Defeating Adult Sleep Apnea

by: Ricki Lewis, Ph.D.

Imagine ceasing to breathe for 10 to 20 seconds, then strenuously gasping in air, then stopping again--hundreds of times during what is supposed to be eight hours of restful slumber. For the sleep apnea sufferer, this happens every night.

Fortunately, the relentless lapses in breathing are not remembered, even though up to three-quarters of total sleep time may be spent not breathing!

For adults, sleep apnea may actually be more disturbing for the bed-mate than for the affected individual, for the frequent fits and starts of breathing are often accompanied by snoring reminiscent of a jackhammer.

Untreated, apnea can greatly affect daytime functioning. Rarely, the only daytime hint of the nocturnal turmoil may be a sense of having slept poorly. But far more often, the person is aware in many ways that all is not right. Awakening is often accompanied by a fierce headache, which lessens in an hour or two. But the person may remain irritable and forgetful, often finding it difficult to concentrate for the rest of the day. Interest in sex may wane, and the person may become depressed.

Annoying as these symptoms are, they aren't the most dangerous. Of far greater concern is the tendency of sleep apnea sufferers to fall asleep, suddenly, during the day. Dozing can prove embarrassing in business meetings or classes, but in some situations, it can be deadly.

It's not surprising that people with sleep apnea face a two- to fivefold greater risk of being in an auto accident compared with people who do not have sleep apnea. The American Sleep Disorders Association calls the condition "a potentially life-threatening disorder."

Portrait of a Sleep Apnea Sufferer

Snoring is not always a sign of sleep apnea. One in 10 adults snores, but only 1 in 10 snorers has sleep apnea. This accounts for some 6 million people, with men outnumbering women 8 to 1. Researchers are not certain why the typical sleep apnea patient is a middle-aged overweight man, but they think it may have something to do with hormones and neck size.

In one study, researchers at the Osler Chest Unit of Churchill Hospital in Oxford, England, queried 900 male patients between the ages of 35 and 65. Did they smoke? Drink alcohol? Take drugs? Have a stuffy nose? Measurements taken included weight, height, neck circumference, and resting arterial oxygen saturation, a measure of how much oxygen is getting into the bloodstream. The only two factors that correlated with apnea were alcohol intake (which greatly worsens symptoms) and neck size! Weight was implicated in a study of more than 1,000 sleep apnea patients at the Stanford Sleep Disorder Clinic. Two-thirds of the patients were obese--defined as being 20 percent or more above ideal body weight.

Premenopausal women are more protected than older women. With menopause, the prevalence of sleep apnea among women becomes closer to that for males. But which hormone, and how it affects breathing, isn't known, says John Shepard, M.D., director of the Sleep Disorders Clinic of the Mayo Clinic in Rochester, Minn.

Role in Other Disorders

Experts believe that sleep apnea probably has several causes. Some cases are part of an underlying hormonal disorder, such as hypothyroidism (an underactive thyroid gland) or acromegaly (excess bone growth due to oversecretion of growth hormone). Sleep apnea also occurs in some patients with Marfan syndrome, an inherited disorder in which anatomical structures built of connective tissue are very weak. A Marfan patient's weakened airway may collapse easily, impeding airflow.

The repeated stop-and-go oxygen delivery in apnea stresses the heart and blood vessels. Sufferers are "two to three times as likely to have hypertension, and have triple the risk of having a stroke, due to oxygen levels dropping," says Scharf. The older and more overweight the patient, the greater the risk of a cardiovascular complication. Hypertension that arises during the night may persist during the day, even though breathing while awake is normal.

Richard Millman, M.D., and co-workers at Rhode Island Hospital in Providence compared prevalence of hypertension among 152 men with sleep apnea and 904 men of similar ethnic background and geographic location who did not have sleep apnea. When the researchers looked at age and weight, they found that the prevalence of hypertension differed in the two groups only among obese men aged 25 to 44. Hypertension, they conclude, may develop only in this subset of apnea sufferers. Women were not evaluated in the study.

Treatment--Lots of Options

A physician can diagnose sleep apnea and suggest treatment based on the patient's complaints of daytime sleepiness, insomnia, awareness of obstructed breathing during sleep, snoring, and headache or dry mouth on waking. The physician examines the bones of the face and jaw and throat structures such as the palates, uvula and tonsils while the patient is in various positions, to see the sizes of spaces through which inhaled air can pass. X-rays may help envision how these structures lie.

