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Sleep Related Breathing Disorders

Sleep Related Breathing Disorders

Sleep Related Breathing Disorders is an umbrella term used to describe disorders related to abnormal breathing during sleep where breathing is repeatedly interrupted. There are several different types of sleep disordered breathing disorders with varying degrees of severity. 

Snoring

Description

Snoring is a very common condition and a symptom of obstructive sleep apnea (OSA). When a person’s airway becomes partially blocked, the restriction prevents some of the air that was inhaled from getting into the lungs. The “extra” air gets redirected into the mouth, creating a negative pressure which vibrates the soft tissue of the palate and creates snoring.

Not everybody who snores has obstructive sleep apnea, and not everybody who has obstructive sleep apnea has snoring. Snoring indicates that there is some resistance to the normal path of air from the outside to the lungs, and snoring is associated with disrupted sleep, daytime fatigue and sleepiness, and decreases in oxygen levels in the body. Snoring can also be extremely disruptive to the sleep of the bedpartner and can stress interpersonal relationships of couples.

Treating Snoring

There are several surgical procedures that can improve snoring, some of which can be performed on an outpatient basis, and that involve reducing the volume of excess tissue in the airway that produces snoring. Oral appliances, which are very similar to mouthguards or retainers which are placed in the mouth during sleep to either the move the lower jaw or tongue forward, can also improve snoring.

Obstructive Sleep Apnea (OSA)

Description

Obstructive sleep apnea occurs when the airway completely or partially collapses repeatedly throughout the night. During sleep, the soft tissues in the throat relax. For someone with obstructive sleep apnea, these tissues can block the upper airway enough to disrupt sleep related breathing.

When the airway is blocked, the oxygen levels in the body drop causing the person to wake up long enough to begin breathing normally again. These awakenings are often very brief, sometimes only a few seconds, and this is the reason that the affected individual is often not aware that they have these awakenings during sleep. This pattern repeats during the night, and someone with severe sleep apnea may wake up hundreds of times each night. Even though the awakenings are usually very short, they fragment and interrupt the sleep cycle. This sleep fragmentation can cause significant levels of daytime fatigue and sleepiness, which is a common symptom of sleep apnea.

There are 3 types of obstructive breathing events:

  • Respiratory Effort Related Arousal (RERA): A limitation in breathing that results in increased respiratory effort and culminates in an arousal; it does not meet the criteria from an apnea or hypopnea.
  • Hypopnea: A decrease in airflow lasting at least 10 seconds.
  • Apnea: A period of at least 10 seconds during which there is a complete or near complete pause in breathing.

Sleep apnea is estimated to occur in approximately 18,000.000 Americans; a quarter of men and one-tenth of women between the ages of 30 and 60 years have sleep apnea, and the prevalence in children is about 1-3%. It is a treatable disease; however, if left untreated, it is associated with serious chronic medical conditions.

Risk factors for obstructive sleep apnea include:

  • Obesity. The extra tissue caused by fat deposits around the throat, chest and abdomen create extra resistance which can hamper breathing. However, just because someone is overweight does not mean they have obstructive sleep apnea. The opposite is also true: many thin people have obstructive sleep apnea.
  • Large neck size. A thick neck can narrow the airway, and increase the likelihood of obstructive sleep apnea. Higher risk of obstructive sleep apnea is associated with a neck circumference greater than 17 inches (43 centimeters) for men and 15 inches (38 centimeters) for women.
  • Narrowed upper airway. A small jaw or enlarged tongue can narrow the upper airway and predispose individuals toward the development of obstructive sleep apnea. Enlarged tonsils and/or adenoids can also restrict the size of the upper airway.
  • Positive obstructive sleep apnea family history. If you have family members with sleep apnea, you may be at increased risk. Like eye color, the shape and size of the airway and cranial facial features may be inherited from our parents and can have an impact on the likelihood of developing obstructive sleep apnea.
  • Old age, male gender, post-menopausal women. Obstructive sleep apnea is more common in adults over the age of 65 years, men, post-menopausal women, and, among those under the age of 35 years.
  • Smoking and use of alcohol or tranquilizers. Smokers are nearly three times more likely to have obstructive sleep apnea, and alcohol or tranquilizers can relax the muscles in your upper airway and predispose it to collapse.
  • Heart problems (including arrhythmias), high blood pressure (hypertension) and diabetes. Obstructive sleep apnea is more likely in people who have cardiac issues, hypertension and up to three times more common in those with diabetes.
  • Chronic nasal congestion. Obstructive sleep apnea occurs twice as often in those with consistent nasal congestion at night, regardless of cause.
  • Enlarged tonsils or adenoids. In children, obstructive sleep apnea is most often associated with sizeable tonsils or adenoids.

A typical obstructive sleep apnea patient is a middle age, obese male; however anyone can develop obstructive sleep apnea, and the symptoms can vary from person-to-person, increase with age, and have different levels of severity.

Common symptoms of obstructive sleep apnea in adults may include:

  • Snoring
  • Choking or gasping for air during sleep
  • Observed pauses in breathing
  • Daytime fatigue and/or sleepiness
  • Dry mouth/sore throat in the morning
  • Morning headaches
  • Night sweats
  • Insomnia
  • Poor concentration and attention
  • Memory problems
  • Anxiety
  • Irritability
  • Sleep walking or night terrors

Obstructive sleep apnea in Children

While some types of snoring can be considered benign in adults, snoring or noisy breathing is never normal in children. Obstructive sleep apnea is often overlooked in kids because the symptoms are more different in children than they are in adults and they tend to be more subtle. Not all children with obstructive sleep apnea snore, and when they are tired they rarely nap, instead they become hyperactive (and may mimic those children with attention deficit-hyperactivity disorder) or develop behavioral problems. These behavioral problems may manifest themselves as irritability, lack of concentration, easy distractibility, and acting out which can lead to problems at school. Additionally, many children with obstructive sleep apnea are not overweight, so they don’t fit the stereotypical picture of some with sleep apnea.

Children with medical conditions impacting the shape of their face, nose and airway or neuromuscular system are at a higher risk of developing sleep apnea. Parents of children with disorders such as Down syndrome should be aware of the elevated risk and should be evaluated when there has been a change in behavior that may be related to obstructive sleep apnea.

Common symptoms of sleep apnea in children may include:

  • Snoring
  • Daytime cognitive and behavior problems, including problems paying attention, easy distractibility, aggressive behavior and hyperactivity
  • Mouth breathing
  • Enlarged tonsils and adenoids
  • Problems sleeping and restless sleep
  • Parasomnias such as sleep walking or night terrors
  • Bed wetting
  • Failure to thrive (weight loss or poor weight gain)
  • Excessive daytime sleepiness

Other Sleep Related Respiratory Conditions

Description

Other sleep related respiratory conditions include such disorders such as Central Sleep Apnea (CSA) and Sleep Related Hypoventilation/Hypoxemic Syndromes. CSA occurs when you repeatedly stop breathing during sleep because your brain does not cue your body to breathe. This differs from Obstructive Sleep Apnea since in CSA, there is no breathing effort because there is no drive to breathe. In its primary form, CSA is the result of instability of the breathing control system as the individual transitions from wakefulness to sleep. Sleep Related Hypoventilation/Hypoxemic Syndromes may be the result of a decreased response to low oxygen or high carbon dioxide during wakefulness and sleep and are characterized by frequent episodes of shallow breathing lasting longer than 10 seconds during sleep.

Treating Other Conditions

Continuous Positive Airway Pressure (CPAP) is typically ineffective at resolving these conditions, though Bilevel Airway Pressure (BPAP) or Auto Servo-ventilation (ASV) devices may help to normalize sleep related breathing in patients with Central Sleep Apnea or Sleep Related Hypoventilation/Hypoxemic Syndromes.

 

Diagnosis

A comprehensive history and physical examination by a sleep physician followed by an overnight sleep study or polysomnogram, is absolutely necessary to diagnose a sleep related breathing disorder in children or adults.

Based on the results of the overnight sleep study, your sleep physician will be able to determine whether or not you have a sleep related breathing disorder that warrants treatment.


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