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Look Up > Conditions > Sleep Apnea
Sleep Apnea
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Laboratory Tests
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Surgical Procedures
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
Definition

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.


Etiology

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.


Risk Factors
  • 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

Signs and Symptoms
  • 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)

Differential Diagnosis
  • Narcolepsy
  • Insomnia
  • Other sleep disorder (periodic leg movement, restless leg syndrome)
  • Hypothyroidism
  • Temporal lobe epilepsy
  • Laryngospasm

Diagnosis
Physical Examination

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.


Laboratory Tests
  • Thyroid hormone levels for hypothyroidism
  • Allergy panel
  • Albumin levels for true hypocalcemia

Other Diagnostic Procedures
  • 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.

Treatment Options
Treatment Strategy
  • 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)

Drug Therapies

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.

Surgical Procedures

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

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.


Nutrition
  • 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.

Homeopathy

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

Patient Monitoring
  • 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).

Other Considerations
Prevention

Weight loss is key in preventing continuance or recurrence of obstructive apnea.


Complications/Sequelae
  • 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

Prognosis

With treatment, patients are able to lead normal lives. Untreated, or if treatment is discontinued, significant health issues and even premature death can result.


Pregnancy
  • 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.

References

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.


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.