Sleep Apnea and Snoring

When the muscles in the throat and tongue relax during sleep, stoppages in breathing can result, potentially blocking the airway. The bed partner often can identify pauses in breathing or a sudden silence or cessation of snoring. Obstructive sleep apnea occurs when repetitive stoppages in breathing (apneas or hypopneas) occur at a frequency of more than 5 to 10 per hour of sleep. Snoring, pauses in breathing, gasping or snorts are strong indications of airway obstruction in sleep, but the severity of snoring is a poor predictor of the actual severity of obstructive breathing during sleep.

Obstructive breathing in sleep causes the brain to either wake up or go to a lighter level of sleep to re-open the airway and resume breathing. Obstructive apneas during sleep can happen from a few times to hundreds of times each night and ranging from as short as 10 seconds to longer than 2 minutes in duration for each event in some patients. Most patients are unaware of their own snoring and rely on a bed partner or family member to inform them of it, even when the snoring is very loud in severity. Your apnea may be mild or severe, depending on the frequency of breathing stoppages or the consequences of these stoppages such as poor quality of sleep or drops in the blood oxygen levels. Excessive daytime sleepiness is one of the most common symptoms experienced by sleep apnea patients because of the repetitive arousals experienced during sleep to re-establish a normal or open airway.

If sleep apnea is suspected, an overnight sleep study called a polysomnogram (PSG) may be recommended. A comprehensive PSG involves monitoring numerous physiological variables including your brain activity (EEG), heart (EKG), leg muscles (EMG) and eye movements (EOG), as well as airflow and blood oxygen levels during the various sleep stages. The occurrence of any apneas (loss of airflow) or hypoapneas (transient reduction of airflow) are closely monitored.

If you are diagnosed with sleep apnea, you may be asked to return for a second overnight polysomnogram dedicated to a continous positive airway pressure (CPAP) therapy titration (see treatment options).

• Nasal CPAP is an acronym for Continuous Positive Airway Pressure (CPAP). CPAP therapy is the most effective non-invasive treatment for patients with OSA. CPAP utilizes a small mask worn over the nose during sleep that is attached to a small blower unit and uses a low level of pressurized room air to open the airway. This "pneumatic splint" opens the airway with air pressure, prevents it from collapsing, and normalizes breathing during sleep. Some patients need very little pressure to open the airway during sleep, whereas others need considerably more. As a result, patients with sleep apnea need to have the CPAP pressure adjusted or "titrated" while they sleep in the sleep laboratory to find the optimal pressure to open their airway. It is highly effective if the appropriate mask, fitting, humidification, and air pressure are selected.
  
  Obtaining an optimal CPAP pressure in the sleep laboratory is very important. If the pressure is too low, patients will have breakthrough breathing stoppages or snoring with the CPAP; but if the pressure is too high, patients may have difficulty tolerating the CPAP. Indeed, having an inappropriate pressure is one of the most common reasons that patients may not tolerate their CPAP (see video on "CPAP Failure"). Another common cause of difficulty using CPAP can be nasal congestion from inadequate humidification of the pressurized air (see video on "Nasal Congestion with CPAP"). With the appropriate mask, pressure and humidification, the vast majority of patients feel that their nighttime quality of sleep and daytime alertness are much improved with CPAP. Contrary to what some patients may have heard, CPAP is generally well tolerated and most patients with sleep apnea do not want to sleep without their CPAP device.
• Weight loss Weight reduction can be one of the most important ways of improving breathing during sleep. Patients with mild OSA may, in some circumstances, normalize breathing in sleep with weight loss. Even if weight reduction does not normalize breathing in sleep, patients on CPAP often will require less CPAP pressure following weight loss. Lower CPAP pressures help minimize complications from CPAP such as nasal congestion or mask leaks. On the other hand, weight gain may increase your pressure requirements with CPAP and possibly leading you to require a repeat sleep study or polysmonographic evaluation.
• Positional therapy Obstructive sleep apnea is typically worse when sleeping in the supine position compared to the lateral or prone (stomach) positions. Sleeping on the side and avoiding sleeping on your back is recommended in patients with mild obstructive breathing in sleep who are not using nasal CPAP. If you are on CPAP, you may sleep in any body position you desire since the CPAP will protect you when on your back.
• Behavioral changes Alcohol is a muscle relaxant and will worsen obstructive sleep apnea, particularly if ingested within 3-5 hours of bedtime. Even for patients on CPAP therapy, having 2 or more alcoholic drinks can cause breakthrough snoring with the CPAP device and lead to more fragmentation of sleep. As a result, alcohol should be avoided in patients with OSA. It is also recommended to quit smoking since cigarette smoke may cause the upper airway tissues to swell and the nasal passages to be congested, all leading to more airway obstruction during sleep.
• Dental Device A mandibular advancement device (which looks like a retainer) can be used to reposition your mandible in a more forward (prognathic) position. The tongue is attached to the front of the lower jaw, or mandible. Moving the mandible forward with a dental device also moves the tongue forward, thereby helping open the posterior (retrolingual) airway during sleep. A dental device is best suited for patients who have a more mild obstructive sleep apnea or prominent snoring during sleep. It is not recommended, and generally not adequately effective, for patients with more severe disease.
  
