Sleep apnea

Sleep apnea is one of the most common disorders in America yet there is an acute lack of awareness of it. EHM speaks with Edward Grandi, Executive Director of the American Sleep Apnea Association to find out the facts.

EHM. Can you explain the three different types of sleep apnea?
EG. The most common form of sleep apnea is what is known as obstructive sleep apnea and it involves an obstruction or occlusion of the upper airway during sleep. This is mainly as a result of an anatomical abnormality, which could be either a narrow airway or excessive tissue in the upper airway that causes a blockage during the deeper stages of sleep when the body is most relaxed.

Another form of sleep apnea, less known about it and it is less common, is called central sleep apnea. It is actually more of a neurological condition than physiological condition. What happens is a disconnection between the signals in the brain to the diaphragm so basically the individual forgets to breathe while sleeping.

The third type is called mixed apnea, which is a combination of both obstructive and central sleep apnea. Frequently sleep apnea patients will have elements of both, though the preponderate of apneic episodes are going to be of the obstructive nature.

EHM. How do you diagnose sleep apnea and what are the consequences of suffering from it?
EG. Sleep apnea is diagnosed by means of a polysomnographic examination, which is done in a sleep laboratory or sleep center. A polysomnographic exam is an overnight study where sleep technicians record information about how an individual is sleeping. Part of the information that they record is the limitations of air-flow during sleep which is a measurement of the pauses in breathing during sleep. This is in part how they detect an apnea.

There are other alternative diagnostic modalities available, but currently most U.S. insurance companies recognize only the in-lab polysomnography as the proper diagnosis for sleep apnea.

The consequences of not getting sleep apnea treated are extensive. Not the least of which are the cardiovascular insults that occur during apneic events. One of the signals of an apnea is not so much when it starts but when it ends – when the body realizes that it is not breathing there is what’s called an arousal and that is manifests itself as the grunting sound somebody makes as they start the breathing process over again. Companion to that arousal is a spike in the blood pressure. If an individual has severe sleep apnea they can be having in excess of 30 apneic events in an hour – I’ve heard people tell of 60 to 80 or 90 apneic events an hour - and if you can imagine that each time you come out of an apneic event you have a spike in your blood pressure your heart is really working hard. As a result of these spikes in blood pressure, the resting blood pressure can be increased. It is this higher resting blood pressure that can lead to cardiovascular disease and hypertension, so sleep apnea patients have a higher incidence of heart attack and stroke.

There is also evidence to associate sleep apnea with diabetes and metabolic syndrome, both of which are not life threatening in themselves but the consequences of both can be very serious. Other co-morbidities are depression and neuro-cognitive deficits – memory loss problems, a reduced quality of life – which occur as a result of excessive daytime sleepiness that flow from interrupted sleep due to multiple apneic events during the course of the night.

Finally, and perhaps from a societal stand point, the most serious consequence of untreated sleep apnea is that excessive daytime sleepiness can impair an individual’s ability to operate a motor vehicle for instance. An increase workplace injuries and reduced productivity are other consequences of untreated sleep apnea.

EHM. Who is most likely to suffer from sleep apnea?
EG. Interestingly enough just about everybody is at risk of sleep apnea. Though generally people who are overweight or have an excessive narrow airway are at a greater risk of having obstructive sleep apnea.

EHM. Is there anything that can be done to prevent it?
EG. Certainly managing weight is the best thing that you can do if in fact there is anything that you can do. Certainly if you are born with a narrow upper airway there is not a whole lot you can do. However, it is something which effects men a bit more than women, and it effects children, and with this increasing prevalence of obesity in the United States and around the world this is only leading to a greater incidence of sleep apnea in the general population.

EHM. How is the American Sleep Apnea Association educating the American public about sleep apnea?
EG. At the American Sleep Apnea Association, our mission is two-fold. We are dedicated to reducing injury, disability and death arising from sleep apnea and to enhancing the lives of those affected with this common disorder. Our mission is to provide educational information as widely as possible. We use a number of different means, many people access our educational resources about evaluation and treatment options for sleep apnea through our website www.sleepapnea.org People also call the association and request printed information from us. Contact information for the association appears in a number of different health directories and we do make ourselves generally available to the consumer media to provide consumer information and links to our website for additional information.

We also hold a sleep awareness day which was on March 8th this year, and that is held during National Sleep Awareness Week® which is when one of our sister organizations – the National Sleep Foundation works to raise awareness about sleep apnea and sleep disorders and sleep hygiene nationally. We partner with them to take one day to specifically raise awareness of sleep apnea.

We also have a network of support groups around the country – the AWAKE (Alert Well And Keeping Energetic) Network provide support to people who are in treatment for sleep apnea and serve as forum for people to learn about sleep apnea and get additional information.

EHM. Can you explain the pillar palatal implant and the difference it has made to patients? Would you recommend this procedure?
EG. The pillar procedure was a procedure that was developed some years ago for the treatment of snoring and as a result of some studies it was determined that it could have a positive impact on a certain amount of individuals who had mild to moderate sleep apnea. A mild to moderate sleep apnea would be an apnea-hypopnea index of less than 30.

The procedure involves the insertion of three or more, small, polyester rods in the soft palate which stiffen the palate and keep the tissue from sagging during sleep. I can say that from the conversation’s that I have had with Ear, Nose and Throat doctors who do the procedure, that they have had success with a specific targeted audience of patients.

EHM. Are there any other procedures you would suggest to patients?
EG. As far as surgical procedures go the sense that I have from the study I’ve done and the conversations I have had with sleep apnea patients is that surgery can be of limited benefit unless you are talking about fairly radical surgery like the maxillofacial mandibular advancement. This basically breaks the jaw and moves the jaw forward increasing the opening of the upper airway. This procedure has been around for a number of years but it is extremely serious and there are risks of nerve damage as a part of the work that gets done, so it is really not for the faint-hearted.

There is also the UPPP (Uvulopalatopharyngoplasty) which involves the removal of excess tissue in the upper airway and some people have success with it but there are people who have the surgery and after a time the condition returns, largely because the tissue begins to sag again.

EHM. Are there any non-surgical procedures that could help?
EG. There are two, the one that is the most common and considered the gold standard for the treatment of sleep apnea, is continuous positive airway pressure and that Colin Sullivan in Australia developed 25 years ago. It involves a device that takes room air, pressurizes it, and delivers it through a hose to a mask that is either worn over the nose or over the nose and mouth. This serves as a stent, a pneumatic stent and keeps the sagging skin taut so that the air is getting down into the lungs and you don’t have the cessation of breathing that results from the obstructions.

In the past 25 years there have been a number of developments and modifications to this continuous positive airway pressure to bi-level machines that have one pressure going in on inhalation, one pressure on exhalation and auto-titrating devices which adjust to the demands of the individual while they are sleeping. There are different types of masks including, nasal masks, full-face masks, a nasal pillow type mask.

There are degrees of interest in new development and these are devices that are fabricated from the specifications of dentists who specialize in sleep medicine and these, like the maxillofacial mandibular advancement, basically move the jaw forward slightly to keep the upper airway open. There are a lot of different technologies that have been developed in this regard and there has been a good deal of success in treatment for a patient who has mild to moderate sleep apnea.

EHM. In your opinion what is the future for patients suffering from sleep apnea?
EG. The future is very bright in the sense that a lot of attention is now being focused on the subject of sleep apnea. The importance of healthy sleep is coming into its own in a way that it hasn’t previously. There is a greater awareness in the sleep physician community of the need to modify the diagnostics modalities to be able to get more people diagnosed and treated. I think that the technology is improving to the point that it should be – there is no reason why somebody who has sleep apnea can’t find a device or mask that will work for them if that is what’s appropriate, and then there are surgical procedures like the pillar procedure - there is a lot of effort being brought to bear to bring new technologies to the treatment of sleep apnea. There is information out there to make them aware of it and there are treatments out there that can help eliminate their problem and help them improve the quality of their life.

For more information please contact the American Sleep Apnea Association on www.sleepapnea.org or on 001 202/293-3650.