Sleep Apnea

if you have obstructive sleep apnoea your breathing pauses for brief periods while
you're asleep normally when you breathe in air flows in through your mouth and nose
and down your throat also called the pharynx air then flows down your windpipe or
trachea spreading through a tree like structure of smaller tubes into your lungs
each time you breathe in negative suction pressure pulls the soft tissues in your
mouth and pharynx inward the muscles in your pharynx respond by pulling the soft
tissues outward again which keeps your airway open when you sleep it's normal for
the muscles in your mouth tongue and pharynx to relax slightly but not enough to
block your airway if you have obstructive sleep apnoea the muscles of your mouth
and pharynx may relax too much your tongue drops on to the soft tissue in the roof
of your mouth pressing it against the back of your throat this completely blocks
the flow of air into your lungs the lack of oxygen in your lungs wakes you up you
may gasp for air to re-establish air flow before falling asleep again the cycle of
apnea and waking up may happen many times at night preventing restful sleep factors
that may contribute to obstructive sleep apnea include obesity because more fat may
be present in the walls of the pharynx a small or receding jaw with a narrowed
airway loss of muscle tone in your pharynx due to aging and swollen tonsils common
symptoms of obstructive sleep apnea are snoring morning headaches chronic daytime
sleepiness fatigue irritability and impaired concentration left untreated
obstructive sleep apnea may lead to complications such as high blood pressure heart
disease irregular heartbeats called arrhythmias stroke and diabetes your doctor may
recommend lifestyle changes to treat obstructive sleep apnea including losing
weight sleeping on your side not smoking and avoiding substances that can make you
sleepy such as alcohol and sedatives for mild or moderate obstructive sleep apnoea
an oral appliance may keep your airway open this device works by pulling your jaw
forward and moving both your tongue and the roof of your mouth away from the back
of your throat the most common and effective treatment for obstructive sleep apnea
is a continuous positive airway pressure or CPAP machine this machine pumps air
through a tube into a mask that fits over your nose or both your nose and mouth the
mild air pressure of the CPAP machine helps keep your airway open enabling you to
get a deep restful sleep
=====================================================================
sleep apnea - causes, symptoms, diagnosis, treatment, pathology
===================================================================
Sleep apnea is a sleep disorder which causes irregular breathing and snoring
patterns that can ultimately cause apnea, which is where a person momentarily stops
breathing altogether. The inability to get restful sleep can also lead to severe
exhaustion. Individuals can have obstructive sleep apnea, central sleep apnea, or
features of both. Obstructive sleep apnea is the most common form, and it develops
when there’s a blockage of the airways. Air has to go from the nose through the
nasopharynx into the laryngopharynx, through the larynx and then into the trachea.
Somewhere along that path, there might be a blockage in the flow of air. Allergies
might cause swelling to become slightly less stiff while sleeping. This means they
are less able to keep the airway open, making it more likely to get squashed or
obstructed. Central sleep apnea refers to the fact that the problem is “central” or
related to the central nervous system. This is where the brain intermittently stops
attempting to breathe for 10 to 30 seconds. The apnea can persist for several
seconds even after waking up, triggering feelings of panic and further disrupting
the sleep cycle. Central sleep apnea starts with an initial episode of hyperpnea,
which is when the brain directs the lungs to hyperventilate during sleep by
increasing the respiratory rate. This rapid breathing causes hypocapnia, a drop in
the blood’s carbon dioxide levels. When the carbon dioxide falls below a certain
threshold, the body slips into a state of apnea, making no effort to breathe and
taking in no oxygen. This causes the carbon dioxide levels to rise back to normal
levels and then, as the apnea persists, they keep rising to which is called
hypercapnia. The really high carbon dioxide levels triggers hyperpnea again, and
the cycle starts all over. Essentially, the respiratory system is going rapidly
back and forth between two states, first making no effort to breathe and then
hyperventilating, with no in-between. The most common symptom of sleep apnea is
severe sleep deprivation. Interrupted sleep can cause nocturia, the excessive need
to urinate during the night, and stress-induced insomnia. The effects are also
apparent during the day, because losing restful sleep leads to difficulty
concentrating, headaches, and fatigue. Apneic episodes are usually preceded by loud
snoring, which can interrupt the sleep of other people as well. Sleep apnea on its
own is rarely fatal, but it can worsen other health problems. For example, drops in
oxygen levels can trigger anginal chest pain, and can irritate heart cells leading
to an arrhythmia—an irregular heartbeat. Broadly speaking, individuals with sleep
apnea have a higher risk for heart failure, respiratory failure, diabetes, and
certain types of cancer. Diagnosing sleep apnea requires a sleep study to help
identify episodes of sleep apnea, the more episodes the more severe the sleep
apnea. A sleep study usually involves getting monitored overnight with a
polysomnogram. A polysomnogram tracks things like brain movement, oxygen and carbon
dioxide blood levels, vital signs, and outward symptoms like snoring and movement.
