Obstructive sleep apnea

Answer 1

Definition

Obstructive sleep apnea is a condition in which a person has episodes of blocked breathing during sleep.

This article discusses obstructive sleep apnea in adults.

See also:

• Central sleep apnea
• Sleep disorders

Alternative Names

Sleep apnea - obstructive; Apnea - obstructive sleep apnea syndrome; Sleep-disordered breathing

Causes, incidence, and risk factors

Normally, the muscles of the upper part of the throat help keep the airway open and allow air to flow into the lungs. Even though these muscles usually relax during sleep, the upper throat remains open enough to let air pass by.

However, some people have a narrower throat area. When the muscles in their upper throat relax during sleep, their airway may completely close. This prevents air from getting into the lungs. Loud snoring and labored breathingoccur. During deep sleep, breathing can stop for a period of time (often more than 10 seconds). This is called apnea.

An apnea episode is followed by a sudden attempt to breathe, and a change to a lighter stage of sleep. The result is fragmented or interrupted sleep that is not restful. As a result, those with sleep apnea feel more drowsy or sleepy during the day, called excessive daytime drowsiness.

Older obese men seem to be at higher risk, although many people with obstructive sleep apnea are not obese. The following factors may also increase your risk for obstructive sleep apnea:

• Certain shapes of the palate and jaw
• Large tonsils and adenoids in children
• Large neck or collar size
• Large tongue
• Narrow airway
• Nasal obstruction
• Obesity

Drinking alcohol or using sedatives before sleep may make you more likely to have an episode of apnea.

Symptoms

A person who has obstructive sleep apnea often is not aware of the apnea episodes during the night. Often, family members, especially spouses, witness the periods of apnea.

A person with obstructive sleep apnea usually snores heavily soon after falling asleep. The snoring continues at a regular pace for a period of time, often becoming louder. It is then interrupted by a long silent period during which there is no breathing. This is followed by a loud snort and gasp, and the snoring returns. This pattern repeats frequently throughout the night.

The main symptoms are usually associated with excessive daytime sleepiness:

• Abnormal daytime sleepiness, including falling asleep at inappropriate times
• Awakening unrefreshed in the morning

Other symptoms may include:

• Depression (possibly)
• Memory difficulties
• Morning headaches
• Personality changes
• Poor concentration
• Restless and fitful sleep
• Frequent waking up during the night to urinate
• Insomnia

Other symptoms that may occur with this disease:

• Hyperactive behavior, especially in children
• Leg swelling (if severe)

Signs and tests

The health care provider will perform a complete history and physical exam. This will involve carefully checking your mouth, neck, and throat. You may be given a survey that asks a series of questions about daytime sleepiness, sleep quality, and bedtime habits.

A sleep study(polysomnogram) is used to confirm obstructive sleep apnea.

Other tests that may be performed include:

• Arterial blood gases
• Electrocardiogram(ECG)
• Echocardiogram
• Thyroid function studies

Treatment

The goal is to keep the airway open so that breathing does not stop during sleep.

The following lifestyle changes may relieve symptoms of sleep apnea in some individuals:

• Avoiding alcohol or sedatives at bedtime
• Avoiding sleeping on the back
• Losing weight

CPAP is now regarded as the first-line treatment for obstructive sleep apnea in most people. Many patients cannot tolerate CPAP therapy. Good follow-up and support from a sleep center can often help overcome any problems in using CPAP. For information on this treatment, see: CPAP.

Some patients may need dental devices inserted into the mouth at night to keep the jaw forward.

Surgery may be an option in some cases. This may involve:

• Uvulopalatopharyngoplasty (UPPP) -- to remove excess tissue at the back of the throat
• More invasive surgeries -- to correct abnormal structures of the face in rare cases when patients have severe sleep apnea or treatment has not helped
• Tracheostomy -- to create an opening in the windpipe to bypass the blocked airway if there are anatomical problems (rarely done)
• Surgery on the nose and sinuses

Surgery to remove the tonsils and adenoids may cure the condition in children; it does not seem to help most adults.

