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Overview |
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Definition |
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Sleep apnea is a disorder that involves repeated episodes of upper airway
occlusion and transient respiratory arrest during sleep. Types include
obstructive (caused by upper airway obstruction, seen in up to 4% of adults),
central (caused by CNS's failure to initiate respirations during sleep, termed
"Ondine's curse"), and mixed. Apneas have significant adverse cardiovascular
effects, create sleep disruptions that cause daytime exhaustion, and are
associated with increased mortality. |
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Etiology |
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In obstructive apnea, the upper airway is narrowed or obstructed by blocked
nasal passages, large tonsils or adenoids, large tongue, short lower jaw, or
fatty tissue resulting from obesity. In central apnea, the CNS respiratory
control stops working during sleep, possibly an inherited neurologic problem,
acquired neuromuscular disorder, or triggered by obstructive
apnea. |
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Risk Factors |
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- Obesity (67% of patients)
- Insensitive breathing reflex
- Incoordination of breathing muscles
- Male gender (three times more common among men)
- Middle age (can occur at any age, but worsens as patients grow
older)
- Drugs such as alcohol, sedatives, hypnotics, short-acting
beta-blockers
- Prematurity in infants
- Allergies
- Nasal obstruction
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Signs and Symptoms |
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- Loud, irregular snoring punctuated by quiet periods when patient is
not breathing for more than 10 seconds; episodes can occur up to 100 times or
more per hour
- Excessive daytime sleepiness and fatigue
- Morning headaches, sore throat, dry mouth, cough
- Personality or behavior change (depression, moodiness,
irritability)
- Change in alertness, memory
- Impotence
- Hypertension (in 20% to 30% of hypertensive
patients)
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Differential
Diagnosis |
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- Narcolepsy
- Insomnia
- Other sleep disorder (periodic leg movement, restless leg
syndrome)
- Hypothyroidism
- Temporal lobe epilepsy
- Laryngospasm
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Diagnosis |
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Physical Examination |
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Daytime sleepiness and/or a partner's report of snoring usually prompt
treatment. Check weight and blood pressure. May try overnight oximetry during
sleep at home to evaluate O2 levels. If significant pattern of low
O2 levels, refer to a sleep clinic. |
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Laboratory Tests |
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- Thyroid hormone levels for hypothyroidism
- Allergy panel
- Albumin levels for true hypocalcemia
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Other Diagnostic
Procedures |
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- Refer to otolaryngologist to rule out anatomic or inflammatory
causes.
- Epworth Sleepiness Scale to evaluate degree of daytime sleepiness.
(Eliminate caffeine before taking test.)
- Refer to sleep clinic.
- Portable or ambulatory monitoring. Sleep test done in home;
appropriate only if symptoms are obvious and severe and patient requires urgent
treatment but cannot come to sleep clinic.
- Multiple Sleep Latency Test. Performed day after all-night sleep
study to assess level of daytime sleepiness and rule out other
causes.
- Definitive test is polysomnography, all-night observation in a sleep
clinic, where the apneic episodes can be
detected.
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Treatment Options |
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Treatment Strategy |
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- Lose weight.
- Decrease or eliminate use of alcohol, antihistamines, tranquilizers,
and short-acting beta-blockers.
- Treat allergies and upper respiratory infections.
- Develop regular sleep habits and sleep for sufficient
periods.
- Avoid supine posture; sleep sitting up or on side.
- Humidify air at night.
- Gargle with salt (without swallowing) to shrink tonsils.
- Eliminate smoking or other irritants.
- Raise the head of the bed.
- CPAP (continuous positive airway pressure) device for moderate to
severe cases
- Surgery for moderate to severe cases (tonsillectomy, nasal surgery,
uvulopalatopharyngoplasty)
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Drug Therapies |
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Drugs for treating central apnea include the following.
- Acetazolamide. Results promising.
- Clomipramine. Side effects (e.g., impotence) limit use. Patient may
develop tolerance in 6 to 12 months.
- Doxapram. Experimental; side effects are hyperactivity, irregular
heart rhythm, increased blood pressure, nausea and diarrhea, urinary retention;
not for use in those with cardiac problems.
- Aminophylline, theophylline, almitrine, naloxone,
medroxyprogesterone, tryptophan. No appreciable improvement; serious side
effects.
- Oxygen. Not consistently effective.
Drugs for treating obstructive apnea include the following.
- Medroxyprogesterone. Somewhat effective; side effects are fluid
retention, nausea, depression, excess hair growth, breast tenderness; not for
use in patients with blood-clotting disorders, liver disease, breast or genital
cancer, or pregnant women.
- Protriptyline. Used rarely; side effects are decreased REM sleep, dry
mouth, constipation, urinary hesitancy or frequency, impotence, confusion
(elderly); not for use if arrhythmias, very high blood pressure, glaucoma, or
prostate disease are present.
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Surgical Procedures |
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Devices for treating central apnea include the following.
- Diaphragmatic pacemaker. Requires delicate surgery with risk of
developing obstructive apnea and injuring phrenic nerves; not practical for most
patients.
- CPAP ventilator. Keeps airway open to eliminate apneic spells; can be
uncomfortable and reduce quality of sleep.
- Negative pressure ventilator (cuirass). Requires tight fit and
careful adjustment of rate; can be uncomfortable and reduce quality of
sleep.
Devices for treating obstructive apnea include the following.
- CPAP ventilator. Excellent results; pressure settings 5 to 20 cm H2O;
side effects are discomfort or claustrophobia wearing mask, inconvenience, nasal
congestion, sneezing.
- Tongue-retaining device. Pulls tongue forward; use generally limited
to nonobese patients with no nasal obstruction.
- Jaw retainers. Custom-fitted to pull jaw forward; still experimental;
side effects are excess saliva, exacerbation of TMJ or dental
problems.
- Internal dilators or external nose strips. Available
over-the-counter; effectiveness unproven.
Surgery options include the following.
- Nasal surgery. By itself not usually effective; may be needed to
allow use of CPAP.
- Uvulopalatopharyngoplasty (UPPP). Smooths and removes excess tissue
from soft palate and throat; effectiveness greater than 20%, with success
depending on body weight control. Outpatient in healthy uncomplicated cases; one
to two days in hospital for others. Risk from anesthesia; results include pain,
difficulty swallowing.
- Laser-assisted uvulopalatoplasty (LAUP). Treats snoring, but leaves
apnea potential.
- Maxillofacial surgery. Effectiveness not proven; risks include
difficulty healing, inconvenience, added orthodontics, possible need for
reoperation, effect of general anesthestic on breathing, pneumonia, difficulty
swallowing, 50% to 75% failure rate in five years.
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Complementary and Alternative
Therapies |
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Alternative therapies may be useful in treating the allergic component of
this condition. Homeopathy and nutrition could be most likely to have a positive
effect. While many supplements are touted as good for weight loss, none have
proved to be as effective as decreasing caloric input and increasing
exercise. |
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Nutrition |
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- Diet: clinical trial of eliminating mucus-producing foods (dairy and
bananas) for two weeks, reintroducing them and noticing any
difference.
- Essential fatty acids (EFAs) moderate inflammatory response, decrease
allergic response; EFAs are found to be low in obese individuals.
- Chromium helps regulate insulin and decrease insulin resistance; may
not be effective at burning fat preferentially, but effective at stabilizing
blood sugar and decreasing sugar cravings.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Grindelia for sleep apnea with advanced cardiac or respiratory
illness, patient starts from sleep with a sensation of suffocation
- Lachesis for sleep apnea, especially if the patient also has
frequent nightmares; patient is unable to sleep on their right side, and is very
loquacious
- Sambucus nigra for difficulty breathing at night; patient may
actually jump up out of bed with a feeling of suffocation, especially with nasal
obstruction or asthma
- Spongia tosta for patients with a sense of suffocation that may
wake them, constriction, tickling or dryness of the throat, a harsh, dry
cough
- Digitalis used homeopathically helps sleep apnea in persons who
have a slow heartbeat that may be accompanied by palpitations, and fear of dying
from heart problems
- Opium for sleep apnea with loud snoring; heavy sleep that is
difficult to disturb, especially if associated with narcolepsy
- Sulphur for sleep apnea with insomnia and nightmares,
especially with skin rashes that become worse with
heat
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Patient Monitoring |
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- Refer for nutritional counseling or supervised exercise program for
weight loss and maintenance.
- Follow-up with sleep clinic or home health care products supplier if
using CPAP device.
- Refer to psychological counseling for personality/behavioral
problems.
- Suggest support group, such as AWAKE or American Sleep Apnea
Association (ASAA).
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Other
Considerations |
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Prevention |
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Weight loss is key in preventing continuance or recurrence of obstructive
apnea. |
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Complications/Sequelae |
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- Nocturnal sudden death (2,000 to 3,000/year in U.S.)
- Chronic heart enlargement or arrhythmias
- Psychological and memory problems
- Marital discord
- Pulmonary hypertension
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Prognosis |
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With treatment, patients are able to lead normal lives. Untreated, or if
treatment is discontinued, significant health issues and even premature death
can result. |
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Pregnancy |
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- Nasal congestion that produces snoring is common in pregnancy but
should not be confused with apnea.
- Apnea may cause fetal distress because of low oxygen supply in the
blood; early recognition and treatment are
required.
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References |
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Caldwell JP. Sleep: Everything You Need to Know. Buffalo, NY: Firefly
Books; 1997.
Dunkell S. Goodbye Insomnia, Hello Sleep. New York, NY: Carol
Publishing Group; 1994
Lipman DS. Snoring From A to ZZZZ: Proven Cures for the Night's Worst
Nuisance. Portland, Ore: Spencer Press; 1996.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993.
Pascualy RA, Soest SW. Snoring and Sleep Apnea: Personal and Family Guide
to Diagnosis and Treatment. 2nd ed. New York, NY: Demos Vermande; 1996.
Smolley LA, Bruce DF. Breathe Right Now: A Comprehensive Guide to
Understanding and Treating the Most Common Breathing Disorders. New York,
NY: WW Norton & Co; 1998. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |