What is Sleep Apnea? Types and Treatment Options

Expert Insights from Dr. Luis Javier Peña-Hernández, MD, FCCP, a lung health specialist at PCSI, the largest integrated pulmonary and chest specialty group in Palm Beach County and Dr. Jennifer Le, Diplomate of Dental Sleep Medicine (ABDSM) and practitioner of Wake Dental Sleep in Raleigh, NC.

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Sleep apnea is a potentially life-threatening sleep disorder characterized by abnormal pauses (apneas) in breathing during sleep. It was once known as Pickwickian syndrome after the symptoms of a character described in Charles Dickens’ 1836 book Pickwick Papers. 

According to the American Sleep Apnea Association, it is estimated that 22 million Americans suffer from obstructive sleep apnea. At least 4% of men and 2% of women are affected. However, it’s common for sleep apnea to go undiagnosed because most people who have it aren’t aware of their disorder.

Despite the popularity of this disease, most people don’t take the risks associated with sleep apnea serious, and the risks are huge. Research indicates individuals with this sleep disorder have an increased mortality rate due to a higher risk of a stroke or heart attack.

Mattress Advisor set out to understand the causes sleep of apnea, what happens if it goes untreated, and how you can determine if you or a loved one has this disorder. To help answer our questions, we called on the expertise of Dr. Luis Javier Peña-Hernández, MD, FCCP, a lung health specialist at PCSI, the largest integrated pulmonary and chest specialty group in Palm Beach County and Dr. Jennifer Le, Diplomate of Dental Sleep Medicine (ABDSM) and practitioner of Wake Dental Sleep in Raleigh, NC.

Types of Sleep Apnea

“There are several types of sleep apnea. These include central sleep apnea, obstructive sleep apnea, and mixed sleep apnea–a combination of the two,” says Dr. Luis Javier Peña-Hernández.

Sleep hypopnea is similar in many respects to sleep apnea, with similar symptoms and long-term effects, although it is less common. It is caused by excessively shallow breathing or an abnormally low respiratory rate, rather than by complete breathing pauses due to obstructions or other causes. This typically leads to loud, heavy snoring, interrupted several times an hour by choking sounds or snorts followed by a silence of up to 20 seconds as insufficient air flows into the lungs. 

Sleep hypopnea and the various kinds of sleep apnea mentioned above are often lumped together under the heading “sleep-disordered breathing.” Upper airway resistance syndrome is a similar, but milder, form of sleep-disordered breathing.

Patients who suffer from sleep apnea are constantly jerked out of reparative sleep. Not only is sleep disrupted, but so is oxygen flow. Sometimes oxygen flow can be interrupted greater than 10 times in one hour — which is enough for your body to enter crisis mode. Because of the complete loss of muscle tone associated with REM sleep, that is the most common time to experience apneas, and they are relatively rare during non-REM sleep.

What Causes Sleep Apnea?

“Sleep apnea can be caused by obesity, inflammation, or an abnormality in the anatomy of the jaw, soft palate, airway, or tonsils,” says Dr. Peña-Hernández.

We’ll explore each of these causes:

Anatomy

First and foremost, sleep apnea can be caused by an anatomic issue. Some of these include jaw position, the structure of the soft palate, excessive tissue narrowing the airway, or enlarged tonsils. Anatomic issues can sometimes be genetic.

Obesity

Another more common cause is being overweight or obese. “When someone is overweight, the extra weight carried in the neck can compress and obstruct the airway,” Dr. Le explains.

Inflammation

Finally, sleep apnea can be caused by inflammation of the soft palate from being sick or eating inflammatory foods.

Symptoms of Sleep Apnea

Dr. Le shared with us the most common symptoms of sleep apnea. These include:

• Loud snoring
• Restless sleep
• Periods of not breathing during sleep
• Irritability or personality change
• Difficulty concentrating and poor memory
• Drowsy driving

What is Obstructive Sleep Apnea?

Obstructive sleep apnea is a serious disorder in which breathing pauses repeatedly for 10 seconds or longer during sleep. People with OSA may stop breathing as many as 30 times each hour they are trying to sleep. As you might imagine, such breathing disruptions also disrupt the snorer’s sleep and prevent them from achieving the deep sleep stages, leaving them exhausted the next day. In the most common case of obstructive sleep apnea, breathing is disrupted by a physical block to the airflow caused by a collapse of the soft tissues in the throat and respiratory tract (the same tissues as produce the sound of snoring, which almost always accompanies sleep apnea).

