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Obstructive sleep apneaBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/obstructive-sleep-apnea/DS00968
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|Obstructive sleep apnea|
Obstructive sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts during sleep. Several types of sleep apnea exist, but the most common type is obstructive sleep apnea, which occurs when your throat muscles intermittently relax and block your airway during sleep. The most noticeable sign of obstructive sleep apnea is snoring.
Anyone can develop obstructive sleep apnea, although it most commonly affects middle-aged and older adults and people who are overweight. Obstructive sleep apnea treatment may involve using a device to keep your airway open or using a mouthpiece to thrust your jaw forward during sleep. Some undergo a procedure to change the structure of their nose, mouth or throat.
Signs and symptoms of obstructive sleep apnea include:
- Excessive daytime sleepiness (hypersomnia)
- Loud snoring
- Observed episodes of breathing cessation during sleep
- Abrupt awakenings accompanied by shortness of breath
- Awakening with a dry mouth or sore throat
- Morning headache
- Difficulty staying asleep (insomnia)
- Difficult-to-control high blood pressure
When to see a doctor
Consult a medical professional if you experience, or if your partner observes, the following:
- Snoring loud enough to disturb your sleep or that of others
- Shortness of breath that awakens you from sleep
- Intermittent pauses in your breathing during sleep
- Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving a vehicle
Many people don't think of snoring as a sign of something potentially serious, and not everyone who snores has obstructive sleep apnea. But be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence. With obstructive sleep apnea, snoring typically is loudest when you sleep on your back, and it quiets when you turn on your side.
Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.
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|Obstructive sleep apnea|
Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula — a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.
When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.
You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths, although this sequence is rare. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.
People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they slept well all night.
Anyone can develop obstructive sleep apnea. However, certain factors put you at increased risk, including:
- Being overweight. More than half of those with obstructive sleep apnea are overweight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has obstructive sleep apnea is overweight and vice versa. Thin people can develop the disorder, too.
- Having a large neck. The size of your neck may indicate whether you have an increased risk. A thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17 inches (43 centimeters) for men and 15 inches (38 centimeters) for women is associated with an increased risk of obstructive sleep apnea.
- Having high blood pressure (hypertension). Obstructive sleep apnea is relatively common in people with hypertension.
- Having a narrowed airway. You may inherit a naturally narrow throat. Or your tonsils or adenoids may become enlarged, which can block your airway.
- Having chronic nasal congestion. Obstructive sleep apnea occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways.
- Having diabetes. Obstructive sleep apnea is three times more common in people who have diabetes.
- Being male. In general, men are twice as likely to have obstructive sleep apnea.
- Being black, Hispanic or Pacific Islander. Among people under age 35, obstructive sleep apnea is more common in blacks, Hispanics and Pacific Islanders.
- Being older. Obstructive sleep apnea occurs two to three times more often in adults older than 65.
- Being postmenopausal. A woman's risk appears to increase after menopause.
- Having a family history of sleep apnea. If you have family members with obstructive sleep apnea, you may be at increased risk.
- Using alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.
- Smoking. Smokers are more likely to have obstructive sleep apnea.
Obstructive sleep apnea is considered a serious medical condition. Complications may include:
- Cardiovascular problems. Sudden drops in blood oxygen levels that occur during obstructive sleep apnea increase blood pressure and strain the cardiovascular system. Many people with obstructive sleep apnea develop high blood pressure (hypertension), which raises the risk of heart failure and stroke. The more severe the obstructive sleep apnea, the greater the risk of high blood pressure. People with obstructive sleep apnea are much more likely to develop abnormal heart rhythms such as atrial fibrillation. If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) could lead to sudden death from a cardiac event.
- Daytime fatigue. The repeated awakenings associated with obstructive sleep apnea make normal, restorative sleep impossible. People with obstructive sleep apnea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving. Children and young people with obstructive sleep apnea may do poorly in school, have reduced mental development or have behavior problems. Treatment of obstructive sleep apnea can improve these symptoms, restoring alertness and improving quality of life.