Expectations (prognosis)

With treatment, the symptoms of sleep apnea should be totally corrected.

Complications

Because of daytime sleepiness, people with sleep apnea have an increased risk of:

• Motor vehicle accidents from driving while sleepy
• Industrial accidents from falling asleep on the job

Untreated obstructive sleep apnea may lead to, or worsen, cardiovascular disease, such as:

• High blood pressure
• Heart failure
• Stroke
• Heart arrhythmias

Calling your health care provider

Call your health care provider if:

• You have excessive daytime sleepiness
• You or your family notice symptoms of obstructive sleep apnea
• You have this condition, and symptoms do not improve with treatment or new symptoms develop

Seek immediate medical attention or call your local emergency number (such as 911) if you experience the following signs of a medical emergency:

• Decreased consciousness
• Extreme sleepiness
• Hallucinations
• Personality changes
• Persistent confusion

Prevention

Children with very large tonsils and adenoids may develop sleep apnea and related problems. They should be checked by a health care provider to determine whether they need further evaluation.

See: Tonsillectomy

References

Bradley TD, Floras JS. Obstructive sleep apnoea and its cardiovascular consequences. Lancet. 2009;373:82-93.

Patel NP, Ahmed M, Rosen I. Split-night polysomnography. Chest. 2007;132(5):1664-1671.

Basner RC. Continuous positive airway pressure for obstructive sleep apnea. N Engl J Med. 2007;356(17):1751-1758.

Patil SP, Schneider H, Schwartz AR, Smith PL. Adult obstructive sleep apnea: pathophysiology and diagnosis. Chest. 2007;132(1):325-337.

Darrow DH. Surgery for pediatric sleep apnea. Otolaryngol Clin North Am. 2007;40(4):855-875.

Answer 2

Definition

Obstructive sleep apnea is a condition in which the flow of air pauses or decreases during breathing while you are asleep because the airway has become narrowed, blocked, or floppy.

A pause in breathing is called an apnea episode. A decrease in airflow during breathing is called a hypopnea episode. Almost everyone has brief apnea episodes while they sleep.

This article discusses obstructive sleep apnea in adults.

See also:

• Central sleep apnea
• Sleep disorders

Alternative Names

Sleep apnea - obstructive; Apnea - obstructive sleep apnea syndrome; Sleep-disordered breathing; OSA

Causes, incidence, and risk factors

All of the muscles in your body become more relaxed during sleep. This includes the muscles that help keep the airway open and allow air to flow into the lungs.

Normally, the upper throat still remains open enough during sleep to let air pass by. However, some people have a narrower throat area. When the muscles in their upper throat relax during sleep, their breathing can stop for a period of time (often more than 10 seconds). This is called apnea.

The snoring in people with obstructive sleep apnea is caused by the air trying to squeeze through the narrowed or blocked airway. However, everyone who snores does not have sleep apnea. Other factors may also increase your risk:

• A lower jaw that is short compared to the upper jaw (retrognathia)
• Certain shapes of the palate or airway that cause the airway to be narrower or collapse more easily
• Large tonsils and adenoids in children that can block the airway
• Large neck or collar size (17 inches or more in men and 16 inches or more in women)
• Large tongue, which may fall back and block the airway
• Obesity

Sleeping on the back also increases sleep apnea episodes.

Symptoms

A person who has obstructive sleep apnea often is not aware of the apnea episodes during the night. Often, family members witness the periods of apnea.

A person with obstructive sleep apnea usually begins snoring heavily soon after falling asleep. Often the snoring gets louder. The snoring is then interrupted by a long silent period during which there is no breathing. This is followed by a loud snort and gasp, as the person attempts to breathe. This pattern repeats.

