One of the more
common disorders that we are seeing nowadays (because we are
becoming much more aware of the health problems associated
with it) is known as sleep apnea. This was just considered for
many years a social problem and snoring was thought more of a
nuisance than as a major health risk.
It is referred to in the literature by Dickens. He describes
a person, Joe, with sleep apnea in the Pickwick
Papers, but we didn't have the clinical diagnosis at the time.
It is alluded to even in the Bible, Proverbs,
"A
little slumber, a little folding of the hands, and poverty
will steal
upon you like a thief."
For most families, there are
memories of at least one person (an uncle or grandparent) who slept through most of the family
gatherings. They were usually , seated in a
comfortable chair and snoring loudly, often an object of
jokes. We are much more aware of the other medical ailments
that are associated with this picture, in that people who do
not achieve rhythmical and restful sleep are prone to a myriad
of other health problems such as high blood pressure, heart
disease, strokes, chronic headaches, depression, obesity, and
many other associated symptom complexes that are still being
discovered by association.
Most office visits may begin with
the patient accompanied by a very tired looking spouse who is no longer able to sleep in the same room because of the noise
of the snoring or the irregular breathing (or what is known as
"resuscitative snorts"), which alarm the bedmate out
of their own sleep. The snorer may complain mostly of being
tired all day, taking frequent naps, falling asleep sitting in
traffic, more serious problems such as auto accidents (as a result
of falling asleep while driving), or difficulty holding a job
from falling asleep at work. If the snorer is not getting restful sleep, then the energy levels decrease, the weight
usually goes up from less exercise related to the lack of energy
and lowered metabolism not burning off the calories that are
taken in.
The key to the evaluation is to
find out if there is an area of obstruction of breathing.
This can be from the beginning of the nose at the nostrils, nasal
deformity from previous injury or familial traits, swollen
tissues from allergies or polyps, through the nasal
cavity to the back of the nose and throat where the adenoids
and tonsils reside, to the soft palate and uvula which may be
elongated or stretched out or enlarged as a result of many
years of mouth breathing, to enlargement of the tongue
or throat structure collapse, as well as to abnormalities anatomically of
the muscles and bones in the neck. This
can be determined and focused on by an office examination
which may include and endoscopic visualization using a small
flexible camera on a TV monitor which can be shown to the
patient and spouse at the same time.
The severity of this snoring (or
sleep apnea disorder) can then be determined by testing that usually includes an overnight sleep study in a sleep
lab. This is where the patient is monitored for certain parameters
including not only the severity of the snoring, but the actual
frequency of stopping breathing, the length of time that there
is no breathing, how low the oxygen goes during these spells,
the effect this has on the heart rate, other factors that
may be triggered like restless leg syndrome, periodic leg
movement, and actual arousals from sleep. These episodes of
irregular breathing, shallow obstructive breathing (hypopneas),
or actual stopping of breathing totally (apneas) are counted over
the course of the test and averaged out to give an idea of the
severity of the disorder. If more than 5 episodes per hour
occur, this is considered sleep apnea and it is further
described as mild, moderate, or severe when seen in some
patients having more than 60 episodes per hour (meaning that
each hour of sleep at night, the body is awakened by the brain
acting as an alarm clock if it is not getting enough oxygen).
That is why patients are tired all night, it is like their
alarm clock going off anywhere from 5 to 60+ times per hour
all night.
This disorder can progress to the
point to where the body is not capable of responding to these episodes of breathing alteration which causes the oxygen in
the blood to drop if there is inadequate breathing. If the
breath is held and the oxygen falls below 90% saturation, the
body and all of the organs are not getting proper nourishment
and can suffer the damage. If your high performance automobile
is built to run on 90+ octane gasoline and you are putting
70-75 octane gas in it, it will eventually be damaged. This is
what happens when the body's organs like the heart, blood
vessels, or the brain are being nourished by deoxygenated blood
that has only 75% oxygenation (the body is damaged).
If the test does show that the
patient suffers from sleep apnea, then the options will be considered, such as trying a CPAP machine
(which is a mask that
is hooked to a compressor that delivers air under pressure to
the nose or full face mask). The pressure builds up in the mask and is measured for each patient to adjust it
to their specific need to overcome the resistance and promote
rhythmic breathing. The long term acceptance of this manner of
correcting sleep apnea is approximately 47%, not well
tolerated by patients who have some obstruction from either
the nose or throat area.
Other options are aggressive medical
involvement to help with previously undiagnosed health problems, weight control, exercise
routines; but these are not
effective long-term in a patient who is always tired from the
sleep apnea. Many times, surgical treatment is effective,
aimed at correcting the obstruction site or sites and usually
requires an overnight hospitalization with about a 10 day
convalescence (but the success rate we have found in our
patients is that more than 80% are free of their sleep apnea
symptoms and daytime sleepiness at the one year follow up interview, about 75% report that the snoring is also
corrected).
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