Sleep apnea

The typical screening process for sleep apnea involves asking patients about common symptoms such as snoring, witnessed pauses in breathing during sleep and excessive daytime sleepiness. A current area requiring further study involves identifying different subtypes of sleep apnea based on patients who tend to present with different clusters or groupings of particular symptoms. These effects may become intractable, leading to depression. ==Risk factors==

Obstructive sleep apnea can affect people regardless of sex, race, or age. However, risk factors include: • male sex • obesity • age over 40 • large neck circumference • enlarged tonsils or tongue • narrow upper jaw • small lower jaw • tongue fat/tongue scalloping • a family history of sleep apnea • endocrine disorders such as hypothyroidism • lifestyle habits such as smoking or drinking alcohol Central sleep apnea is more often associated with any of the following risk factors: • transition period from wakefulness to non-REM sleep • older age • heart failure • atrial fibrillation • stroke • spinal cord injury ==Mechanism==

Obstructive sleep apnea The causes of obstructive sleep apnea are complex and individualized, but typical risk factors include narrow pharyngeal anatomy and craniofacial structure. This carbon dioxide build-up may be due to the decrease of output of the brainstem regulating the chest wall or pharyngeal muscles, which causes the pharynx to collapse. As a result, people with sleep apnea experience reduced or no slow-wave sleep and spend less time in REM sleep. Central sleep apnea There are two main mechanism that drive the disease process of CSA, sleep-related hypoventilation and post-hyperventilation hypocapnia. The most common cause of CSA is post-hyperventilation hypocapnia secondary to heart failure. This occurs because of brief failures of the ventilatory control system but normal alveolar ventilation. In contrast, sleep-related hypoventilation occurs when there is a malfunction of the brain's drive to breathe. The underlying cause of the loss of the wakefulness drive to breathe encompasses a broad set of diseases from strokes to severe kyphoscoliosis. == Complications ==

OSA is a serious medical condition with systemic effects; patients with untreated OSA have a greater mortality risk from cardiovascular disease than those undergoing appropriate treatment. Other complications include hypertension, congestive heart failure, atrial fibrillation, coronary artery disease, stroke, and type 2 diabetes. Alzheimer's disease and severe obstructive sleep apnea are connected because there is an increase in the protein beta-amyloid as well as white-matter damage. These are the main indicators of Alzheimer's, which in this case comes from the lack of proper rest or poorer sleep efficiency resulting in neurodegeneration. Having sleep apnea in mid-life brings a higher likelihood of developing Alzheimer's in older age, and if one has Alzheimer's then one is also more likely to have sleep apnea. This is demonstrated by cases of sleep apnea even being misdiagnosed as dementia. With the use of treatment through CPAP, there is a reversible risk factor in terms of the amyloid proteins. This usually restores brain structure and cognitive impairment. Evidence continues to be found supporting there is an association between BMI and Alzheimer's. There is also evidence of increased risk of developing Alzheimer's for those with a higher BMI in women ages 70 and above. While continuous positive airway pressure (CPAP) was not found to significantly improve cognitive performance, it was found to benefit other symptoms like depression, anxiety, etc. ==Diagnosis==