For mild obstructive sleep apnea, treatment often consists of avoiding sleeping on one's back, says Shepard. "Other people have a significant problem when the nose is congested, so decongestant therapy may be helpful for them. A more drastic treatment, if the patient is very overweight, is weight reduction. Also, avoid central nervous system depressants, such as alcoholic beverages or hypnotic or sedative drugs," he adds.

Most serious sleep apnea cases can be relieved by a treatment called nasal continuous positive airway pressure, or CPAP. CPAP uses a small mask held onto the nose by straps, and has pouches that insert into the nostrils. The mask is connected to a motor that regulates the amount and pressure of air sent into the nose, exerting pressure to keep the nasal passages open. The pressure is determined by polysomnography. CPAP works by holding open the nose and the back of the throat--Shepard compares it to inflating a bicycle tube.

CPAP usually brings immediate relief. Snoring stops. A smooth breathing pattern is restored. Blood oxygen levels stabilize. During the first week of CPAP therapy, the sleep pattern may still be grossly abnormal, but with peaceful stretches of sleep gradually growing, as if the body is trying to catch up. Sleep eventually settles down to a more normal pattern, often for the first time in years.

Unfortunately, many CPAP users never continue therapy beyond the first night, let alone the first week, because they find sleeping with a mask on the face uncomfortable. Colin Sullivan, M.D., the University of Sydney researcher who invented CPAP in 1981, admits that "sleeping with a nose mask and feeling the pressure sensation of CPAP, while not uncomfortable, are certainly novel experiences." Shepard points out, however, that the spouses of successful CPAP users are most grateful for the newfound silence!

Several CPAP devices have been cleared for marketing by FDA. "The typical approval process for any medical device involves the manufacturer submitting an application describing a product, and how it is similar to or different from devices that are already on the market. We determine if the new device is as safe and effective as the previous product," explains Arthur Ciarkowski, of FDA's Center for Devices and Radiological Health. Newer CPAP devices cleared for marketing by FDA attempt to make the experience more pleasant by building air pressure slowly, moisturizing the air to stem the common complaint of dry throat, and filtering out dust and pollen.

Before CPAP was invented, severe sleep apnea was treated by tracheostomy--a hole made surgically in the throat and a tube inserted to ease breathing. Choosing to live with a hole in the throat is a drastic measure, but several studies found that tracheostomy patients felt it was worth it to get complete relief from their apnea symptoms. Today, this procedure is used only in the most extreme cases, such as a person who cannot tolerate CPAP and who has severe hypertension with a high risk of heart failure due to apnea.

Other forms of surgery might provide relief for the 10 percent of patients with serious sleep apnea for whom CPAP does not work. In the nearly unpronounceable but helpful uvulopalatopharyngoplasty (UPPP), the back part of the soft palate and tissue at the back of the throat are removed, opening up more airspace. "It's like a big tonsil- adenoidectomy," says Shepard.

For people with mild sleep apnea for whom first-line measures are ineffective and who dislike CPAP, another alternative is a dental device that brings the jaw forward, holds back the tongue, or raises the soft palate, or some combination of these. Dental devices, too, must be cleared for marketing by FDA. In one study of 68 patients using a dental device, researchers at the University of New Mexico in Albuquerque found 75 percent compliance after seven months, and decreased snoring and daytime sleepiness, plus a decrease in the average number of apnea events per hour from 47 to 20. Dental devices are not as consistently effective as is CPAP, according to the American Sleep Disorders Association.

Whatever treatment is prescribed, a follow-up evaluation in a sleep lab should take place within three to six months of the start of therapy. And, happily, in most cases, the person who once spent most of each night not breathing can now enjoy a blissfully restful night--and those close by can too!

Ricki Lewis, a writer in Scotia, N.Y., teaches biology at the State University of New York at Albany.

Types of Adult Sleep Apnea

In all cases of sleep apnea some part of the respiratory system narrows, impairing oxygen intake. Lowered blood oxygen levels then trigger the brain to prompt the intake of breath. The sleeper gasps, jump-starting the breathing process--until the next halt. But doctors distinguish three variations on this theme: