Sleep Apnea……
The not so silent killer
“Doc, I’m tired all the time.”
Whenever patients tell me this, and I hear it often, it sets off a series of questions in my mind. So the first thing I try to do is find out what the patient means by “tired”.
“So when you tell me you’re tired, do you mean that you don’t have the physical energy to do something, or is it that you want to take a nap or maybe fall asleep in a meeting?”
“I can exercise no problem. But as the day goes on I get sleepy.”
As you can imagine this sets off a whole new series of other questions.
“How do you sleep, straight through the night or do you wake up often?”
“When you wake up in the morning, are you refreshed or do you wake up tired?”
“Do you snore?”
“Does your bed partner ever say that you hold your breath while you’re sleeping and then snore loudly after that?”
Sometimes the answer to that one is “ I don’t know, I snore so loud they sleep in another room.”
If a patient tells me that they snore, wake up tired and are progressively more sleepy throughout the course of the day, then at that point I’m pretty sure they have sleep apnea. One of the most telling suggestions that someone has sleep apnea is if their bed partner indeed hears them stop breathing for several or more seconds followed by very loud snoring. This is known as witnessed apnea.
So what is sleep apnea?
There are two types of sleep apnea. There is a central kind that comes from problems with your brain and there is the obstructive kind which revolves around problems with your upper airway. Today we’re going to be focusing on the latter, obstructive sleep apnea ( OSA).
OSA is a condition where patients actually hold their breath (apnea)while they’re sleeping to the point that their oxygen levels drop below 90%. This may or may not be associated with snoring. Sometimes patients don’t snore but simply don’t breathe deeply enough to maintain their oxygen level. So, in essence they’re just not taking deep enough breaths to fill up their lungs. This is called hypopnea.
Apnea means not breathing.
Hypopnea means you’re not breathing affectively or deeply enough
So why is sleep apnea important?
As I tell my patients, the snoring may be more important to your bed partner or perhaps your neighbors but that’s just the tip of the iceberg and is really an indication that there’s a bigger problem at hand.
If you’re holding your breath multiple times during the course of eight hours of sleep you are putting your body under tremendous amounts of physiologic stress.Your body was made to work with oxygen as fuel.
The lack of oxygen causes the release of multiple substances not the least of which are adrenaline and noradrenaline. Both of these substances will increase your heart rate and raise your blood pressure. Sometimes patients awaken in the middle of the night during one of these episodes and complain that they feel like their heart is racing.
In essence this is very similar to the flight or fight response . Your body is under physiologic stress so you release these hormones for you to escape, or fight. But when it comes to sleep apnea you can’t escape it or fight it….. unless you get treatment.
As a result of this abnormal physiology, sleep apnea has a variety of deleterious effects on your overall health. Here are just a few -
- Elevated blood pressure
- Elevated blood sugar
- Morning headaches
- Progressive damage to the lungs tissue resulting in shortness of breath with minimal activity
- Progressive weakening of the heart muscle that could result in congestive heart failure
- As a result of the damage to the heart muscle, you could be prone to life-threatening cardiac rhythm disturbances
- Memory loss
Regarding memory loss — it is my unproven theory that persistent untreated sleep apnea will result in oxygen deprivation damage to your brain which over time will lead to memory loss such as we see in dementia, like Alzheimer’s disease. I question whether or not this persistent oxygen deprivation (hypoxia) may be one of the triggers that causes the deposition of Tau proteins in the brain that lead to Alzheimer’s disease. Hopefully, one day we’ll find out.
In addition to the items mentioned above, you should also know that many patients with atrial fibrillation (type of heart rhythm problem that is very common) may have sleep apnea and sleep apnea may make it difficult to control. Likewise, about 50% of patients with congestive heart failure also have sleep apnea. All patients with congestive heart failure should have a sleep apnea study done and it should be treated if found. I usually do the same with my atrial fibrillation patients after taking their history and if I am suspicious that they have OSA.
What are the risk factors for sleep apnea?
Let me start by saying that although I will name some risk factors here, virtually anybody can have sleep apnea. Some of the classic risk factors of the following –
- Males or more likely than females
- Older age
- Obesity or being overweight (BMI greater than 25)
- Neck circumference greater than 17 inches
- A relatively small opening in the back of your throat compared to the size of your tongue
- Facial deformities such as a recessed chin (this is known as micrognathia)
- Family history of OSA
How do I know if I have sleep apnea?
If you think you might have sleep apnea there are several steps you should take. One thing you can do is take a very short questionnaire call the Epworth Screening Tool and bring the results to your doctor for further discussion. Here is a link to the tool for you to access.
A word of caution here. You should not be using this tool to diagnose yourself. You can have a normal score on the test and still have sleep apnea. A high score on the test makes it more likely that you do have sleep apnea. Nonetheless you should discuss the results regardless of what they are with your physician and come to a decision on further testing.
After meeting with your physician and discussing your case, the doctor may find that further testing is needed and that would mean that it’s time for a sleep apnea study. This is known as a polysomnogram.
There are many different types of sleep studies. Some of them are called multi-channel. This means that they monitor a series of inputs from your body during your sleep. For example, if you have a sleep study formally done at a sleep center, it will monitor how many breaths do you take a minute, your oxygen level in your blood, volume of your snoring, and also brainwave activity as well as leg movement during sleep. And someone is visually monitoring your sleep from a control room.
This type of testing tends to be more expensive than many times insurance companies don’t approve it right out of the gate. However there is good news. There is a similar test that can be done at home that is only monitoring a lesser number of inputs. And this is called ( wait for it!!) … a home sleep test.