Classification There are three types of sleep apnea. OSA accounts for 84%, CSA for 0.9%, and 15% of cases are mixed. Obstructive sleep apnea In a systematic review of published evidence, the United States Preventive Services Task Force in 2017 concluded that there was uncertainty about the accuracy or clinical utility of all potential screening tools for OSA, and recommended that evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. The diagnosis of OSA syndrome is made when the patient shows recurrent episodes of partial or complete collapse of the upper airway during sleep resulting in apneas or hypopneas, respectively. Criteria defining an apnea or a hypopnea vary. The American Academy of Sleep Medicine (AASM) defines apnea as a reduction in airflow of ≥ 90% lasting at least 10 seconds. A hypopnea is defined as a reduction in airflow of ≥ 30% lasting at least 10 seconds and associated with a ≥ 4% decrease in pulse oxygenation, or as a ≥ 30% reduction in airflow lasting at least 10 seconds and associated either with a ≥ 3% decrease in pulse oxygenation or with an arousal. To define the severity of the condition, the Apnea-Hypopnea Index (AHI) or the Respiratory Disturbance Index (RDI) are used. While the AHI measures the mean number of apneas and hypopneas per hour of sleep, the RDI adds to this measure the respiratory effort-related arousals (RERAs). The OSA syndrome is thus diagnosed if the AHI is > 5 episodes per hour and results in daytime sleepiness and fatigue or when the RDI is ≥ 15 independently of the symptoms. According to the American Association of Sleep Medicine, daytime sleepiness is determined as mild, moderate and severe depending on its impact on social life. Daytime sleepiness can be assessed with the Epworth Sleepiness Scale (ESS), a self-reported questionnaire on the propensity to fall asleep or doze off during daytime. Screening tools for OSA comprise the STOP questionnaire, the Berlin questionnaire and the STOP-BANG questionnaire which has been reported as being a powerful tool to detect OSA. Criteria According to the International Classification of Sleep Disorders, there are 4 types of criteria. The first one concerns sleep – excessive sleepiness, non-restorative sleep, fatigue or insomnia symptoms. The second and third criteria are about respiration – waking with breath holding, gasping, or choking; snoring, breathing interruptions or both during sleep. The last criterion revolved around medical issues as hypertension, coronary artery disease, stroke, heart failure, atrial fibrillation, type 2 diabetes mellitus, mood disorder or cognitive impairment. Two levels of severity are distinguished, the first one is determined by a polysomnography or home sleep apnea test demonstrating 5 or more predominantly obstructive respiratory events per hour of sleep and the higher levels are determined by 15 or more events. If the events are present less than 5 times per hour, no obstructive sleep apnea is diagnosed. Since sequential nights of testing would be impractical and cost prohibitive in the sleep lab, home sleep testing for multiple nights can not only be more useful, but more reflective of what is typically happening each night. Polysomnography Nighttime in-laboratory Level 1 polysomnography (PSG) is the gold standard test for diagnosis. Patients are monitored with EEG leads, pulse oximetry, temperature and pressure sensors to detect nasal and oral airflow, respiratory impedance plethysmography or similar resistance belts around the chest and abdomen to detect motion, an ECG lead, and EMG sensors to detect muscle contraction in the chin, chest, and legs. A hypopnea can be based on one of two criteria. It can either be a reduction in airflow of at least 30% for more than 10 seconds associated with at least 4% oxygen desaturation or a reduction in airflow of at least 30% for more than 10 seconds associated with at least 3% oxygen desaturation or an arousal from sleep on EEG. An "event" can be either an apnea, characterized by complete cessation of airflow for at least 10 seconds, or a hypopnea in which airflow decreases by 50 percent for 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen saturation or an arousal from sleep. To grade the severity of sleep apnea, the number of events per hour is reported as the apnea-hypopnea index (AHI). An AHI of less than 5 is considered normal. An AHI of 5–15 is mild; 15–30 is moderate, and more than 30 events per hour characterizes severe sleep apnea. Central sleep apnea The diagnosis of CSA syndrome is made when the presence of at least 5 central apnea events occur per hour. There are multiple mechanisms that drive the apnea events. In individuals with heart failure with Cheyne-Stokes respiration, the brain's respiratory control centers are imbalanced during sleep. This results in ventilatory instability, caused by chemoreceptors that are hyperresponsive to CO2 fluctuations in the blood, resulting in high respiratory drive that leads to apnea. ==Management==

