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Sleep apnoea

sleep-apnoea

Sleep apnea is described as a symptom complex (group of symptoms) or a syndrome characterized by erratic breathing while sleeping. Because of this, a person’s oxygen level in the blood falls, (sometimes drastically) at regular intervals without the person even knowing it. Typically, the person feels very sleepy during the day, wakes up very often during the night, and experiences general fatigue. If proper treatment is not provided to treat sleep apnea, it can lead to various health issues such as cardiomyopathy, heart attack, stroke, hypertension and diabetes. This condition if left untreated can lead to work-related accidents, underachievement in school by children, motor vehicle crashes and job impairment.

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Types

Sleep apnea is divided into two subtypes-


  • Obstructive sleep apnoea - In this type of apnoea, reoccurring partial or complete airway obstruction episodes can occur. Usually, breathing is associated with the loud sound of gasp or body jerk; this is because the diaphragm and chest muscles work more. There is more requirement of pressure to open the airway. During obstructive sleep apnoea, heart rhythm irregularities decreased flow to vital organs and interference with sound sleep can occur.

  • Central sleep apnoea - In this type of apnoea, the brain fails to send a signal to the muscle to breathe because of the unstable respiratory control centre. The airway is not blocked in this situation, and the central apnoea affects the central nervous system.

Symptoms

Symptoms of obstructive sleep apnea are as follows:


  • Daytime sleepiness or fatigue

  • Dry mouth or sore throat upon awakening

  • Restlessness during sleep; frequent night-time awakenings

  • Snoring

  • A feeling of gasping or choking while waking up from sleep

  • Mood disturbances

  • Frequent night-time urination

  • Headaches

  • Night sweats

  • Sexual dysfunction

  • Cognitive impairment such as trouble concentrating, forgetfulness or irritability

  • A feeling of gasping or choking while waking up from sleep


Symptoms of central sleep apnoea are as follows:

  • Lack of sleep

  • Reoccurring awakenings in the night

  • Gasping or choking sensation during awakening


Symptoms amongst children are as follows:

  • Sleepiness or sluggishness, often misinterpreted as laziness in the classroom

  • Excessive sweating at night

  • Bedwetting

  • Poor school performance

  • Daytime mouth breathing and swallowing difficult

  • Irregular sleeping positions such as sleeping on the knees and hands or with the neck hyper-extended

  • Inward movement of the ribcage when inhaling

Causes And Risk Factors

Causes

What happens is, there are involuntary pauses during sleep which are called apnoeic events. During the pauses, there is no or reduced intake of oxygen and no exhaling of carbon dioxide. Hence, the oxygen levels in the blood drop and carbon dioxide levels increase. The number of these events and the level of oxygen level drop determines the severity of the sleep apnoea. The more severe it is, the faster and severe will be its effects such as extreme fatigue, lack of concentration, high blood pressure, respiratory complications, depression and heart ailments.

Risk Factors

Most people don’t know about sleep apnea and think that snoring is just something to laugh off. But it can be quite dangerous. There are conditions that predispose people to the condition, they are


  • obesity,

  • those who have very little or no physical activity,

  • those who snore heavily while asleep,

  • people with thyroid disorders,

  • those who drink alcoholic beverages

  • those who have other obstructions in their breathing passages

  • conditions like deviation of the nasal septum (where the centre bridge of the nose tilts to either the left or the right)

  • or those with a bulky tongue

  • male gender

  • more than 50 years of age

  • structural abnormalities such as low hanging soft palate, nasal obstruction and enlarged tonsils

  • excessive weight


Rarely, there are cases where sleep apnoea is linked to inflamed tonsils or adenoids. Research has also shown that habits such as eating fried, high-calorie junk food are linked to the condition.

Diagnosis

Sleep apnoea is diagnosed by various methods as specified-




  • Overnight sleep evaluation may be performed to evaluate your sleep apnoea. This evaluation is often performed with the help of a sleep specialist.

  • A polysomnogram (PSG) is a test that performs overnight sleep studies, which were conducted under the observation of a trained technologist in a sleep laboratory.

