Sleep Medicine: some medical conditions can interrupt your normal sleeping patterns, without you even being aware of them. These medical conditions never let you reach a deep and restful state of sleep as you should. As a result, you may never feel completely refreshed when you wake up in the morning. You may feel extremely sleepy during the day. Your energy and concentration levels may be affected. You may have trouble staying awake on the job, at home, or in the car. The only way your physician can find out if you have one of these sleep conditions is to test your sleep during a Sleep Study.
Sleep Apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly and you feel tired even after a full night's sleep. There are multiple causes for sleep apnea and more than one treatment. Take the Epworth Sleepiness Scale to determine if you may have sleep apnea.
If you are getting ready for a sleep study please access the Patient Corner Tab and submenu Sleep Study to access information and preparatory forms for your Sleep Study.
I. There are two types of Sleep Apnea:
1. Obstructive Sleep Apnea, the more common form that occurs when throat muscles relax.
2. Central Sleep Apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing.
II. The signs and symptoms of Obstructive and Central Sleep Apnea overlap, sometimes making the type of Sleep Apnea more difficult to determine. The most common signs and symptoms of Obstructive and Central Sleep Apnea include:
• Excessive daytime sleepiness (Hypersomnia)
• Loud snoring, which is usually more prominent in Obstructive Sleep Apnea
• Episodes of breathing cessation during sleep witnessed by another person
• Abrupt awakenings accompanied by shortness of breath, which more likely indicates Central Sleep Apnea
• Awakening with a dry mouth or a sore throat
• Morning headache
• Difficulty staying asleep (Insomnia)
• Attention problems
III. A medical professional should be consulted if you experience, or if your partner notices the following:
• Snoring loud enough to disturb the sleep of others or yourself
• 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
Many people don't think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores.
But be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence (delayed breathing).
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.
IV. Complications of Sleep Apnea
Sleep Apnea is considered a serious medical condition. Complications may include:
• High Blood Pressure or Heart Problems
Sudden drops in blood oxygen levels that occur during Sleep Apnea increase blood pressure and strain the cardiovascular system. If you have Obstructive Sleep Apnea, your risk of high blood pressure (Hypertension) is greater. However, Obstructive Sleep Apnea increases the risk of stroke, regardless of whether or not you have high blood pressure. If there's underlying heart disease, these multiple episodes of low blood oxygen (Hypoxia or Hypoxemia) can lead to sudden death from a cardiac event. Studies also show that Obstructive Sleep Apnea is associated with increased risk of atrial fibrillation, congestive heart failure, and other vascular diseases. In contrast, Central Sleep Apnea usually is the result, rather than the cause, of heart disease.
• Daytime Fatigue
The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue, and irritability. You may have difficulty concentrating and find yourself falling asleep at work while watching TV or even when driving. You may also feel irritable, moody or depressed. Children and adolescents with sleep apnea may do poorly in school or have behavior problems.
• Complications with Medications and Surgery
Obstructive Sleep Apnea is also a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea and how it's treated. Undiagnosed sleep apnea is especially risky in this situation.
• Liver Problems
People with sleep apnea are more likely to have abnormal results on liver function tests, and their livers are more likely to show signs of scarring.
• 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 go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep-deprived as well.
People with Sleep Apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, a need to urinate frequently at night (Nocturia), and a decreased interest in sex.
V. Helpful Lifestyle Modifications
In many cases, self-care may be the most appropriate way for you to deal with Obstructive Sleep Apnea and possibly Central Sleep Apnea. Try these tips:
• Lose excess weight
Even a slight loss in excess weight may help relieve constriction of your throat. Sleep Apnea may be cured in some cases by a return to a healthy weight. If you don't already have a weight-loss program, talk to your doctor about the best course of action for weight loss.
Getting 30 minutes of moderate activity, such as a brisk walk, most days of the week may help ease Obstructive Sleep Apnea symptoms.
• Avoid alcohol and certain medications such as tranquilizers and sleeping pills near bedtime
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
Use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using any nasal decongestants or antihistamines because these medications are generally recommended only for short-term use.
• Stop smoking, if you're a smoker
POLYSOMNOGRAPHY (Sleep Study)
A Sleep Study is a medical diagnostic study to find out if you are getting a restful night's sleep. The Polysomnogram measures bodily functions during sleep. 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. Each test may vary depending on the patient's specific needs.
The measurements use electrodes that are attached to the body:
- Brain Waves (skin surface electrodes on the head)
- Eye Movements (skin surface electrodes above and below the eyes)
- Muscle Tension (skin surface electrodes on the legs)
- Leg Movements (skin surface electrodes on the legs)
- Breathing Sounds (air movement sensors attached near the nose and mouth)
- Blood Oxygen Levels (a small sensor is attached to the ear, finger or toe).
