Treatment

What is Sleep Apnea?

Sleep apnea is a condition in which one stops breathing while asleep. During sleep, your breathing is interrupted by repeated pauses known as apneic events.

How we breathe while sleeping?

With normal respiratory drive, after exhalation, the blood level of oxygen decreases and that of carbon dioxide increases. Exchange of gases with a lungful of fresh air is necessary to replenish oxygen and rid the bloodstream of built-up carbon dioxide. Oxygen and carbon dioxide receptors in the blood stream (chemo receptors) send nerve impulses to the brain, which then signals reflex opening of the larynx and movements of the rib cage muscles. These muscles expand the chest cavity so that a partial vacuum is made within the lungs and air rushes in to fill it.

Types of Sleep Apnea

The types of sleep apnea include: obstructive sleep apnea, which is the most common form of sleep apnea; central sleep apnea; and mixed (or complex) sleep apnea, which combines the two other types.

Sleep apnea is a killer disease and can cause many serious health problems. It can increase the risk for stroke, obesity, diabetes, heart attack, heart failure, irregular heartbeat, and high blood pressure. It may also increase the risk for accidents while working or driving, as some people with sleep apnea may fall asleep during those activities.

What Is Central Sleep Apnea?

In central sleep apnea, breathing is disrupted regularly during sleep because of the way the brain functions. It is not that you cannot breathe (which is true in obstructive sleep apnea); rather, you do not try to breathe at all. The brain does not tell your muscles to breathe. This type of sleep apnea is usually associated with serious illness, especially an illness in which the lower brainstem — which controls breathing — is affected.

In central sleep apnea, the basic neurological controls for breathing rate malfunction and fail to give the signal to inhale, causing the individual to miss one or more cycles of breathing.

In general, the main risk factors for sleep apnea are male, being overweight, and being over 40 years of age. However, anyone can have any of the types of sleep apnea.

Central sleep apnea is often associated with other conditions. One form of central sleep apnea, however, has no known cause and is not associated with any other disease. In addition, central sleep apnea can occur with obstructive sleep apnea, or it can occur alone.

Conditions that may be associated with central sleep apnea include the following:

• Congestive heart failure

• Hypothyroid Disease

• Kidney failure

• Neurological diseases, such as Parkinson’s disease, Alzheimer’s disease, and amyotrophic lateral sclerosis.

• Damage to the brainstem caused by encephalitis, stroke, injury, or other factors

What happens to breathing in Sleep Apnea?

During central apneas, the central respiratory drive is absent, and the brain does not respond to changing blood levels of the respiratory gases. No breath is taken despite the normal signals to inhale. The immediate effects of central sleep apnea on the body depend on how long the failure to breathe endures. At worst, central sleep apnea may cause sudden death.

Symptoms of Central Sleep apnea

The main symptom of central sleep apnea is temporary stoppages of breathing while asleep. Although snoring is a very strong symptom of obstructive sleep apnea, snoring is usually not found with central sleep apnea. The central sleep apnea is rare when compared to obstructive sleep apnea. The symptoms of central sleep apnea are for the most part the same as those of obstructive sleep apnea. They include chronic fatigue, daytime sleepiness, morning headaches and restless sleep. But if the cause is a neurological disease, the CSA sufferer may also experience difficulty swallowing, voice changes, and an overall sense of weakness and numbness.

If the pause in breathing is long enough, the percentage of oxygen in the circulation will drop to a lower than normal level and the concentration of carbon dioxide will build to a higher than normal level. Brain cells need constant oxygen to live, and if the level of blood oxygen goes low enough for long enough, the consequences of brain damage and even death will occur. Fortunately, central sleep apnea is more often a chronic condition that causes much milder effects than sudden death.

In any person, hypoxia and hypercapnia have certain common effects on the body. The heart rate will increase, unless there are such severe co-existing problems with the heart muscle itself or the autonomic nervous system that makes this compensatory increase impossible. The more translucent areas of the body will show a bluish or dusky, which is the change in hue that occurs owing to lack of oxygen in the blood (“turning blue”).