The treatment of obstructive sleep apnea is different from that of central sleep apnea. Treatment often starts with behavioral therapy and some people may be suggested to try a continuous positive airway pressure (CPAP) device. Many people are told to avoid alcohol, sleeping pills, and other sedatives, which can relax throat muscles, contributing to the collapse of the airway at night. Changing sleep position More than half of people with obstructive sleep apnea have some degree of positional obstructive sleep apnea, meaning that it gets worse when they sleep on their backs. Sleeping on their sides is an effective and cost-effective treatment for positional obstructive sleep apnea. Weight loss Excess body weight is thought to be an important cause of sleep apnea. People who are overweight have more tissues in the back of their throat which can restrict the airway, especially when sleeping. In weight loss studies of overweight individuals, those who lose weight show reduced apnea frequencies and improved apnoea–hypopnoea index (AHI). Weight loss effective enough to relieve obesity hypoventilation syndrome (OHS) must be 25–30% of body weight. For some obese people, it can be difficult to achieve and maintain this result without bariatric surgery. Rapid palatal expansion In children, orthodontic treatment to expand the volume of the nasal airway, such as nonsurgical rapid palatal expansion is common. The procedure has been found to significantly decrease the AHI and lead to long-term resolution of clinical symptoms. Since the palatal suture is fused in adults, regular RPE using tooth-borne expanders cannot be performed. Mini-implant assisted rapid palatal expansion (MARPE) has been recently developed as a non-surgical option for the transverse expansion of the maxilla in adults. This method increases the volume of the nasal cavity and nasopharynx, leading to increased airflow and reduced respiratory arousals during sleep. Changes are permanent with minimal complications. Surgery Several surgical procedures (sleep surgery) are used to treat sleep apnea, although they are normally a third line of treatment for those who reject or are not helped by CPAP treatment or dental appliances. but has been found to be ineffective at reducing respiratory arousals during sleep. Pharyngeal obstruction Tonsillectomy and uvulopalatopharyngoplasty (UPPP or UP3) are available to address pharyngeal obstruction. Hypopharyngeal or base of tongue obstruction Base-of-tongue advancement by means of advancing the genial tubercle of the mandible, tongue suspension, or hyoid suspension (aka hyoid myotomy and suspension or hyoid advancement) may help with the lower pharynx. However, health professionals are often unsure as to who should be referred for surgery and when to do so: some factors in referral may include failed use of CPAP or device use; anatomy which favors rather than impedes surgery; or significant craniofacial abnormalities which hinder device use. Potential complications Several inpatient and outpatient procedures use sedation. Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing or collapses in a patient's airways. Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided. Other Neurostimulation Diaphragm pacing, which involves the rhythmic application of electrical impulses to the diaphragm, has been used to treat central sleep apnea. In April 2014, the U.S. Food and Drug Administration granted pre-market approval for use of an upper airway stimulation system in people who cannot use a continuous positive airway pressure device. The Inspire Upper Airway Stimulation system is a hypoglossal nerve stimulation implant that senses respiration and applies mild electrical stimulation during inspiration, which pushes the tongue slightly forward to open the airway. Medications There is currently insufficient evidence to recommend any medication for OSA. This may result in part because people with sleep apnea have tended to be treated as a single group in clinical trials. Identifying specific physiological factors underlying sleep apnea makes it possible to test drugs specific to those causal factors: airway narrowing, impaired muscle activity, low arousal threshold for waking, and unstable breathing control. Those who experience low waking thresholds may benefit from eszopiclone, a sedative typically used to treat insomnia. The antidepressant desipramine may stimulate upper airway muscles and lessen pharyngeal collapsibility in people who have limited muscle function in their airways. There is limited evidence for medication, but 2012 AASM guidelines suggested that acetazolamide "may be considered" for the treatment of central sleep apnea; zolpidem and triazolam may also be considered for the treatment of central sleep apnea, but "only if the patient does not have underlying risk factors for respiratory depression". Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects. In December 2024, the FDA approved tirzepatide, an anti-diabetic and weight loss medication, as a component in the combination treatment of adults with obesity suffering from moderate to severe obstructive sleep apnea. Other components of the therapy are a reduced-calorie diet and increased physical activity. Oral appliances An oral appliance, often referred to as a mandibular advancement splint, is a custom-made mouthpiece that shifts the lower jaw forward and opens the bite slightly, opening up the airway. These devices can be fabricated by a general dentist. Oral appliance therapy is usually successful in patients with mild to moderate obstructive sleep apnea. While CPAP is more effective for sleep apnea than oral appliances, oral appliances improve sleepiness and quality of life and are often better tolerated than CPAP. Many dental appliances can expand the maxilla and increase the nasal airway volume as measured by CBCT and acoustic rhinometry but the novel C.A.R.E. device (DNA, mRNA and mmRNA) has a protocol for wear time and adjustment that is different than these devices. This has resulted in the safe and effective resolution of sleep apnea in children and adults . The CARE device (DNA, mRNA and mmRNA) and protocol was FDA cleared for snoring and for obstructive sleep apnea in 2023. Larger studies are needed. Cross-functional team research is needed to specifically determine the impact of oral devices and their materials that i.e. might stimulate osteogenesis potentially changing the size and shape of a bone (the maxilla). Determining a mechanism of action at the interface of the materials and biology is important if these novel clinical results have shown impact to the resolution of sleep apnea downstream. It can then be applied to all forms of dental devices and protocols. In the end, 'The development of an OSA treatment that is simple, affordable, comfortable, noninvasive, effective at all severity levels, and accepted by most patients is still the holy grail of sleep medicine'. Nasal EPAP Nasal EPAP is a bandage-like device placed over the nostrils that uses a person's own breathing to create positive airway pressure to prevent obstructed breathing. Oral pressure therapy Oral pressure therapy uses a device that creates a vacuum in the mouth, pulling the soft palate tissue forward. It has been found useful in about 25% to 37% of people. ==Prognosis==

