it.

One of the most commonly encountered problems contributing to OSA is obesity. To counteract this, a program of diet and exercise to reduce weight is mandatory. This approach may sound simple, but often times it is difficult to put into practice. Given that early signs and symptoms are not perceived as life threatening to most people, motivation to go the diet and exercise route is lacking. It is also important to note that while weight loss can improve the condition, it is not a cure. Bearing in mind the ultimate consequences of unaddressed OSA, could lead to appreciation of  the benefits of such a program and taking the necessary steps. 

Other relatively simple steps to help ameliorate OSA include avoiding alcohol in the evening, discontinuing the use of tobacco products or sleeping pills, and changing the position you sleep in. External nasal dilator strips, internal nasal dilators, and lubricant sprays may reduce snoring, but there is no evidence they help to treat OSA. In fact, such interventions could delay recognition by masking snoring, a key symptom associated with the condition.

In addition to the above mentioned lifestyle changes, there are other interventions that can eliminate or improve OSA. A suitably qualified dentist may be able to craft a device that theoretically corrects or reduces both snoring and OSA. It acts by advancing the jaw bone and some can also pull the tongue forward. Emerging evidence suggests these approaches are reasonably effective, at least in mild to moderate cases. Surgery is also an option to correct enlarged tonsils, nasal polyps, a narrow airway, or some other form of airway obstruction. A last resort surgical approach is to perform a tracheostomy, which entails making an incision into the wind pipe, below the level of obstruction. This is an extreme measure usually reserved for those individuals who cannot be treated with less intrusive means.

One of the most common and effective ways to treat OSA is to use a specially designed mask at night, which allows air to be pumped gently into the nose using a continuous positive airway pressure (CPAP) machine. Studies have shown that CPAP is effective in reducing ES and improving quality-of-life in patients with moderate as well as severe OSA. There is evidence that CPAP also lowers blood pressure and reduces the risk of cardiac events in OSA patients. Patients that find the constant pressure of CPAP unsuitable for them may turn to bi-level positive airway pressure or variable positive airway pressure (VPAP) machines. Bi-level positive airway pressure and VPAP machines provide different inspiratory and expiratory pressures that can be altered depending on the individual’s needs and results obtained during a sleep study. Today’s better fitting masks and humidified air can often times alleviate past problems of irritation, making it easier to stay on the program to reduce the risks of untreated OSA. From a societal perspective, both are very efficient and effective treatments, especially if medical resources aren’t abundant. Currently, no medications  can cure OSA, though FDA approved medications exist that treat the ES experienced by some individuals who have their OSA under control. Modafinil, a wakefulness promoting agent , is recommended by AASM for such patients.

Under-diagnosis is the chief hindrance of OSA treatment. Conversely, realization of the litany of comorbid conditions and negative impact on life down the road is the chief motivation to investigate possible OSA. Effective intervention not only provides symptomatic benefits, by way of better sleep, but may also improve high blood pressure and reduce the risk of fatal, and nonfatal, cardiovascular events in patients with OSA. If symptoms are recognized do not falsely attribute them—ES can be particularly debilitating, having a negative impact on a patient’s life and daily functioning but it’s often chalked up to other factors. A good night’s sleep is worth a lot to most people, long term health is worth even more. The two being intertwined, makes a talk with your doctor even more vital if you suspect OSA is affecting you or a loved one.