DIAGNOISIS

After taking a sleep history, overnight sleep study called a polysomnogram is conducted. This test is performed in a sleep lab or home under the direct supervision of a trained technologist. During the test, the following body functions may be monitored:

• Electrical activity of the brain

• Eye movements

• Muscle activity

• Heart rate

• Breathing patterns

• Air flow

• Blood oxygen levels

After the study is completed, the technologist will tally the number of times that breathing is impaired during sleep and then grade the severity of sleep apnea. In some cases, a multiple sleep latency test is performed on the day after the overnight test to measure how quickly you fall asleep. In this test, patients are given several opportunities to fall asleep during the course of a day when they normally would be awake.

Any individual, no matter how healthy, who is given enough of a central respiratory depressant drug, will develop apnea on a central basis. Generally, drugs that are sedative effects, alcohol, opiates can make central apnea worse.

Should these individuals have general anesthesia, for example, they require prolonged monitoring after initial recovery, as compared to a person with no history of sleep apnea, because apnea is likely to occur with even low levels of the drugs in their system.

Premature babies with immature brains and reflex systems are at high risk for central sleep apnea syndrome, even if these babies are otherwise healthy. Fortunately, those premature babies who have the syndrome will generally outgrow it as they mature, providing they receive careful enough monitoring and supportive care during infancy to survive. Because of the propensity toward apnea, medications that can cause respiratory drive depression are either not given to premature infants, or given under careful monitoring, with equipment for resuscitation immediately . Cot death or sudden deaths in infants are sometimes attributable to sleep apnea.

Central Apnea and Heart Diseases

Adults suffering from congestive heart failure are at risk for a form of central sleep apnea called Cheyne-Stokes respiration. This is periodic breathing with recurrent episodes of apnea alternating with episodes of rapid breathing. In those who have it, Cheyne-Stokes respirations occur while both awake and asleep. There is good evidence that replacement of the failed heart cures central apnea in these patients. The uses of some medications that are respiratory stimulants decrease the severity of apnea in some patients. There is an association between atrial fibrillation and central sleep apnea.

How Is Central Sleep Apnea Treated?

If central sleep apnea is associated with some other condition, such as congestive heart failure, that condition is treated.

Some of the more conservative treatments for obstructive sleep apnea would likely benefit people with central sleep apnea as well. Some of these conservative treatments include:

• Losing weight if necessary, and then maintaining a healthy weight

• Avoiding the use of alcohol and sleeping pills, as these items make the airway more likely to collapse during sleep

• Sleeping on your side if you have apneic events when sleeping on your back, possibly using pillows or other devices to keep you in place

• Using nasal sprays or breathing strips to keep air flowing if you have sinus problems or nasal congestion

• Avoiding sleep deprivation

Another treatment is continuous positive airway pressure (CPAP), which is the preferred initial treatment for most people with obstructive sleep apnea. The treatment has been beneficial in people with central sleep apnea, as well. This is especially true of people who have central sleep apnea associated with heart failure.

With CPAP, patients wear a mask over their nose and/or mouth. An air blower forces air through the nose and/or mouth. The air pressure is adjusted so that it is just enough to prevent the upper airway tissues from collapsing during sleep. The pressure is constant and continuous. CPAP prevents airway closure while it is being used, but apnea episodes return when CPAP is stopped or is used improperly. Other styles and types of positive airway pressure devices are available for people who have difficulty tolerating CPAP.

Treatment for central sleep apnea differs slightly in that the device is not set at one optimal constant pressure as with CPAP, but at two different settings for inhalation (IPAP) and for exhalation (EPAP), therefore aiding respiration. Other specifications, for instance the breathing rate and the duration of a single breath, can also be programmed. This device is called BiPAP (bi-level positive airway pressure, meaning it is set at two different pressures). Both CPAP and BiPAP devices can be connected to a humidifier to humidify and heat the inhaled air, thus reducing unpleasant symptoms such as a sore throat or blocked nose that can result from inhaling cold, dry air.

