Do you snore at night?

Do you feel sleepy during the daytime? Are you overweight?
You could be having Obstructive Sleep Apnea (OSA)!

What is snoring?

Snoring is the noise generated as a result of turbulent airflow in the throat, during sleep, commonly following a partial obstruction to the upper airway.

Obstructive-sleep-apnea-snoring1
How does snoring occur?
  • Our throat, like most parts of our body, is held in place by groups of muscles which help to keep our upper airway open and assists in functions such as speech and swallowing.
  • In some people, the muscles in the throat relax excessively during sleep, causing the upper airway to collapse on itself which obstruct the free flow of air, thereby causing a turbulent airflow. This turbulent airflow generates a noise which is commonly referred to as “Snoring”
  • What else can cause snoring?
    • Reduced muscle tone in throat and tongue during deep sleep, following alcohol consumption and normal aging leading to weak muscles.
    • Deformities in the nose such as a deviated septum (the structural wall of cartilage between each nostril).
    • Long soft palate and/or uvula (the suspended ball of tissue at the back of the oral cavity).
Labelled-anatomy
Does snoring always indicate an underlying disorder?
  • NO! We all may snore at some point in life and this is almost a universal phenomenon.
  • Snoring can be considered non-pathological if it does not cause any symptoms such as day time sleepiness or insomnia.
    •  

What is Obstructive Sleep Apnea (OSA)?

  • Obstructive Sleep Apnea (OSA), as the name implies is the sudden, transient interruption to the free flow of air (or breathing) in the upper airway, during sleep, due to a transient closure of the upper airway which carry air into the lungs.
  • Obstructive Sleep Apnea (OSA) is the commonest sleep related breathing disorder worldwide.
  • Sleep related breathing disorders are broadly classified as obstructive sleep apnea, Central Sleep Apnea and mixed sleep apnea.
What happens in Obstructive Sleep Apnea?
  • The airway that carries air to the lungs passes through your throat. Our throat, like most parts of are body, are held in place by groups of muscles which helps to keep our upper airway open and assists in functions such as speech and swallowing.
  • In some people, the muscles in the throat relax excessively during sleep, causing the upper airway to collapse on itself which obstruct the free flow of air, thereby causing a turbulent airflow. This turbulent airflow generates a noise which is commonly referred to as “Snoring”.
  • A complete obstruction to the air flow in the throat or upper airway lasting for more than 10 seconds or more is called an apnea.
    • NB; A partial obstruction (50% or more reduction in air flow) lasting for more than 10 seconds accompanied by drop in oxygen levels in the blood is called a hypopnea.
  • During these apneic attacks, air does not reach the lungs in sufficient amounts to maintain a health blood oxygen level. The low blood oxygen level is then detected by the brain and immediately brings the person from a state of deep sleep to light sleep, or even completely wakes the person up after which the person starts to breathe again. These apneic attacks occur repeatedly throughout the sleep reducing the quality of sleep and ultimately leading to complications associated with insufficient sleep.
  • An episode of obstructive apnea where the throat closes during sleep is comparable to strangulation!
    • Imagine if someone strangles you, what will happen?
    • You will panic, your heart rate will go up, blood pressure will go up and you would be under a lot of stress. A similar situation arises during an apneic attack in OSA. It is a stressful situation for the body, which then releases intrinsic stress hormones such as cortisol, adrenaline and norepinephrine which adversely affect our bodies’ metabolism, which over time leads to diseases such as diabetes and high blood pressure.
What are the complications of Obstructive Sleep Apnea?
  • OSA can lead to many chronic complications, even sudden death!

    • High blood pressure – majority of patients with OSA need more than two blood pressure medications to control their blood pressure.
    • Diabetes mellitus.
    • Ischemic heart disease.
    • Stroke.
    • Arrhythmias (abnormal heart rhythm).
    • Polycythemia.
    • Sexual dysfunction.