- Complications with medications and surgery. Obstructive sleep apnea also is a concern with certain medications and general anesthesia. If you have obstructive sleep apnea, you may be more likely to experience complications after major surgery because you're prone to breathing problems, especially when sedated and lying on your back. Before you have surgery, tell your doctor if you have obstructive sleep apnea. Undiagnosed obstructive sleep apnea is especially risky in this situation.
- Eye problems. Some research has found a connection between obstructive sleep apnea and certain eye conditions, such as glaucoma and optic nerve swelling (papilledema). Successful treatment of the sleep disorder usually resolves the eye condition, as well.
- Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to choose to sleep in another room. Many bed partners of people who snore are sleep deprived as well.
People with obstructive sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, and a need to urinate frequently at night (nocturia).
Preparing for your appointment
If you suspect that you have obstructive sleep apnea, you'll likely first see your family doctor or a primary care doctor. Your doctor may refer you to a sleep specialist.
It's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and to know what to expect from your doctor.
What you can do
- Be aware of any pre-appointment requests. When you make your appointment, ask if there's anything you need to do in advance, such as keeping a sleep diary. In a sleep diary, you record your sleep patterns — bedtime, number of hours slept, nighttime awakenings and awake time — as well as your daily routine, naps and how you feel during the day. You may be asked to record a sleep diary for one to two weeks.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for your appointment.
- Write down key personal information, including new or ongoing health problems, major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements you're taking. Include anything you've taken to help you sleep.
- Take your bed partner along, if possible. Your doctor may want to talk to your partner to learn more about how much and how well you're sleeping.
- Write down questions to ask your doctor. Preparing a list of questions can help you make the most of your time with your doctor.
For obstructive sleep apnea, some basic questions to ask your doctor include:
- What is likely causing my symptoms?
- Other than the most likely cause, what are other possible causes for my symptoms?
- Is my condition likely temporary or chronic?
- What kinds of tests do I need?
- Should I go to a sleep clinic?
- What is the best course of action?
- What are the alternatives to the primary approach that you're suggesting?
- Are there any restrictions that I need to follow?
- I have other health conditions. How can I best manage them together?
Don't hesitate to ask other questions that occur to you.
What to expect from your doctor
A key part of the evaluation of obstructive sleep apnea is a detailed history, meaning your doctor will ask you many questions. These may include:
- When did you begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- Do you snore? If so, does your snoring disrupt anyone else's sleep?
- How often do you snore? Do you snore in all sleep positions or just when sleeping on your back?
- Do you ever snore, snort, gasp or choke yourself awake?
- Has anyone ever seen you stop breathing during sleep?
- How refreshed do you feel when you wake up?
- Do you experience headache or dry mouth upon awakening?
- Are you tired during the day?
- Do you doze off or have trouble staying awake while sitting quietly or driving?
- Do you nap during the day?
- Do you use tobacco or drink alcohol?
- Do you worry about falling asleep or staying asleep?
- Do you have any family members with sleep problems?
- What medications do you take?
What you can do in the meantime
- Try to sleep on your side. Most forms of obstructive sleep apnea are milder when you sleep on your side.
- Avoid drinking alcohol close to bedtime. Alcohol worsens obstructive sleep apnea.
- If you're drowsy, avoid driving. If you have obstructive sleep apnea you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. To be safe, schedule rest breaks. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving.
Tests and diagnosis
Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help decide whether you need further evaluation. The evaluation may involve overnight monitoring of your breathing and other body functions during sleep. Tests to detect obstructive sleep apnea include:
- Nocturnal polysomnography. During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. This can help your doctor rule out other conditions — such as periodic limb movements or narcolepsy — that can also cause excessive daytime sleepiness, but require different treatment.
- Oximetry. This screening method involves using a small machine that monitors and records your blood oxygen level while you're asleep. A simple sleeve fits painlessly over one of your fingers to collect the information overnight at home. If you have obstructive sleep apnea, the results of this test will often show drops in your blood oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may have you undergo polysomnography to confirm the diagnosis. Oximetry doesn't detect all cases of obstructive sleep apnea, so your doctor may still recommend a polysomnogram even if the oximetry results are normal.
- Portable cardiorespiratory testing. Under certain circumstances, your doctor may provide you with at-home tests to diagnose obstructive sleep apnea. These tests usually involve oximetry, measurement of airflow and measurement of breathing patterns.