 

What is Snoring and Sleep Apnea?
Snoring is the sound produced by vibration of the uvula and soft palate while the child is sleeping. The opening and closing of the air passage causes a vibration of the tissues in the throat. The loudness is affected by how much air is passing through and how fast the throat tissue is vibrating. Loud and regular nightly snoring is often abnormal in otherwise healthy children. Sometimes it is a sign of a respiratory infection, a stuffy nose or allergy; other times it may be a symptom of obstructive sleep apnea.
Obstructive sleep apnea (OSA) is a disorder in which a person stops breathing during the night, perhaps hundreds of times. These stoppages of breathing are called apneas. The word apnea means absence of breath. An obstructive apnea episode is defined as the absence of airflow for at least 10 seconds. Sleep apnea is usually accompanied by snoring, disturbed sleep, and daytime sleepiness. Obstructive sleep apnea (OSA) occurs when tissues in the upper throat collapse at different times during sleep, thereby blocking the passage of air.
Young children’s tonsils and adenoid are quite large in comparison to the throat, peaking at five to seven years of age. Swollen tonsils and adenoid can block the airway, making it difficult to breathe and could signify apnea.
About Tonsil and Adenoid
The tonsils are located in the back of the mouth on each side. The adenoids are in the back of the nose. The tonsils can be seen by looking in the mouth, but the adenoids usually cannot be seen on routine exam. Evaluating the adenoids usually requires passing an endoscope through the nose, using a mirror in the back of the mouth or obtaining an x-ray or CT scan.

Why Tonsil Adenoid in Children?
Tonsils and adenoids are lymphoid tissue and part of the immune system, but their role is limited. Removing tonsils and adenoids does not weaken the immune system. Instead, their removal may actually reduce the frequency of illnesses in some children.

Problems of Enlarged Adenoid and Tonsil
Children with obstructive sleep may experience excessive daytime sleepiness including fatigue and may fall asleep at inappropriate times. In actuality, the more common daytime consequence of children’s poor sleep quality is irritability and poor concentration, not tiredness. They tend to be cranky. They can have difficulty concentrating resulting in poor school performance. Admittedly, to determine whether poor behavior and school performance is more due to sleep issues or other factors is difficult.

Children with enlarged tonsils and adenoids may be slow eaters and refuse certain foods due to the difficulty in chewing and breathing at the same time. They may have difficulty swallowing and occasional choking. In addition, they may have a poor appetite due to diminished senses of smell and taste resulting from poor airflow through the nose.

Delayed growth can be caused by the eating problems associated with enlarged tonsils and adenoids. Delayed growth can also result from disrupted sleep because growth hormone is predominantly produced during deep sleep. In addition to these growth issues, severe obstructive sleep apnea can, on rare occasions, lead to heart and lung problems.

Other Signs and Symptoms
• obstructed breathing during sleep (i.e. sleep apnea)
• Poor disposition and irritable behavior
• Poor appetite
• delayed growth, poor performance in school
• Constant nasal obstruction and congestion
• Poor alignment of teeth and abnormal facial development
• Mouth breathing throughout the night
• Restless and fitful sleep that result in moving all around in the bed
• sleeping in unusual positions including tilting the head back or sleeping propped up
• choking episodes, periods of not breathing or apparent struggling to breathe
• waking up or sweating during the night for unknown reasons
• Age-inappropriate bed wetting

Nasal Symptoms in Children
Enlarged adenoids, allergies, sinus infections and colds can all cause nasal obstruction. Determining which one is the cause of the obstruction can be difficult. In general, enlarged adenoids cause constant nasal obstruction without significant discharge. In contrast, nasal obstruction from allergies may fluctuate based on different seasons, locations and activities. Allergies often cause other symptoms in addition to nasal obstruction including clear discharge and itchy nose and eyes. Nasal obstruction from sinus infections and colds occurs when the child is sick and is associated with infected secretions.

Any dental problems?
Their enlargement leads to chronic mouth-breathing which may result in abnormal facial development, misalignment of the teeth, and tooth discoloration. Admittedly, not all children with enlarged tonsils and adenoids develop a poor bite requiring orthodontic work. Orthodontists have differing opinions on the need for tonsil and adenoid removal to prevent or assist with dental braces.