Death could occur from untreated OSA due to lack of oxygen to the body. There is increasing evidence that sleep apnea may lead to liver function impairment, particularly fatty liver diseases (see steatosis). It has been revealed that people with OSA show tissue loss in brain regions that help store memory, thus linking OSA with memory loss. Using magnetic resonance imaging (MRI), the scientists discovered that people with sleep apnea have mammillary bodies that are about 20% smaller, particularly on the left side. One of the key investigators hypothesized that repeated drops in oxygen lead to the brain injury. 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. Short of death, drops in blood oxygen may trigger seizures, even in the absence of epilepsy. In people with epilepsy, the hypoxia caused by apnea may trigger seizures that had previously been well controlled by medications. In other words, a seizure disorder may become unstable in the presence of sleep apnea. In adults with coronary artery disease, a severe drop in blood oxygen level can cause angina, arrhythmias, or heart attacks (myocardial infarction). Longstanding recurrent episodes of apnea, over months and years, may cause an increase in carbon dioxide levels that can change the pH of the blood enough to cause a respiratory acidosis. ==Epidemiology==

The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans was affected by at least moderate sleep apnea. The costs of untreated sleep apnea reach further than just health issues. It is estimated that in the U.S., the average untreated sleep apnea patient's annual health care costs $1,336 more than an individual without sleep apnea. This may cause $3.4 billion/year in additional medical costs. Whether medical cost savings occur with treatment of sleep apnea remains to be determined. == Frequency and population ==

Sleep disorders including sleep apnea have become an important health issue in the United States. Twenty-two million Americans have been estimated to have sleep apnea, with 80% of moderate and severe OSA cases undiagnosed. OSA can occur at any age, but it happens more frequently in men who are over 40 and overweight. ==History==

A type of CSA was described in the German myth of Ondine's curse where the person when asleep would forget to breathe. The clinical picture of this condition has long been recognized as a character trait, without an understanding of the disease process. The term "Pickwickian syndrome" that is sometimes used for the syndrome was coined by the famous early 20th-century physician William Osler, who must have been a reader of Charles Dickens. The description of Joe, "the fat boy" in Dickens's novel The Pickwick Papers, is an accurate clinical picture of an adult with obstructive sleep apnea syndrome. The early reports of obstructive sleep apnea in the medical literature described individuals who were severely affected, often presenting with severe hypoxemia, hypercapnia and congestive heart failure. Treatment The management of obstructive sleep apnea was improved with the introduction of continuous positive airway pressure (CPAP) machines, first described in 1981 by Colin Sullivan and associates in Sydney, Australia. The first models were bulky and noisy, but the design was rapidly improved and by the late 1980s, CPAP was widely adopted. The availability of an effective treatment stimulated an aggressive search for affected individuals and led to the establishment of hundreds of specialized clinics dedicated to the diagnosis and treatment of sleep disorders. Though many types of sleep problems are recognized, the vast majority of patients attending these centers have sleep-disordered breathing. Sleep apnea awareness day is 18 April in recognition of Colin Sullivan. == See also ==