Snoring and Excessive Daytime Sleepiness (EDS)

EDS in IT Professionals

I see almost every day many young IT professionals and like in my clinic with daytime sleepiness. Some of them have encountered problem from their employers and some being fired from job, either found sleeping on the desk or for poor performance.

Also, newly married youngsters visit me with snoring and sleep apnea causing havoc in their married life. Some live frustrated, with poor sex drive, erectile dysfunction, poor libido, and at time coming to a stage of separation and even divorce. Most of these youngsters are in their mid 20s or 30s, living a sedentary life and overweight. These guys snore at night and cause immense nuisance to the family and gets depressed at the end.

About EDS

Excessive Daytime Sleepiness is a condition in which a person is unable to maintain alertness during the daytime hours. Excessive Sleepiness Disorder is an actual diagnosable condition, though it tends to go hand in hand with other medical conditions like snoring and sleep apnea.

About OSA

Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea > 10 sec).

Symptoms include restlessness, snoring, recurrent awakening, morning headache, and excessive daytime sleepiness. Most cases remain undiagnosed and untreated and are often associated with hypertension, heart failure, and injury or death due to motor vehicle crashes and other accidents resulting from hyper somnolence.

Diagnosis is based on sleep history and Sleep study (Home Sleep study)

Treatment

Conservative Treatment:

Initial treatment aims at optimal control of modifiable risk factors, including obesity, alcohol and sedative use, hypothyroidism, and other chronic disorders. Although modest weight loss (15%) may result in clinically meaningful improvement, weight loss is extremely difficult for most people, especially those who are fatigued or sleepy. Bariatric surgery reverses symptoms and improves AHI in 85% of morbidly obese (BMI > 40) patients.

CPAP Therapy

Nasal CPAP is tried for most patients with OSA and subjective daytime sleepiness; adherence is lower in patients who do not experience sleepiness. CPAP improves upper airway patency by applying positive pressure to the collapsible upper airway segment. Effective pressures typically range from 3 to 15 cm H2O. Disease severity does not correlate with pressure requirements. If clinical improvement is not apparent, pressure can be titrated during monitoring with repeat sleep study. Regardless of improvement in the AHI, CPAP will reduce cognitive impairment and BP. If CPAP is withdrawn, symptoms recur over several days, though short interruptions of therapy for acute medical conditions are usually well tolerated. Duration of therapy is indefinite.

Failures of nasal CPAP are common because of limited patient adherence. Adverse effects include dryness and nasal irritation, which can be alleviated in some cases with the use of warm humidified air, and discomfort resulting from a poorly fitting mask.

Dental Appliances:

Currently there are in excess of 200 different types of appliances available. Universally they all have similar effect of repositioning and holding the mandibular (lower jaw) in a protruded position during sleep.  Dental appliances are designed to advance the mandible or, at the very least, prevent retrusion with sleep. Some are also designed to pull the tongue forward. Use of these appliances to treat both snoring and OSA is gaining acceptance.

Surgical Treatment:

Surgical correction of upper airway obstruction caused by enlarged tonsils and nasal polyps should be considered. Surgery for macroglossia or micrognathia is also an option. Surgery is a first-line treatment if anatomic encroachment is identified; otherwise, surgery is a second-tier approach.

Laser Assisted Uvulopalatopharyngoplasty (LAUP) is the most commonly used procedure. It involves resection of submucosal tissue from the tonsillar pillars to the Pharyngeal fold, including resection of the uvula and soft palate, to enlarge the

upper airway. Soft palate splints, and radiofrequency tissue ablation also have been promoted as treatments for loud snoring in patients with OSA.

Adjunctive surgical procedures include nasal surgery, tonsillo-adenoidectomy, midline glossectomy, hyoid advancement, tongue base reduction, and mandibulomaxillary advancement.

Tracheostomy is the most effective therapeutic maneuver for OSA but is done as a last resort. It bypasses the site of obstruction and is indicated for patients most severely affected (e.g., those with cor pulmonale).

A number of drugs have been used to stimulate ventilatory drive (e.g., tricyclic antidepressants, theophylline but cannot be routinely advocated because of limited efficacy, a low therapeutic index, or both. Modafinil can be used for residual sleepiness in OSA in patients who are effectively using CPAP.

Supplemental O2 improves blood oxygenation, but a beneficial clinical effect cannot be predicted. Also, O2 may provoke respiratory acidosis and morning headache in some patients.

Nasal dilatory devices and throat sprays sold OTC for snoring have not been studied sufficiently to prove benefits for OSA.

Is it the right way ahead?

Not only are people staying at work longer, but the use of laptops and cell phones allows a person to be accessible at any time of the day. We sleep less and we think that sleeping less is a sign of our dedication to the job. In fact, those who sleep the least are lauded for their drive and their focus. But is this really the best way to get ahead in the world?