It’s actually quite simple to do and I’ve done one myself. You’ll be sent a kit that includes the following -
- A belt that goes around your chest to monitor your respiratory rate and breathing effort
- A device that straps to your finger to monitor your oxygen level
- A nasal cannula that measures breathing patterns or airflow
- A recording device
You wear the device for one night at your house. Get up in the morning, turn it off, put it back in the shipping box and off it goes. You should have results back within two weeks which will be sent to your doctor.
So what happens if my test is negative but I still have symptoms?
This happens sometimes and will necessitate a discussion with your doctor about next steps. If based on your history they are firmly convinced that you do have sleep apnea it may require you to go and have a more detailed sleep test at a facility as mentioned above. This could also mean that you have some other type of sleep disturbance and they may want to send you to see a sleep specialist.
Those other sleep disturbances include the following:
- Restless leg syndrome
- Narcolepsy
- Obesity Hypoventilation Syndrome
- Idiopathic Hypersomnolence
- Central Sleep Apnea
I won’t get into the details on all of those disorders here but as you can see you would probably need a specialist to help figure out which one you had. Regarding idiopathic hypersomnia — this just means that you are tired all the time but we don’t have a reason why. The good news is that there is a treatment available via oral medication.
If I have OSA, what are my treatment options?
There are several treatment options for OSA. The gold standard is what is called Continuous Positive Airway Pressure ( CPAP).
When you have OSA, your airway essentially collapses while you are trying to breathe in, kind of like trying to drink through a straw while someone pinches it.
What CPAP does is to keep pressure inside of your airway continuously as the name implies, and therefore prevents it from collapsing. This allows for adequate air exchange both breathing in and breathing out.
A CPAP device sits on top of your bedside cabinet and usually has a humidifier attached to it so that you don’t dry out your airways. It attaches to you bye a hose and you either wear a mask or something called nasal pillows. Nasal pillows fit into your nasal cavity and I have found in my experience that patients tolerate nasal pillows much better than they do a full face mask. If you would like to see what these look like just Google CPAP devices and look at the images to get a feel for what is entailed.
Modern CPAP machines have some artificial intelligence built into them and we can make the settings vary from, for example, 4 to 20 cm of pressure. The machine will ramp up and establish the amount of pressure that you need to keep you breathing properly.
The problem with CPAP is that many patients quickly give up on it. In my opinion that’s a mistake. You need to learn how to get used to using it and there are many techniques that you can help you to do so.
One of the things I teach my patients is to begin by using it in the living room while you’re watching TV for about a half hour before you go to bed. If you just go to bed and put it on you’re going to be focused on what the machine feels like and it may be difficult for you to fall asleep.
Eventually you will become habituated to using it and as a friend of mine who has sleep apnea says “I never travel anywhere without it”. How serious is he about that last comment? Well let me just say that he once traveled to the arctic tundra of Quebec and ran his CPAP machine off of a generator while he was there because it’s been that much of a life-changing experience for him.
If you cannot tolerate the machine after using some habituation techniques, your other option is to have a custom fitted sleep apnea oral appliance. This is usually fitted for you by an oral surgeon. I’m not going to lie to you –these devices also take some getting used to. They are also not as good as the CPAP device for controlling your sleep apnea. Again, you can search for these on Google to see what you are getting yourself in to for OSA.
Surgery is a last option for sleep apnea and I almost never, ever recommend this. The surgery is called UvuloPalatinePharyngoPlasty (UPPP).
Why don’t I recommend it?
First of all it’s a big surgery. They have to remove your tonsils and adenoids if you have them, and they also have to go ahead and trim off some of the soft tissue from your pharynx area including your uvula ( that little punching bag that hangs down in back of your throat.) Don’t kid yourself, it’s a pretty big surgery. And on top of that there’s only about a 50% success ratio that it will work. As another friend of mine says, “there’s not a lot of juice left in that squeeze.”
Lately, you may have seen advertised on TV that there is a device that is implanted into your chest. This has some electrodes that then go ahead and stimulate the hypoglossal nerve. You can turn this device on and off with a handheld remote. Essentially what it does is stimulate that nerve to push your tongue forward and keep it off the back of your throat thereby trying to keep your airway open.
I am not a fan for a variety of reasons.
First and foremost, now we are implanting artificial devices into your body. There are risks with that, not the least of which could be infection.
Secondly, OSA is a complex problem. If you have a lot of other redundant or floppy tissue in your oropharynx, just by stimulating the tongue to move forward may not cure your problem. So if a patient really wanted this device I would refer them to sleep specialist to get their opinion.
If I lose weight will that cure my OSA?
That’s a very good question. In my experience the answer is no, it will not cure your sleep apnea but most likely it will make it better and may require you to use less pressure on your CPAP device if you use one. But is not a guarantee that your sleep apnea will go away.
How would you know if it got better or went away after losing significant amount of weight? We would need to repeat asleep test and see how are you do.
As you can see, OSA is a serious medical issue that needs to be addressed and is probably under diagnosed in our country.
As always, I hope you found this information helpful. The first step towards diagnosing this is to have a high index of suspicion that you may indeed have sleep apnea. Don’t be afraid to bring up the conversation with your physician and take the next steps.
Good luck in your health journey!
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Remember- the information I present is for your information only , and should not be used to diagnose or treat any medical condition. You should seek medical care from a qualified medical doctor.
Disclaimer- the words and opinions expressed are the author’s and his alone, and not those of his employer.
