Diagnosis and Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea occurs when breathing stops during sleep, perhaps hundreds of times a night. About 75% of the patients seen each year at sleep disorders laboratories are diagnosed with obstructive sleep apnea (OSA). OSA usually occurs because tissues of the throat and mouth improperly block the airway. Less common is another type of sleep apnea, central sleep apnea, which appears to be related to a malfunction of the brain’s normal signal to breathe.

Sleep-disordered breathing is strongly associated with high blood pressure, coronary heart disease, heart attack and stroke, as well as compromised quality of life and significant social and emotional problems. OSA is very common in children, occurring with symptoms such as poor attention, behavioral problems, delayed growth and snoring. Often, enlarged tonsils and adenoids (growths of lymph node tissue in the upper throat) are the cause.

Abnormal snoring and excessive sleepiness are two of the major symptoms of sleep apnea. The result of sleep apnea is frequent awakening, which causes restless sleep. Sleep apnea sufferers may report not feeling refreshed when they awake in the morning or frequently falling asleep during the day, which can be very dangerous when driving. Many patients with sleepiness are unaware of a problem. A careful history may be required to differentiate sleepiness from OSA.

Other commonly reported symptoms include nocturia (excessive urination at night), gastroesophageal reflux (the back flow of stomach acid into the food pipe that connects the stomach to the throat), enuresis (involuntary discharge of urine after age of urinary control), morning headaches and moodiness, impaired memory and concentration, and decreased sexual drive.

Diagnosis

Many patients become used to being sleepy and are unaware of their snoring and breathing habits during sleep. Their partners or family members may offer essential information that the patient is unaware of. Sleep apnea may have genetic factors and may run in families who share similar facial and airway structures.

Diagnosing OSA solely on history and symptoms is difficult. Neck circumference, obesity, and the internal structures of the mouth and throat are important factors. Physical examination, fiberoptic endoscopic evaluation (using a tiny telescope), and special X-rays help physicians understand the patient’s upper airway structure and other factors that contribute to OSA syndrome. In addition, men and people of Hispanic, African-American or Asian heritage are at increased risk of OSA.

Sleep studies are used to confirm the diagnosis, establish severity and may help start treatment. While asleep, devices measure various variables including ingoing and outgoing air pressure, heart rate, blood oxygen content and respiratory effort. Diagnosis will identify the type of obstruction causing OSA and any associated conditions.

Treatment

Treatment of OSA is determined by the severity of the disease, the desired outcome and associated medical conditions. Often, multiple therapies may be required as no single treatment is appropriate for all patients. There are five forms of treatment.

1) Factors that predispose an individual to have OSA may be addressed. Losing weight, increasing exercise, improving sleep hygiene (making time for adequate sleep, establishing a regular wake-up time, minimizing noise, etc.), treating nasal obstruction, avoiding sedatives, caffeine and alcohol, and quitting smoking may help alleviate OSA.

2) Treating underlying medical causes, such as hypothyroidism, pituitary disorders and congestive heart failure, may help alleviate OSA.

3) Drugs may rarely be used to treat OSA, usually in conjunction with other measures. Protryptyline, a non-sedating anti-depressant increases muscle tone of the upper airway and offers other benefits for OSA patients, but side effects limit its use.

4) Medical devices, such as nasal continuous positive airway pressure (CPAP) applies pressure to the upper airway and acts like a splint to keep the airway open, thus alleviating OSA. CPAP, which utilizes an airtight mask over the nose during sleep, has to be carefully calibrated to each patient. This is the primary treatment for OSA. However, patients must be willing to comply with CPAP on a consistent basis for successful treatment. Oral appliances which reposition the jaw or tongue may relieve mild sleep apnea in less obese patients.

5) The final treatment option involves surgery. Surgical candidates must meet at least one of several criteria, including a lifestyle that precludes other treatments or failed medical OSA treatments. Surgery may either bypass the upper airway or modify the upper airway using soft-tissue or skeletal techniques to prevent collapse and obstruction. Stabilizing the airway during sleep by altering size, shape or collapsibility is the goal of sleep apnea surgery.

B. Tucker Woodson, MD
Professor
Otolaryngology & Communication Sciences
Medical College of Wisconsin

Medical Director
Froedtert & Medical College Sleep Disorders Program

Medical College of Wisconsin physicians at Froedtert Hospital performed the first somnoplasty surgery in the Midwest and the first pharyngeal/tongue suspension suture for OSA syndrome in the nation. The upper airway laboratory at Froedtert Hospital is the only one of its kind in the US.