Obstructive sleep apnea
Obstructive sleep apnea is the most common sleep-related breathing disorder. This type of sleep apnea is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a sleep disruption, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, whichin combination with disturbances in blood oxygenationis thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome or obstructive sleep apnea–hypopnea syndrome may be used to refer to OSA when it is associated with symptoms during the daytime.
Most individuals with obstructive sleep apnea are unaware of disturbances in breathing while sleeping, even after waking up. A bed partner or family member may observe a person snoring or appear to stop breathing, gasp, or choke while sleeping. People who live or sleep alone are often unaware of the condition. Symptoms may persist for years or even decades without identification. During that time, the person may become conditioned to the daytime sleepiness, headaches, and fatigue associated with significant levels of sleep disturbance. Obstructive sleep apnea has been associated with neurocognitive morbidity, and there is a link between snoring and neurocognitive disorders.
Classification
In the third edition of the International Classification of Sleep Disorders, obstructive sleep apnea is classified amongst the sleep-related breathing disorders and is divided in two categories, namely adult OSA and pediatric OSA. Obstructive sleep apnea is differentiated from central sleep apnea, which is characterized by episodes of reduction or cessation in breathing attributable to decreased effort, rather than upper airway obstruction. The respiratory effort must then be assessed in order to correctly classify the apnea as obstructive given the specificity of the diaphragmatic activity in this condition: the inspiratory effort is continued or increased through the entire episode of absent airflow.When hypopneas are present alongside apneas, the term obstructive sleep apnea-hypopnea is used. If it is associated with daytime sleepiness and other daytime symptoms, it is known as obstructive sleep apnea-hypopnea syndrome. To be categorized as obstructive, the hypopnea must meet one or more of the following symptoms: snoring during the event, increased oronasal flow flattening, or thoraco-abdominal paradoxical respiration during the event. If none of them are present during the event, then it is categorized as central hypopnea.
Signs and symptoms
Common symptoms of obstructive sleep disorder syndrome include unexplained daytime sleepiness, restless sleep, frequent awakenings and loud snoring. Less common symptoms are morning headaches; insomnia; trouble concentrating; mood changes such as irritability, anxiety, and depression; bruxism, forgetfulness; increased heart rate or blood pressure; erectile dysfunction, unexplained weight gain; increased urinary frequency or nocturia; frequent heartburn or gastroesophageal reflux; and heavy night sweats.Many people experience episodes of OSA transiently, for only a short period. This can be the result of an upper respiratory infection that causes nasal congestion, along with swelling of the throat, or tonsillitis that temporarily produces very enlarged tonsils. The Epstein-Barr virus, for example, is known to be able to increase the size of lymphoid tissue dramatically during acute infection, and OSA is fairly common in acute cases of severe infectious mononucleosis. Temporary spells of OSA syndrome may also occur in people who are under the influence of a drug that may relax their body tone excessively and interfere with normal arousal from sleep mechanisms.
Adults
The hallmark symptom of OSA syndrome in adults is excessive daytime sleepiness. Typically, an adult or adolescent with severe long-standing OSA will fall asleep for very brief periods in the course of usual daytime activities if allowed to sit or rest. This behavior may be quite dramatic, sometimes occurring during conversations with others at social gatherings.The hypoxia related to OSA may cause changes in the neurons of the hippocampus and the right frontal cortex. Research using neuroimaging revealed evidence of hippocampal atrophy in people with OSA. They found that OSA can cause problems in mentally manipulating non-verbal information, in executive functions and working memory. OSA may also be associated with an increased risk of a person developing Alzheimer's disease.
Obesity is a major risk factor for OSA. In the severely obese, the risk for sleep apnea can be between 55 and 90%. However between 20 and 25% of patients with sleep apnea are not overweight. What is often unrecognized in primary care is that it is crucial to identify these patients because they are four times more likely to develop hypertension than obese individuals without OSA. And non-obese patients are at a higher risk for early atherosclerosis. In fact, approximately 2.7 times more than obese patients without OSA. This risk increases as the severity of the syndrome increases. Factors in this population may include inherited anatomical features, instability of ventilatory control, neuromuscular inefficiency of the dilator muscles of the upper airways, or a lower threshold for awakening in response to respiratory stimuli.