How to diagnosis obstructive sleep apnea?
A sleep study can be performed in the hospital or a sleep lab or at home which records numerous aspects of sleep including breathing pattern, oxygen level, heart rhythm and brain waves. By measuring these parameters, the presence and severity of obstructive sleep apnea can be determined. A formal sleep study is a reasonable consideration if uncertainty exists regarding the degree of a child’s obstructive sleep problems. On the other hand, if a parent describes a sleeping pattern consistent with significant obstruction, most physicians will proceed directly with tonsillectomy and adenoidectomy based solely on parental observations without a sleep study.

Treatment-Tonsil Adenoid Removal
Both tonsils and adenoids are removed through the mouth without any external incisions. The instruments used to remove the tonsils and adenoids vary between surgeons because none has been proven to be consistently safer, less painful and more cost-effective than another. Bleeding is usually minimal and easily controlled with electrocautery, not sutures. The time in the operating room is typically less than one hour.
A parent is allowed to go back to the recovery room once the child is becoming more alert. The child is initially upset and disoriented but soon settles down. He/she remains at the surgical facility for at least a few hours after surgery to ensure that there are no problems with pain, nausea, bleeding or breathing. If a child is having any such difficulties, or if the child is under three years old, then he/she may be admitted to a hospital overnight for observation.

Benefits of Surgery
Tonsillectomy and adenoidectomy has an excellent chance of eliminating obstructive sleep problems. If a child has fatigue, irritability, or concentration problems due to poor sleep quality, then these problems can also be improved. A child may eat better and gain weight after tonsillectomy and adenoidectomy. In addition, the surgery often allows a child to breathe better through the nose which potentially can help with normal facial and dental development. Although removal of tonsils and adenoids has multiple potential benefits, these benefits cannot be guaranteed in every case.

Any risks of tonsillectomy and adenoidectomy?
The main risk associated with tonsillectomy is bleeding. Scabs form where the tonsils are removed. These scabs fall off after approximately one week and can lead to bleeding. Stopping the bleeding may require going back to the operating room. Even in the cases of post op bleeding, needing a transfusion or choking on the blood is extremely rare. Other uncommon risks of tonsillectomy include teeth injury, taste disturbance, and cautery burns.

The main risk associated with adenoidectomy is a change in voice quality. Adenoidectomy opens more space behind the nose which allows more air into the nose while talking, possibly resulting in a high-pitched, squeaky voice. While a temporary nasal voice is common, a permanent voice problem is rare.

Dehydration can occur during recovery due to poor pain control. The duration and severity of pain varies among children. In general, the pain lasts approximately one week and can be controlled with medications. On rare occasions, the discomfort prevents adequate fluid intake, requiring a return to the hospital for intravenous (IV) fluids. Dehydration requiring intravenous fluids can also result from persisting nausea and/or vomiting.

Any alternatives to Surgery?
Antibiotics are unlikely to permanently reduce the size of tonsils and adenoids. Medical treatment of any associated allergies or chronic sinus infections may improve nasal breathing and sleep quality, but probably will not affect the size of the tonsils and adenoids.

Watchful waiting may be a reasonable alternative. Tonsils and adenoids typically get smaller as the child gets older. They usually are at maximum size around six years of age and have substantially reduced in size by around 12 years. The issue usually is not whether the child will outgrow the problem. Instead, the issue is the impact on the child’s quality of life while waiting for conditions to improve. The other concern is any long-term consequences on the heart, lung, or facial development.

My advice to parents whose child is habitually snoring
If you suspect your child may have symptoms of snoring and sleep apnea, talk to your doctor who may refer you to a ENT specialist and get an overnight sleep study. They can then offer you the most appropriate treatment.

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Over the last one year, this blog was dormant and many of my readers requested me to restart and start writing articles in snoring related topic. Now the hiatus is over and I have decided to start posting once again. You can expect more in depth articles in the future. For the last few months ,I was busy in preparing an e book on snoring and sleep apnea-“ istop snoring”This e book will be available in this site and http://drpaulose.com