Sleep apnea syndrome: what it is, causes, treatment in adults and children

Introduction

Sleep apnea syndrome - a serious illness in which breathing repeatedly stops for a long enough time, disrupting sleep; it often temporarily lowers oxygen levels and increases blood carbon dioxide levels.

• People with sleep apnea are often very sleepy during the day, snore loudly, and have episodes convulsive swallowing of air or choking, temporary cessation of breathing and sudden awakenings with loud snoring.
• Although diagnosis of the syndrome relies in part on a doctor's assessment of symptoms, doctors usually use polysomnography to confirm the diagnosis and determine the severity disorders.
• Sleep apnea can be treated with continuous positive airway pressure, fitting oral applicators by dentists, and sometimes surgery.

There are three types of sleep apnea syndrome:

• obstructive sleep apnea syndrome (OSAS);
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• central sleep apnea syndrome (CASA);
• mixed sleep apnea syndrome (combination of OSAS and SCAS).

Obstructive sleep apnea syndrome

OSAS, the most common type of sleep apnea syndrome, occurs when the throat or upper airway is repeatedly closed during sleep. The upper respiratory tract includes the airways from the mouth and nostrils to the pharynx and down to the vocal apparatus; these structures can change their position during the breathing process.

This type of apnea affects approximately 2 to 9% of people. OSAS is more common in obese people.

In OSAS, breathing is interrupted repeatedly during sleep for more than 10 seconds. These people experience from 5 to 30 or more episodes of interruption of breathing per hour.

Obesity, possibly in combination with age-related changes and other factors, leads to a narrowing of the upper airways. Alcohol abuse and the use of sedatives aggravate OSAS. A narrow throat, thick neck, and round head, which are usually hereditary, increase the risk of sleep apnea. Low levels of thyroid hormones (hypothyroidism) or excessive and pathological growth due to excessive secretion of growth hormone (acromegaly) can contribute to OSAS. Sometimes the reason can be stroke.

Obstructive sleep apnea syndrome in children

Children have enlarged tonsils or adenoids, certain dental diseases (for example, severe deep bite), obesity, and certain malformations (such as an unusually small lower jaw) can result in to OSAS.

Almost all children with sleep apnea snore. Other symptoms during sleep may include restless sleep and night sweats. Some children wet the bed. Daytime symptoms may include mouth breathing, headache upon waking, and trouble concentrating.

Learning problems and certain behavioral problems (such as hyperactivity, impulsivity, and aggression) are common symptoms of severe obstructive sleep apnea in children. Growth retardation can also occur in children. Excessive daytime sleepiness is less common in children than in adults with OSAS.

Central sleep apnea syndrome

SCAS, a much rarer type of sleep apnea syndrome, is caused by impaired breathing control in a region of the brain called the brainstem. Typically, the brain stem is very sensitive to changes in the level of carbon dioxide (a byproduct of metabolism) in the blood. At high levels of carbon dioxide in the blood, the brain stem sends a signal to the respiratory muscles to breathe deeper and faster in order to expel carbon dioxide as you exhale, and vice versa. In SCAS, the brain stem is less sensitive to changes in carbon dioxide levels. As a result, people with central sleep apnea syndrome breathe more shallowly and more slowly than normal breathing.

Central sleep apnea syndrome can be caused by the use of opioids for pain relief, as well as some other drugs. Staying at a high altitude can also trigger an NCAS. SCAS can occur in people with heart failure. A brain tumor very rarely causes this disorder. Unlike OSAS, obesity is not a cause of SCAS.

For a form of central sleep apnea syndrome called the curse of Ondine and usually occurs in newborns, patients may not breathe properly or stop breathing altogether, unless they are completely are awake. The Curse of Ondine can be fatal.

Mixed sleep apnea syndrome

The third type, mixed sleep apnea syndrome, is a combination of OSAS and SCAS during an episode of sleep apnea syndrome. Mixed episodes are most often started and treated as obstructive sleep apnea.

