Apnea is the cessation of breathing. There are three types of apnea that occur during sleep: obstructive, central, and mixed. Obstructive sleep apnea (OSA) is the most common type, affecting approximately 4% of men and 2% of women, but it is greatly under-diagnosed. Common symptoms are excessive daytime sleepiness (EDS) and loud snoring. In addition, the sleep partner often reports the cessation of breathing.
There are dangers associated with untreated sleep apnea. It is a major contributor to hypertension and other cardiovascular impairments. It contributes as well to dulling of memory and intellect, depression, obesity, and the risk of motor vehicle accidents. When sleep apnea is combined with other disorders (such as cardiac, cerebrovascular, or pulmonary diseases) mortality risk increases.
Obesity is a strong risk factor in that 70% of people with OSA are obese. Overweight people tend to have excess tissue in the neck. Because OSA is caused by the collapse of tissue of the upper airway onto the back of the tongue (thereby causing the obstruction and resulting apnea), overweight people often require more muscle tone to initiate respiration. Other factors besides excess weight increase the risk of sleep apnea. Alcohol and sedatives can exacerbate tissue collapse in the upper airway by further relaxing the body.
Other forms of sleep apnea are less prevalent than OSA.
Evaluation to determine severity (and success of treatment) is best done through an overnight polysomnography (sleep study). Basic treatment includes weight loss, avoidance of stimulants prior to bedtime, adjustment of sleep position to avoid sleeping on the back, and so on. However, significant weight loss is rarely maintained for the long term.
The most successful forms of treatment are CPAP (continuous positive airway pressure) or BiPAP (Bilevel Positive Airway Pressure). These are mechanical devises, using a mask combined with a pump, which provide air flow during inhalation of breath and thus preventing collapse of the airway. The success of treatment depends on compliance of the individual in using the machine every night for several hours, but it is sometimes difficult to adjust to the mask and the noise of the equipment.
A surgical procedure known as uvulopalatopharyngoplasty (UPPP), which involves the removal of excessive tissue of the soft palate, is useful in relieving most snoring problems, but only 50% show objective improvement in their apnea. Oral devices for the mouth also help snoring, but often do not help apnea.
More aggressive surgical treatment may be necessary in some cases of OSA. Tracheotomy, which is curative, involves permanent placement of a tube into the neck. Surgery to change the shape of the jaw or the tongue helps in some cases.
Rating for OSA is determined by the severity of the disease - as measured by the number of apnea episodes per hour (apnea index) and degree of hypoxia (low blood oxygen level). Type of treatment, age, and co-existing disorders such as heart or lung disease are also considered in the final assessment. Favorable features include mild disease (with no more than 20 apneic episodes per hour and minimal hypoxia), consistency in using CPAP/BiPAP, controlled hypertension, no risky driving events, and no co-existing heart or lung disease. Favorable cases are generally not rated. Other cases range from Table C to rejection.
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