Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is the temporary cessation of breathing for 10 seconds or more due to the blockage of the upper airways during sleep.
During sleep, the body's muscles relax, which can cause excess tissue to collapse into the upper airway and block breathing.
When breathing is interrupted by an obstruction in the airway, the body reacts by waking enough to start breathing again.
These arousals may happen hundreds of times each night but do not fully awaken the patient, who remains unaware of the loud snoring, choking and gasping for air that are typically associated with obstructive sleep apnea.
Symptoms of Obstructive Sleep Apnea
Since these awakenings are rarely remembered, sleep apnea sufferers are unaware of the source of their symptoms: daytime sleepiness, increased irritability or depression, decreased concentration and work productivity and even an increased number of traffic accidents.
In fact, the excessive daytime sleepiness often is mistaken for narcolepsy. Obstructive sleep apnea should be suspected in patients who are overweight, snore loudly, and have chronic daytime sleepiness.
Obstructive Sleep Apnea Treatment:
CPAP:
Continuous positive airway pressure (CPAP) is the most consistently efficient treatment for clinically significant obstructive sleep apnea. In general, obese patients with thicker necks require higher pressure settings.
As patients age or gain weight, additional pressure may be necessary. Complications of CPAP use include nasal dryness and congestion, claustrophobia, facial skin abrasions, air leaks, and conjunctivitis.
Strategies to improve patient compliance include allowing patients to try a number of masks to find the most comfortable fit, adding humidification, treating nasal disease and, most importantly, providing close follow-up and encouragement.
Patients who cannot be treated adequately with CPAP or other conventional measures and who have clinically significant disease may want to consider more invasive treatment.
Uvulopalatoplasty is a surgical or laser procedure that removes part of the uvula and soft palate in an attempt to alleviate snoring and sleep-disordered breathing. Radio frequency methods (i.e., Somnoplasty) also can reduce palatal soft tissue.
Palatal surgery:
Palatal surgical procedures tend to alleviate snoring but are not consistently effective in treating obstructive sleep apnea. Many patients with sleep apnea have airway obstruction beyond the palatal area that is not treated by soft tissue procedures.
Jaw surgery:
Patients with maxillomandibular advancement that predisposes them to airway obstruction may be considered for jaw surgery. Maxillomandibular advancement surgery effectively treated sleep apnea in as many as 95 percent of patients; however, no randomized studies are available.
Oxygen therapy:
Oxygen and medications may have adjunctive roles in the treatment of obstructive sleep apnea in some patients. They hardly used as primary treatments. Oxygen therapy is only partly effective.
Although it helps to treat the oxyhemoglobin desaturation that occurs with some respiratory events, it does not reverse obstruction. When supplemental oxygen is used, apneas occur less frequently but may last longer.
Oxygen therapy may be useful in patients for whom no other treatments are satisfactory, but carbon dioxide retention is a danger in patients with severe underlying lung disease.
Oral appliances:
Oral appliances are inconsistently effective in the management of obstructive sleep apnea but may be an alternative in patients with mild disease who cannot tolerate CPAP.
Bariatric surgery:
In patients with morbid obesity, weight loss via bariatric surgery helps to reduce the severity of obstructive sleep apnea. However, the possible complications and cost of this type of surgery downgrade it to a secondary role in the treatment of obstructive sleep apnea.
Sleep Hygiene:
Patients who snore but have no more than obstructive sleep apnea on laboratory testing may be treated adequately with conservative measures involving good sleep hygiene. The physician should verify that patients are spending adequate time in bed. Sleep deprivation increases a person's tendency to snore.
Treatment of disorders that reduce nasal airflow, such as chronic rhinitis, nasal polyps, or septal deviation, is important because reduced nasal airflow increases the tendency to snore.
Moreover, mouth breathing during sleep, which results from nasal obstruction, causes the jaw to drop and reduces the diameter of the pharyngeal airway, increasing the possibility of obstructive sleep apnea.
Patients with obstructive sleep apnea should avoid alcohol and other sedating agents. Because patients with obstructive sleep apnea tend to sleep inadequately, they are more likely to turn to sedatives to promote sleep.
Tracheotomy:
Tracheotomy is a last-resort measure that is used only in life-threatening situations, such as acute respiratory failure or when patients are severely apneic and noncompliant. Because of complications and disability, tracheotomy generally is not well accepted by patients as a long-term treatment.
Raising the head of the bed and avoiding the supine position during sleep are methods of decreasing the incidence of obstructive sleep apnea. Elevation of the head tends to bring the tongue forward, while sleeping on the side moves the tongue laterally.