Symptoms and Signs

Symptoms during sleep, as a rule, are first noticed by the one who sleeps nearby, or the roommate (s) in the room or apartment. In all types of sleep apnea syndrome, breathing can pathologically slow down and become superficial, or it may stop suddenly (sometimes for up to 1 minute), and then resume.

For all types of sleep apnea, sleep disturbances can lead to daytime sleepiness. fatigue, irritability, headaches in the morning, slow thinking and difficulty concentration. Because oxygen levels in the blood can decrease significantly, it can develop atrial fibrillation and blood pressure rise.

- Obstructive sleep apnea syndrome.

In obstructive sleep apnea syndrome, snoring is the most common symptom, although most people who snore do not have sleep apnea syndrome. In OSAS, snoring is usually intermittent, with episodes difficulty breathing or choking, pauses in breathing, and sudden awakening with loud snoring. A person may wake up with a bout of suffocation and in fright.

In the morning, people are often unaware that they have woken up many times during the night. Some people wake up with a sore throat and dry mouth. In severe OSAS, repeated bouts of snoring and prolonged loud snoring occur at night, and during the day a person experiences drowsiness or involuntarily falls asleep for a short time.

People may have intermittent sleep.

In people who live alone, daytime sleepiness may be the most noticeable symptom. As a result, sleepiness starts to interfere with working during the day and reduces the quality of life. For example, a person may fall asleep while watching TV, in a meeting, or, even more excessively sleepy, even while driving, such as by stopping at a red traffic light. Memory can be impaired, libido can be weakened, and interpersonal relationships suffer, because that the person is unable to take an active part in the relationship due to drowsiness and irritability.

With obstructive sleep apnea syndrome, there is an increased risk of stroke, myocardial infarction, atrial fibrillation (abnormal heart rhythm disorders) and increased blood pressure. Middle-aged men with 30 or more OSAS episodes per hour are at increased risk of premature death.

- Syndrome of central sleep apnea.

Snoring is less pronounced with SCAS. However, the breathing rhythm is irregular and interrupted by pauses. Cheyne-Stokes breathing (intermittent breathing) is a type of central sleep apnea syndrome. With Cheyne-Stokes breathing, a person gradually begins to breathe faster, then more slowly, then breathing stops for a short period and resumes again. Then the cycle repeats again. Each cycle lasts from 30 seconds to 2 minutes.

- Syndrome of hypoventilation due to obesity.

Extremely obese people may also suffer from obesity-related hypoventilation syndrome (Pickwick syndrome) with or without obstructive sleep apnea. Excess fat interferes with the movement of the chest, and excess fat under the diaphragm constricts the lungs, which collectively causes less effective shallow breathing. Excess fat around the throat constricts the upper airways, reducing air flow. Respiratory control may be impaired, resulting in central sleep apnea syndrome.

Diagnostics

Sleep apnea syndrome is suspected based on the person's symptoms. Sometimes doctors use questionnaires to help identify symptoms such as excessive daytime sleepiness that can be caused by OSAS. The diagnosis is usually confirmed and the severity of the disease is determined in a sleep laboratory using a test called polysomnography. This test can help doctors distinguish between OSAS and SCAS.

At polysomnography:

• Electroencephalography (EEG) is used to monitor changes in sleep levels and eye movements.
• Oximetry, in which an electrode is placed on the tip of a finger or earlobe, is used to determine the level of oxygen in the blood.
• Air flow measurement is carried out using devices that are placed in front of the nostrils and mouth.
• The amplitude and type of breathing are measured using a monitor placed on the chest.

Most often, portable monitors used at home are used to diagnose the syndrome. These monitors measure your heart rate, blood oxygen levels, breathing effort, position and airflow through your nose.

Sometimes doctors need to do additional testing to determine the cause. People with sleep apnea may be screened for complications such as high blood pressure and atrial fibrillation. If doctors suspect SCAS, tests are rarely needed to determine the cause.

Treatment

Treatment includes the following:

• Control of risk factors;
• Continuous positive airway pressure or the use of mouth guards or other devices selected by the dentist;
• Possibly airway surgery or electrical stimulation of the upper airways.