Treating sleep apnea starts with avoiding things like sleeping pills, alcohol, and
other depressant medications because they can relax the throat muscles around the
airway and make the airways more likely to collapse during sleep. In addition,
sleeping on the side instead of on the back can also help because it creates better
airflow into the lungs. For severe sleep apnea, individuals can use a continuous
positive airway pressure device or CPAP device for short. This machine forces the
airways open with a steady stream of pressurized air delivered through a plastic
facemask or nasal prongs. Used properly, This is very effective, but it requires
continuous use. Many people eventually stop using it, finding it annoying or
difficult to wear, and the problem persists. Some people with obstructive sleep
apnea can benefit from custom made oral mouthpieces that help improve airflow
during sleep. Sometimes, obstructive sleep apnea can be managed surgically, for
example removing large adenoid tissue or realigning the jawbone, however,
procedures can be complicated because the anaesthesia and surgical swelling can
both worsen sleep apnea in the short term. All right, as a quick recap - sleep
apnea can be due to physical obstruction of the airway or from a neurological
malfunction initiated by imbalances in the blood’s oxygen and carbon dioxide
levels, which regulate breathing cycles. Left untreated, the condition can interact
negatively with other underlying health conditions, leading to serious
complications.
=========================================================
How to know if you have sleep apnea
=========================================================
a sleep study is a study which is done in a laboratory where you come in and you
stay overnight arrive around nine o'clock at night you mean with the technician and
they hook up a whole lot of electrodes on your scalp your chain your chest and your
legs and they watch you while you sleep and this will tell you whether or not you
suffer from a sleep disorder such as obstructive sleep apnea central sleep apnea
restless leg syndrome nighttime seizures any of a number of other more common types
of sleep disorders that we sometimes look for you also there's a different kind of
a study called a home sleep test this is a type of test which is designed look only
for sleep apnea and that is the only thing that particular type of study looks for
one of the problems with the home sleep test is you don't have brainwave mutters
the reason you monitor the brain waves is because it tells you one very important
fact and that is whether a person is asleep awake when you're in the laboratory
you're monitoring their brainwaves and you can tell when they've fallen asleep how
long they stay asleep and also what stage of sleep there in the reason we track eye
movement is to tell whether you're into a special kind of steep stage called stage
REM sleep Rama sorry M stands for rapid eye movement sleep and the reason is
because it's the deepest stage of sleep where you have the most vivid dreams it's
also the stage where basically the whole body's paralyzed and the only muscles
which work during REM sleep are basically the heart the muscles with which you pull
air and in and out of your lungs and the eyes you want to know when a person gets
into this rapid eye movement sleep because a lot of people will only have sleep
apnea only when they go into that particular stage and the reason is because that's
when the muscles of the upper airway most flaccid the most important reason to have
a sleep study is because if you have a sleep disorder it affects your life leaves
you feeling tired run down sleepy all the time walk prone to depression and mood
swings and you basically just don't enjoy life as much as you should obstructive
sleep apnea if left untreated can lead to a much higher risk of strokes heart
attacks high blood pressure as well as abnormal rhythms the as a result and leave
you debilitated later in life and your quality of life goes down you

The Relationship Between Sleep Apnea and Cardiovascular Disease

howdy I'm Jay Whitmer cardiology fellow here at Mayo Clinic Rochester during
today's recording will be discussing sleep apnea its impact on the cardiovascular
system treatment options and I'm joined by my friend and colleague dr. Varun
summers who is an expert book in cardiovascular diseases and sleep apnea welcome
dr. Somers thanks Jay thanks so inviting me absolutely so we'll get started so
briefly tell us a little bit about sleep apnea what is it and why does this occur
so when you think of sleep apnea is really two essential types of obstructive apnea
and central apnea obstructive apnea is the kind of apnea that's noisy socially
destructive associated with snoring patients often obese and generally affects
males but also affects females maybe a two-to-one ratio and the apnea occurs
because when people fall asleep they lose their postural muscle tone and because
the upper airway has tries add muscle it loses torn the upper airway as well so
particularly during REM or dream sleep when you really want to have low muscle tone
