Sleep Apnea - An ignored sleep disorder

Sleep apnea is a common sleep disorder in which a person's breathing is interrupted during sleep.

A person with this disease suddenly wakes up from sleep with a choking or snorting sound to restore the breath. 

Symptoms of Sleep Apnea

• Loud or frequent snoring
• Frequent breaks or pauses in breathing
• Choking or gasping sounds
• Daytime sleepiness or fatigue
• Unrefreshing sleep
• Dry Mouth
• Insomnia
• Morning headaches
• Nocturia (waking during the night to go to the bathroom)
• Difficulty concentrating
• Memory loss
• Decreased sexual desire
• High Blood Pressure
• Irritable & Depressed

A person suffering from Sleep Apnea might have some to many of the above-mentioned symptoms.

Why does Sleep Apnea occur

Our throat is surrounded by muscles that control the airway for breathing, speaking and swallowing. During sleep, these muscles relax, and this causes the throat to narrow. In most people, this narrowing of the throat does not affect breathing, but in others, it can cause snoring, sometimes with reduced or completely blocked airflow. 

Insufficient breathing causes oxygen levels to fall. Brain comes in action and send signals which awakes the person to activate the upper airway muscles. As the person awakens, he or she may move briefly, snort or snore, and take a deep breath. Less frequently, a person awake completely with a sensation of gasping or choking. 

Commonly, people fall back to sleep quickly, and thus do not remember the event. Many people with sleep apnea aren't aware of their abnormal breathing in sleep, and all patients underestimate how often their sleep is interrupted.

Types of Sleep Apnea

There are 2 types of Sleep Apnea:

Obstructive sleep apnea (OSA): The more common of the two forms of apnea, it is caused by a blockage of the airway, usually when the soft tissue in the back of the throat collapses during sleep. Risk factors for OSA include being overweight, a family history of the condition, allergies, a small airway, and enlarged tonsils.
Central sleep apnea: In this, the airway is not blocked, but the brain fails to signal the muscles to breathe, due to instability in the respiratory control centre.

Out of the 2, OSA is a more common form of Sleep Apnea accounting to more than 99% of total cases of Sleep Apnea. 

Facts on Sleep Apnea-

• Around 1 in 5 people have mild symptoms of obstructive sleep apnea (OSA), while 1 in 15 has moderate to severe symptoms.

• Approximately 18 million Americans have this condition, but only 20 per cent have been diagnosed and treated.

•  Risk of OSA is more in Menopausal and postmenopausal women

• Sleep apnea is an independent risk factor for hypertension (high blood pressure).

• While sleep apnea is more prevalent in those aged 50 years and above, it can affect people of all ages, including children.

Prevalence statistic country-wise

There are over 936 million people suffering from Sleep Apnea worldwide

America- Total population of the US is over 326 million. An estimated 22 Million people in the US suffer from moderate to severe sleep apnea.

• 10% of people mild OSA (AHI>5)
• 3.5% of people have moderate OSA (AHI>15)
• 4% have severe OSA (AHI>30)

Australia (the Year 2010)- 1.5 million Australians (8.9% of the population) suffered from Sleep Apnea.

India (2015)- As per an estimate by Philips Healthcare India, India is suspected to have over 91 million people suffering from sleep apnea. Despite being a common disease, a large number of OSAS cases, an estimated 82%, are not diagnosed due to lack of diagnostic facilities. According to a study conducted in India, around 6.4% of the adult Indian population suffered from snoring and prevalence of OSA was 3.42%. 

Interesting report on sleep apnea prevalence in India

As per a study (in 2017) carried out by India's one of the top hospital All India Institute of Medical Sciences (AIIMS)  reveals that Obstructive Sleep Apnea (OSA) prevalence is around 15-20 per cent in Delhi's private school's students in comparison to mere 2 per cent students in government schools. Speaking on the causes behind the high presence of OSA among the students of private students, AIIMS director said: "Students in private schools have a poor diet, lifestyle in comparison to students in government schools. Data also shows that government school students have more physical activities such as walking."

Ref: https://www.news18.com/news/india/15-20-delhi-private-school-students-have-sleep-apnea-aiims-study-1402041.html

The Philippines - The prevalence of OSA is higher in the country and is estimated to be around 8 to 13 per cent of the population.

China - Prevalence of most common form of sleep apnea is around 1 in every 5 people.

Risk Factors of Obstructive sleep apnea (OSA)

Male gender 
• Obesity
• Central (abdominal) obesity 
• Neck circumference 
• Hypertrophied tonsils, tongue, retrognathia, micrognathia 
• Nasal congestion 
• Endocrine abnormalities: hypothyroidism/acromegaly 
• Anatomical abnormalities of the craniofacial region (e.g.Treacher-Collins syndrome, Pierre Robbin's syndrome) 
• Down’s syndrome 
• Genetic predisposition 
• Familial aggregation 
• Menopause 
• Polycystic ovarian syndrome 
• Drugs e.g., alcohol, benzodiazepines, muscle relaxants, testosterone therapy

Risk of Cancer in Women- As per the latest research women with OSA are more likely to be diagnosed with cancer than men with this condition. "Our study of more than 19,000 people shows that the severity of OSA is linked to a cancer diagnosis," said study lead author Athanasia Pataka, Assistant Professor at Aristotle University of Thessaloniki in Greece. The researchers analysed data from 19,556 people ( 5789 women and 13,767 men) in the European Sleep Apnoea Database to figure out relation between OSA, low blood oxygen levels and cancer. The data showed that 2.8 per cent of all women had been diagnosed with serious cancer compared to 1.7 per cent of all men in the group.  