Patients should be warned of the risks associated with driving, operating heavy equipment, or other activities that could be hazardous to accidentally fall asleep. People who are going to have surgery should inform their anesthesiologist that they suffer from sleep apnea because anesthesia can sometimes cause additional narrowing of the airways ways.

Support groups can provide people with sleep apnea and their families with the information they need to help them cope with the condition.

- Obstructive sleep apnea syndrome.

With adequate treatment, the prognosis is usually excellent. This disorder does not affect life expectancy, and the most serious complications can be prevented. Weight loss, smoking cessation and alcohol abuse can help. Nasal infections and allergies need to be treated. Treatment of hypothyroidism and acromegaly is required. Following surgery (bariatric) for obesity in people who are overweight (morbid obesity), the severity of the syndrome is often reduced and symptoms are allowed, but even if people lose significant body weight after surgery, they may not experience a significant reduction in the severity of sleep apnea and related sleep apnea symptoms.

People with heavy snoring and frequent bouts of choking during sleep are prohibited from drinking alcohol or sleeping pills, sedative antihistamines, or other medications that cause drowsiness. Sleeping on your side or lifting your head can help reduce snoring. Special devices attached to the back prevent people from sleeping on their backs. There are various snoring devices and sprays commercially available that can help with simple snoring, but they are not effective for OSAS. There are several surgical procedures available to treat snoring, but there is insufficient evidence for their effectiveness and duration.

People with OSAS, especially those who suffer from excessive daytime sleepiness, are most likely to benefit from continuous positive airway pressure (CPAP) treatment. During CPAP, people breathe through a face mask or nasal mask that provides slightly higher airway pressure. This increased pressure opens the throat when the person inhales. With CPAP, the supply air can be additionally humidified. Close medical supervision is required during the first 2 weeks of the course to ensure proper mask adherence and help you get used to sleeping with the mask.

Some people who use CPAP continue to experience excessive daytime sleepiness. These people may benefit from modafinil, which is a mild stimulant used to treat daytime sleepiness in people with obstructive sleep apnea. Other drugs are also being tested to treat people with OSAS.

Removable oral applicators, chosen by dentists, can help relieve OSAS (and snoring) in people with mild to moderate sleep apnea. These applicators, which are only worn during sleep, help keep the airway open. Most applicators separate the jaws and push the lower jaw forward to prevent the tongue from moving backward and blocking the throat. Other devices pull the tongue forward.

Upper airway stimulation is a procedure in which an implanted device is used to activate one of the two cranial nerves of pair 12 (hypoglossal nerve). This therapy may be successful in people with moderate to severe OSAS who cannot tolerate CPAP therapy.

Surgery to the head or neck as a treatment for sleep apnea can help with enlarged palatine tonsils or obvious blockage of the upper airways of any other structure. In children, the most common treatment is surgery to remove the tonsils and adenoids.

This type of surgery usually relieves the syndrome, especially if the tonsils or adenoids are enlarged. Surgery is sometimes attempted in people without apparent blockage if other treatments have failed. Another common procedure is uvulopalatopharyngoplasty, which removes tissue around the upper airway (such as tonsils and adenoids). Most often, this procedure helps people with moderate sleep apnea. Other surgical procedures are sometimes performed, but they are not yet well understood.

- Syndrome of central sleep apnea.

As far as possible, the underlying disease is treated. For example, drugs are prescribed to reduce the severity heart failure. There are several well-organized clinical trials currently underway for other treatments for the syndrome. Oxygen delivered through nasal cannulas (not pressurized) can reduce the number of apnea episodes in people whose oxygen levels decrease during sleep.

Some people with central sleep apnea may benefit from CPAP. This treatment in people with SCAS with Cheyne-Stokes breathing reduces the number of episodes of apnea and decreases the severity of heart failure, but does not improve survival.

The use of acetazolamide can help people with central sleep apnea syndrome caused by high altitude, and probably also people at sea level. Some people are helped by surgically implanting a device that stimulates the diaphragm (phrenic / abdominal nerve stimulator) to help the person breathe.