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Obstructive Sleep Apnea—The Snore You Can’t Ignore

Aug 22, 2014 09:00AM ● By Cate Reynolds
By Kathleen Jepsen

You are held in a room overnight. Sensors on your face and scalp measure eye movement and brain activity. Sensors in your nose measure airflow. Sensors on your fingers record oxygen in your blood, while electric belts around your chest and belly gauge your effort to breathe. Someone nearby monitors everything.

You are not being probed by aliens. You are participating in a polysomnogram, a sleep study. In recent years, sleep studies have grown in popularity as a diagnostic tool. Medicare reimbursements alone for this procedure have increased 39 percent from 2005 to 2011. Driving this increase is research into a condition called obstructive sleep apnea, OSA, characterized by repeated pauses in breathing during sleep. These pauses occur as muscles in the airway collapse, and can last 10–20 seconds and happen 20–30 times an hour. According to the National Heart, Lung, and Blood Institute (NHLBI), after each interval “breathing typically starts up again, sometimes with a loud snort or choking sound.” NHLBI warns that this “chronic condition moves you out of a deep sleep and into light sleep making sleep quality poor.” Most experts believe that OSA is the leading cause of daytime sleepiness, which can affect occupational efficiency as well as safety by impacting memory and impairing cognitive performance. But untreated obstructive sleep apnea represents an even bigger threat than that.

A 2009 study at Johns Hopkins and six other U.S. medical centers found that, for middle-aged and elderly patients, the oxygen deprivation involved in OSA increased their risk of death by 17 percent (for those with moderate cases) to 46 percent (for those with severe cases). Low levels of blood oxygen are extremely stressful to the heart and brain, and frequent awakenings send hormonal systems into chaos. Blood pressure and CO2 levels rise, while brain patterns and heart rhythms vary from the norm. Moreover, the effects of OSA seem to carry over into our waking state, since researchers have found higher daytime levels of adrenaline and higher resting blood pressure in those with the condition.

Rough estimates in the United States put the number of people who snore at 30 to 50 percent of us. Most snoring is the result of obstruction within the airway system, causing vibration of tissue. Allergies, nasal defects, mouth anatomy, and obesity are common causes of regular snoring. Extremely loud snoring is referred to as heroic snoring (although the bed partner is the one who is more likely to be heroic). Recent research, however, has resulted in a shift in our traditional response to loud snoring. Once seen simply as a nuisance, loud snoring is now viewed as a wake-up call to the potentially fatal condition of OSA.

In OSA, muscles in the back of the throat relax and the airway narrows, making adequate oxygen intake temporarily impossible. The American Sleep Apnea Association, “dedicated to reducing injury, disability, and death from sleep apnea,” asserts that OSA will almost always lead to loud and frequent snoring, but that snoring does not always indicate OSA. Researchers estimate that 10 percent of all those who snore may actually have obstructive sleep apnea. As with regular snorers, the majority of OSA snorers are male. According to the American Sleep Association, 1 out of 25 middle-aged men and 1 out of 50 middle-aged women have OSA. In addition, OSA is more common in African Americans, Hispanics, and Pacific Islanders than Caucasians. Although most children who snore do not have the condition, pediatric OSA has been linked to growth problems, ADHD, and learning difficulties.

Risk factors for OSA include
⎥ excessive weight
⎥ thick neck circumference
⎥ gender (males twice as likely as females)
⎥ age (increased likelihood over age 60)
⎥ family history of OSA
⎥ race
⎥ alcohol, tranquilizer or sedative use
⎥ smoking (three times more likely than non-smokers)

Modern medicine offers a variety of treatment options for OSA. Since obesity is a contributing factor, the first prescription a doctor is likely to write is, “Lose Weight.” Surgical options like Tracheostomy (creating an opening into the windpipe) and procedures that remove excess tissue from the airways both achieve success but involve risks. Less invasive, alternative treatments also exist, such as using acupuncture to build up the tongue muscles and strengthening the airways by playing woodwind instruments like the didgeridoo, an Australia aboriginal instrument. More traditional therapies include dental appliances to reposition the lower jaw, and nasal strips placed over the nostrils to modify the pressure in the airway. Recently, the FDA approved a neurostimulator that delivers an electrical pulse to the back of the tongue to prevent blockage in the airway.

Continuous Positive Airway Pressure, first described by Colin Sullivan and Associates in Sydney Australia in 1981, is one of the most effective options for OSA. CPAP is respiratory ventilation that uses mild air pressure to keep airways open, and has been endorsed by the American Academy of Sleep Medicine. During sleep, a machine delivers air though a mask over the nose or over both the nose and mouth. Most insurers now cover both polysomnography and CPAP appliances. The machines record nightly use, and insurers will discontinue payment if patients fail to comply with prescribed treatment. Unfortunately, some patients have difficulty adjusting to the presence of the masks or to the noise of the machine. Only about half of the patients who are diagnosed with OSA actually comply with their CPAP treatment. Experts suggest that better patient education and preparation could improve that situation. CPAP has proved reliable in lowering blood pressure and alleviating the deadly effects of OSA. Those who do comply report more satisfying sleep and more energized waking hours.

Obstructive sleep apnea is a snore you can’t ignore. If your bed partner is a heroic snorer who regularly gasps for breath, don’t send him to the guest room with his pillow and blanket. Send him to the doctor’s office for a medical evaluation and possible testing. Responding to OSA with a treatment plan might allow you both to get a good night’s sleep.

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The profile of OSA has been evident since ancient times. In the fourth century, B.C., Hippocrates and his colleagues wrote of the relationship between obesity and sudden death in “open-mouthed snorers.” Roman writer Pliny the Elder was described as extremely obese and falling asleep during the day. William Shakespeare depicted his iconic character Falstaff as exhibiting classic OSA symptoms. In 1918, physician William Osler, co-founder of Johns Hopkins Hospital, first referred to the condition as “Pickwickian Syndrome,” after an overweight, drowsy character in Charles Dickens’ first novel, The Pickwick Papers. Although many historic figures have been the subjects of speculation as sufferers (Napoleon, Brahms, Queen Victoria), only President William Howard Taft was actually diagnosed with what we now refer to as OSA. After he left office, he lost weight and allegedly experienced fewer symptoms. —K.J.

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