Complications associated with inadequate sleep/ excessive sleepiness during the day

  • Road traffic accidents – as a result of falling asleep at the wheel!
  • Memory impairment/ forgetfulness.
  • Change in personality. Feeling irritable and angry.
  • Increased risk of psychiatric illnesses such as depression.
  • Interrupt healthy metabolic and hormonal functioning.
  • Increased risk of sexual dysfunctions such as impotence, reduced sex drive, infertility.
  • Disrupts social functioning – daytime sleepiness, lethargy, feeling tired at work.
  • Inadequate sleep will shorten your lifespan!
  •  
Who are at risk of developing Obstructive Sleep Apnea?
  • People who are overweight or obese, especially if the neck circumference/ collar size is more than 42 cm in a male, and more than 40 cm in a female.
    • When a person puts on weight, there is a lot of fat deposited in the neck and around the throat, which makes the upper airway narrow, leading to airflow limitation in the throat.
    • 60% of moderate to severe OSA is attributable to obesity.
  • People who snore.
  • Heredity – First-degree relatives of OSA patients are twice as likely to have OSA. 
  • Certain disease conditions increase the risk of OSA or are associated with OSA. If you have any of the below diseases, you should be checked for OSA.
    • Cardiovascular,
      • Hypertension.
      • Heart attacks.
      • Heart failure.
      • Cardiac rhythm disorders.
      • Pulmonary hypertension – high blood pressure in the lungs.
    • Metabolic,
      • Diabetes.
      • Dyslipidemias.
      • Thyroid disorders.
    • Kidney disease,
      • Chronic kidney disease.
    • Lung disease,
    • Restless Legs syndrome.
    • Neurological disorders = Parkinson’s disease, Motor neurone disease.
    • Kyphoscoliosis (abnormally curved spine) and other diseases involving bones and muscles of the chest.
    • Alcohol increases the risk of OSA as it relaxes the upper airway muscles, thereby worsening snoring.
When should you suspect Obstructive Sleep Apnea?
  • If you have any one of these, you may be having OSA,
    • Snoring, choking, gasping during sleep.
    • Partner noticing apneic episodes at night.
    • Daytime sleepiness, falling asleep while driving – Take a 60 second online test to check if you are unusually sleepy.
    • Irritable throughout the day, mood changes, inability to concentrate.
    • Obese or overweight.
    • Poorly controlled blood pressure, development of high blood pressure at young age.
    • Poorly controlled diabetes.
    • New onset stroke or myocardial infarction.
How is Obstructive Sleep Apnea diagnosed?
  • If you think you have any of the symptoms and signs mentioned above or you completed the above 60 second test and the result came up as moderate or high for OSA, please visit your nearest doctor who will refer you to a specialist in sleep. Or get in touch with us through our online chat or contact our hotline 
  • Following a thorough history and physical examination by a clinician, OSA maybe clinically suspected and followed up with investigations such as an overnight sleep study.
How is Obstructive Sleep Apnea treated?
  • The main mode of treatment is the prevention of airway collapse during sleep by keeping the throat open.
  •  The 2 most popular methods of treatment that is available in Sri Lanka are listed below,
    • Continuous Positive Airway Pressure ventilation (CPAP).
      • CPAP – this is a small machine with a mask. The person wears the mask when going to sleep. The machine produces a jet of air which splints the airway open, without letting it close. Snoring stops immediately and the person wakes up refreshed in the morning
    • Surgical correction of a narrowed airway.
      • Surgical therapy is aimed at making the airway larger and thereby preventing the airway from collapsing on itself.
      • This may be considered in certain groups of patients. Those with anatomical facial abnormalities, large tonsils that may be contributing to upper airway obstruction will benefit from surgery.
      • Surgery is also offered to those who show poor response with CPAP.
      • There are many types of surgeries available.
  • Other methods of treatment,
    • Weight reduction with diet and exercise is very important.
      • All patients who are overweight should undergo weight reduction with diet and exercise! Read more
    • Oral appliances = Mandibular advancement devices.
      • Oral appliances look and feel like mouth guards, and are designed and fitted by dentists.
      • These devices move the lower jaw forwards and upwards, which then moves the tongue forwards and increases the size of the upper airway, keeping it open.
      • These devices are mainly used in those with snoring and mild to moderate OSA in whom CPAP treatment has been unsuccessful.
Where to get help?
  • Most government hospitals with a respiratory physician have facilities to screen and diagnose those with OSA. If facilities are not available, you will be referred to a nearby hospital.
  • Currently sleep services are available in the following hospitals and clinics.
  • Please visit our support page for more information.

What is Central Sleep Apnea?

  • In Central Sleep Apnea, unlike OSA, the airway is not blocked, but the brain fails to signal the muscles to breathe, due to instability in the respiratory control center.
  • This can happen in those with disorders of the brain and nervous system.
  • It may even occur in patients following stroke and advanced heart failure.
    •  

Obesity Hypoventilation Syndrome (OHS)

OHS is a condition in which very obese people fail to breath adequately resulting in inability  to get enough oxygen into their blood stream and exhale carbon dioxide.

