These are common signs and symptoms seen with obstructive sleep apnea (OSA), a sleep disorder commonly seen in many adults and
. Adult Obstructive Sleep Apnea is an extremely common disorder in the United States, affecting up to 20 million Americans.
Obstructive Sleep Apnea occurs when there is increased resistance to breathing during sleep. Patients with OSA stop breathing many times throughout the night- ranging from several times an hour to over 60 times an hour. Each pause in breathing can last from several seconds to a minute or more. More severe pauses are called apneas and less severe pauses are called hypopneas. Patients do not usually wake consciously from sleep during most of these pauses but are aroused from a deeper and more restful sleep. Oxygen levels can often decrease during the night.
Yes, moderate or severe Obstructive Sleep Apnea can be associated with an increased risk of certain types of chronic heart and lung disorders. Patients with OSA have a higher risk of depression, mood disorders, and impaired quality of life due to chronic sleep deprivation. Any parent who has had to stay up with an infant all night will have an understanding of what Obstructive Sleep Apnea feels like. However, there is no catch up sleep and the chronic sleep deprivation will continue until adequately treated.
No, that is a common misconception. Many adults who are not overweight have Obstructive Sleep Apnea. In fact, the majority of non-obese patients with OSA will never be diagnosed. The reason for this is that many doctors will not think of Obstructive Sleep Apnea and screen for this disorder in patients that are not overweight. For other patients, however, obesity is a strong contributing factor to the severity of Obstructive Sleep Apnea and weight loss should be one of the primary goals of treatment.
Can I have Obstructive Sleep Apnea and not feel tired during the day?
Yes. Because sleepiness and fatigue is a subjective feeling, not everyone with Obstructive Sleep Apnea will feel tired during the day. Patients who snore frequently and are overweight or have other risk factors for Obstructive Sleep Apnea should still be evaluated for Obstructive Sleep Apneabecause of the risk of chronic heart and lung disease.
How is Obstructive Sleep Apnea diagnosed?
A patient suspected of Obstructive Sleep Apnea will undergo a nocturnal sleep study (polysomnography), which will assess the number and severity of obstructions that occur during sleep. Additionally, the sleep study will also monitor the brain function (EEG), heart rhythm (EKG), oxygen levels, muscle movements, and snoring levels. Other potential sleep disorders can be evaluated during the sleep study.
How is the severity of Obstructive Sleep Apnea measured?
During the sleep study, the number of times a patient stops breathing during each hour of sleep is calculated and given as an index or score. There are typically three types of breathing abnormalities that are included in this index, which include:
- Apneas: complete cessation of airflow for at least 10 seconds.
- Hypopneas: partial cessation of airflow for 10 seconds
- RERA’s (Respiratory Event Related Arousal)
RERA’s occur when there is increased resistance to breathing but airflow is not decreased to the level seen with an apnea or hypopnea. However, RERA’s may still interfere with deep restorative sleep, leading to daytime sleepiness and other symptoms associated with Obstructive Sleep Apnea.
There are two types of indexes that are calculated:
1) AHI (Apnea-Hypopnea Index)
The total number of apneas and hypopneas that occur during each hour of sleep. For instance, an AHI of 10 means that there are a total of 10 apneas and hypopneas during each hour of sleep.
2) RDI (Respiratory Disturbance Index)
The RDI adds the number of apneas, hypopneas, and RERA’s that occur during each hour of sleep. So an RDI of 10 means that there are a total of 10 apneas, hypopneas, and RERA’s during each hour of sleep.
Which index is better to use - AHI or RDI?
The Respiratory Disturbance Index (RDI) is a more sensitive measure of Obstructive Sleep Apnea than the Apnea-Hypopnea Index (AHI) because it includes RERA’s in the score. RERA’s are an important cause of sleep disruption in patients with Obstructive Sleep Apnea.