The Electrode Sensors and Monitoring Equipment will be attached to your body with tape or paste prior to bedtime. These sensors transmit output data to a computerized recording that is continuously monitored by a qualified Technologist. The Technologist will be monitoring and documenting throughout the night and will be available to assist you with trips to the restroom, if needed. You may also be video/audio monitored to document sleep position, snoring, and any other activity that occurs throughout the night (it is NOT recorded). If your Physician has ordered a “Split Night Study”, the Technologist will prepare you for the possibility of using CPAP (Continuous Positive Airway Pressure) Therapy after approximately 2 hours of diagnostic monitoring. CPAP is a therapy used to treat Obstructive Sleep Apnea. Positive Air Pressure is delivered through a nasal or nasal/oral mask and splints open the airway. This positive pressure will prevent obstruction or collapsing of the airway which causes apnea (pauses in breathing). During this portion of the testing, the Technologist will adjust the levels of air pressure to determine which level best works for you.
WHAT TO EXPECT
Sleep Studies are usually performed at night. When you arrive at your scheduled time, the Sleep Study Technologist will set up monitoring equipment at your bedside. The Sleep Study Technologist will be in your room for about forty-five minutes to an hour, setting up the sleep monitoring equipment. The Technologist will help you understand the sleep study process, and will be happy to answer any questions you may have at that time. The Technologist will attach soft electrode patches to your head, face chest, and legs, and connect the patches to the monitoring equipment. The Technologist will also wrap two belts around your chest and stomach. You will experience no discomfort during this process.
The monitors will record your life signs - your brainwaves, your breathing, movements and any possible snoring while you are asleep. If you have any difficulty sleeping, the monitors will record this difficulty. Likewise, if you have no difficulty sleeping, the monitors will record a perfect picture of your sleep patterns.
The Sleep Study is completely painless. Remember that the purpose of the study is to measure the way you normally sleep. If the sleep study were to be uncomfortable in any way, your doctor could not get a normal picture of your sleep patterns. Most people find that undergoing a sleep study is a new and interesting experience. If you need help sleeping, a medication can be prescribed for you prior to the study. The Technologist cannot provide a sleep aid for you if you did not bring one. You will be able to change positions while sleeping and if you need to use the restroom, the Technologist will quickly unhook the main wire and reattach it when you are done.
When you are woken up in the morning, the sleep study will be over. The monitors will contain an entire night's information on how you have slept. The Sleep Study Technologist will come to your room and unhook the wires. Once read, the physician reading the study will send a printed report of your sleep patterns to your physician. This usually takes several business days.
Your physician will look at your Sleep Study results and decide whether you need a second Sleep Study with CPAP. If you do need additional help sleeping, your physician will discuss different ways to help you get the sleep you need.
EPWORTH SLEEPINESS SCALE
|Situation||Chance of Dozing|
Refers to your usual way of life in recent times.
Even if you have not done some of these things recently, try to work out how they would have affected you.
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
|Sitting and Reading|
|Sitting, inactive, in a public place|
|As a passenger in a car for an hour|
|Lying down in the afternoon|
|Sitting quietly after lunch without alcohol|
|In a car, while stopped for a few minutes in traffic|
Score of 1-6: You're getting enough sleep
Score of 4-8: You tend to be sleepy during the day; this is the average score
Score of 9-15: You are very sleepy and should seek medical advice
Score of 16 or greater: You are dangerously sleepy and should seek medical advice
OBSTRUCTIVE SLEEP APNEA
Obstructive Sleep Apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), the tonsils, and the side walls of the throat and tongue. When the muscles relax, your airway narrows or closes as you breathe in, and you can't get an adequate breath in. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so you can reopen your airway. This awakening is usually so brief that you don't remember it. You may make a snorting, choking or gasping sound. This pattern can repeat itself 5 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, some people with this type of Sleep Apnea think they sleep well all night.
II. Risk Factors
• Excess weight
Fat deposits around your upper airway and it may obstruct your breathing. However, not everyone who has Sleep Apnea is overweight. Thin people develop this disorder too.
• Neck Circumference
People with a thicker neck may have a narrower airway.
• A Narrowed Airway
You may have inherited a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.
• Being Male
Men are twice as likely to have Sleep Apnea. However, women increase their risk if they're overweight, and their risk also appears to rise after menopause.
• Being Older
Sleep Apnea occurs significantly more often in adults older than 60.
• Family History
If you have family members with Sleep Apnea, you may be at increased risk.
In people under 35 years old, blacks are more likely to have Obstructive Sleep Apnea.
• Use of Alcohol, Sedatives or Tranquilizers
These substances relax the muscles in your throat.
Smokers are three times more likely to have Obstructive Sleep Apnea than people who've never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. These risks likely drop after you quit smoking.
• Nasal Congestion
If you have difficulty breathing through your nose — whether it's from an anatomical problem or allergies — you're more likely to develop Obstructive Sleep Apnea.
• Continuous Positive Airway Pressure (CPAP)
If you have moderate to severe Sleep Apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air and is just enough to keep your upper airway passages open, preventing sleep apnea and snoring.
Although CPAP is the most common and reliable methods of treating Sleep Apnea, some people find it cumbersome or uncomfortable. Many people give up on CPAP. But with some practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit. You may need to try more than one type of mask to find one that's comfortable. Some people benefit from also using a humidifier along with their CPAP system.