“When left untreated and undiagnosed, sleep apnea can be a very dangerous sleep disorder,” says Dr. Peña-Hernández.

During these pauses in breathing (or apneas), the sleeper effectively starts to suffocate (in addition to experiencing a sharp loss in blood oxygen levels and increased carbon dioxide levels), and the brain sends an immediate emergency signal to the body to wake up. When the sleeper wakes and takes a deep breath, the brain is replenished and the person is able to go back to sleep.

Daytime sleepiness is just the beginning of the problems associated with lack of sleep. Left untreated sleep apnea can lead to:

• Weight gain
• Heart disease and heart failure
• Irregular heartbeat
• High blood pressure
• Stroke
• Diabetes
• Poor judgment
• Depression
• Increase in severity of ADHA symptoms
• Increased accidents

More on these risks and others below.

Snoring: It’s More Serious Than You Think

Snoring is known to be something that people poke fun at. “Our society has made snoring something to chuckle about, but it’s not normal,” Dr. Le explains.

What people fail to realize is that snoring is actually a sleep disorder in itself.

“Snoring occurs when there is a partial obstruction to the flow of air through the nose and mouth. The sound occurs when loose structures in the throat, like the uvula and soft palate, vibrate as air passes over them. Snoring can get worse when the muscles in the back of the throat are too relaxed either from drugs that induce sleep or alcohol consumption.”

Snoring is an interruption of you and your partner’s quality of sleep. When sleep is interrupted, you can’t complete your sleep stages, which has various repercussions that we’ll discuss later on.

Snoring is the precursor to sleep apnea and has similar causes. Dr. Le recommends that if you snore every night, you should go to your primary physician and have an open conversation about it. That way, you can work together to rule out other disorders.

Long-term Implications if Sleep Apnea Goes Untreated

Sleep apnea that goes untreated has a number of consequences. The frequent partial awakenings that are caused by sleep apnea (often referred to as micro-awakenings) lead, over time, to chronic sleep deprivation and excessive daytime sleepiness. Sleep apnea can disturb sleep to such an extent that, even after a full night in bed, the sleeper does not feel rested due to the compromised quality of the sleep.

In addition to excessive daytime sleepiness, the constant sleep interruptions may lead to loss of energy, headaches, forgetfulness, and, in the longer term, to high blood pressure, heart attack, stroke, depression, or other mood disorders. The lowered blood oxygen level during sleep apnea can also disrupt the stages of sleep in a person’s sleep cycles.

Let’s take a deeper look at the impacts of sleep apnea if left untreated.

Interrupted Sleep That Leads to Forgetfulness

Did you know people who suffer from sleep apnea can’t dream? That’s because restorative sleep is interrupted so frequently, they can’t make it far enough into their sleep cycle where dreaming occurs.

Dr. Le explains that the body uses sleeping hours to repair itself and process what it learned that day. The brain’s ability to compartmentalize information during sleep assists in memory recall. That’s why patients who suffer from sleep apnea have difficulty concentrating or remembering information.

Hormone Disruption

Additionally, lack of sleep causes all sorts of hormones to be out of whack — including cortisol, insulin, leptin and, ghrelin to name a few.

• Cortisol: At night, cortisol levels should decrease. However, if you have lost sleep, these levels may stay elevated. This promotes insulin resistance, which is a risk factor for obesity and diabetes.

• Leptin: This hormone signals satiety to the brain, meaning it suppresses appetite. Lack of sleep causes a decrease in leptin. In other words, your brain is telling you that you’re still hungry, even when you’re full.

• Ghrelin: Related to leptin, ghrelin stimulates appetite. It’s been proven lack of sleep increases levels of ghrelin. Meaning, if you aren’t getting enough sleep, you might be taking in more calories than you need, especially carbohydrates.

Learn more about how sleep affects hormones here.

The ramifications of poor sleep are cyclical. Take an overweight individual that suffers from sleep apnea for example. This individual may have sleep apnea due to excess weight that obstructs the airway. Because of their sleep apnea, they suffer from sleep deprivation. Sleep deprivation throws their levels of leptin and ghrelin out of whack, which increases their appetite. The excess calories from unnecessary snacking cause them to put on more weight that may worsen their sleep apnea.

Additional Health Risks

There are many other health risks associated with sleep apnea other than the consequences that come with lack of restful sleep. Risk of stroke, heart failure, diabetes, depression, high blood pressure, and mental impairment are far more common in people with sleep apnea. Wondering why? Dr. Le explained it like this:

“If the main highway in your city is shut down that creates detours. Meaning traffic is going to be redirected to roads that were never built to accommodate the amount of traffic a highway can accommodate. As a result, these roads start to break down from potholes, pavement deterioration, etc. A similar thing happens if your main airway is obstructed. The body overcompensates for the problem by compromising other systems: blood vessels, organs, etc.”

Comorbid Conditions

A comorbid condition can be the direct result of a primary condition, in this case sleep apnea, or it may be that the comorbid condition plays a role in creating the primary condition. We have a bit of a which came first question here, but in either case, it is almost always the comorbid condition that causes the more serious threat to life. Just how serious? Let’s take a look.

Type II Diabetes

Both sleep apnea and type II diabetes are associated with weight gain and obesity, and it may be that extra weight causes and aggravates both of these conditions. Type II diabetes is linked to sleep apnea and about 80% of people who have type II diabetes, also have sleep apnea. They damage that diabetes does to your body can be fatal, and it is strongly correlated with heart attack and stroke.

Obesity

Extra weight is a primary factor in developing sleep apnea and obesity is common among people who have sleep apnea. Since sleep apnea causes an interruption to sleep, which further disrupts hormones that can cause weight gain, we see a vicious circle of weight gain which causes sleep apnea, which causes a lack of sleep, which leads to weight gain—round and round it goes. Sleep apnea is further associated with metabolic syndrome, making hard to lose weight. Obesity puts an enormous strain on the heart and is associated with fatal episodes.

Cardiovascular Disease

38,000 people die from heart disease yearly where sleep apnea is a complicating factor. 60% of people with heart failure have sleep apnea. Having sleep apnea increases the risk of a heart attack by 30%. Having sleep apnea increases the risk of stroke by between 30 and 50%. These are very real statistics on the likelihood of acquiring cardiovascular disease comorbid with sleep apnea.

Cancer

Sleep apnea doesn’t cause cancer that we know of, but if you have cancer and sleep apnea together, it increases the risk of death from cancer. The sleep apnea, which decreases health in many ways, seems to be a tipping factor in whether you are more likely to recover from cancer or to have it be fatal.

There is no doubt that the conditions associated with sleep apnea raise your risk for serious problems and can be a direct cause of death.

Who is at Risk for Sleep Apnea?

Men are more likely to suffer from sleep apnea than women and children, and the risk increases with age, body weight and smoking habits. In particular, sleep apnea is highly correlated with obesity, mainly due to excess fat on the sides of the neck that can cause obstructions in the airway. Several other conditions also increase the risk of sleep apnea, including menopause, asthma, epilepsy, Down syndrome, etc. In children, it may result from enlarged tonsils or adenoids.

Often, a sufferer from sleep apnea is completely unaware of the condition, which may therefore continue for years without identification. Even then it may only be identified by someone else witnessing the episodes or complaining about the loud snoring that usually accompanies it, or merely as a consequence of the ongoing daytime sleepiness, fatigue and irritability that result from it.

It has become apparent in recent years that those with sleep apnea are more vulnerable to a variety of parasomnias, such as sleep-walking, sleep-sex, sleep-eating, confusional arousals, night terrors, etc, as well as other sleep disorders like periodic limb movement disorder, restless legs syndrome, etc.

Pediatric Obstructive Sleep Apnea: A Health Hazard in Children

Pediatric obstructive sleep apnea (OSA) is one of the most common causes of sleep problems in children. OSA is a condition where breathing during sleep is disrupted due to partial or complete obstruction of the upper airway.

If I were to ask you to envision someone with sleep apnea, you’d likely conjure up the image of an older adult who is carrying around some extra weight. Unfortunately, this association leads to doctors often missing sleep apnea symptoms in children.

Children with OSA and other sleep disorders are at a higher risk of developmental abnormalities. Kids who don’t get proper sleep can experience:

• Stunted growth
• Learning disorders
• Behavior problems
• Cardiovascular distress
• Death (in extreme cases)

While the most common cause of sleep apnea in adults is obesity, the risk factors for children’s sleep apnea are a bit different. Sleep apnea in kids is often due to swollen or enlarged tonsils and adenoids. Common causes of the enlargement of these parts of the respiratory tract include:

• Allergies
• Asthma
• Tonsillitis
• Abnormalities from birth

Other risk factors of developing sleep apnea for children include obesity, low birth weight, family history of OSA, and a variety of disorders, including cerebral palsy and neuromuscular disease.

Because sleep apnea shares many of its symptoms with other sleep disorders and ADHD, it’s tough to diagnose OSA without proper testing.

If your child is exhibiting the above symptoms, the first step is to discuss them with your primary care physician. You will likely be referred to a sleep specialist who may conduct a sleep study and other testing to determine if your child has OSA, and if so, what the underlying cause is.

Treatment Options

The goal of any type of sleep apnea treatment is to keep the airway open. With that being said, patients need to know they have options.

Related: Sleep apnea testing

One of the most important things Dr. Le stressed to us about treatment options for sleep apnea is that they should be modified to best suit a patient’s needs. For this to happen, patients must see a trained doctor that addresses the issue from a holistic point of view. That includes managing your sleep hygiene*, monitoring weight gain and finding the mode of sleep apnea treatment that works best for you.

Common treatments include lifestyle changes (such as avoiding alcohol and other muscle relaxants, losing weight and quitting smoking), sleeping on a 30 degree angle or on one’s side or using a weight blanket of various weight , various kinds of oral/dental appliances or masks (particularly continuous positive airway pressure, or CPAP, masks, which remains the leading therapy for severe sleep apnea), or even surgical procedures to increase the size of the airway.

*By managing sleep hygiene we mean monitoring your sleep habits. Dr. Le suggests limiting the amount of TV you watch at night, reducing the amount of alcohol consumed before bed and finding the proper mattress to name a few. Basically, create an environment that is conducive to getting the best sleep possible.

Read More: Best Mattress for Sleep Apnea

Here are some potential treatment options that may be available to you.

Types of Sleep Apnea Treatments

• Oral sprays — Oral sprays are designed to lubricate the soft muscle tissues in the back of the throat to prevent vibrations. They are more often used to reduce snoring but are sometimes used to treat very mild cases of sleep apnea.
• Nasal Dilators — These devices consist of two small rings that are placed inside the nostrils and open your nasal passages. They can reduce snoring and improve sleep, but don’t effectively treat sleep apnea.
• Tongue stabilizing device (TSD) — These devices sit at the lips and use suction to pull the tongue forward and lift the soft tissues away from the back of your throat, which can reduce sleep apnea symptoms.
• Mandibular advancement device (MAD) — Mandibular advancement devices are the most widely used mouthpiece used to treat sleep apnea. MAD devices are like mouth guards with metal hinges that allow the lower jaw to gently slide forward, opening the airway.
• Sleep positioning device — Episodes of sleep apnea are reduced when you sleep on your side as opposed to your back. Sleep positioners prevent you from rolling from your side onto your back while you sleep.
• Positive airway pressure (PAP) — Positive airway pressure, or PAP, is the most effective and widely used method for treating obstructive sleep apnea. It uses a small device or machine with a face mask to introduce pressurized air into the throat in order to prevent the soft tissues from collapsing. There are several different PAP devices or sleep apnea machines available to treat moderate to severe cases of sleep apnea.

Oral Sprays

Oral sprays lubricate the soft muscle tissues in the back of the throat in order to prevent the tissues from vibrating. Some work to tone up the tissues at the back of the throat to prevent it from obstructing the airway. Oral sprays are more effective at reducing snoring rather than treating sleep apnea.

Pros:

• Less expensive
• No prescription needed
• Non invasive

Cons: 

• Not considered an effective treatment for sleep apnea
• Side effects include tingling in the throat

Nasal Dilators

Nasal Dilators are made up of two small rings that fit into the nostrils and open the nasal cavity. While they are great for increasing airflow, reducing snoring, and improving sleep quality, they aren’t an effective sleep apnea treatment.

Pros: 

• Can reduce snoring
• Can improve sleep quality

Cons: 

• Not considered an effective treatment for sleep apnea
• Can be painful to remove

Oral Appliances

Oral appliances are often used to treat snoring and mild to moderate sleep apnea. They are usually more easily tolerated than bulky sleep machines like CPAPs.

Tongue stabilizing device (TSD)

Tongue stabilizing devices sit at the lips and look somewhat like a pacifier. They use suction to pull the tongue forward and lift the soft tissues away from the back of your throat.

Pros: 

• Less expensive than CPAP
• Smaller and easier to travel with

Cons: 

• Not as effective as positive airway pressure (PAP) therapy
• Can cause excess saliva

Mandibular advancement device (MAD)

Mandibular advancement devices are similar to mouth guards that fit inside the mouth, but have metal hinges that allow the lower jaw to gently slide forward.

Pros: 

• Less expensive than CPAP
• Smaller and portable

Cons: 

• Not as effective as positive airway pressure (PAP) therapy
• Can be uncomfortable

Sleep Positioning Devices

Episodes of sleep apnea are less frequent while sleeping on your side as opposed to your back. Sleep positioners are therapy devices that prevent you from rolling from your side onto your back.

Some consist of collars that fit around the neck and vibrate when they sense you rolling over in order to force you back on your side. Others fit around the torso and have protrusions on the back that stop you when you try to roll over.

Pros: 

• Can hold you in side-sleeping position and reduce sleep apnea episodes
• Can reduce snoring as well

Cons: 

• These devices can be uncomfortable
• May wake you when you attempt to roll over and interfere with a good night’s sleep

Positive Airway Pressure Devices

EPAP (Expiratory Positive Airway Pressure)

EPAP is a device that enables you to draw in more air and exhale less air through the nostrils. This creates positive air pressure that prevents the airways from collapsing. EPAPs are usually made of adhesive strips that stick to the nose that allow you to inhale normally through your nostrils, but exhaling is more difficult.

Pros: 

• EPAPs are not machine-assisted
• More portable than other PAP devices

Cons: 

• It may feel odd not to fully exhale through your nose,
• It can take a week or longer to get used to the therapy.

CPAP (Continuous Positive Airway Pressure)

CPAP therapy is a common treatment for sleep apnea. CPAP devices consist of a face mask that’s hooked up to a machine by a long hose. The machine provides a continuous flow of air into the airway.

Pros: 

• Provides continuous positive airway pressure for effective sleep apnea treatment
• Newer models are quieter, have lighter weight face or nasal masks, and add-ons like heated humidifiers

Cons: 

• Some find the face masks and continuous positive airway pressure claustrophobic
• Wearing a CPAP mask throughout the night can cause dry mouth, dry nose, and congestion

BiPAP (Bilevel Positive Airway Pressure)

Unlike CPAP machines which deliver a single level of pressure, BiPAP machines deliver one pressure for inhaling and another pressure for exhaling.

Pros: 

• Can be a more comfortable option for people who cannot tolerate CPAP’s single continuous pressure
• BiPAPs make it easier to exhale, and reduce the risk of side effects caused by too much CO2 buildup

Cons: 

• In most cases, BiPAP is not recommended until CPAP therapy has failed
• Wearing a BiPAP mask overnight can cause dry mouth, dry nose, and congestion

APAP (Automatic Positive Airway Pressure)

APAP therapy has two separate settings — high and low — which allow the machine to automatically adjust to varying pressure needs as you sleep and change positions during the night.

Pros: 

• APAP’s automatic adjustable setting is generally more tolerable than CPAP’s constant pressure
• A good option for combination sleepers or people who toss and turn a lot at night

Cons:

• In most cases, APAP is not recommended until CPAP therapy has failed
• Not recommended for patients with chronic heart failure or obesity hypoventilation syndrome

Surgeries and Procedures

People with obstructive sleep apnea who cannot tolerate CPAP or similar positive airway pressure therapy may be candidates for medical procedures or surgeries.

Nasal surgery — Nasal obstructions and nighttime nasal congestion can contribute to sleep apnea. Nasal surgery for these issues usually involves straightening the septum (the cartilage in the nose that separates the nostrils) which creates room for air to pass smoothly. In some cases, cartilage removed from the septum can be used to strengthen the nostril valve and prevent collapse. These procedures are usually performed in hospitals as out-patient surgeries.