so you don't act out your dreams you end up having a very lacks upper airway
because the loss of muscle tone and so the inspiration the airway collapses causes
and obstruction and the resolution of the structure occurs when the patient's brain
wakes up the patient doesn't know he or she is waking up but the brain wakes up
that muscle tones restored they start breathing again so that's obstructive apnea
central apnea is more quiet kind of apnea the apnea that occurs with heart failure
you'll also see it in your kids or your spouse when you travel to altitude the low
carbon dioxide that's generated by being at altitude causes a central apnea and
it's also known we know it also has changed ox breathing so it's it's a non
obstructive apnea and the apnea occurs because the lack of the central drive to
breathe so we see that mainly in heart failure see in normal people at the altitude
you also see it in premature infants they often have a high likelihood of central
happening so we've got obstructive which is a noisy a kind of apnea but central
which occurs particularly with severe heart failure again occurs mainly in males
but the difference is that the central Afghan heart failure tends to be more
prominent in people with with low body weight low muscle mass more cardiac
cachectic they will often have central apnea interesting so you mentioned heart
failure and some central sleep apnea with regard to those two types of sleep apnea
are there any that are particularly associated with cardiovascular disease or do
they cause cardiovascular disease good question so what obstructive first
obstructive is associated with a breath of cardiovascular diseases hypertension
atrial fibrillation myocardial ischemia Patil II the schema it occurs at night if
people wake from sleep with chest pain think about obstructive sleep apnea heart
attacks particularly heart attacks occurring at night someone has a heart attack
chest pain or could at night look for obstructive apnea high likelihood that he or
she has obstructive apnea the other thing that sleep apnea is has been obstructive
apnea has been linked to his sudden death there seems to be an increased risk of
sudden death and people with obstructive apnea and there's also an increased risk
of sudden death and defibrillator firing that occurs at night so if patient has an
ICD and it triggers at night wakes them from sleep then look for look for sleep
apnea both ischemic and non ischemic causes at okay and absolutely and and so the
so the but the more important question you ask or at least the other important
question arises does sleep apnea cause the heart disease we don't know for sure
this is there's good evidence suggesting it does cause it and certainly makes it
worse but we haven't got the definitive answer to that yet I think the best we can
do at this point is say sleep apnea probably is a cause of high blood pressure
excellent the rest of it it's a jury still out at least on what central apnea
central apnea things are less clear patients with central apnea and heart failure
the central apnea seems to be an complement of the heart failure current whether
the central apnea is causing the heart failure to become worse we don't know
probably not based on on evidence that emerged recently which we will talk about
right excellent so we talked a little bit about a schema card disease and heart
failure are there any other cardiovascular conditions that would be associated with
sleep apnea or we need to think about sleep apnea well I think I think in those
cardiovascular issues that that we mentioned I think if the patient has intractable
hypertension or recurrent atrial fibrillation then you or heart failure that's not
responsive to standard therapy then you must look for stairs for sleep apnea
because often or sometimes treating the apnea can make the underlying
cardiovascular condition more amenable to to to being treated with drugs or
standard therapy now things that I haven't mentioned yeah it aneurysmal dilatation
of the ahta has been linked to obstructive sleep apnea patients with pulmonary
emboli they've been that they seem to have a higher prevalence of sleep out in here
than we'd expect certainly patients with DVT have a high prevalence of sleep apnea
now some work that that came from from us at Mayo showed that if you have a p fo
and you have a left-to-right shunt generally during the during obstructive apnea
during the Mulla maneuver you can actually get reversed or the shunt so you get a
right to left shunting if you have a DVT that's embolize up to the to the right
atrium and suddenly you get a change to the obstructive apnea from left-right
right-left unting you can get a paradoxical ambu's so these are the more esoteric
things that are linked to to sleep at but certainly something we all need to be
thinking about in clinical realm absolutely so in terms of treatment options for
sleep apnea what are some of the treatment options and what are their impact really
on the cardiovascular disease you mentioned a little bit earlier about treating
hypertension and so forth but what are some of the ways that we can treat it and
then how is that going to help our patients sure so so little strong with