  • This test helps assess different body functions like eye movements, heart rate, the electrical activity of the brain, breathing patterns, muscle activity, blood oxygen levels and airflow are recorded. This study documents the frequency of breathing impairment during sleep, and this is graded as per the severity.

  • Another test available for adults is a home sleep test (HST). This study can be performed at home; however, it captures a few organ functions than the polysomnogram. The study records blood oxygen, air-fluid levels, snoring and breathing a fourth and grades sleep apnoea to moderate or severe. The home sleep test cannot be performed on the patient without symptoms. This test cannot be performed on patients with medical problems such as cardiac disease, pulmonary disease, neuromuscular disorders or sleep disorders such as insomnia, circadian rhythm disorder, narcolepsy, restless leg syndrome or parasomnia, in addition to obstructive sleep apnoea.

Treatment

Early and milder forms of sleep apnoea can and should be treated with changes in lifestyle, eating and drinking habits. Another important change that has to be implemented is to change one’s sleeping posture such as lying on the side. An important step is to manage the associated medical conditions such as hypothyroidism and obesity.

In the case of more advanced or non-responding sleep apnoea, there are ways to manage the condition surgically. Surgeries like tonsillectomy (removal of the tonsils), adenoidectomy (removal of adenoids), surgery to reduce the size of a bulky tongue, or corrective surgery for the straightening of a deviated nasal septum etc. help relieve the conditions. Other non-surgical methods include wearing a breathing mask attached to a pressure pump every night which delivers air at increased pressure to the breathing passages and lungs. This method can be combined with surgical methods to help the patient.

Though there are some unique products that are available in the market to stop snoring, it is unlikely that they will offer a significant relief since Snoring and Sleep apnoea are two different entities. At best they can offer a temporary solution.

Lifestyle/management

Lifestyle modifications in patients with obstructive sleep apnoea are as follows:




  • Weight loss - Even a very close of 10% can decrease the apneic events among patients. 

  • Alcohol cessation - Patients with sleep apnea should avoid the use of alcohol.

  • Sleeping pills - These should be avoided in patients with sleep apnoea because they can cause airway collapse during sleep or prolong the apnoea period.

  • Use of wedge pillow - Use of wedge pillow can help patients with breathing causes when sleeping on the back or when suffering from mild obstructive sleep apnoea.

  • Avoid sleep deprivation.

Prognosis And Complications

Prognosis

Obstructive sleep apnoea has an excellent short-term prognosis for the patient. However, mild obstructive sleep apnoea patients show differences, and long-term cardiovascular disorder outcomes have shown temporary improvement in symptoms. Obstructive sleep apnea left untreated can be life-threatening. Excessive daytime sleeping can lead to sleepiness related incidents. Usually, patients develop cardiopulmonary disease, neurocircuitry dysfunction and cerebrovascular incidents if moderate-to-severe obstructive sleep apnoea is left untreated. The therapeutic pathways have, however, not been effective in reducing cardiovascular events and neurocognitive functions in the long term.

Complications

Anyone who suffers from sleep apnoea is more at risk of sudden cardiac death and also death due to its other systemic effects. If sleep apnoea is not properly treated it can give rise to various health issues such as arrhythmias, stroke, hypertension, diabetes, heart failure, heart attacks, obesity, and cardiomyopathy, i.e. the enlargement of the heart muscle. Sleep apnoea is a complication in people with heart failure or atrial fibrillation; this is because of changes in carbon dioxide levels, recurrent hypoxia, increased inflammatory markers and direct effect on the heart within the chest. Finally, sleep apnoea is a serious condition, the best thing to do in cases of severe snoring is to visit your doctor.


 

References 


1. Cleveland clinic. Sleep Apnea [Internet] Available at https://my.clevelandclinic.org/health/diseases/8718-sleep-apnea. Accessed on March 23, 2021. (https://my.clevelandclinic.org/health/diseases/8718-sleep-apnea)


2. Stat Pearls. Sleep Apnea Syndrome [Internet] [Updated on November 7, 2020] Available at https://www.ncbi.nlm.nih.gov/books/NBK564431/. Accessed on March 23, 2021. (https://www.ncbi.nlm.nih.gov/books/NBK564431/)

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