Consequences of OSA  

Consequences of untreated OSA are associated with increased mortality. Severe OSA has a 3.8 fold greater risk for allcause mortality and 5.2-fold greater risk for cardiovascular mortality than

those without OSA. The consequences of OSA are described in the table below:

Clinical Diagnosis

As with most medical conditions, the key to suspect the diagnosis of sleep apnea and various other sleep-related disorders is to know a patient's history. To evaluate the patient of a suspected sleep disorder, always divide the patient into one of the three broad subgroups

1. Those who cannot stay asleep - 

Disorders like restless leg syndrome, men with Upper Airway Resistance Syndrome, stress, anxiety, depression and medical problems like Parkinsonism fall into this broad category. Many times, women with Obstructive sleep apnea also present with insomnia and fall into this subgroup of patients.

2. Those who have abnormal behaviour in sleep - 

Sleep induced behavioural disorders and epileptic activity in sleep fall into this category and is more of neurologists domain.

3. Those who cannot stay awake - 

This group includes those with excessive daytime sleepiness and include obstructive sleep apnea, narcolepsy, medications overuse, hypothyroidism, alcohol, idiopathic hypersomnolence, psychological and insufficient sleep due to hectic schedules. This is basically the domain of a pulmonologist.

The common symptoms of OSA are - 

1. Loud habitual snoring and snore arousals.
2. Witnessing of sleep apneas by the sleep partner.
3. Excessive daytime sleepiness and decreased performance at school or work.
4. Morning headaches and non-refreshening sleep.
5. Dry mouth, mouth breathing, nocturia, impotence, personality changes and progressive weight gain.
6. Cognitive impairments like poor memory, difficulty in focusing attention.
If any of these symptoms are present, irrespective of age or gender, a thorough clinical check up and a visit to a sleep expert is essential. Many of these patients often present to an ENT specialist, Neurologist,Pulmonologist or a Psychiatrist and the diagnosis may need a multidisciplinary approach.

BMI - A body mass index of more than 27 is a strong risk factor for OSA, but the absence of obesity cannot certainly rule out OSA.

Neck girth - Neck girth more than 17 inches in males and more than 15 inches in females is a strong risk factor for OSA. Similarly, mentohyoid distance (between the chin and the hyoid bone) of less than 3
finger width is strongly associated with OSA.

Upper airway evaluation for the presence of tonsillar and adenoid hypertrophy, high arched palate, septal deviation of the nasal
bone, macroglossia (unusually large tongue), retrognathia and long bulky uvula predispose the patients for developing OSA, irrespective of their BMI and should be therefore carefully evaluated routinely.

Treatment for Sleep Apnea

If you suspect to have sleep apnea, to see a doctor is a must. Be prepared with all the symptoms you face such as snoring, excessive daytime sleepiness, morning headache, fatigue etc. Ask your bed partner if you snore heavily, choke, gasp, or stop breathing during sleep. One of the most common and accurate test used to diagnose sleep apnea is a sleep study, which may require an overnight stay at a sleep centre. Sleep study is also called Polysomnography (PSG). The sleep study monitors a variety of functions during sleep including sleep state, eye movement, muscle activity, heart rate, respiratory effort, airflow, and blood oxygen levels. Along with a diagnosis of sleep apnea, its severity is also determined. 

Polysomnography (PSG) - PSG remains the most accurate test for the diagnosis of sleep apnea and also measures the severity of the disease. It evaluates a person's sleep pattern by using multiple parameters like sleep cycle, sleep staging, oximetry, apneas and hypopneas, cardiac function etc.

Various parameters measured in PSG are-

1. Monitoring Sleep Stages:

• EEG

• EOG (REM OR NREM)

• EMG (PERIODIC LEG MOVEMENT)

2. Identifying Apneas/ Hypopneas and record airflow:

• Nasal/oral Airflow, thermistors
• Thoracic & abdominal respiratory efforts
• Capnography
• Tracheal sound & body position

3.  Assess Physiologic Consequences:

• ECG
• Pulse oximetry

4. Video recording

As per the American Academy of The Sleep Medicine, PSG can be classified into 4 types as shown in the table below:

PSG can be classified into 4 types

Type 1 and Type 2 are recommended and Gold-standards for the diagnosis of OSA. 

A typical polysomnogram

Obstructive apnea is defined as the cessation of airflow for more than 10 seconds, when inspiratory efforts are made against a closed upper airway with the continued presence of respiratory drive

A central apnea is cessation of respiratory drive resulting in absence of airflow

Yoga might help in improving Sleep Apnea

Yoga might not cure Sleep Apnea to 100 percent however can improve overall breathing quality of an individual and in-turn might be of great help towards improvement in Sleep Apnea symptoms. 

Some of the Yoga asanas/poses that can help to improve breathing quality are as follows:

1. Bhujangasana (Cobra Pose)

• It helps in opening up chest and clears the lungs
• Improves blood circulation
• Improves flow of oxygen
• Reduces anxiety and stress

2. Ustrasana

• Improves digestion
• Improves posture
• Opens the chest
• Stimulates all organs of abdomen
• Relieves respiratory system
• Increases blood flow to the brain

Celebrities suffering from sleep apnea

• Shaquille O'Neal - Basketball player
• Reggie White- Football Player, he died from complications of sleep apnea
• Roseanne Barr - She is an American actress, comedian, writer, and television producer
• Jerry Garcia - American singer
• Rick Perry - American politician
• Quincy Jones - Musician
• William Shatner, actor
• Amy Poehler - American actress
• Arianna Huffington - Co-founder and former editor-in-chief of The Huffington Post
• John Candy - Canadian actor

To be continued...
                                                                                                       
                                                                                                        This blog does not provide medical advice, diagnosis or treatment