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Is Sleep Apnea Disrupting Your Life?


Sleep apnea can disrupt your sleep

As the name implies, Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) means a pause in breathing pattern or decrease in the rate of breathing due to partial or complete collapse of the airway. An apnea means 10 seconds or longer pause in breathing while hypopnea is defined as a 10 seconds or longer reduction in rate or depth of breathing. The disturbance in breathing during nighttime can cause symptoms such as snoring, snorting, and gasping. 

Apnea-Hypopnea Index (AHI) is a measuring index to evaluate the severity of OSAHS, which is calculated by dividing the number of episodes of apnea/ hypopnea by the total number of hours of sleep. Even if a patient does not have any symptoms, a patient is diagnosed with OSAHS if he has an AHI greater than 15 episodes per hour.

Cause and Risk Factors of Sleep Apnea

When we breathe in, a negative pressure is created inside our pharyngeal airway, the collapse of which is prevented by pharyngeal dilator muscles. During sleep, the tone of these muscles decreases which obstructs the pharyngeal airway leading to turbulent airflow resulting in snoring. 

Important risk factors of OSAHS are male gender and obesity, which increases the risk by two times. Other known risk factors include small mandible, posterior displacement of mandible, a positive family history of OSAHS, genetic syndromes (for e.g., Down syndrome), tonsillar enlargement (especially in children), menopause (in women), and decreased level of thyroid hormone. Alcohol and sedative drugs also predispose to OSA by relaxing the upper airway dilator muscles. Increased prevalence of OSAHS is also seen among patients with diabetes and hypertension.

Clinical Features of Sleep Apnea

Snoring and excessive daytime sleepiness are the most common symptoms of Sleep Apnea. Bed partners might notice a pause in breathing pattern (apnea) and snoring in all body positions. After waking up from sleep, the patient feels unrefreshed.

Other features include difficulty concentrating on any task, impaired work performance, depression and irritability, dry mouth, heartburn during nighttime, and morning headache. OSA increases the risk of resistant hypertension, stroke, and diabetes and is a major contributor to heart disease, metabolic disorders, and premature death.

Diagnosing Sleep Apnea

A quantitative assessment of daytime sleepiness is assessed by the Epworth sleepiness scale. Overnight studies of sleep quality, breathing, and oxygenation are done, which is known as polysomnogram (PSG). Although it is said that OSAHS is ruled out if PSG done inside the laboratory is negative, PSG can be a false negative if the study is not able to gather representative information on the patient’s usual sleep. 

A cost-effective method for diagnosis of OSAHS without significant comorbidity who have a high probability of OSAHS is a home sleep test. However, home sleep tests can show false negative results; therefore, further evaluation may be required. For the identification of anatomic risk factors of OSA, various imaging studies including cephalometric radiography, MRI, CT, and fiberoptic endoscopy can be used.

Management of Sleep Apnea

Drivers should be advised not to drive until their symptoms are relieved because daytime sleepiness while driving can cause motor vehicle accidents. Some treatment protocols for OSAHS are:
  • Weight loss: All patients with OSAHS should be advised to lose weight and avoid sleeping in a supine position. 
  • CPAP: The majority of patients need CPAP delivered by nasal mask every night for splinting the airway open. CPAP has shown to provide a dramatic relief in symptoms but unfortunately, about 50% of patients do not tolerate CPAP. 
  • Devices: Mandibular advancement devices that hold the mandible forward opening the pharynx are also effective in some patients. 
  • Surgery: Upper airway surgery is less effective than CPAP and is reserved for patients who cannot tolerate CPAP. Bariatric surgery is an option for obese patients with OSAHS and it improves not only sleep problems but also overall health conditions associated with obesity.
  • Alternative procedures: Other procedures that decrease snoring include laser-assisted uvulopalatoplasty, injection of the soft palate (resulting in stiffening), and radiofrequency ablation. Another recently tested alternative treatment is upper airway neurostimulation. Unilateral stimulation of the hypoglossal nerve through a surgically implanted device has shown to improve symptoms of sleep apnea.

Recent Advances and Clinical Trials for Sleep Apnea

  • AtoOxy (Atomoxetine plus oxybutynin): This study will assess whether the combination of atomoxetine plus oxybutynin improves the apnea-hypopnea index (AHI). It will also determine whether there is an improvement in clinical symptoms of a patient after taking this drug.
  • Magnetic apnea prevention (MAGNAP) device to treat OSA: MAGNAP device consists of a neodymium-iron boron earth magnet with a ferromagnetic directional back-plate encased in titanium. It will be implanted surgically in a bone in the neck called the hyoid. After surgery, the patient is fitted with a second magnet which is a removable external accessory device. This removable external magnet is worn only during sleep so that the external magnet attracts the internal magnet and thus prevents airway collapse.  The objective of this clinical trial is to assess the safety and feasibility of this device in the treatment of OSA.
  • Some people consume beetroot juice to decrease the snoring problem although there is no scientific evidence regarding this till now. A clinical trial is underway to determine if 4 weeks of daily beetroot juice supplementation decreases peripheral chemoreflex sensitivity in healthy older adults who have a normal response to acute hypoxia.
  • Head-to-Head Comparison of upper airway stimulation (UAS) and CPAP: This study aims to evaluate a pilot cohort of patients with OSA treated with CPAP or UAS using a polysomnography system.
  • Combined upper airway and Breathing control therapies for OSA: This clinical trial combines two treatments for OSA, oral appliances and supplemental inspired oxygen. The two main objectives of this study are to determine whether supplemental inspired oxygen further reduces OSA severity in patients using an oral appliance and to evaluate whether baseline OSA phenotypes can predict the efficacy of oral appliance vs supplemental oxygen vs combined treatment of both.
  • Use of remotely controlled mandibular protrusion (RCMP) to predict treatment outcomes of maxillomandibular advancement (MMA) surgery for OSA: This clinical trial aims to determine predictors of success with MMA in patients with moderate to severe OSA.
  • AD182: AD182 is a newly developed drug.  A clinical trial is in phase 2 to evaluate the safety and efficacy of AD 182 to treat OSA. Another study evaluating the safety and efficacy of AD182 and another new drug AD504 vs placebo is also undergoing currently.
Berry R, Wagner M: Sleep Medicine Pearls, 3rd ed. Philadelphia, Elsevier, 2015.

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Javaheri S et al: Sleep apnea: Types, mechanisms, and clinical cardiovascular consequences. J Am Coll Cardiol 769:841, 2017.

Kapur VK et al: Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 13:479, 2017.

McEvoy RD et al: CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 375:919, 2016.

Strollo PJ Jr et al: Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 370:139, 2014.

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