Many people wake up unrefreshed in the morning and feel sleepy or drowsy throughout the day. This is called excessive daytime sleepiness (EDS).

People with sleep apnea may:

• Act grumpy, impatient, or irritable
• Be forgetful
• Fall asleep while working, reading, or watching TV
• Feel sleepy while driving, or even fall asleep while driving
• Have hard-to-treat headaches

Problems that may occur with this condition:

• Depression that becomes worse
• Hyperactive behavior, especially in children
• Leg swelling (if severe)

Signs and tests

The health care provider will perform a complete history and physical exam. This will involve carefully checking your mouth, neck, and throat. You may be given a survey that asks a series of questions about daytime sleepiness, sleep quality, and bedtime habits.

A sleep study(polysomnogram) is used to confirm obstructive sleep apnea.

Other tests that may be performed include:

• Arterial blood gases
• Electrocardiogram(ECG)
• Echocardiogram
• Thyroid function studies

Treatment

The goal is to keep the airway open so that breathing does not stop during sleep.

The following lifestyle changes may relieve symptoms of sleep apnea in some people:

• Avoiding alcohol or sedatives at bedtime, which can make symptoms worse
• Avoiding sleeping on the back may help with mild sleep apnea
• Losing weight may decrease the number of apnea spells during the night

Continuous positive airway pressure (CPAP) is now the first treatment for obstructive sleep apnea in most people. CPAP is delivered by a machine with a tight-fitting face mask.

Many patients have a hard time sleeping with CPAP therapy. Good follow-up and support from a sleep center can often help overcome any problems in using CPAP. For information on this treatment, see: CPAP.

Some patients may need dental devices inserted into the mouth at night to keep the jaw forward.

Surgery may be an option in some cases. This may involve:

• Uvulopalatopharyngoplasty (UPPP) -- to remove excess tissue at the back of the throat. This surgery has not been proven to completely clear up sleep apnea. Long-term side effects are also possible.
• More invasive surgeries -- to correct problems with the face structures in rare cases when patients have severe sleep apnea and treatment has not helped
• Tracheostomy -- to create an opening in the windpipe to bypass the blocked airway if there are physical problems (rarely done)

Surgery to remove the tonsils and adenoids often cures the condition in children. It does not seem to help most adults.

Expectations (prognosis)

People with poorly treated sleep apnea often have:

• An increase in anxiety and depression
• A loss of interest in sex
• Poor performance at work or school

Because of daytime sleepiness, people with sleep apnea have an increased risk of:

• Motor vehicle accidents from driving while sleepy
• Industrial accidents from falling asleep on the job

With treatment, the symptoms and problems of sleep apnea should be totally corrected.

Complications

Untreated obstructive sleep apnea may lead to or worsen Heart disease, including:

• Heart arrhythmias
• Heart failure
• High blood pressure
• Stroke

Calling your health care provider

Call your health care provider if:

• You have excessive daytime sleepiness
• You or your family notice symptoms of obstructive sleep apnea
• You have this condition, and symptoms do not improve with treatment or new symptoms develop

References

Kasai T, Bradley TD. Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications. J Am Coll Cardiol. 2011;57:119-127.

McArdle N, Singh B, Murphy M, et al. Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration. Thorax. 2010;65:606-611.

Tomfohr LM, Ancoli-Israel S, Loredo JS, Dimsdale JE. Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trila. Sleep. 2011;34:121-126.

Epstein LJ, Kristo D, Strollo PJ Jr., et al. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management, and long-term care of obstructive sleep apnea in adults. J Clin SleepMed. 2009;5:263-276.

Patil SP, Schneider H, Schwartz AR, Smith PL. Adult obstructive sleep apnea: pathophysiology and diagnosis. Chest. 2007;132(1):325-337.

Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33:1408-1413.

Reviewed By

Review Date: 07/31/2011

Denis Hadjiliadis, MD, Assistant Professor of Medicine, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.