Don't just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. Additionally, contact your doctor if you are still snoring despite treatment or if you begin snoring again. If your weight changes, the pressure settings may need to be adjusted.
• Adjustable Airway Pressure Devices
If CPAP continues to be a problem for you, you may be able to use a different type of airway pressure device that automatically adjusts the pressure while you're sleeping. For example, units that supply Bi-Level Positive Airway Pressure (BPAP) are available. These provide more pressure when you inhale and less when you exhale.
• Expiratory Positive Airway Pressure (EPAP)
This is the most recent treatment approved by the Food and Drug Administration (FDA). These small, single-use devices are placed over each nostril before you go to sleep. The device is a valve that allows air to move freely in, but when you exhale, air must go through small holes in the valve. This increases pressure in the airway and keeps it open. This device helps reduce snoring and daytime sleepiness when compared to a sham device. And it may be an option for some who can't tolerate the CPAP.
• Oral Appliances
Another option is wearing an oral appliance designed to keep your throat open. CPAP is more reliably effective than oral appliances, but oral appliances may be easier to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild Obstructive Sleep Apnea. A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you'll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure the fit is still good and to reassess your signs and symptoms.
Surgery is usually only an option after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for those few people with certain jaw structure problems, it's a good first option. The goal of surgery for Sleep Apnea is to enlarge the airway through your nose or throat that may be vibrating and causing you to snore or that may be blocking your upper air passages and causing Sleep Apnea.
Surgical Options may include:
o Tissue removal. During this procedure, which is called Uvulopalatopharyngoplasty (UPPP), your doctor removes tissue from the rear of your mouth and the top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. However, it may be less successful in treating Sleep Apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general Anesthetic. Removing tissues in the back of your throat with a laser (Laser-Assisted Uvulopalatoplasty) isn't a recommended treatment for Sleep Apnea. Radiofrequency Energy (Radiofrequency Ablation) may be an option for people who are unable to tolerate CPAP or oral appliances.
- o Jaw Repositioning. In this procedure, your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure, which is known as Maxillomandibular Advancement, may require the cooperation of an oral surgeon and an Orthodontist, and at times may be combined with another procedure to improve the likelihood of success.
o Implants. Plastic Rods are surgically implanted into the soft palate while you're under local anesthetic. This procedure may be an option for those with snoring or milder Sleep Apnea who can't tolerate the CPAP.
o Tracheostomy (Creating a New Air Passageway). You may need this form of surgery if other treatments have failed and you have severe, life-threatening Sleep Apnea. In this procedure, 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.
o Other types of surgery may help reduce snoring and contribute to the treatment of sleep apnea by clearing or enlarging air passages:
• Nasal Surgery to remove polyps or straighten a crooked partition between your nostrils (Deviated Nasal Septum)
• Surgery to remove enlarged tonsils or adenoids
CENTRAL SLEEP APNEA
Central Sleep Apnea, which is much less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or have a difficult time getting to sleep or staying asleep. Like with Obstructive Sleep Apnea, snoring and daytime sleepiness can occur. The most common cause of Central Sleep Apnea is heart failure and less commonly, a stroke. People with Central Sleep Apnea may be more likely to remember awakening than are people with Obstructive Sleep Apnea.
II. Risk factors
• Being Male
Males are more likely to develop Central Sleep Apnea.
• Being Older
People older than 65 years of age have a higher risk of having Central Sleep Apnea, especially if they also have other risk factors.
• Heart Disorders
People with atrial fibrillation or congestive heart failure are more at risk of Central Sleep Apnea.
• Stroke or Brain Tumor
These conditions can impair the brain's ability to regulate breathing.
III. Treatments for Central and Complex Sleep Apnea may include:
• Treatment for Associated Medical Problems
Possible causes of Central Sleep Apnea include heart or neuromuscular disorders and treating those conditions may help. For example, optimizing therapy for heart failure may eliminate Central Sleep Apnea.
• Supplemental Oxygen
Using Supplemental Oxygen while you sleep may help if you have Central Sleep Apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs.
• Continuous Positive Airway Pressure (CPAP)
This method, also used in Obstructive Sleep Apnea, involves wearing a pressurized mask over your nose while you sleep. The mask is attached to a small pump that forces air through your airway to keep it from collapsing. CPAP may eliminate snoring and prevent Sleep Apnea. As with Obstructive Sleep Apnea, it's important that you use the device as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made.
• Bi-Level Positive Airway Pressure (BPAP)
Unlike CPAP, which supplies steady and constant pressure to your upper airway as you breathe in and out, BPAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale. The goal of this treatment is to assist the weak breathing pattern of Central Sleep Apnea. Some BPAP devices can be set to automatically deliver a breath if the device detects you haven't taken one after so many seconds.
• Adaptive Servo-Ventilation (ASV)
This more recently approved airflow device learns your normal breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to normalize your breathing pattern and prevent pauses in your breathing. ASV appears to be more successful than other forms of positive airway pressure for treating Central Sleep Apnea in some people.