  • This results in low levels of oxygen in the blood and high levels of carbon dioxide (CO2) in the blood.
  • OHS is characterized by obesity and daytime high CO2 level (hypercapnia).
  • OHS is commonly associated with Obstructive Sleep Apnea (OSA).
  • Patients with OHS commonly complain of excess daytime sleepiness.
  • They may also experience morning headaches.
  • Other features are changes in mood, fatigue, impaired concentration and poor memory.

Fun fact = Obesity Hypoventilation Syndrome (OHS), a condition related to sleep apnea, was first called Pickwickian Syndrome. It’s named after The Pickwick Papers by Charles Dickens because the novel features a character “Joey the fat boy” that has all the classic symptoms of the condition

Pickwick and Sleep Apnea | Charles Dickens Info.

Positive Airway Pressure devices - "PAP" devices

How do these devices help in Obstructive Sleep Apnea?
  • What is OSA?
    • Obstructive sleep apnea (OSA), as the name implies is the sudden, transient interruption to the free flow of air (or breathing) in the upper airway, during sleep, due to a transient closure of the upper airway which carry air into the lungs.
    • Learn more about OSA
  • PAP devices delivers and maintains a positive pressure within the upper airway, thus preventing it from collapsing and getting obstructed during sleep. The jet of air splints the airway open. This results in an unobstructed open upper airway allowing air to flow into the lungs.
  • Elimination of obstruction will eliminate snoring.
  • Restoration of airflow to the lungs will prevent awakenings due to lack of oxygen to the brain.
  • Sleep patterns will be normalized and normal restorative sleep will be achieved.
  • Day time sleepiness and other adverse effects of inadequate sleep will disappear.
What benefits will you get by using a PAP device?
  • You will wake up the next morning feeling refreshed!
  • Day time energy levels will increase, you will have more energy and motivation for physical activity.
  • With time, as sleep is restored and nocturnal awakenings are reduced, your stress hormone levels will drop and you may have better blood pressure and diabetic control if you suffer from these conditions.
  • Your mood will improve, irritability and fatigue will improve .
  • Alertness while driving will  eliminate the risk of sleep related motor vehicle accidents.
  • There are two main types of positive airway pressure devices
       1. CPAP
       2. BiPAP

Continuous Positive Airway Pressure devices (CPAP)

