Sleeping Disorders

Sleep Apnea (Obstructive, Central, and Mixed)

Sleep Apnea (also called Sleep Apnoea) is a common sleep disorder that is characterized by brief interruptions of breathing during sleep, which force the sufferer to wake up to resume normal breathing, and disrupt and disturb their normal sleep cycle. These episodes, called apneas, usually last from a few seconds up to as long as sixty seconds in severe cases, and may occur repeatedly throughout the night.  People with Sleep Apnea partially awaken as they struggle to breathe, but, because of the stage of sleep they were in when they were woken, they may not remember any disturbances to their sleep in the morning.  Most sufferers are only aware of these events because they are informed by their sleep partner in the morning.
There are three types of Sleep Apnea:
· Obstructive Sleep Apnea (OSA): is the most common type of sleep apnea, and is caused by the temporary relaxation and partial collapse of soft tissue in the respiratory tract at the back of the throat, and this causes a blockage to the passage of air into the lungs.
· Central Sleep Apnea (CSA): is caused by irregularities in the brain’s signals that instruct our bodies to breathe.
· Mixed Apnea: occurs when a person suffers from both Obstructive Sleep Apnea (OSA) and Central Sleep Apnea (CSA).
Sufferers usually resume breathing within a few seconds of each episode, but periods as long as sixty seconds are may occur in severe cases.

Symptoms

The main symptom of Sleep Apnea is Excessive Daytime Sleepiness (EDS).
Additional symptoms may include:
· anxiety,
· depression.
· forgetfulness,
· increased heart rate,
· irritability,
· loud snoring with periods of silence followed by gasping for breath,
· mood and behavior changes,
· morning headaches,
· restless sleep – causing the sufferer to feel un-refreshed the next day,
· trouble concentrating, and,
· weight gain.
Few if any of these symptoms may be present, however, and many people who suffer from even severe sleep apnea have no complaints about sleepiness or fatigue.

Causes

Almost everybody who has sleep apnea is a snorer, often a very heavy snorer.
Obstructive Sleep Apnea is more likely to occur in men than in women, and is also more likely to occur in people who are overweight or obese, snore, consume alcohol, and/or have anatomical abnormalities of the jaw or soft palate.
However, atypical cases do occur in people who do not fit this profile.

Diagnosis

An "event" can be either an apnea, which is characterized by a complete cessation of airflow for at least 10 seconds, or a hypopnea, in which airflow decreases by 50 percent for 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen saturation or an arousal from sleep.
To grade the severity of sleep apnea the number of events per hour is reported as the Apnea-Hypopnea Index (AHI).  An AHI of less than 5 is considered normal, while an AHI of 5-15 is mild, an AHI of 15-30 is moderate, and more than 30 events per hour characterizes severe sleep apnea.
The following tests are performed by a sleep specialist to diagnose Narcolepsy:
· Polysomnogram,
· Pulse Oximeter, and,
· SleepStrip.
The Polysomnogram involves continuous recording of sleep brain waves and a number of other nerve and muscle functions during nighttime sleep.  The Polysomnogram also helps detect other possible sleep disorders that could cause the daytime sleepiness.
A Pulse Oximeter is small device that is attached to a fingertip to measure the oxygen saturation of the blood.  That is, the percent of the total hemoglobin that is combined with oxygen.  This monitors the difference in the color of the oxygenated and the deoxygenated hemoglobins in the blood.  Recordings of blood oxygen saturation during sleep can provide an estimate of the severity of any sleep apnea related problems.  However, oximetry is not considered to be a reliable screening tool for diagnosing sleep apnea.
A SleepStrip is a disposable screening device, which provides a single use test for sleep apnea.  The device is worn overnight under the nose and records when the patient stops breathing.  In the morning, the patient can see a score, which correlates well with a standard sleep lab Apnea Hypopnea Index (AHI).  The device is more accurate with patients with moderate to severe sleep apnea.