Diagnosis of obstructive sleep apnea is significantly more common among people in relationships, who are alerted to their condition by being informed by their sleeping partner, since individuals with obstructive sleep apnea are often unaware of the condition. There is a stigma associated with loud snoring. It is not considered a feminine trait. Consequently, females are less likely to be told by their partners that they snore, or to admit it to themselves or doctors. Furthermore, CPAP machines are also perceived negatively by females, and less likely to be utilized to their full extent in this group.
Children
Although this so-called "hypersomnolence" may also occur in children, it is not at all typical of young children with sleep apnea. Toddlers and young children with severe OSA instead ordinarily behave as if "over-tired" or "hyperactive"; and usually appear to have behavioral problems like irritability, and an attention deficit.Adults and children with very severe OSA also differ in typical bodily habitus. Adults are generally heavy, with particularly short and heavy necks. Young children, on the other hand, are generally not only thin but may have "failure to thrive", where growth is reduced. Poor growth occurs for two reasons: the work of breathing is intense enough that calories are burned at high rates even at rest, and the nose and throat are so obstructed that eating is both tasteless and physically uncomfortable. OSA in children, unlike adults, is often caused by obstructive tonsils and adenoids and may sometimes be cured with tonsillectomy and adenoidectomy.
This problem can also be caused by excessive weight in children. In this case, the symptoms are similar to those adults experience, such as restlessness and exhaustion. If adenotonsillar hypertrophy remains the most common cause of OSA in children, obesity can also play a role in the pathophysiology of upper airway obstruction during sleep which can lead to OSA, making obese children more likely to develop the condition. The recent epidemic increase of obesity prevalence has thus contributed to changes in the prevalence and in the characteristics of pediatric OSA, the severity of OSA is proportional to the degree of obesity.
Obesity leads to the narrowing of upper airway structure due to fatty infiltration and fat deposits in the anterior neck region and cervical structures. Alongside with the additional weight loading on the respiratory system, it increases the risk of pharyngeal collapsibility while reducing the intrathoracic volume and diaphragm excursion. Moreover, excessive daytime sleepiness resulting from sleep fragmentation can decrease physical activity and thus lead to weight gain. The obesity-related obstruction of upper airway structure has led some authors to distinguish between two types of OSA in children: type I is associated with marked lymphadenoid hypertrophy without obesity and type II is first associated with obesity and with milder upper airway lymphadenoid hyperplasia. The two types of OSA in children can result in different morbidities and consequences. Studies have shown that weight loss in obese adolescents can reduce sleep apnea and thus the symptoms of OSA.
Diagnosis
The diagnosis of OSA syndrome is made when the patient shows recurrent episodes of partial or complete collapse of the upper airway during sleep, resulting in apneas or hypopneas, respectively. Criteria defining an apnea or a hypopnea vary. The American Academy of Sleep Medicine defines an apnea episode as a reduction in airflow of ≥ 90% lasting at least 10 seconds. A hypopnea is defined as a reduction in airflow of ≥ 30% lasting at least 10 seconds and associated with a ≥ 4% decrease in pulse oxygenation, or as a ≥ 30% reduction in airflow lasting at least 10 seconds and associated either with a ≥ 3% decrease in pulse oxygenation or with an arousal.To define the severity of the condition, the Apnea-Hypopnea Index or the Respiratory Disturbance Index is used. While the AHI measures the mean number of apneas and hypopneas per hour of sleep, the RDI adds to this measure the respiratory effort-related arousals. The OSA syndrome is thus diagnosed if the AHI is > 5 episodes per hour and results in daytime sleepiness and fatigue or when the RDI is ≥ 15 independently of the symptoms. Daytime sleepiness may be classified as mild, moderate, or severe depending on its impact on social life. Daytime sleepiness can be assessed with the Epworth Sleepiness Scale, a self-reported questionnaire on the propensity to fall asleep or doze off during daytime. Screening tools for OSA itself comprise the STOP questionnaire, the Berlin questionnaire and the STOP-BANG questionnaire which has been reported as being a powerful tool to detect OSA.