Template:Short description Template:Cs1 config Template:Use dmy dates Template:Infobox medical condition (new)
Sleep apnea (sleep apnoea or sleep apnœa in British English) is a sleep-related breathing disorder in which repetitive pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor ventilation and sleep disruption.<ref name="Chang-2023">Template:Cite journal</ref><ref name="Roberts-2022" /> Each pause in breathing can last for a few seconds to a few minutes and often occurs many times a night.<ref name="NIH2012What4" /> A choking or snorting sound may occur as breathing resumes.<ref name="NIH2012What4" /> Common symptoms include daytime sleepiness, snoring, and non restorative sleep despite adequate sleep time.<ref name="Stansbury-2015">Template:Cite journal</ref> Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day.<ref name="NIH2012What4" /> It is often a chronic condition.<ref>Template:Cite journal</ref>
Sleep apnea may be categorized as obstructive sleep apnea (OSA), in which breathing is interrupted by a blockage of air flow, central sleep apnea (CSA), in which regular unconscious breath simply stops, or a combination of the two.<ref name="NIH2012What4" /> OSA is the most common form.<ref name="NIH2012What4" /> OSA has four key contributors; these include a narrow, crowded, or collapsible upper airway, an ineffective pharyngeal dilator muscle function during sleep, airway narrowing during sleep, and unstable control of breathing (high loop gain).<ref name="Dolgin3">Template:Cite journal</ref><ref name="Osman-2018">Template:Cite journal</ref> In CSA, 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. If the pause in breathing is long enough, the percentage of oxygen in the circulation can drop to a lower than normal level (hypoxemia) and the concentration of carbon dioxide can build to a higher than normal level (hypercapnia).<ref>Template:Cite book</ref> In turn, these conditions of hypoxia and hypercapnia will trigger additional effects on the body such as Cheyne-Stokes Respiration.<ref>Template:Cite book</ref>
Some people with sleep apnea are unaware they have the condition.<ref name="NIH2012What4" /> In many cases it is first observed by a family member.<ref name="NIH2012What4" /> An in-lab sleep study overnight is the preferred method for diagnosing sleep apnea.<ref name="Osman-2018" /> In the case of OSA, the outcome that determines disease severity and guides the treatment plan is the apnea-hypopnea index (AHI).<ref name="Osman-2018" /> This measurement is calculated from totaling all pauses in breathing and periods of shallow breathing lasting greater than 10 seconds and dividing the sum by total hours of recorded sleep.<ref name="Chang-2023" /><ref name="Osman-2018" /> In contrast, for CSA the degree of respiratory effort, measured by esophageal pressure or displacement of the thoracic or abdominal cavity, is an important distinguishing factor between OSA and CSA.<ref name="Badr-2019">Template:Cite journal</ref>
A systemic disorder, sleep apnea is associated with a wide array of effects, including increased risk of car accidents, hypertension, cardiovascular disease, myocardial infarction, stroke, atrial fibrillation, insulin resistance, higher incidence of cancer, and neurodegeneration.<ref name="Lim4">Template:Cite journal</ref> Further research is being conducted on the potential of using biomarkers to understand which chronic diseases are associated with sleep apnea on an individual basis.<ref name="Lim4"/>
Treatment may include lifestyle changes, mouthpieces, breathing devices, and surgery.<ref name="NIH2012What4" /> Effective lifestyle changes may include avoiding alcohol, losing weight, smoking cessation, and sleeping on one's side.<ref name="Gottlieb&20202">Template:Cite journal</ref> Breathing devices include the use of a CPAP machine.<ref name="NIH2012Tx2">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> With proper use, CPAP improves outcomes.<ref name="Spi20152">Template:Cite journal</ref> Evidence suggests that CPAP may improve sensitivity to insulin, blood pressure, and sleepiness.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Long term compliance, however, is an issue with more than half of people not appropriately using the device.<ref name="Spi20152" /><ref name="Hsu20032">Template:Cite journal</ref> In 2017, only 15% of potential patients in developed countries used CPAP machines, while in developing countries well under 1% of potential patients used CPAP.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>Template:Unreliable source Without treatment, sleep apnea may increase the risk of heart attack, stroke, diabetes, heart failure, irregular heartbeat, obesity, and motor vehicle collisions.<ref name="NIH2012What4" />
OSA is a common sleep disorder. A large analysis in 2019 of the estimated prevalence of OSA found that OSA affects 936 million—1 billion people between the ages of 30–69 globally, or roughly every 1 in 10 people, and up to 30% of the elderly.<ref>Template:Cite journal</ref> Sleep apnea is somewhat more common in men than women, roughly a 2:1 ratio of men to women, and in general more people are likely to have it with older age and obesity. Other risk factors include being overweight,<ref name="Lim4"/> a family history of the condition, allergies, and enlarged tonsils.<ref name="NIH2012Cau2">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
Signs and symptomsEdit
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.<ref name="Lim4"/> There is a wide range in presenting symptoms in patients with sleep apnea, from being asymptomatic to falling asleep while driving.<ref name="Lim4" /> Due to this wide range in clinical presentation, some people are not aware that they have sleep apnea and are either misdiagnosed or ignore the symptoms altogether.<ref name="elad2">Template:Cite journal</ref> 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.<ref name="Lim4" />
OSA may increase risk for driving accidents and work-related accidents due to sleep fragmentation from repeated arousals during sleep.<ref name="Lim4" /> If OSA is not treated it results in excessive daytime sleepiness and oxidative stress from the repeated drops in oxygen saturation, people are at increased risk of other systemic health problems, such as diabetes, hypertension or cardiovascular disease.<ref name="Lim4" /> Subtle manifestations of sleep apnea may include treatment refractory hypertension and cardiac arrhythmias and over time as the disease progresses, more obvious symptoms may become apparent.<ref name="Stansbury-2015"/> Due to the disruption in daytime cognitive state, behavioral effects may be present. These can include moodiness, belligerence, as well as a decrease in attentiveness and energy.<ref name="aloiaetal2">Template:Cite journal</ref> These effects may become intractable, leading to depression.<ref>Template:Cite journal</ref>
Risk factorsEdit
Obstructive sleep apnea can affect people regardless of sex, race, or age.<ref>Template:Cite journal</ref> However, risk factors include:<ref name="nhlbi2">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
- male sex<ref name="nhlbi2" /><ref name="sleep.hms.harvard.edu2">{{#invoke:citation/CS1|citation
|CitationClass=web }}</ref><ref name="Badr-2019"/>
- obesity<ref name="nhlbi2" /><ref name="sleep.hms.harvard.edu2" />
- age over 40<ref name="nhlbi2" />
- large neck circumference<ref name="nhlbi2" />
- enlarged tonsils or tongue<ref name="nhlbi2" />
- narrow upper jaw<ref name="Osman-2018"/>
- small lower jaw<ref name="sleep.hms.harvard.edu2" />
- tongue fat/tongue scalloping<ref name="Osman-2018"/>
- a family history of sleep apnea<ref name="nhlbi2" />
- endocrine disorders<ref name="nhlbi2" /> such as hypothyroidism<ref name="sleep.hms.harvard.edu2" />
- lifestyle habits such as smoking or drinking alcohol<ref name="nhlbi2" />
Template:Colend Central sleep apnea is more often associated with any of the following risk factors:<ref name="Badr-2019"/>
- transition period from wakefulness to non-REM sleep<ref name="Badr-2019"/>
- older age<ref name="Badr-2019"/>
- heart failure<ref name="Badr-2019"/>
- atrial fibrillation<ref name="Badr-2019"/>
- stroke<ref name="Badr-2019"/>
- spinal cord injury<ref name="Badr-2019"/>
MechanismEdit
Obstructive sleep apnea
The causes of obstructive sleep apnea are complex and individualized, but typical risk factors include narrow pharyngeal anatomy and craniofacial structure.<ref name="Osman-2018"/> When anatomical risk factors are combined with non-anatomical contributors such as an ineffective pharyngeal dilator muscle function during sleep, unstable control of breathing (high loop gain), and premature awakening to mild airway narrowing, the severity of the OSA rapidly increases as more factors are present.<ref name="Osman-2018"/> When breathing is paused due to upper airway obstruction, carbon dioxide builds up in the bloodstream. Chemoreceptors in the bloodstream note the high carbon dioxide levels. The brain is signaled to awaken the person, which clears the airway and allows breathing to resume. Breathing normally will restore oxygen levels and the person will fall asleep again.<ref>Template:Cite book</ref> 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.<ref name="Pur20182">Template:Cite bookTemplate:Page needed</ref> As a result, people with sleep apnea experience reduced or no slow-wave sleep and spend less time in REM sleep.<ref name="Pur20182" />
Central sleep apnea
There are two main mechanism that drive the disease process of CSA, sleep-related hypoventilation and post-hyperventilation hypocapnia.<ref name="Badr-2019"/> The most common cause of CSA is post-hyperventilation hypocapnia secondary to heart failure.<ref name="Badr-2019" /> This occurs because of brief failures of the ventilatory control system but normal alveolar ventilation.<ref name="Badr-2019" /> In contrast, sleep-related hypoventilation occurs when there is a malfunction of the brain's drive to breathe.<ref name="Badr-2019" /> The underlying cause of the loss of the wakefulness drive to breathe encompasses a broad set of diseases from strokes to severe kyphoscoliosis.<ref name="Badr-2019" />
ComplicationsEdit
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.<ref name="Das-2022">Template:Cite journal</ref> Other complications include hypertension, congestive heart failure, atrial fibrillation, coronary artery disease, stroke, and type 2 diabetes.<ref name="Das-2022" /> Daytime fatigue and sleepiness, a common symptom of sleep apnea, is also an important public health concern regarding transportation crashes caused by drowsiness.<ref name="Das-2022" /> OSA may also be a risk factor of COVID-19. People with OSA have a higher risk of developing severe complications of COVID-19.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
Alzheimer's disease and severe obstructive sleep apnea are connected<ref name="ReferenceB">Template:Cite journal</ref> 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.<ref name="Jackson et al 2020">Template:Cite journal</ref><ref name="Weihs Frenzel Grabe 2021 pp. 87–96">Template:Cite journal</ref><ref>Template:Cite journal</ref> 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.<ref name="Owen et al 2020">Template:Cite journal</ref> This is demonstrated by cases of sleep apnea even being misdiagnosed as dementia.<ref>Template:Cite news</ref> 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.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="Cooke Ayalon Palmer Loredo 2009 pp. 305–309">Template:Cite journal</ref> Evidence continues to be found supporting there is an association between BMI and Alzheimer's.<ref>Template:Cite journal</ref> There is also evidence of increased risk of developing Alzheimer's for those with a higher BMI in women ages 70 and above.<ref>Template:Cite journal</ref> While continuous positive airway pressure (CPAP) wasn't found to significantly improve cognitive performance, it was found to benefit other symptoms like depression, anxiety, etc.<ref>Template:Cite journal</ref>
DiagnosisEdit
ClassificationEdit
There are three types of sleep apnea. OSA accounts for 84%, CSA for 0.9%, and 15% of cases are mixed.<ref>Template:Cite journal</ref>
Obstructive sleep apneaEdit
{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}}
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,<ref>Template:Cite journal</ref> and recommended that evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults.<ref>Template:Cite journal</ref>
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.<ref name="Obstructive sleep apnea is a common">Template:Cite journal</ref> Criteria defining an apnea or a hypopnea vary. The American Academy of Sleep Medicine (AASM) defines an 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.<ref>Berry RB, Quan SF, Abrue AR, et al.; for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.6. Darien, IL: American Academy of Sleep Medicine; 2020.</ref>
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).<ref>Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
CriteriaEdit
According to the International Classification of Sleep Disorders, there are 4 types of criteria.<ref>Template:Cite book</ref><ref name="aasm">Template:Cite bookTemplate:Page needed</ref> The first one concerns sleep – excessive sleepiness, nonrestorative 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.<ref name="aasm"/>
A considerable night-to-night variability further complicates diagnosis of OSA. In unclear cases, multiple nights of testing might be required to achieve an accurate diagnosis.<ref>Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref>
PolysomnographyEdit
| AHI | Rating |
|---|---|
| < 5 | Normal |
| 5–15 | Mild |
| 15–30 | Moderate |
| > 30 | Severe |
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.<ref name="stats2">Template:Cite journal Template:CC-notice</ref>
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.<ref>Template:Cite journal</ref> 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 apneaEdit
{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} The diagnosis of CSA syndrome is made when the presence of at least 5 central apnea events occur per hour.<ref name="Roberts-2022">Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref> 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.<ref name="Roberts-2022" /> Another common mechanism that causes CSA is the loss of the brain's wakefulness drive to breathe.<ref name="Roberts-2022" />
CSA is organized into 6 individual syndromes: Cheyne-Stokes respiration, Complex sleep apnea, Primary CSA, High altitude periodic breathing, CSA from medication, CSA from comorbidity.<ref name="Roberts-2022" /> Like in OSA, nocturnal polysomnography is the mainstay of diagnosis for CSA.<ref name="Badr-2019"/> The degree of respiratory effort, measured by esophageal pressure or displacement of the thoracic or abdominal cavity, is an important distinguishing factor between OSA and CSA.<ref name="Badr-2019"/>
Mixed apneaEdit
Some people with sleep apnea have a combination of both types; its prevalence ranges from 0.56% to 18%. The condition, also called treatment-emergent central apnea, is generally detected when obstructive sleep apnea is treated with CPAP and central sleep apnea emerges.<ref name="Badr-2019"/> The exact mechanism of the loss of central respiratory drive during sleep in OSA is unknown but is most likely related to incorrect settings of the CPAP treatment and other medical conditions the person has.<ref name= ComplexRev2014>Template:Cite journal</ref>
ManagementEdit
The treatment of obstructive sleep apnea is different than 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.<ref name=SleepApneaTreatments /> The evidence supporting one treatment option compared to another for a particular person is not clear.<ref name="pmid36278514">Template:Cite journal</ref>
Changing sleep positionEdit
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.<ref name="pmid28852945">Template:Cite journal</ref> Sleeping on their sides is an effective and cost-effective treatment for positional obstructive sleep apnea.<ref name="pmid28852945" />
Continuous positive airway pressureEdit
Template:See also For moderate to severe sleep apnea, the most common treatment is the use of a continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP) device.<ref name=SleepApneaTreatments>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=2012review/> These splint the person's airway open during sleep by means of pressurized air. The person typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine.<ref name=SleepApneaTreatments/>
Although CPAP therapy is effective in reducing apneas and less expensive than other treatments, some people find it uncomfortable. Some complain of feeling trapped, having chest discomfort, and skin or nose irritation. Other side effects may include dry mouth, dry nose, nosebleeds, sore lips and gums.<ref name=AHRQ2011/>
Whether or not it decreases the risk of death or heart disease is controversial with some reviews finding benefit and others not.<ref name="Spi20152"/><ref>Template:Cite journal</ref><ref name="pmid36278514" /> This variation across studies might be driven by low rates of compliance—analyses of those who use CPAP for at least four hours a night suggests a decrease in cardiovascular events.<ref>Template:Cite journal</ref>
Weight lossEdit
Excess body weight is thought to be an important cause of sleep apnea.<ref name="young">Template:Cite journal</ref> People who are overweight have more tissues in the back of their throat which can restrict the airway, especially when sleeping.<ref>Template:Cite news</ref> In weight loss studies of overweight individuals, those who lose weight show reduced apnea frequencies and improved apnoea–hypopnoea index (AHI).<ref name="young"/><ref>Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref>
Rapid palatal expansionEdit
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.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
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.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Changes are permanent with minimal complications.
SurgeryEdit
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.<ref name="Spi20152"/> Surgical treatment for obstructive sleep apnea needs to be individualized to address all anatomical areas of obstruction.<ref name="Chang-2023" />
Nasal obstructionEdit
Often, correction of the nasal passages needs to be performed in addition to correction of the oropharynx passage. Septoplasty and turbinate surgery may improve the nasal airway,<ref>Template:Cite journal</ref> but has been found to be ineffective at reducing respiratory arousals during sleep.<ref>Template:Cite journal</ref>
Pharyngeal obstructionEdit
Tonsillectomy and uvulopalatopharyngoplasty (UPPP or UP3) are available to address pharyngeal obstruction.<ref name="Chang-2023" />
The "Pillar" device is a treatment for snoring and obstructive sleep apnea; it is thin, narrow strips of polyester. Three strips are inserted into the roof of the mouth (the soft palate) using a modified syringe and local anesthetic, in order to stiffen the soft palate. This procedure addresses one of the most common causes of snoring and sleep apnea — vibration or collapse of the soft palate. It was approved by the FDA for snoring in 2002 and for obstructive sleep apnea in 2004. A 2013 meta-analysis found that "the Pillar implant has a moderate effect on snoring and mild-to-moderate obstructive sleep apnea" and that more studies with high level of evidence were needed to arrive at a definite conclusion; it also found that the polyester strips work their way out of the soft palate in about 10% of the people in whom they are implanted.<ref name=pillar>Template:Cite journal</ref>
Hypopharyngeal or base of tongue obstructionEdit
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.<ref name="Chang-2023" />
Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or throat, procedures done at either a doctor's office or a hospital. Small shots or other treatments, sometimes in a series, are used for shrinkage, while the insertion of a small piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues.<ref name=SleepApneaTreatments/>
Multi-level surgeryEdit
Maxillomandibular advancement is considered the most effective surgery for people with sleep apnea, because it increases the posterior airway space.<ref>Template:Cite journal</ref> 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.<ref name="auspre01">Template:Cite journal</ref>
Potential complicationsEdit
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.<ref>Template:Cite bookTemplate:Page needed</ref> Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.<ref name="Chang-2023" />
Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the effects in the immediate postoperative period. Once the swelling resolves and the palate becomes tightened by postoperative scarring, however, the full benefit of the surgery may be noticed.<ref name="Chang-2023" />
A person with sleep apnea undergoing any medical treatment must make sure their doctor and anesthetist are informed about the sleep apnea. Alternative and emergency procedures may be necessary to maintain the airway of sleep apnea patients.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
OtherEdit
NeurostimulationEdit
Diaphragm pacing, which involves the rhythmic application of electrical impulses to the diaphragm, has been used to treat central sleep apnea.<ref name="BhimjiDia15">Template:EMedicine</ref><ref>Template:Cite journal</ref>
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.<ref name="FDAInspire14">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
MedicationsEdit
There is currently insufficient evidence to recommend any medication for OSA.<ref name="Efficacy of pharmacotherapy for OSA">Template:Cite journal</ref> 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.<ref name="Dolgin">Template:Cite journal</ref><ref name="Wellman">Template:Cite journal</ref> Those who experience low waking thresholds may benefit from eszopiclone, a sedative typically used to treat insomnia.<ref name="Dolgin"/><ref>Template:Cite journal</ref> The antidepressant desipramine may stimulate upper airway muscles and lessen pharyngeal collapsibility in people who have limited muscle function in their airways.<ref name="Dolgin"/><ref>Template:Cite journal</ref>
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,<ref name="Lambert">Template:Cite journal</ref> but "only if the patient does not have underlying risk factors for respiratory depression".<ref name="Efficacy of pharmacotherapy for OSA"/><ref name=2012review>Template:Cite journal</ref> Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects.<ref name=PsychToday>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="pmid11181239">Template:Cite journal</ref><ref name="pmid2609134">Template:Cite journal</ref>
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.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
Oral appliancesEdit
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.<ref>Template:Cite journal</ref><ref name="ReferenceA">Template:Cite journal</ref> 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.<ref name="ReferenceA"/>
Nasal EPAPEdit
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.<ref name=Riaz2015rev>Template:Cite journal</ref>
Oral pressure therapyEdit
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.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
PrognosisEdit
Death could occur from untreated OSA due to lack of oxygen to the body.<ref name=AHRQ2011>{{#invoke:citation/CS1|citation |CitationClass=web }}. A 2012 surveillance update Template:Webarchive found no significant information to update.</ref>
There is increasing evidence that sleep apnea may lead to liver function impairment, particularly fatty liver diseases (see steatosis).<ref name="aloiaetal">Template:Cite journal</ref><ref name="apnea">Template:Cite journal</ref><ref name="apnea2">Template:Cite journal</ref><ref name="apnea3">Template:Cite journal</ref>
It has been revealed that people with OSA show tissue loss in brain regions that help store memory, thus linking OSA with memory loss.<ref>Template:Cite journal</ref> 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.<ref>Template:Cite journal</ref>
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.<ref name="Epilepsy and sleep apnea syndrome">Template:Cite journal</ref> 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.Template:Medical citation needed
EpidemiologyEdit
{{ safesubst:#invoke:Unsubst||date=__DATE__ |$B= Template:Ambox }} The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans was affected by at least moderate sleep apnea.<ref name="pmid8464434" /><ref name="pmid19690624" /> It also estimated that in middle-age as many as 9% of women and 24% of men were affected, undiagnosed and untreated.<ref name="young"/><ref name="pmid8464434">Template:Cite journal</ref><ref name="pmid19690624">Template:Cite journal</ref>
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.<ref>Template:Cite journal</ref>
Frequency and populationEdit
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.<ref name="www.sleepapnea.org-2017">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
OSA can occur at any age, but it happens more frequently in men who are over 40 and overweight.<ref name="www.sleepapnea.org-2017" />
HistoryEdit
A type of CSA was described in the German myth of Ondine's curse where the person when asleep would forget to breathe.<ref name=Yen2013>Template:Cite book</ref> 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.<ref>Template:Cite journal</ref>
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.Template:Medical citation needed
TreatmentEdit
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.<ref>Template:Cite journal</ref> 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.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
See alsoEdit
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- Congenital central hypoventilation syndrome
- Modes of mechanical ventilation
- Periodic breathing
- Obesity hypoventilation syndrome
- Respiratory disturbance index (RDI)
- Upper airway resistance syndrome
ReferencesEdit
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