Uvulopalatopharyngoplasty (UPPP) — UPPP is the most performed sleep apnea surgery. It involves removing excess tissue from the soft palate and pharynx and, in some cases, the tonsils. This surgery usually requires an overnight stay in the hospital, and pain can persist for up to a week after the surgery has been performed.

Soft palate implants — Also called the Pillar Procedure, this involves the placement of polyester rods into the soft palate, which creates an inflammatory response that stiffens the tissues. This procedure can be done during a medical clinic visit with the patient awake under local anesthesia.

Mandibular maxillomandibular advancement surgery — This is a type of facial skeletal surgery that repositions the jaws to move them forward in order to expand the airway. Incisions are usually performed inside the mouth. It generally requires a one- to two-day hospital stay.

Upper airway stimulation (UAS) — This sleep apnea treatment involves surgically implanting a system that monitors breathing patterns and provides a small amount of stimulation to contract the throat muscles to keep the airway open.

Hyoid advancement — The hyoid is a U-shaped bone at the base of the neck that supports the tongue. People with sleep apnea often have a large tongue base that is more prone to obstructing the airway during sleep. Hyoid advancement surgery repositions the bone to expand the airway and prevent collapse. It is usually performed in the hospital as an outpatient surgery.

Tongue base reduction — This procedure involves using radiofrequency waves to shrink the tissues at the base of the tongue to help open air passages and prevent obstruction. This surgery requires a one-night stay in the hospital.

Tongue base advancement — This surgery moves forward one of the muscles of the tongue to limit the tongue’s backward fall during sleep. This procedure usually requires an overnight stay in the hospital.

Tracheostomy — A tracheostomy is a temporary or permanent procedure in which a hole is made in the trachea in the neck where a tube is inserted that delivers air to the lungs, bypassing any obstructions in the mouth or throat. It is an option for people who are morbidly obese with a condition known as obesity hypoventilation syndrome, or people with significant craniofacial anomalies.

Somnoplasty — Somnoplasty is a procedure used to treat snoring and is not recommended for sleep apnea. It uses heat to modify the tissues of the uvula and the soft palate. Somnoplasty is generally performed in a doctor’s office with the patient awake, under local anesthesia.

Lifestyle Adjustments

Sometimes making a small adjustment to your lifestyle can greatly reduce episodes of sleep apnea. Here are some suggestions:

• Avoid alcohol. Alcohol can relax the muscles in your throat and cause them to fall into your airway.
• Avoid sleeping pills. Just like alcohol, sleep medicine can relax the muscles in your throat and cause an airway obstruction.
• Lose weight. Studies show that you can reduce episodes of sleep apnea by 50% by losing just 10-15% of your body weight. Some people saw a complete reduction of sleep apnea with more substantial weight loss.
• Change sleep positions. Back sleepers are more prone to snoring and sleep apnea because gravity is working against them, causing the soft tissues in the mouth to fall into the airway. Reduce your risk by rolling over onto your side.
• Get an adjustable bed. It might be worth investing in a new mattress that works with an adjustable bed frame. Sleep apnea symptoms can often be alleviated by adjusting the head of the bed up.
• Quit smoking. Smoking cigarettes can increase inflammation and fluid retention in the upper airway, leading to sleep apnea.

How to Choose the Best Sleep Apnea Products

If you think you suffer from sleep apnea and would benefit from treatment, you should first talk with your doctor or, if your insurance provides coverage without a referral, go directly to a sleep specialist. Sleep specialists come from different medical backgrounds such as pulmonology, otolaryngology, neurology, and psychiatry, and use their expertise to help diagnose you with a particular sleep disorder, like obstructive sleep apnea, and the best treatment options.

To diagnose you with sleep apnea, your doctor may ask you to take a sleep apnea test called a polysomnogram. This is usually performed at a sleep disorder clinic. The test records your brain activity while you sleep using electrodes placed on your face and scalp, your breathing with belts around your chest and abdomen, and the oxygen levels in your blood with an oximeter probe on your finger.

Once a diagnosis is made, you will work closely with your sleep specialist to determine which treatment options are best for you.

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