Your doctor also may refer you to an ear, nose and throat doctor to rule out any anatomic blockage in your nose or throat.
Treatments and drugs
For milder cases of obstructive sleep apnea, your doctor may recommend lifestyle changes:
- Lose weight.
- Drink alcohol moderately, if at all, and don't drink several hours before bedtime.
- Quit smoking.
- Use a nasal decongestant.
- Don't sleep on your back.
If these measures don't improve your sleep or if your apnea is moderate to severe, other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.
Positive airway pressure. If you have obstructive sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. The most common type is called continuous positive airway pressure, or CPAP (SEE-pap). With this treatment, the pressure of the air breathed is continuous and somewhat greater than that of the surrounding air, which is just enough to keep your upper airway passages open. This prevents obstructive apnea and snoring.
There are two types of CPAP — fixed and autotitrating. Fixed CPAP delivers airway pressure at a constant level. Autotitrating adjusts the level of pressure if it senses increased airway resistance.
Although CPAP is the most consistently successful and most commonly used method of treating obstructive sleep apnea, some people find it cumbersome and uncomfortable. With some practice, most people learn to adjust the mask to obtain a comfortable and secure fit. You may need to try different types to find a suitable mask. If you're having particular difficulties tolerating pressure, there are machines that have special adaptive pressure functions to improve comfort. Many people also benefit from using a humidifier along with their CPAP system.
There are also bilevel positive airway pressure (BPAP) appliances, which deliver a preset amount of pressure when you breathe in and a different amount of pressure when you breathe out. CPAP is more commonly used because it's been well studied for obstructive sleep apnea. For people who have difficulty tolerating fixed CPAP, BPAP or autotitrating CPAP may be worth a try.
Don't stop using your positive airway pressure machine if you have problems. Check with your doctor to see what adjustments you can make to improve its comfort. In addition, contact your doctor if you still snore despite treatment or begin snoring again. If your weight changes, your doctor may need to adjust the pressure settings.
Mouthpiece (oral device). While positive airway pressure is nearly always an effective treatment, oral appliances are a successful alternative for some people. These devices are designed to keep your throat open. Some do so by bringing your jaw forward, which can sometimes relieve snoring and obstructive sleep apnea. Others hold your tongue in a different position.
If you and your doctor decide to explore this option, you'll need to see a dentist experienced in dental sleep medicine appliances for the fitting and follow-up therapy. A number of devices are available. Close follow-up is needed to ensure successful treatment.
Surgery or other procedures
The goal of surgery for obstructive sleep apnea is to prevent blockage of the upper airway during sleep. Surgical options may include:
- Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids are commonly removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. UPPP usually is performed in a hospital and requires a general anesthetic.
- Jaw surgery. In this procedure, called maxillomandibular advancement, the upper and lower parts of your jaw are moved forward from the rest of your facial bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure requires an oral surgeon and possibly an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.
- Surgical opening in the neck. You may need this form of surgery if other treatments have failed and you have severe, life-threatening obstructive sleep apnea. In this procedure, called a tracheostomy, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.
- Implants. The Pillar procedure is a minimally invasive treatment that involves placement of three tiny polyester rods in the soft palate. These inserts stiffen and support the tissue of the soft palate and reduce upper airway collapse and snoring. This treatment is recommended only for people with mild obstructive sleep apnea.
Doctors sometimes remove tissue from the back of the throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) to treat snoring. However, these procedures aren't recommended for treating obstructive sleep apnea.
Other types of surgery may help reduce snoring and sleep apnea by clearing or enlarging air passages, including:
- Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
- Surgery to remove enlarged tonsils or adenoids
Lifestyle and home remedies
In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea. Try these tips:
- Lose weight. Even a slight loss of excess weight may help relieve constriction of your airway.
- Avoid alcohol and medications such as tranquilizers and sleeping pills. These relax the muscles in the back of your throat, interfering with breathing.
- Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.
- Keep your nasal passages open at night. If you have congestion, use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using nasal decongestants or antihistamines, because, unlike saline sprays, these medications are generally recommended only for short-term use.
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