Many sleep experts consider an AHI or RDI of less than 5 events/ hour to be “normal.” The typical measures of severity:
- Mild: 5-15 events/hour
- Moderate: 15-29 events/hour (scores in the moderate range may be associated with certain heart conditions such as high blood pressure)
- Severe: >30events/hour (Significant risk of: accidental injury, such as falling asleep while driving, and chronic heart/lung conditions)
Can I have a low AHI or RDI score and still have significant daytime sleepiness?
Yes. The score does not necessarily correlate with the severity of subjective symptoms associated with Obstructive Sleep Apnea. Many patients are very tired during the day but have a low score. Alternatively, patients can have a high score and have minimal daytime sleepiness. In fact, many patients have daytime sleepiness from OSA even with a “normal” score.
So I can still have significant subjective symptoms from Obstructive Sleep Apnea but have a “normal” AHI or RDI score?
Yes. The reason for this is that sleep centers use different methods to detect breathing abnormalities associated with OSA. For example, only a few sleep centers in the country use the most sensitive method to detect subtle forms of Obstructive Sleep Apnea - an esophageal catheter. During the sleep study, the catheter is inserted into the esophagus in order to measure pressure changes in the lungs during sleep. The catheter requires additional expertise and is perceived to cause more patient discomfort. If the catheter is not used during a sleep study, subtle but significant forms of Obstructive Sleep Apnea may be frequently overlooked. So patients that have persistent snoring
and daytime sleepiness or other symptoms associated with OSA may need a sleep study that utilizes the esophageal catheter in order to make sure Obstructive Sleep Apnea is accurately diagnosed. If your sleep center did not utilize this type of catheter- you may still have Obstructive Sleep Apnea.
I was recently diagnosed with Obstructive Sleep Apnea. What are the treatment options?
The first treatment option that should be considered in adults is a CPAP machine. CPAP stands for Continuous Positive Airway Pressure. Many refer to this as a “breathing machine.” CPAP works by forcing air into the airway to keep it from collapsing during sleep.
I have tried using the CPAP machine for a week but I can’t seem to tolerate it. What can I do now?
For many people, it may take up to 4 weeks or more to become acclimated to sleeping with the CPAP machine. It is very important not to give up too soon. Your sleep specialist will be able to work with you to make changes that can allow you to better tolerate the machine. Different masks and machine settings may make a big difference in tolerability.
Nasal congestion makes it hard to use the CPAP machine. How can I treat my nasal congestion?
Before deciding that you cannot tolerate the CPAP machine, the reasons should be investigated. For many, persistent nasal congestion
can cause significant discomfort when using CPAP. Treating nasal congestion can help improve the tolerability of the CPAP machine. An allergist can help identify any allergies
that may be contributing to persistent nasal congestion
Okay, I have done everything I can to try to use the CPAP machine but I really cannot tolerate it. What are the other sleep apnea treatment options?
Sleep apnea oral devices
Sleep apnea surgery
- Oral devices may be helpful for mild Obstructive Sleep Apnea. Dentists that specialize in Obstructive Sleep Apnea can help decide if an oral device may be helpful for you. There are many different devices to choose from and range from hundreds to thousands of dollars depending on the quality and durability of the device.
- The oral device is worn during sleep and helps to prevent the tongue and soft palate from collapsing.
- CPAP is clearly a more effective treatment option and should be considered the initial and primary treatment for adults with Obstructive Sleep Apnea if tolerated. Oral devices may be helpful for some patients with mild Obstructive Sleep Apnea who are not able to tolerate the CPAP machine. However, the majority of patients using the oral devices may not experience a significant improvement in symptoms such as daytime sleepiness. Oral devices may be particularly helpful in preventing snoring, however. It should be understood that apnea can persist even when snoring has improved with the oral device. Oral devices can also be considered for patients that travel frequently or as a treatment option before considering surgery. Dentists may be overly optimistic regarding the chances of success with an oral device. Complications can include a change in bite and discomfort of the jaw joint (TMJ) among others.
