Most of us assume snoring and sleep apnea is due to being overweight. The reality is that sleep apnea can happen to anyone, and you shouldn't ignore it. There are many risk factors, potential causes, and treatments.
Obstructive sleep apnea can be a daunting problem. The first step is usually determining whether the patient is just making noise at night with snoring, or if there is a real diagnosis of obstructive sleep apnea.
Without proper diagnosis and treatment, obstructive sleep apnea may lead to serious health problems such as heart disease, hypertension, diabetes, stroke, and more. Obstructive sleep apnea places undue stress on our bodies with a lack of oxygen, increasing levels of carbon dioxide, and increased levels of inflammation.
Conservative therapy is preferred by far as the initial approach. If surgery is indicated, it is important to carefully consider all options. In some cases, the best approach is no upper airway surgery at all and bariatric surgery instead.
Keep in mind that even in the best situations, with the best surgeon and surgical results, continual conservative measures such as CPAP or BIPAP may still be necessary afterward. Once the upper airway is altered by surgery, the body must adjust to the new setpoint on the sleep and respiratory thermostat.
There are also distinct kinds of sleep apnea, but this article focuses on the most common type, called obstructive sleep apnea where there is a blockage of the upper airway.
Sleep and obstructive sleep apnea
Sleep is our body’s rest and recharging cycle. It is essential to excellent health, although good sleep health is ill-defined and variable. Our sleep continuity, quantity, and timing are usually how we judge if we had a good night's sleep.
Proper sleep can be multidimensional, affecting our overall health, combining our behavioral health, physiological being, and mental state, all with our eyes closed. We alternate between sleep and wakefulness in a recurring pattern that supposedly reflects coordinated positive changes to our dynamic functioning brains.
The hope is that sleep restores us. Sleeping encompasses genetic, social, environmental, behavioral, and many health care factors, including potentially setting us up for disease if we fail to get the requisite sleep. When we have a disturbance of sleep, particularly if we can never really get enough sleep, there is a disruption in our homeostatic and circadian processes. This is important because we have an internal thermostat that keeps us in a relatively stable equilibrium, and some of that has to do with simple things like whether it is light or dark.
This can be a problem for people who are blind, for example, since they cannot tell if it is time for sleep or not. When a body is unable to determine day or night, it is called non-24 sleep-wake disorder.
A more widespread problem occurs when our breathing stops and restarts during sleep, preventing us from getting enough oxygen and forcing us to wake up or never really fall asleep. This occurs with blockage of our upper airway or obstructive sleep apnea.
Obstructive sleep apnea can be associated with the loud rattle of snoring as our airflow is reduced or completely stopped, or it can be more ominous and involve only a whisper. The most critical features of the diagnosis and treatment of obstructive sleep apnea include:
- The severity of the problem.
- What effect any potential change in the person’s upper airway will have on their internal sleep and respiratory thermostat.
It is significant to note that people with obstructive sleep apnea, especially those with severe physical obstruction, live with their respiratory thermostats set too high. Any change to the thermostat settings, such as getting surgery, may be serious and even life-threatening. In other words, there are potential risks and no easy solutions.
For these reasons, upper airway surgery can be one of the most challenging aspects of medicine. Potential surgery is not to be taken lightly just because of a spouse or family's frustration of trying to fix someone’s loud snoring, or as we refer to it in the clinic "heroic snoring.”
What are the typical symptoms of obstructive sleep apnea?
- Mental, such as poor concentration, forgetfulness, grouchiness.
- Waking up gasping for air.
- Getting up to urinate.
- Night sweats.
- Sexual dysfunction.
Testing for obstructive sleep apnea
Patients who present with loud snoring and many of the above symptoms require a thorough history and physical examination. The physical exam of the upper airway is crucial. It is best performed by an Otolaryngologist-Head and Neck Surgeon or ENT.
Every part of the upper airway should be investigated, including everything from the air entering the mouth and nose down to the person’s larynx or voice box. It means more than just telling the patient to open their mouth and say “ah.”
The examination should include an assessment of the nasal airway, including the wall separating the two sides called the septum and the nasal lining called the turbinates. Any nasal polyps or sinus obstruction should be addressed.
The critical area where the air from the mouth and nose meets in the back of the throat called the pharynx should be examined. There is a ring of tissue in this area, which includes the back of the tongue, tonsils, and palate. Most surgical treatments attempt to alleviate the floppiness of tissue in this area. In some cases, a flexible fiberoptic endoscope is used for visualization.
With a positive history and suspicious physical exam, the best way to confirm a diagnosis of obstructive sleep apnea involves a polysomnogram or sleep study. There are many ways to have a sleep study today. The traditional process is to go to a sleep center, sleep, and have continuous monitoring. The latest methods include at-home sleep monitoring. Choosing the right sleep study for you is a discussion for you and your doctor.
The sleep study will provide many different physiological readings. The most important ones include the frequency and timing of your stopping breathing during sleep. Most people with suspected sleep apnea will stop breathing for less than 10 seconds. This is called a hypopnea.
True apnea is defined as stopping breathing for 10 seconds or longer. Think about that for a moment: 10 seconds is a long time.
Your doctor will take the results of your sleep study and combine that information with your history and physical examination to determine the best course of action for you. Sometimes, that means adopting healthier lifestyle changes such as regular physical activity, better sleep habits, limiting alcohol consumption, quitting smoking, and maintaining a healthy weight.
Other treatment options
- Breathing devices, such as CPAP or BiPAP machine that provide continuous positive airway pressure.
- Oral appliances or mouth guards.
- Oral facial therapy exercises, which are minimally effective in most moderate/severe cases.
Surgical procedures, including:
- UPPP (uvulopalatopharyngoplasty), which is restructuring of the soft palate and uvula.
- Tonsillectomy or adenoidectomy, sometimes included with UPP.
- Radiofrequency reduction of the base of the tongue or palate, called a somnoplasty.
- Nasal surgery, which is used to augment, not replace other procedures.
- Surgical implants in the back of the throat that monitor breathing and stimulation of the tongue muscles to keep your airway open. It is the newest procedure and only recommended for select patients.
- Maxillary or jaw advancement surgery.
- Bariatric (weight loss) surgery.
- Tracheotomy, a placement of a tube in windpipe that is only for the most severe cases or surgical failures.