obstructive apnea and treatment options for obstructive apnea the patient's
overweight you want them to lose weight if they have sleep apnea that's worse on
their backs it's very much a gravitational thing because it there's a loss of
muscle tone in the upper airway the tongue can fall backwards into the airway
that's worse when they sleep in the backs and this is why patients with apnea are
often improved if they sleep on their sides so that's something else you can do and
how do we do that you can get a t-shirt with tennis balls sewn in so when they
sleep on the backs and comfortable say sleep over on their sides that can help
relieve apnea to some extent the the there's several other approaches we could talk
about but I think probably the gold standard of sleep apnea therapy is CPAP or
continuous positive airway pressure and what that does is splints the airway open
during inspiration so it makes it easier for the subject to breathe there are new
investigational therapies on the horizon for for example obstructive sleep apnea
there is a stimulator for the nerves that control the upper airway so that when you
have an apnea those the simulator activates and maintains a way tone and again
that's fairly experimental there have been some papers on it suggestive of you know
reasonable results but we have to wait and see central apnea is you the probability
be the optimal way to treat central apnea is what we call adaptive servo
ventilation it's kind of a CPAP light device that in a simplistic way it kind of
learns your breathing when you're awake and breathing normally and tries to
simulate that kind of breathing pattern when you the to stabilize your breathing so
if you think CPAP continuous positive airway pressure is a pressure driven
breathing aid ASV or adaptive sort of ventilation seeks to maintain the volume of
airflow and so when you stop breathing it's not a question of airway collapses
they're not breathing so this thing tries to generate the breathing for you now you
did ask what's the effects of therapy I'm going to talk about obstructive apnea
first we do know that treating obstructive apnea in hypertensive patients
particularly those with severe sleep apnea and with severe hypertension who are
sleepy will lower blood pressure how does treating sleep apnea do in terms of
increasing lifespan we've had a fairly large study the safe study come on the New
England Journal a few months ago and those results were a little disappointing
because when they treated people with establish cardiovascular disease randomized
some to CPAP treatment and the others to usual care without CPAP the ones getting
CPAP didn't really show any striking improvement in outcome now there are many
possible explanations for this one is they only took non sleepy patients and what
we've learned over the years is it's the sleepy obstructive apnic's who seem to be
at greatest risk there's something about having obstructive apnea and being sleepy
that actually confers risk Willa T because of the sleepiness is also the cause of
the cardiovascular problem we don't know it certainly isn't interestingly to think
about so this study unfortunately did not include sleepy patients what did it find
though was that in those people who use their CPAP diligently who used them for a
significant part of the night there was a strong suggestion towards their outcomes
so the question is you know although the the randomization of CPAP didn't work on
an intention-to-treat basis perhaps using CPAP more diligently with Beth Durin's
may give you a better outcome we don't know that for sure interesting and let's
talk about central apnea because those is on some more clear and this is study
that I was involved in it was called serve HF where we had about 1,300 patients
with predominant central apnea and low ejection fraction heart failure so yes we're
less than 45% we randomized them to either ASV which is good for treating central
apnea and on low ASV and our expectation was that ASV would improve outcomes we
turned out it actually did not improve outcomes in heart failure patients with low
ejection fraction also have central sleep apnea in fact what we found was an
increase in cardiovascular mortality in the treated group so what does that tell us
it tells us that maybe we shouldn't be treating central sleep apnea in low ejection
fraction heart failure with ASV when the treating it with other methods makes a
difference we don't know but to clarify we want to I want to be very clear that
this does not apply to to patients with normal ejection heart failure right there's
a normal ejection fraction and you have heart failure there's you know we we still
have to figure out if ASV is good for you or not good to know good to know so a lot
of different treatment options yeah and certainly a lot of things to go through in
terms of diagnosis risk stratification comorbidities and then and then looking at
what options at us for patients yeah and great well this has been very instructive
thank you for a very welcome for giving us these insights so thank you for joining
us today on the heart org on Medscape