- Surgical treatment options can be a consideration for some adults with Obstructive Sleep Apnea. There are many different surgical options available to treat Obstructive Sleep Apnea, ranging from minimally invasive to very invasive. Generally speaking, the less invasive the procedure, the less effective it will be. Covering the different surgical options is beyond the scope of this educational material. It is my opinion that surgery should only be considered when other non-surgical options have failed. On a personal note, I have suffered from Obstructive Sleep Apnea and have gone through most surgical procedures for Obstructive Sleep Apnea. It has dramatically improved my life. For some people, surgery can lead to life-changing improvements in quality of life. It is an option that must be considered carefully in light of the benefits and potential risks and complications.
How important is surgeon selection?
Very. This is a crucial factor to consider. It is important for the surgeon to have not only excellent surgical skills but also an in-depth understanding of OSA. Surgeons that dedicate a significant percentage of their practice to treating Obstructive Sleep Apnea should be chosen. This point cannot be emphasized enough. Also, it may be helpful to have more than one opinion prior to proceeding with surgery. There are only a handful of surgeons in the country able to perform the full spectrum of Obstructive Sleep Apnea surgeries.
What type of surgeons operate on adults with Obstructive Sleep Apnea?
Ear, Nose, and Throat (ENT) Doctor:
An ENT surgeon can perform many of the procedures utilized to treat adult Obstructive Sleep Apnea. However, most procedures that an ENT performs typically lead to only short term improvements. It is my opinion that most ENT surgeons do not have adequate expertise in treating adults with Obstructive Sleep Apnea.
Oral Maxillofacial Surgeons (oral surgeons):
Oral maxillofacial surgery is a sub-specialty of dentistry. Oral surgeons have a unique expertise in what many consider the most effective surgical procedure for adult Obstructive Sleep Apnea. This procedure is called maxillary-mandibular advancement (MMA), during which the upper and lower jaws are moved forward. As a result, the tongue and soft palate are moved forward, increasing the size of the airway. This procedure is the most effective long-term surgical option for adults with Obstructive Sleep Apnea. Reported long-term success rates range from 75-100% depending on the skill and expertise of the surgeon. However, MMA has the longest recovery time and can be associated with significant complications. Although there are several stages to the recovery, it may take 6 months or longer for a full recovery. In my opinion, this procedure is under-utilized in treating adults with Obstructive Sleep Apnea.
Unfortunately, most non-surgical sleep specialists do not have extensive knowledge of this procedure and are unlikely to recommend it for their patients. Of course, the risks and benefits should carefully be considered prior to proceeding with surgery. For most patients, it should only be considered after attempting other non-surgical options. I cannot emphasize enough how important it is to research the various surgical procedures and the surgeon. Generally speaking, surgeons with the most experience performing MMA will have better results with fewer complications. There are many online forums that provide excellent insight into the various procedures and surgeons.
What are the anatomic factors that most often need to be addressed during the surgical treatment of Obstructive Sleep Apnea?
Most adult patients with OSA will require “multi-level” surgery. This means that multiple sites near the mouth and nasal passage need to be addressed during surgery.
Anatomic factors that frequently contribute to adult Obstructive Sleep Apnea:
- Soft palate and uvula: In many patients with OSA the soft palate and uvula are large and floppy, decreasing the size of the airway in the back of the throat
- Tongue: Adults with OSA frequently have a tongue that is either too large and/or positioned too far back in the mouth, allowing the airway to collapse at night
- Recessed lower jaw and chin: A lower jaw (mandible) and chin that is recessed (set farther back) increase the risk of Obstructive Sleep Apnea
- Large tonsils: Large tonsils can contribute to OSA but are rarely a primary cause for adults
- Small airway and narrow jaw structure: During development, many environmental and genetic factors can lead to a smaller airway and narrow jaw
Should I look into life insurance or disability insurance prior to having my sleep study?
Because a diagnosis of OSA may affect premium rates for life insurance or disability insurance, it may be prudent to evaluate your insurance needs prior to having a sleep study. Disability insurance is often provided through an employer’s insurance carrier. However, you will not be covered if you leave your job. You may want to consider private disability insurance if you are only covered by your employer’s policy.