  Some patients with a dental device may experience some side effects such as temporalmandibular joint (TMJ) pain or movement of their teeth. However, the dental device is generally well tolerated. If you have a dental device and continue to snore or experience daytime sleepiness even after sleeping with it on a regular basis, you should consult a sleep medicine specialist for a more thorough evaluation. Snoring or persistent daytime sleepiness in spite of using your dental device are signs that it is not adequately effective in treating your obstructive breathing in sleep. Finally, all patients who have been fitted with a dental device to treat obstructive sleep apnea, should have a re-evaluation polysomnogram with the dental device in place to verify that your breathing in sleep is adequately treated.
• Surgical options: Numerous surgical treatments may be appropriate when a specific physical abnormality is present or when other treatment plans have failed. The type of surgery selected should be directed to the specific site of the obstruction. Choosing the wrong surgery for the wrong patient will typically not be successful for improving breathing during sleep.
  
  The most successful surgical intervention for OSA involves moving the mandible (lower jaw) and maxilla (upper jaw) permanently forward using a procedure called a mandibulomaxillary advancement (MMA). Moving the upper and lower jaws forward using the MMA procedure can be a cure for OSA. Ideal patients for this procedure are younger, have at least moderate to severe OSA and have a naturally small or retrognathic mandible (small lower jaw). As noted above, the tongue is attached to the lower jaw. If the mandible is pushed back (retrognathic), the tongue naturally is pushed back as well, making for a narrow behind the tongue (retrolingual) posterior airway space. Advancing the jaw forward with this procedure, moves the tongue forward and opens the airway. This is generally a relatively well-tolerated procedure, but selecting the appropriate patients is a key for success.
  
  Nasal and throat surgical treatments include removing excessive tissue from your upper airway with a scalpel or using a laser or similar device to cauterize and shrink tissues of the soft palate. Some patients may have large tonsils or extensive soft palatal tissue that may be amenable to surgical intervention. Tonsillectomy and/or adenoidectomy can be helpful in patients (and often in children) who have obstructive breathing during sleep and who also have enlarged tonsillar or adenoidal tissue. A different procedure involves shaving off the uvula and part of the soft palate, a procedure called a uvulopalatopharyngoplasy (UPPP) commonly performed by Ear, Nose and Throat (ENT) surgeons, but has not been very successful in improving obstructive breathing during sleep. A UPPP procedure may be helpful in patients who have a mild obstructive breathing in sleep and a selectively lengthened soft palate with an otherwise open airway. Patients with a large tongue base should generally not be considered for this procedure.
• Medication Very few Medications have shown promise in improving obstructive breathing during sleep. However, protriptyline (Vivactil) is one such medication that several randomized, double blind, placebo-controlled, clinical trials have shown to improve breathing in patients with obstructive sleep apnea. The use of protriptyline was first described in the late 1970’s by Dr. Helmut Schmidt, the founding president of the Ohio Sleep Medicine Institute. Protriptyline was originally used for moderate to severe sleep apnea. However, nasal CPAP therapy was discovered shortly thereafter, and the sleep research community essentially stopped exploring the use of medications to treat sleep apnea with the advent of CPAP.
  
  During the late 1990’s, it became apparent that patients with more mild obstructive breathing in sleep may not need or tolerate CPAP therapy, yet still have disrupted sleep at night from snoring and intermittent but mild breathing stoppages, leading to daytime fatigue. We now use protriptyline specifically for this more mild, sleep-disordered breathing, patient population. Another advantage of protriptyline relates to its alerting properties and its ability to improve symptoms of daytime sleepiness or fatigue. Side effects of protriptyline include dry mouth, constipation, urinary retention in men, and blurred vision. Such side effects are generally not a problem with the low doses used for improving breathing in sleep, but can limit its use for some patients.

The combination of general anesthesia, narcotic pain medications and the back or supine sleeping position is a "recipe for disaster," potentially causing life threatening consequences from sleep apnea such as heart attack, stroke, or cardiac and respiratory arrest during sleep after surgery. Untreated sleep apnea also increases the risks for other complications when recovering from surgery. Patients with sleep apnea who do not use their CPAP tend to have longer hospital stays, are more likely to need blood transfusions, have a higher risk for aspiration pneumonia and have more difficulty coming off of the ventilator.

If you are suspected of having sleep apnea, you should undergo a sleep evaluation prior to surgery so that you may start CPAP therapy before going to the hospital. Using the CPAP prior to surgery helps you become well rested and maximizes your general health status before undergoing a stressful surgical intervention. Once on CPAP, you should bring your CPAP and mask with you to the hospital and use the CPAP whenever sleeping in the hospital or at home after surgery, even during naps. You should also minimize, when possible, medications that may worsen sleep apnea such as narcotic pain medications or muscle relaxants. Using your CPAP can markedly decrease your risk of complications from surgery and potentially help you recover faster.