Man-on-cpap-machine
How does CPAP work?
  • CPAP devices are machines that provide a constant pressure to the upper airway, delivered via a tubing connected to the device and a mask applied to the face or nose. This pressure prevents collapsing of the upper airway during sleep and maintains airflow into our lungs
Two types of CPAP devices
  • Fixed pressure devices.
    • The pressure needed to keep the upper airway open varies from person to person and also the degree of upper airway obstruction, hence the pressure needed for you will be decided by your sleep specialist. These devices can provide pressure ranging from 5-20cm water.
  • Auto pressure devices (auto CPAP).
    • These devices are similar to fixed pressure devices but are able to detect automatically  the pressure needed by an individual to keep their upper airway open.
    • When pressures are set between a certain range the device automatically detects the degree of upper airway obstruction and applies pressures accordingly thus preventing upper airway collapse.
How long will it take for me to feel the benefits of CPAP?
  • Generally 1-2 weeks. The device should be used for at least 4 hours during a night and at least 5 nights a week.
  • CPAP is very effective as long as you continue to use it.
Once I start CPAP, what should I do next?
  • Once you start, 2 weeks into CPAP, you should ask the machine provider to download the data from the data card in the machine. You should visit your sleep specialist/respiratory physician who prescribed CPAP for you with this data. He or she will then look at the data and advice you.
Will I ever be able to stop using CPAP? Is it for life?
  • OSA like diabetes is a long term condition with no known cure. CPAP is the most effective treatment available as long as you continue to use it.
  • If you are very unhappy with CPAP, there are other ways of treating OSA. Please visit your sleep specialist/ respiratory physician to discuss these options.
If I lose weight can I stop using the CPAP device?
  • Weight loss can reduce the severity of sleep apnea but will not cure it . However a more than 10% weight loss can reduced CPAP pressure settings.
  • Bariatric surgery can help with significant weight loss and you may be able to stop CPAP.
How will I prepare for CPAP?
  • Before starting PAP therapy you will  be assessed by an Ear Nose and Throat ( ENT) surgeon for upper airway abnormalities that would make PAP therapy uncomfortable.
  • You will be screened for the presence of diabetes, high blood pressure and other medical problems that may lead to sleep Apnea.
  • If you are overweight or obese you will be seen by a nutritionist who will help with weight reduction and life style changes .
  • If you are morbidly obese you may be assessed and advised on the role of bariatric surgery (surgery performed to reduce the size of the stomach ) thus promoting weight loss.
How will I know if my CPAP pressure needs adjusting?
  • If you have recurrence of OSA symptoms such as snoring, excessive day time sleepiness etc.
  • If you gain weight.
  • Ideally, you should be regularly followed up by your respiratory physician who prescribed CPAP for you.
What are the problems that can occur while on CPAP?
  • Skin irritation, sores and bruises from mask.
    • You may be applying the mask too tight . There should be enough space between the mask and facial skin to slip in two fingers.
    • Your mask cushion may need replacing
    • Mask liners may help to resolve skin irritation and leak.
    • You could try nasal pillows.
  • Waking up without mask on but having no memory of removing it.
    • This is mostly due to you removing the mask during sleep due to mask discomfort or leak
    • Get mask fit checked by CPAP provider.
    • Attend to other factors that are causing mask discomfort and leak.
  • Eyes getting swollen and irritated or red eyes.
    • This indicates leak from the top part of your mask.
    • Gently tighten the top mask straps making sure not to tighten too much.
    • May indicate a worn mask cushion that needs replacing
  • Feeling claustrophobic
    • Can try nasal pillows.
  • Mask leak
    • See how you can fix your mask securely below.
  • Mask causing a whistling noise
    • Masks have exhalation ports that allows exhaled air to escape . These tiny holes can get clogged by body oil
    • Clean mask and use a toothpick to clean these tiny holes.
  • Getting entangled in tubing
    • Have tubing over your head, hang it over the bed post.
  • Exhalation ports of mask getting blocked when head sinks deep into pillow.
    • Use a firm pillow than softer pillows.
    • Also there are special pillows designed for CPAP users.
  • CPAP is causing dry mouth/throat, runny or stuffy nose, sneezing
    • A humidifier will sort these issues to a certain extent.
    • Start with lowest humidifier setting and turn up as needed for moisture.
    • Simple saline nasal spray will help with nasal dryness.
  • Water in CPAP tubing
    • This happens when temperature in the bed room is cooler than air coming out of CPAP device.
    • Insulating tube covers will resolve this problem
  • Water spill from humidifier to CPAP device
    • Always remove water chamber unit from CPAP device before filling with distilled water.
  • CPAP pressure too high symptoms and side effects can include:
    • Uncomfortable CPAP therapy.
    • Significant air leaks from your mask.
    • Mouth breathing.
    • Dry mouth and throat, even when you are using heated humidification.
    • Swallowing air.
    • Most people with OSA need CPAP pressures between 6-14 cm H20 for control of apneas
      • The average pressure needed is around 10 cm H20
  • CPAP pressure too low symptoms,
    • These users will continue to experience the negative effects of sleep apnea, including poor sleep, waking up gasping for air, feeling air-starved, feeling tired.
    • Another sign your air pressure may be too low is continuing to snore loudly during your CPAP therapy.
Mask fit adjustment tips

Mask leak is one of the commonest problems. To ensure proper fit use the following guide.

  • When retiring to sleep sit on your bed and place the mask on your face with straps loose.
  • Turn the CPAP device on.
  • Lay down on the pillow in your normal sleeping position.
  • Slowly tighten mask straps until you get a good seal , do not tighten too much ( you should be able to slip two fingers between mask strap and facial skin.
  • After the straps are adjusted pull the mask away from your face ( about 2 inches) and gently allow to settle back on face. This will allow the dual mask cushion to inflate and assure the best possible seal.
  • Mask fit varies with sleeping position, may need readjusting if you roll on your back.
  • This is best avoided by training yourself to sleep on a side.

Bi-level Positive Airway Pressure devices (BPAP)

BPAP devices produces two levels of pressure. A higher level of pressure during breathing in (inspiration) and a lower level of pressure during breathing out (exhalation). Pressure applied during inspiration is called IPAP and pressure applied during exhalation is called EPAP.

  • BPAP devices are useful in patients who require,
    • High PAP settings (more than 20 cm water).
    • Find exhalation difficult against CPAP devices.
    • Those who do not breath due to poor effort.
    • Obesity Hypoventilation Syndrome (OHS).
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