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Sleep Apnea Defined
The Greek word "apnea" literally means "without breath." There are three types of sleep apnea: obstructive, central, and mixed; of the three, obstructive sleep apnea (OSA) is the most common. Despite the difference in the root cause of each type, in all three, people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer.
Obstructive sleep apnea is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. In central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Mixed sleep apnea, as the name implies, is a combination of the two. With each apnea event, the brain briefly arouses sleep apnea victims from sleep in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality.
Sleep apnea is extremely common, as common as adult diabetes, and affects more than twelve million Americans, according to the National Institutes of Health. Risk factors include being male, overweight, and over the age of forty, but sleep apnea can strike anyone at any age, even children. Yet still because of the lack of awareness by the public and healthcare professionals, the vast majority remain undiagnosed and therefore untreated, despite the fact that this serious disorder can have significant consequences.
Untreated, sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, impotency, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and motor vehicle crashes. Fortunately, sleep apnea can be diagnosed and treated. Several treatment options exist, and research into additional options continues.
Sleep Apnea Fact Sheet
 | Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep.
"Apnea" is a Greek word meaning "without breath." An apnea is clinically defined as a cessation of breath that lasts at least ten seconds.
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"Hypopnea" also comes from Greek: "hypo" meaning "beneath" or "less than normal" and "pnea" meaning "breath." A hypopnea is not a complete cessation of breath but can be defined as a perceptible reduction in airflow that leads to sleep fragmentation or to a decrease in the oxygen level in the bloodstream.
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The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) refers to the total number of apneas and hypopneas divided by the total sleep study in a patient's sleep study. The AHI gives one measure of the severity of the sleep apnea.
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There are three types of sleep apnea: obstructive, central, and mixed (a combination of obstructive and central). Obstructive sleep apnea (OSA) is the most common.
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Typically the soft tissue in the rear of the throat collapses and closes the airway, forcing victims of sleep apnea to stop breathing repeatedly during sleep, as frequently as a hundred.
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Although the typical sleep apnea patent is overweight, male, and over the age of forty, sleep apnea affects both males and females of all ages and of ideal weight.
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The most common symptoms of sleep apnea are loud snoring and excessive daytime sleepiness (i.e., falling asleep easily and sometimes inappropriately).
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Untreated sleep apnea can be life threatening; consequences may include high blood pressure and other cardiovascular complications.
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More than twelve million Americans suffer from sleep apnea, and it is estimated conservatively that ten million remain undiagnosed.
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Symptoms of Sleep Apnea
All or some of the following may be noted with sleep apnea (although some patients with severe sleep apnea have no symptoms at all):
| Sleepiness, sleep attacks.
| Driving on `auto-pilot' with no recall of the trip.
| Memory loss and episodes of confusion.
| Declining job or school performance.
| Depression, irritability and mood swings.
| Dry or sore throat on awakening.
| Swelling of the uvula (the finger like appendage that hangs from the soft palate.
| Morning headaches.
| Restless sleep; bed torn up.
| Night sweats.
| Impotence.
| Snoring or gasping in sleep.
| Awakenings with chest pain, shortness of breath, choking, palpitations or panic.
| Awakening with no symptoms at all.
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Risk Factors for Sleep Apnea
| Some studies have shown that a family history of sleep apnea increases the risk of OSA two to four times.
Being overweight is a risk factor for OSA, as is having a large neck.
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Sleep apnea is more likely to occur in men than in women.
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Abnormalities of the structure of the upper airway contribute to sleep apnea.
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Sleep apnea may be more common among African-Americans, Pacific Islanders, and Mexicans.
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Smoking and alcohol use increase the risk of sleep apnea.
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Treatments for Sleep Apnea
| There are a variety of treatments for sleep apnea. The most appropriate treatment depends on an individual's medical history and the severity of the disorder.
Treatment regimens included lifestyle changes such as avoiding alcohol, oral appliances, and surgery.
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Nasal Continuous Positive Airway Pressure (CPAP) is the most common treatment for sleep apnea. The CPAP machine pushes air through the airway at a pressure high enough to keep the airway open during sleep.
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| Courtesy of the American Sleep Apnea Association | |||
American Sleep Apnea Association
The ASAA is a non-profit organization dedicated to reducing injury, disability, and death from
sleep apnea and to enhancing the well-being of those affected by this common disorder.
1424 K Street NW, Suite 302
Washington, DC 20005
202/293-3650
fax: 202/293-3656
asaa@sleepapnea.org
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I am a fifty-two-year-old male, married, and the father of a four-year old child. I am currently a manager for a government agency and supervise nine employees, thanks to successful treatment of my sleep apnea. Life before treatment was not as good. I was finally diagnosed with sleep apnea in 1993, the result of my spouse's complaints about my snoring, but it was not appropriately treated until four years later. Symptoms of my apnea included daytime sleep attacks and intense fatigue, depression, weight gain, memory problems, inability to concentrate, and more. Needless to say, untreated sleep apnea affected every aspect of my life. As far back as high school and college, I remember I was always tired. Photos of me even as a young child reveal dark circles under my eyes. No matter how much sleep I got, I was still tired. I suffered from a deviated septum and engorged turbinates (the latter condition remains); both together nearly closed my right nasal passage and, I think, contributed to my breathing difficulties. The problem of sleep apnea began in earnest late in 1972, in my second year of teaching public school. I have painful memories of repeated episodes at my desk struggling to stay awake. Yet, despite the undiagnosed apnea, I then still managed to be very successful in my endeavors. I was asked to head a district-wide program on creative and performing arts and was appointed as one of four lead teachers to start a special school for gifted students. I even engaged in freelance services. My career prospects were bright. Yet by 1975, my last year in teaching, I was constantly so tired and sleepy that I simply could not cope with the demands of the 450 students I saw weekly. Until this point I had been able to hide the problem from others, a problem I believed was of my own creation. Moreover, I thought no one else had this problem, no one could understand it—or even believe I had a problem, if I were to explain it. As my ability to cope diminished, personal setbacks mounted. I resigned my teaching position in December of 1975. Not only did that obviously not resolve the sleep apnea, it created financial problems. Fortunately, family and friends helped out here. However, they could not help me with diminished self-esteem, depression, weight gain, lethargy, limited social interaction, poor decision-making on many levels, suicidal thoughts, and feelings of helplessness and failure. I was spiritually shutting down. The future looked bleak, to say the least. After leaving the teaching profession, I opened my own business, a franchise hundreds of miles from home, at that point my only option for employment. I struggled with the vagaries of the new enterprise. I was so tired, I literally had to drag myself out of bed to get myself to work each day. Photographs taken of me during this time painfully and clearly reveal the impact of my predicament. As the problem grew in all its guises, I realized I had to concentrate on somehow healing myself. I embarked on a long course of ultimately unsuccessful therapy, and, sadly, in the process of focusing on my own survival, I became unnecessarily estranged from family members who thought I no longer loved or needed them. Pressures mounted and, in the early 1980s, I closed my business after three years. Perhaps six months later I was able to land a decent job in the field that I should have been in all along. It was a major relief, and money was no longer an issue. I continued to persevere with my career and was even able to buy my first home. Nonetheless, the apnea symptoms continued to worsen. I constantly fought sleep at the office, suffered from memory problems and a growing inability to concentrate, and endured more frequent bouts of depression. My relationships with peers and supervisors were poor. For the next eleven years, however, through more successively responsible positions, I somehow managed to hide the problem of chronic fatigue and severe daytime somnolence. My marriage did not fare as well. Married in 1985, we were divorced three years later. Fortunately luck of a special sort was with me, and in 1989 I met my second wife, a trained social worker with supportive sensibilities and sensitivities to match. We married in 1992, and not too long after that, she began to complain about my snoring. My spouse also noted that I twitched and jerked a lot while sleeping, and that I seemed to stop breathing periodically (typical symptoms of sleep apnea). Somewhere along the way, my constant complaints of sleepiness became attributed to the snoring. This was the beginning of the end of my sleep apnea. The first of four sleep studies was conducted in 1993, and my wife's observations of my twitching and jerking were corroborated. The doctor then prescribed medication for_of all things_Parkinson's disease. The medications didn't do anything for me, so I did not take them for very long. Soon after, I had a second and third sleep study, at my wife's insistence. They did not result in a prescription of any use, although I was finally diagnosed with sleep apnea. I suffered from more than 800 arousals (or momentary awakenings) in a single night. During both of these sleep studies, the same well-meaning technician attempted to apply the CPAP mask. Unfortunately, because of my breathing problems and fear of suffocation, I was claustrophobic and could not tolerate the CPAP device at all. Or so I thought. After refusing CPAP, in hopes of finding another solution to sleep apnea, I made visits to pulmonary specialists and ENT (ear, nose, and throat) physicians, had a third and fourth operation on my nose, and underwent the UPPP surgical procedure (to remove my adenoids and tonsils and to shorten the uvula). None diminished the fatigue, improved my breathing, or even ended the snoring! The daytime sleepiness continued to worsen. My sleepiness from untreated sleep apnea was further complicated by my sleep deprivation after becoming the father of a newborn baby. In 1996, what appeared to be the job of a lifetime presented itself. It turned out to be a very high-stress position that required much energy, far exceeding my diminished physical capacity. I managed a budget of $5 million and supervised a staff of eighteen. At this point, unfortunately, my sleep apnea was at its most severe. My eating habits changed and my weight began to climb. I would fight sleep at my desk constantly. My employer was clearly dissatisfied with my performance (as was I). I lasted nine months. It was, to put it mildly, a bitter disappointment. I again went to my primary care physician about my problem with sleep apnea. He then recommended that I see another doctor at a different sleep center, which I did in mid-1996. Another sleep study ensued and I was again faced with the issue of tolerating the CPAP. Here I would like to make a very important point. The manner in which the technician helped me gradually become accustomed to wearing the CPAP mask was crucial to overcoming my resistance to it. Ultimately he set me on the road to recovery. The technician did not give up when I said I could not tolerate the mask and air pressure. He employed a technique to address my complaint: he did not have me strap on the entire contraption with the air flowing full-blast in the beginning. Instead, with the machine on, the air pressure set at the lowest level, and me seated upright, he had me hold the mask loosely against my face for just a couple of seconds. After several tries, I was able to increase the length of time until I was able to hold it in place for a minute or more. Next, while still sitting up, I strapped on the mask and continued to breath with the CPAP device using the "ramping" feature. (This lets the air pressure start low before it gradually builds up to the prescribed setting.) I then lay down, turned off the lights for the rest of the night and went to sleep. While I did not awaken feeling rested (I think my sleep debt was too great), at my doctor's urging, I did purchase a CPAP machine for home use. A month later I started a new job. Within eleven months, I was promoted to supervisor. Over the course of the first eighteen months, I received four cash awards, a certificate of recognition for outstanding service, and an outstanding performance evaluation. Above all though, the best reward I've received since conquering sleep apnea was hearing what my supervisor said upon informing me of my promotion: "I wish I had three of you!" I think I might further improve my current condition by moving to the use of a bi-level machine; I will soon explore this with my doctor. For the time being, I continue to use the CPAP; I even bring it with me when I travel for business or pleasure. I've tried to go without it, but now I cannot fall asleep without it. The sound and rush of cool air usually lulls me to sleep in five minutes. The successful application of the CPAP is supported and reinforced by the use of prescription nasal sprays (to overcome the engorged turbinates) and a chin strap which prevents me from breathing through my mouth (this was a critical addition for me). It's taken a while to overcome the discomfort of the triangular mask and to learn to adjust the tautness of the mask straps to create an airtight seal without leaving ugly marks and bruises on the bridge or under the tip of my nose. (Another, simpler device called nasal pillows did not work because I found it did not provide as much air as the mask.) However, the purple bags under my eyes are almost gone; I've joined a health club and now exercise more; and my spouse no longer complains about my snoring. For those out there who suffer chronic fatigue, snoring, and daytime somnolence no matter how much sleep they get, do not give up hope. See a sleep specialist. Undergo a sleep study. Persist in finding your solution. Do not give up. And if you have sleep apnea, by all means, give yourself every chance to get used to breathing and sleeping with a CPAP. It is truly life-changing. |
Reprinted with permission.
American Sleep Apnea Association
Sleep Apnea and Driving
Sleepiness, like excessive speed, alcohol, aggressive driving, and inclement weather, contributes to or causes motor vehicle crashes. In the past few years, sleep as a factor in automobile crashes has begun to be investigated but, without sufficient data, is still not fully understood. One reason for the lack of data on the role of sleepiness in crashes is that not all jurisdictions' accident reports include sleepiness (or a term used as its equivalent) as a factor. In addition, it is often difficult to ascertain at the scene that sleepiness was involved: there is no simple procedure like a blood alcohol content test to confirm a driver's sleepiness at the time of the crash. Moreover, not all investigators are yet properly trained on the role sleep may play in crashes. Instead, when sleepiness is cited as the cause, it is often only when there are no brake marks or other attempts to avoid the collision, when the crash occurs during the sleepy phase of the circadian rhythm, and/or when the driver admits falling asleep. (However, self-report from the driver has been shown to be unreliable because people either deny falling asleep or are unaware of falling asleep at the wheel.)
Nonetheless, sleepiness does cause and contribute to motor vehicle crashes; in fact, a higher percentage of fall-asleep crashes result in fatalities than those attributed to other causes. As more attention is paid to these crashes, the steps that can reduce these crashes need to be explored as well.
Sleepiness is generally caused by sleep deprivation, untreated sleep disorders, and circadian rhythm factors such as jet lag and shiftwork. In addition, sleepiness may be caused by medication (prescription or over-the-counter) and alcohol, or a combination. The most common cause of sleepiness is sleep deprivation. Studies to date indicate that most fall-asleep crashes are caused by young males under the age of 26, individuals who are most likely to be sleep-deprived. The number of sleep-related crashes due to untreated sleep disorders is not known.
Sadly, Americans have not been taught that sleep, like exercise and proper diet, is crucial to good health. The American Sleep Apnea Association strongly supports efforts to educate Americans about the importance of sleep, the causes of sleepiness, and the potential consequences of sleepiness: people must understand that ignoring sleepiness may be fatal. If drivers are sleepy, they should know not to get behind the wheel. Further, drivers should know what steps to take in order to correct the cause of the sleepiness or to prevent sleepiness.
Likewise, the ASAA supports efforts to educate Americans about the symptoms of sleep disorders so that these disorders can be diagnosed and treated appropriately. Untreated sleep apnea can cause medical problems such as high blood pressure and other cardiovascular disease; when clinically significant, sieep apnea should be treated regardless of driving status. The ASAA does not believe that individuals who are excessively sleepy because of a diagnosed but untreated sleep disorder should drive; they are a risk to themselves and others. However, there is no indication that a treated sleep disorder increases anyone's risk for a fall-asleep crash.
Some states now have or are considering regulations to restrict the driving privileges of individuals with sleep disorders. The ASAA is concerned that such restrictions will discourage people who think they may have a sleep disorder from being diagnosed if they fear being diagnosed will lead unnecessarily to the revocation of their license. Such regulations may have an unintended effect and may harm efforts to reduce the number of Americans with undiagnosed and untreated sleep disorders. However, regardless of the regulations, health care professionals who recognize that their patient presents a risk on the road should not hesitate to warn the patient about driving until the cause of the sleepiness is investigated and remedied. In certain situations, such as when the driver's condition is unmanageable or when the driver is unwilling to restrict driving until effective treatment has been instituted, health care professionals may need to seek advice from the local department of motor vehicles.
Having Your Child Evaluated for Obstructive Sleep Apnea
If you suspect that your child has obstructive sleep apnea (OSA), you may want to consult first with your child's primary care provider (usually a pediatrician or family physician) and share your concerns. You may also choose to consult with an otolaryngologist (ear, nose, and throat specialist or ENT) or a pulmonologist (a specialist in lung problems) who deals with children. Sometimes, because of the hyperactivity, inattentiveness, aggressive behavior, irritability, and mood swings associated with pediatric OSA, a mental health provider, such as a child psychiatrist or psychologist, or a neurologist may be the first to recognize the problem. However, before seeing any specialist for an evaluation, you should check with your insurance company as you may need a referral or have to go to a specific provider.
Doctors who specialize in sleep medicine may also practice in your area. They have usually trained under other sleep specialists and/or studied sleep medicine through a residency program, continuing medical education (CME) courses, and scientific meetings. Some are certified by the American Board of Sleep Medicine (ABSM) as well, although there is not a separate certification for pediatric sleep specialists. You should feel free to ask any doctor or health care provider about his/her credentials and experience, especially in dealing with children. You should be satisfied with the explanations of what sleep apnea is and how it is diagnosed and treated in your child's particular case.
In most cases, the initial evaluation for children with suspected OSA includes a complete medical history (symptoms; previous and current medical problems; operations, especially removal of the tonsils and/or adenoids; medications; and allergies), a review of any behavioral or developmental problems, a sleep history, and a physical exam (including weight and height). Blood tests, x-rays, and other specialized tests may be needed in some cases.
Based on the initial evaluation, your health care provider may suggest an overnight sleep study. A sleep study or polysomnogram can help to make a diagnosis of OSA in children and can help to judge the severity of the problem.
The parts or components of a sleep study are very similar in adults and children. These generally include an electroencephalogram (EEG) to measure brain waves and an electroculogram (EOG) to measure eye and chin movement, both to monitor the different stages of sleep; an electrocardiogram (EKG) to measure heart rate and rhythm; chest bands to measure breathing movements; and additional monitors to sense oxygen and carbon dioxide levels in the blood as well as monitors to record leg movement. None of the devices is painful and there are no needles involved, and sometimes the technician can attach the monitoring devices after the child has fallen asleep in the lab. Still the process may be a little frightening for a young child; hence, most sleep labs accommodate a parent's stay with the child overnight.
While there are currently only a few clinics around the country that specialize specifically in pediatric sleep problems, their number is growing. Moreover, many sleep study facilities (usually called sleep labs or sleep centers) perform studies on children as well as adults. Check first to make sure that the facility you use is equipped to handle children and that the sleep lab technicians are comfortable working with them. You should also ask if the doctor who will interpret the sleep study is familiar with reading pediatric sleep studies as they differ some from those of adults.
If you have a choice of doctors and sleep testing facilities, you can find a referral from a few different sources. There is no one complete list of all such facilities, and as a non-profit organization, the American Sleep Apnea Association (ASAA) does not endorse or recommend any company, product, or health care provider. However, there is a list of sleep centers and laboratories accredited by the American Academy of Sleep Medicine (AASM) that pay their AASM membership dues. (The AASM, formerly known as the American Sleep Disorders Association or ASDA, is the professional society in the field of sleep medicine that accredits such facilities; accreditation implies adherence to a certain set of standards). The most up-to-date list of accredited member sleep centers and laboratories appears on the AASM's Web site: www.aasmnet.org, if you have access to the Internet. You can request a list from the ASAA as well. Remember that other centers are in the process of being accredited, have chosen not to be accredited, or do not qualify for accreditation. You can also check with local hospitals and health care professionals to find a testing facility. It is technically possible to have a sleep study in the home, but home sleep studies have yet to be validated for children.
OSA in children is a serious disorder that, untreated, may result in health problems as well as behavior and academic problems. Although common, OSA often goes unrecognized, but it can usually be easily treated if detected. Symptoms of pediatric OSA should not be ignored.
This piece is written for children age one or older who have not yet entered puberty and does not encompass infantile apnea or apnea of prematurity. As children begin to enter puberty, their symptoms—and hence the diagnosis and treatment of the disorder—become more like those of adults.
Some insurance policies specifically exclude the diagnosis and/or treatment of sleep disorders and some do not cover durable medical equipment (however, relatively few children are treated with durable medical equipment or DME; surgery is more common). Such coverage is worth considering when examining your policy and whenever thinking about changing your policy (such as during your employer's open season).
Choosing a CPAP
CPAP, or Continuous Positive Airway Pressure, therapy is the most common form of treatment for sleep apnea. There are several CPAP manufacturers that offer different types of machines with different features. Once you have been diagnosed with sleep apnea and have been prescribed CPAP therapy, you may be able to choose one machine among the many offered. (You must have a physician's prescription in order to obtain a CPAP.) A CPAP, typically covered by insurance, is most often rented or purchased through a home health care company (also known as a durable medical equipment company) but may be purchased over the Internet.
Talk to your doctor and your home care company representative about which machine is best for you, and keep in mind any restrictions on cost and/or provider which your insurance company may impose. In deciding which CPAP machine to use, think about what features you want or need. Options include a carrying case, the ability to convert to foreign currents, an attached heated humidifier, ramping (which allows for a gradual increase in pressure), DC (direct current) operations via a car or boat battery, and the capability to adjust for different altitudes. Bi-level devices with two different pressures—one for inhalation and a lower pressure for exhalation—are also available. In addition, the Food and Drug Administration has approved some auto-adjusting devices for the market; these machines are to change the pressure automatically as needed.
Some machines can monitor how often you use the CPAP, while others can also record if you had any apneas while using the machine (this can indicate a need to adjust the pressure). Your doctor may want to download this data periodically to verify the adequacy of your treatment, and the compliance monitor can also be an important feature if you need an objective verification that you are obtaining sufficient amounts of sound sleep. For the data to be downloaded, you may have to take the machine (or, if the data is imbedded in a small, thin card, the card) in to the sleep center or home care company.
You may be able to send the data via the Internet.
The mask fit will also be critical to you. Again, talk to your doctor and home care company representative about your choices, and keep in mind that the mask may be manufactured by one company and the CPAP by another.
On the back is a list of CPAP manufacturers, in alphabetical order, with their addresses and phone numbers if you wish to contact them directly for more information about their products.
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AirSep Corporation 290 Creekside Drive Buffalo, NY 14228-2070 800-874-0202
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Fisher&Paykel Healthcare 22982 Alcade Drive, Suite 101 Laguna Hills, CA 92653 800-446-3908
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Invacare Corporation One Invacare Way Elyria, OH 44036-2125 800-333-6900
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Mallinckrodt, Inc. 2800 Northwest Blvd. Minneapolis, MN 55441 800-248-0890
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Medical Industries America 2879 R Ave. Adel, IA 50003-8055 800-759-3038
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Nidek Medical, Inc. 3949 Valley East Industiral Dr. Birmingham, AL 35217 800-822-9255
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ResMed, Corp 14040 Danielson St. Poway, CA 92064-6857 800-424-0737
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Respironics, Inc. 1001 Murry Ridge Drive Murrysville, PA 15668-8550 800-345-6443
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SensorMedics Corporation 22705 Savi Ranch Parkway Yorba Linda, CA 92887 800-231-2466
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Sunrise Medical P.O. Box 635 Somerset, PA 15501-0635 800-338-1988
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Vital Signs, Inc. 20 Campus Road Totowa, NJ 07512 800-932-0760
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Choosing a Mask and Headgear
Once you have been prescribed Continuous Positive Airway Pressure (CPAP) therapy, you will need to be fitted for a mask and headgear. The mask is attached to tubing that, connected to the CPAP machine, delivers the pressurized air that prevents apneas from occurring. It is very important that the mask is comfortable and provides a proper seal for the airflow; the proper air pressure level cannot be established unless the fit is correct. Moreover, a comfortable mask that fits well will make using CPAP easier.
Most masks are triangular in shape and are worn over your nose (or the nose and mouth, with a full-face mask) while the adjustable straps of the headgear hold the mask in place. Straps that are too loose will permit air to leak. In some cases, straps that are too tight can break the seal and create leaks; any strap pulled too tightly can cause discomfort. Headgear straps must be snug enough for a good fit in all sleeping positions (back, side, and front) but not tight. You may be able to use "quick-release" straps with your mask: either clips attach to the straps at the front of the mask or the strap hooks to one part of the mask; both allow for quick, easy removal of the mask. They also keep the straps in place so you do not have to adjust them each time you use the mask. Headgear comes in a variety of colors, sizes, and materials, but some masks can be used only with specific headgear (many masks now are often sold prepackaged with headgear). If you breathe through your mouth, you may also want to consider using a chin strap to help keep your mouth closed. (If you regularly breathe through your mouth during the day because of nasal obstruction, a consultation with an ear-nose-and throat physician may be in order.) Another alternative is a mask that covers your face completely.
CPAP machines compensate for the "built-in leak" in the mask system (the exhalation port) that is necessary to keep the air supply fresh. One mask now includes over its exhalation port a small plastic piece filled with sound-absorbing material that muffles the sound and dissipates or spreads the exhalation flow that may bother a bedpartner. Too much leaking, though, may occur if the mask does not fit properly; excessive leaking reduces the set pressure and must be corrected (not to mention that leaks can irritate your eyes). Masks that are too large tend to leak more easily than those that are snug, so as a rule of thumb, if in doubt, select the smaller size. If you extend your tubing, keep in mind that hoses longer than twelve feet generally will not maintain the proper pressure and may require increasing the pressure. (Discuss using such long hoses with a health care professional.) If the tubing gets in your way during sleep, try draping it over your headboard or similar object.
Many masks have a hard plastic body and softer silicone seal that touches the face and may have varying features. For example, a mask may include an adjustable pad that rests on the forehead. The seal may inflate once the machine is turned on so the straps do not need to be as tight. If the mask has a lower profile and does not sit too high at the nose's bridge, it can typically accommodate eyeglasses better. One mask, worn just under the nose, particularly accommodates glasses. Another new mask that works only with a specific headgear has inside the silicone seal a soft, foam-like type material with memory for facial contours. This mask also includes a thin plastic piece that glides from side to side across the mask as the person moves in sleep: this allows the headgear, but not the mask, to move with the user and alleviates mask leaks. Some triangular masks have two openings or connection ports so, when necessary, oxygen can be used with the CPAP machine. If allergic to silicone, try a mask made from materials like synthetic rubber or vinyl.
Several masks on the market now are made out of gel-like material. They are intended to mold to each person's face in order to alleviate pressure points and to be more comfortable. However, because some of these masks are larger and heavier than traditional types, certain people find them less comfortable. In addition, the Food and Drug Administration has approved a thin seal, also made of a gel-like material with wound-healing promotion characteristics as well, that can be attached to one line of masks. The seal usually lasts two to four weeks, depending upon care of the seal. Again, it is intended to alleviate pressure points and to be more comfortable. (Another seal is made of soft foam.) A variation of the gel-type masks is one that can be boiled, cooled slightly, and then pressed against the face in order to fit the individual. A more recent variation of the gel-type masks, marketed as one-size-fits-all, has a soft, flexible shell and gel cushion with a pliable wire molded into the shell that allows the mask to be shaped to adjust for individual differences.
Nasal pillows are another option. Instead of wearing a triangular mask, the user inserts into the nostrils two small flexible pieces (shaped somewhat like mushroom caps) that are attached to a plastic adapter that is in turn attached to the tubing. However, people with higher pressures sometimes experience discomfort with the pillows. The pillows can also be inserted into headgear made of pliable metal and plastic which curves over your head and can be adjusted at four points. The pillows, which do not rest on the nose, upper lip, or cheeks, may solve the problem of allergies to mask material as well as complaints of claustrophobia. Some people, especially people with a beard or moustache, simply prefer nasal pillows to a mask. (While some masks are made with moustaches and beards in mind, facial hair can compromise the effectiveness of CPAP masks.) This headgear can now be used with a triangular-shaped mask.
Dry skin can also reduce the effectiveness of a mask. Skin moisturizers can help with this problem. Although they slightly reduce the mask's life, an improved facial seal may very well be worth it. Some moisturizers are manufactured specifically for CPAP users and can be used inside the nose as well, but avoid petroleum-based products. Conversely, excess skin oil may reduce the ability to maintain a seal between the mask and face. This may be addressed with improved skin care.
In addition to the masks described above—the standard mode of CPAP delivery—there is another newer device that combine two therapies: oral appliances and pressurized air. Oral appliances, which in these cases are to open the airway by moving the lower jaw forward, are connected to CPAP tubing so that the pressurized air is delivered either through the nose (via nasal pillows) or the mouth (through the appliance). The oral appliance attachment requires fitting and adjustment by an appropriate dental practitioner. The oral appliance may also be used alone.
Just as there are several CPAP manufacturers that offer different types of machines with different features, there are different masks and headgear styles within manufacturers' lines. The mask may be manufactured by one company and the CPAP by another. Virtually any mask will fit the standard air hose (or can be adapted easily), but, as mentioned, some masks work only with specific headgear, and auto-titrating machines are typically designed to work only with specific masks. It is also possible to have masks custom-made, so ask your doctor, home care company's representative, or dentist about all options. Varying the style or type of mask can reduce chronic nose, lip, or facial discomfort caused by repeated nightly use of the same mask. However, some insurance carriers resist paying for more than one CPAP mask in a specific time period (such as six months or a year), so additional masks may be an out-of-pocket expense for you. Before selecting a mask, try using it with the CPAP on and under realistic conditions (for example, lying down moving from side to side). You, the wearer, should be happy with it. If you have discomfort with any mask, ask to try other ones, though keep in mind any restrictions on cost and/or provider your insurance company may impose.
Considering Surgery for OSA?
With obstructive sleep apnea (OSA), blockages somewhere in the airway occur repeatedly and cause breathing to stop for at least ten seconds and maybe for a minute or longer. The intention of surgery is to open the airway sufficiently to eliminate or to reduce obstructions to a clinically insignificant level. In order to do so, surgical therapy in adults often must reconstruct the soft tissues (such as the uvula and the palate) or the bony tissues (the jaw) of the throat.
If you have been diagnosed with OSA and are considering surgery, talk to a sleep specialist and/or experienced surgeon about the different procedures, the chances they will be effective for you with your anatomy and why, and the risks involved with surgery. Untreated sleep apnea can be harmful to your health, and surgery cannot always address all the points of obstruction. Eliminating the snoring does not necessarily eliminate the apneas. Sometimes surgery does not cure sleep apnea but reduces the number of apneas so that more treatment options are available to you and/or more comfortable. Yet in some circumstances, surgery may actually worsen the apnea.
Insurance typically covers surgery for sleep apnea but not all surgical procedures. However, insurance companies that initially refuse to pay for a surgery may be convinced otherwise upon an appeal that demonstrates the efficacy and appropriateness of the surgery in your case. Throat pain from the major surgeries varies but is generally significant, often for one to two weeks. Most surgical procedures for sleep apnea are conducted in a hospital under general anesthetic. (People with sleep apnea must be cautious about general anesthesia—no matter for what medical condition the surgery is—because of the effects anesthesia has on the airway.
The most common surgery for sleep apnea is the uvulopalatopharyngoplasty, or UPPP procedure, which is intended to enlarge the airway by removing or shortening the uvula and removing the tonsils and adenoids, if present, as well as part of the soft palate or roof of the mouth. (The uvula is the tissue that hangs from the middle of the back of the roof of the mouth; the word comes from the Latin "uva" meaning "grapes.") According to the "Practice Parameters for the Treatment of Obstructive Sleep Apnea: Surgical Modifications of the Upper Airway," issued in 1996 by the American Academy of Sleep Medicine (formerly the American Sleep Disorders Association), the overall efficacy is 40.7%. A more recent surgery using a laser (laser-assisted uvulopalatoplasty or LAUP, a modification of the UPPP where the surgeon cuts the uvula with a laser) is performed for snoring. There is not yet enough information to say whether LAUP is effective for OSA. A tracheotomy—the surgical creation of a hole in the trachea or windpipe below the site of obstructions—is the most effective surgery for OSA. Unacceptable to most people, it is generally reserved for serious apnea that has failed other treatment. The hole is plugged (and usually covered) during the day for normal breathing and unplugged during sleep so obstructions are bypassed. The site must be cleaned carefully daily to prevent infections.
Other surgical procedures include laser midline glossectomy and lingualplasty where part of the tongue is removed. Two others which try to enlarge the airway by moving the jaw forward are maxillomandibular osteotomy or advancement (MMO or MMA) and the two-part inferior sagittal mandibular osteotomy and genioglossal advancement with hyoid myotomy and suspension (GAHM). These surgeries have very high success rates but are long and involved surgeries (lasting several hours) with a significant recovery period and potential complications that patients may reject. As a rule, success rates for these complicated surgeries are higher when performed by an experienced surgeon. You may have to undergo more than one surgery to eliminate the apneas sufficiently.
Another but relatively new surgical procedure for sleep apnea, one typically done in the doctor's office, is radio frequency tissue ablation (RFTA), with the trade name Somnoplasty. Approved by the Food and Drug Administration in November of 1998, it is to shrink the size of the tongue and/or palate. Multiple treatments are often necessary, and it may be performed in conjunction with other therapies as well. RFTA is still viewed as a new procedure, and relatively little published data on the procedure are currently available. A different surgical system designed to treat OSA was approved by the FDA in February 1998. Known as the tongue suspension procedure (with the trade name Repose), it is intended to keep the tongue from falling back over the airway during sleep with a small screw inserted into the lower jaw bone and stitches below the tongue. Usually performed in conjunction with other procedures, this surgery is potentially reversible. No studies on the long-term success are available, and little clinical data to demonstrate the efficacy of the procedure have yet been published in a peer-reviewed journal.
In general, when weighing surgery, consider whether data on the safety and efficacy of the procedure have met the key standard of being published in a peer-reviewed medical journal and whether the cases studied are similar to yours. Surgery helps many, but effectiveness varies from person to person. (With any surgery, follow-up sleep studies are often adviseable.) If unsure about proceeding, you can get a second opinion. Only a doctor who has examined you and your airway can advise you on having surgery.
There are additional treatment options for OSA that do not require surgery, including devices to keep the airway open. As mentioned, some surgeries are performed to make using them more comfortable. Which treatment is right for you depends upon the severity of your OSA and other aspects of your medical condition. Talk to your doctor about what is best for you, and remember your doctor may take a step-wise approach to treatment.
Physicians who perform surgery for sleep apnea are most commonly otolaryngologists (specializing in the ears, nose, and throat) and oral and maxillofacial surgeons. If you are seeking a referral to a surgeon or a second opinion, you may find one through your physician or through a sleep center, and keep in mind that your insurance policy may require you to get a referral for a specialist and/or to see a specific provider.
American Sleep Apnea Association
1424 K Street NW, Suite 302
Washington, DC 20005
202/293-3650
fax: 202/293-3656
asaa@sleepapnea.org
Sleep Apnea and Same-Day Surgery
It is well known that sleep apnea can be a complicating factor in the administration of general anesthesia. It is also known that when the anesthesiologist is aware of the sleep apnea in the patient undergoing surgery and takes appropriate measures to maintain the airway, the risks of administering anesthesia to people with sleep apnea can be minimized.
Although there have been no clinical trials on anesthesia in sleep apnea patients, clinical experience confirms that anesthesia can be problematic in these patients. The cause of potential problems is seen in an anatomic and physiologic understanding of sleep apnea: the syndrome of obstructive sleep apnea is characterized by repetitive episodes of upper airway obstruction during sleep. ("Apnea" literally means "without breath" and is clinically defined as a cessation of breath that lasts at least ten seconds.) Sleep apnea may be accompanied by sleep disruption and arterial oxygen desaturation.
General anesthesia suppresses upper airway muscle activity, and it may impair breathing by allowing the airway to close. Anesthesia thus may increase the number of and duration of sleep apnea episodes and may decrease arterial oxygen saturation. Further, anesthesia inhibits arousals which would occur during sleep. Attention to sleep apnea should continue into the post-operative period because the lingering sedative and respiratory depressant effects of the anesthetic can pose difficulty, as can some analgesics.
Given the nature of the disorder, it may be fitting to monitor sleep apnea patients for several hours after the last dose of anesthesia and opioids or other sedatives, longer than non-sleep apnea patients require and possibly through one full natural sleep period. Hence there is concern that same-day surgery (also known as out-patient or ambulatory surgery) may not be appropriate for some sleep apnea surgery patients.
Before surgery, the anesthesiologist should first conduct a thorough preoperative assessment (including history of anesthesia) and physical examination. The use of preoperative sedatives must be considered carefully as sedative medication, like anesthesia, suppresses upper airway muscle activity. During surgery, maintaining the patency of the airway is the anesthesiologist's primary concern.
The period of awakening from anesthesia after surgery can also be problematic for sleep apnea patients. In patients who have undergone surgery to treat sleep apnea, the airway can be narrowed from swelling and inflammation. There may also be some upper airway swelling secondary to intubation and extubation. As mentioned, the lingering sedative and respiratory depressant effects of the anesthetic can pose difficulty. If narcotics are found to be necessary in the post-operative period, appropriate monitoring of oxygenation, ventilation, and cardiac rhythm should be provided as narcotic analgesics can precipitate or potentiate apnea that may result in a respiratory arrest. Perioperative vigilance must continue into the postoperative period.
Many patients require postoperative intubation and mechanical ventilation until fully awake. Patients who already use a prescribed CPAP (Continuous Positive Airway Pressure) machine should utilize it, but the pressure should be monitored to ascertain that it is adequate. CPAP can also be employed postoperatively in other patients without their own machine to support breathing. For certain patients, it may be judicious to admit them to an intermediate care or intensive care area postoperatively to facilitate close monitoring and airway support measures.
Therefore it is deemed wise to let sleep apnea patients remain in the care of medical personnel until it can be ascertained that their breathing will not be obstructed. While sleep apnea patients may require a longer period of time in the care of medical personnel than would otherwise be required of the surgical procedure, this precaution is prudent and enables anesthesiologists to provide safe anesthetic care for sleep apnea patients.
It should be remembered that the overwhelming majority of sleep apnea cases have not been identified. Thus it is not sufficient simply to ask if a patient has sleep apnea. Instead, health care professionals must ask proper screening questions of their patients, especially those individuals at risk for sleep apnea and those children undergoing a tonsillectomy and adenoidectomy, before making decisions on patient care.
For more information about sleep apnea and anesthesia, including screening questions, anesthesiologists can read "Anesthesia Safety Always an Issue with Obstructive Sleep Apnea" by Okoronkwo U. Ogan, MD and David J. Plevak, MD, Anesthetic Patient Safety Foundation Newsletter, Summer 1997 (Volume 12, No. 2, p. 14-15), http://www.gasnet.org/apsf/newsletter/1997/summer/sleepapnea.html. (A search of the Global Anesthesiology Network entire site, www.gasnet.org, using the term "sleep apnea," may also be beneficial.) A source of information for the general public is the article "Sleep Apnea and Anesthesia" from the June-July 1996 issue of the ASAA newsletter WAKE-UP CALL The Wellness Letter for Snoring and Apnea.
Considering Surgery for Snoring
Before determining whether surgery is appropriate, consider the cause of the snoring. Pure snoring is the vibration of tissues in the airway, whereas with obstructive sleep apnea, blockages occur repeatedly somewhere in the airway. Of course, not everyone who snores has sleep apnea—and not everyone who has untreated sleep apnea snores—but snoring is a common symptom of sleep apnea. Before undergoing surgery for snoring, it is wise to consider if sleep apnea is present. Untreated sleep apnea can be harmful to your health, and eliminating the snoring does not necessarily eliminate the apneas.
Some people snore only in certain situations, for example, when they have nasal congestion and cannot breathe through their mouth (people who breathe through their mouth are more prone to snore). Likewise, people who have deviated nasal septums or blocked nasal passages from other causes are more likely to snore. Sleeping flat on the back or drinking alcoholic beverages close to bedtime also induces snoring. (Such situations may induce apneas as well.) A thorough evaluation and sleep study can determine whether the snoring is associated with apneas and, if so, the severity of the sleep apnea.
Generally deemed cosmetic, surgery for snoring is rarely covered by insurance policies and may be a significant expense. Most surgical procedures for snoring can be conducted in a physician's office under local anesthetic. (People with sleep apnea must be cautious about general anesthesia—no matter for what medical condition the surgery is done—because of the effects anesthesia has on the airway.) Pain from the surgeries varies.
One common surgery for snoring is the laser-assisted uvulopalatoplasty or LAUP, a modification of the uvulopalatopharyngoplasty, or UPPP procedure. It is also occasionally performed for sleep apnea. In the LAUP, the surgeon uses a laser to cut away the uvula, the tissue that hangs from the middle of the back of the roof of the mouth (from the Latin word "uva" meaning "grapes"). More than one session may be needed.
Another but relatively new surgical procedure for snoring, also typically done in the doctor's office, is radio frequency tissue ablation (RFTA) with the trade name Somnoplasty. Approved by the Food and Drug Administration (FDA) in July of 1997, it is to shrink the uvula. Like LAUP, more than one session may be needed. RFTA is still viewed as a new procedure, and relatively little published data on the procedure are currently available. An even newer type of tissue ablation which can be used for snoring (known by the trade name Coblation-Channeling) was approved by the FDA in February, 2000. It likewise uses radio frequency energy to shrink tissue in the airway; it can also remove tissue. However, it is not temperature-controlled, and to date, nothing on the efficacy of this procedure has been published in a peer-reviewed, scientific journal.
Another surgical system designed to treat snoring (as well as obstructive sleep apnea) was approved by the FDA in February 1998. Known as the tongue suspension procedure (with the trade name Repose), it is intended to keep the tongue from falling back over the airway during sleep with a small screw inserted into the lower jaw bone and stitches below the tongue. Usually performed in conjunction with other procedures, this surgery is potentially reversible. No studies on the long-term success are available, and little clinical data to demonstrate the efficacy of the procedure have yet been published in a peer-reviewed journal.
Nasal surgery to remove obstructions in the nose or to correct a deviated septum may also be done. (This surgery, because it can also improve breathing during the day, is typically covered by insurance.) These are likely to treat snoring successfully when there is significant blockage in the nose and nowhere else. Other surgeries for snoring include major ones such as that to advance the jaw.
Ask your doctor what surgery, if any, may be appropriate for your anatomy and what risks are involved. Also consider whether data on the safety and efficacy of the surgical procedure have met the key standard of being published in a scientific, peer-reviewed journal and, if so, whether the cases studied are similar to yours. The effectiveness varies from person to person. If unsure about proceeding, consider getting a second opinion. Only a doctor who has examined your airway can advise you on having surgery.
Because snoring can be a symptom of sleep apnea and because approximately ten million Americans have undiagnosed sleep apnea, snoring cannot be ignored. As a general rule, snoring that does not respond to simple remedies, including non-surgical ones, should be discussed with a physician or sleep specialist. Loud snoring coupled with periods of silence must be brought to a doctor's attention.
If you do have sleep apnea, it can be diagnosed and treated, with surgery or without. Which option is right for you depends upon the severity of your sleep apnea and other aspects of your medical condition. Talk to your doctor about what is best for you, and remember that your doctor may take a step-wise approach to treatment.
Physicians who perform surgery for snoring are most commonly otolaryngologists (specializing in the ears, nose, and throat) and oral and maxillofacial surgeons. If you are seeking a referral to a surgeon or a second opinion, you may find one through your physician or through a sleep center. Keep in mind that your insurance policy may require you to get a referral for a specialist and/or to see a specific provider.