Complications / Issues

The complications and issues caused by Sleep Apnea are very serious indeed and can include:
· asphyxia,
· cardiac arrhythmias
· daytime fatigue,
· death,
· depression,
· gout,
· heart attack,
· heart failure,
· high blood pressure,
· hypertension,
· irregular heartbeat,
· social and family disruption, and,
· stroke.
Central Sleep Apnea (CSA) has also been linked to various serious cerebral vascular conditions, congestive heart failure, and premature aging.
If left untreated, Sleep Apnea can be life threatening.  Excessive Daytime Sleepiness (EDS) can cause people to fall asleep at inappropriate times, such as while driving, endangering their lives and the lives of their passengers and those around them.
Sleep apnea also appears to put individuals at risk for stroke and Transient Ischemic Attacks (TIAs), also known as "mini-strokes", and is associated with coronary heart disease, heart failure, irregular heartbeat, heart attack, gout and high blood pressure.
Sleep Apneas and other obstructions of the upper airway may also be a cause of or may contribute to Sudden Infant Death Syndrome (SIDS).

Treatment

There are a variety of treatments for Sleep Apnea, depending on an individual’s medical history and the severity of the disorder.  The available treatments are applied in this order:
· Lifestyle Changes
· Physical Intervention
· Medical Treatments
· Surgical Treatments
Some individuals may need a combination of these treatments to successfully treat their Sleep Apnea.

Lifestyle Changes

Most treatments begin with lifestyle changes, such as:
· avoiding alcohol,
· losing weight,
· quitting smoking,
are all that are required to reduce or even eliminate Sleep Apnea.
In some cases, weight loss can and will reduce the number and severity of apnea episodes.  However, for most patients, being overweight tends to be an aggravating factor rather than the cause of Obstructive Sleep Apnea (OSA).  In the morbidly obese, a major loss of weight, such as occurs after serious dieting and exercise, or after bariatric surgery, can sometimes cure the condition.
Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep.
If necessary, medications that relax the central nervous system, such as sedatives and muscle relaxants, can also be used in conjunction with these lifestyle changes.
If these conservative methods are inadequate, then doctors may recommend Physical Intervention, Medical Treatments, or even Surgical Treatments.

Physical Intervention

A treatment that is commonly used for mild or moderate Sleep Apnea sufferers is a Mandibular Advancement Splint (MAS).  This device is a mouth guard that is similar to those used to protect the teeth during sports.  For apnea patients, the mouth guard is designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position, and this position keeps the tongue further away from the back of the airway, allowing easier breathing during sleep.  A MAS device is simple and user-friendly, and it may be enough to relieve mild apnea and improve breathing for some patients.  However, for more effective treatments, one of the PAP treatments below may be required.
For moderate to severe Sleep Apnea sufferers, the most widely used therapeutic intervention is Positive Airway Pressure (PAP) whereby a breathing machine pumps a controlled stream of air through a mask worn over the nose, mouth, or both.  The additional air pressure holds open the relaxed muscles in the airways and keeps them open to aid breathing.
There are several variations on the types of PAP machines available:
· Continuous Positive Airway Pressure (CPAP): in which a controlled air compressor generates an stream of air at a constant pressure, according to the pressure setting recommended by the doctor following tests.
· Variable Positive Airway Pressure (VPAP): (also known as Bilevel or BiPAP), uses an electronic circuit to monitor the patient's breathing, and provides two different pressures, a higher one during inhalation and a lower pressure during exhalation.  Because of the extra circuitry, a VPAP system is more expensive than a CPAP system.  VPAP is sometimes used with patients who have other respiratory problems, or those who find breathing out against the increased pressure of a CPAP air stream to be uncomfortable or disruptive to their sleep.
· Automatic Positive Airway Pressure (APAP): is the most advanced and most expensive form of air treatment.  An APAP machine incorporates pressure sensors and a computer which continuously monitors the patient's breathing performance, and adjusts pressure continuously, increasing it when the user is attempting to breathe but cannot, and decreasing it when the pressure is higher than necessary.
These machines, even though they are based on air compressors, are extremely quiet.
While the face mask makes some sufferers hesitant to try these treatments, many patients find that the initial difficulty of adapting to the machine is quickly surpassed by the improved, deeper sleep that they obtain while using the machine.
In addition, the introduction of masks that resemble an oversized oxygen cannula have been better tolerated by some users.  The vast majority of patients are surprised to find that they adapt to and tolerate the mask fairly easily, and quickly learn to sleep well while wearing it.
These treatments are often used with accompanying humidification, as some users experience a drying effect of the airway and mucous membranes.  In some countries, such as the United States, the use of these machines require a doctor's prescription / authorization.  Before this is granted, a sleep study is conducted to determine what kind of treatment is needed, and to determine the proper settings for the PAP device.

