Normal Airway
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Obstructive Sleep Apnea
Sleep Apnea is a sleep disorder whereby breathing stops repeatedly for short periods of time during sleep. Sleep apnea can be classified as obstructive, central and complex. Obstructive sleep apnea (OSA) is the most common type of sleep apnea due to relaxation of the muscles that normally hold the airway open, causing the airway to narrow or obstruct. Central sleep apnea occurs when the brain doesn't send correct signals to the respiratory muscles. Complex sleep apnea occurs while OSA is being treated and central apneic events becomes evident.
Obstructed Airway
CPAP-Treated Airway
The following data pertain specifically to obstructive sleep apnea.
Prevalence (AHI≥5 events/hr)
| Age | 30-60 yrs (n=602) | >65 yrs (n=420) |
| Male | 24% | 28% |
| Female | 9% | 20% |
Source: NEJM 1993; 328:1230-1235 / Sleep 1991; 14(6): 486-495
Risk Factors
- Obesity
- Alcohol and sedative drugs
- Anatomic abnormalities such as receding chin
- Enlarged tonsils and adenoids
- Family history of OSA, although there are no proven genetics
- Nasal obstruction
- Smoking due to inflammation and airway narrowing
- Other such as hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post-polio syndrome, neuromuscular disorders, Marfan's syndrome, Down's syndrome
Signs & Symptoms
The signs and symptoms of obstructive sleep apnea and central sleep apnea can be similar. Confirmation by polysomnography will determine the type of sleep apnea.
| Signs | Symptoms |
| Hypertension | Excessive daytime somnolence |
| Increased BMI (weight/height2) | Fatigue |
| Increased neck circumference | Mental status change |
| Narrowed pharyngeal area | Morning headache |
| Right heart strain | Nocturnal awakening |
| Tongue/jaw abnormalities | Non-restorative sleep |
|
Reduced libido/impotence |
|
| Snoring | |
| Witnessed apnea |
Complications & Prognosis
With OSA comes an increase in mortality risk. It has also been linked with diabetes, hypertension, myocardial infarction, congestive heart failure, stroke, daytime sleepiness, reduced or altered cognitive function and motor vehicular accidents.
| Relationship between Sleep Apnea and Traffic Accidents* |
|||
| AHI | Cases% Patients |
Control% Patients |
Adjusted OR |
| ≥5 | 28.4 (n=29) | 4.6 (n=7) | 11.1 |
| ≥10 |
20.6 (n=21) | 3.9 (n=6) | 7.2 |
| ≥15 | 16.7 (n=17) | 3.3 (n=5) |
8.1 |
*Adapted from NEJM 1999: 340:847-851
Treatment of Sleep Apnea
There are a variety of treatment options available for the support of Obstructive Sleep Apnea (OSA). The interpreting sleep physician will make a recommendation of the preferred treatment choice based on the severity of the condition, the potential for quality of life improvement and the patient’s acceptance of therapy.
A. CPAP (Continuous Positive Airway Pressure)
- Treatment of choice.
- Non-invasive.
- 95% effective.
- 60-70% compliance.
- Effective in both OSA and Central Sleep Apnea.
- Funding assistance available through the Ontario Ministry of Health and Long Term Care for eligible applicants.
- Private health plans very commonly also supplement the cost of therapy.
B. Oral Appliances (Mandibular Advancement Devices)
- Numerous styles.
- Effective in 70% of cases.
- Best made by an experienced dentist with expertise in dental sleep medicine.
- Portable.
- Teeth shift can occur over the long term.
- Should not be used in patients with pre-existing temporal-mandibular joint disease.
C. Surgery (most have limited/no long term follow up data except UPPP and tracheostomy)
- Nasal reconstruction.
- Uvulopalatopharngoplasty (UPPP) - 50% of cases improved.
- Laser assisted uvuloplasty (LAUP).
- Radiofrequency therapy (RFA).
- Palatal implants.
- Tonsillectomy.
- Maxillary mandibular advancement (MMA).
- Tracheotomy.
D. Weight Reduction
E. Medication (very limited role)
- Aminophylline.
- Hormone replacement therapy.
- Mirtazapine (Remeron).
- Acetozolamide.
- Protryptilline.
- Physistigmine.
- Nasal decongestants.