Medical Treatment

Only a few drug-based treatments of Obstructive Sleep Apnea (OSA) are known despite decades of research and testing.  They include the following:
· Oral administration of the methylxanthine theophylline (chemically similar to caffeine) can reduce the number of episodes of apnea, but can also produce side effects such as palpitations and insomnia.
· Theophylline is generally ineffective in adults with Obstructive Sleep Apnea (OSA), but is sometimes used to treat Central Sleep Apnea (CSA), and infants and children with apnea.
· Neuroactive Drugs: Some neuroactive drugs, such as the antidepressant mirtazapine, have been found to reduce incidences of Obstructive Sleep Apnea (OSA).
When other treatments do not completely treat the Obstructive Sleep Apnea (OSA), drugs are sometimes prescribed to treat a patient's daytime sleepiness.  These range from stimulants such as amphetamines to modern anti-narcoleptic medicines., such as modafinil.

Surgical Intervention

The following surgical procedures can be used to remove tissue and improve the size or tone of the patient's airway:
· Tracheostomy: For decades, a tracheostomy was the only effective treatment for sleep apnea.  However, now a range of better treatments are available, and it is used today only in very rare, intractable cases that have defied other attempts at treatment.
· Nasal Surgery: including turbinectomy (removal or reduction of a nasal turbinate), or straightening of the nasal septum, in patients with nasal obstruction or congestion which reduces airway pressure and complicates Obstructive Sleep Apnea (OSA).
· Tonsilectomy: and/or Adenoidectomy are used in an attempt to increase the size of the airway.
· Removal or reduction of parts of the soft palate and some or all of the uvula, such as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP).  Modern variants of this procedure sometimes use radiofrequency waves to heat and remove tissue.
· Reduction of the tongue base, either with laser excision or radiofrequency ablation.
· Genioglossus Advancement: in which a small portion of the lower jaw which attaches to the tongue is moved forward, to pull the tongue away from the back of the airway.
· Hyoid Suspension: in which the hyoid bone in the neck, another attachment point for tongue muscles, is pulled forward in front of the larynx to pull the tongue away from the back of the airway.
· Maxillomandibular Advancement (MMA): A more invasive surgery usually only tried in difficult cases where other surgeries have not relieved the patient's Obstructive Sleep Apnea (OSA), or where an abnormal facial structure is suspected as a root cause of the apnea.  In MMA, the patient's upper and lower jaw are detached from the skull, moved forward, and reattached with pins and/or plates.
· Pillar Procedure: where three small inserts are injected into the soft palate to offer support, reducing snoring and sleep apnea.
Please Note:  Often the long term success rate of these surgical procedures is low, prompting many doctors to favor CPAP (or VPAP or APAP) as the preferred methods of treatment.

Prevention

At this time, there is no cure for Sleep Apnea.
The best way to prevent or reduce the risk of the onset of Sleep Apnea is to quit (or, better yet, never take up) smoking, limit alcohol consumption, and maintain a healthy body weight.  A healthy, balanced diet, low in fats and sugars, and regular exercise are the keys to weight loss.
The best way to prevent the onset of the symptoms of Sleep Apnea is for the sufferer to work with their doctor so that the symptoms can be treated, removed, or reduced.

Sleep Bruxism (Tooth-Grinding)