Sleep Apnea is characterized by a period of time during sleep when a person either stops breathing or their breath is significantly reduced. Doctors consider a cessation of breathing to be apnea if it lasts for 10 seconds or more. It is estimated that more than 6% of the US population suffer from sleep apnea, and that number may be higher because many people who live alone are unaware they have the condition.

Symptoms of Sleep Apnea

The symptoms of sleep apnea are distinctive, making the condition hard to ignore and fairly easy to diagnose. The most common symptoms of sleep apnea are:

• Loud snoring, sometimes punctuated by very loud, abrupt snoring episodes.
• A temporary cessation of breathing, typically for at least 10 seconds, sometimes longer.
• A dry mouth upon awakening.
• A sensation of suffocating while sleeping.
• Trouble staying asleep.
• Daytime fatigue.

As we mentioned, about the only time these symptoms will go undetected is if a person lives and sleeps alone.

The Different Types of Sleep Apnea

There are three generally recognized forms of sleep apnea. They are:

• Obstructive sleep apnea – The most common form of sleep apnea.
• Central sleep apnea – A less common form that is neurological in origin.
• Complex sleep apnea – A combination of the two that is extremely rare and only recently recognized.

Let’s take an in-depth look at all three types.

Obstructive Sleep Apnea

Obstructive sleep apnea is what most people think of when (if) they think of sleep apnea. It’s called “obstructive” sleep apnea because it occurs when the muscles in the back of the throat relax and obstruct the airway. When this happens the person is unable to draw an adequate breath. Oxygen levels in the blood dip as a result and the brain typically wakes the person up in order to prevent them from suffocating. Often times the person is only awake for a fraction of a second and it’s possible they won’t remember the episode.

In extreme cases a person may be awakened several times every hour. Perhaps as often as every couple of minutes if they don’t turn over onto their side. They may make loud snorting sounds, gasp for air, or feel like they’re choking. It can all make getting a restful night’s sleep nearly impossible.

Risk Factors for Obstructive Sleep Apnea

While none of the following are absolute guarantees of a person developing sleep apnea they are believed to be potential contributing factors in many cases.

• Being a male – Studies indicate that men are 2 or 3 times more likely to develop sleep apnea than females. Although a woman’s risk rises after menopause.
• Obesity – Obese people are considered to be among the highest risk individuals as fat deposits around the neck and upper airway are known to obstruct breathing.
• Age – Older people are at much higher risk of sleep apnea than young people.
• Alcohol use – The use of alcohol or other sedatives causes the muscles of the throat to relax which may cause, or at the very least worsen, sleep apnea.
• A history of nasal congestion – People who have difficulty breathing through their nose are more likely to develop this condition than those with clear nasal passages.
• Other conditions – High blood pressure, type 2 diabetes, Parkinson’s disease, hormonal disorders, asthma and congestive heart failure all increase the risk of developing sleep apnea.

The Importance of Treating Obstructive Sleep Apnea

When someone with obstructive sleep apnea considers the treatment options they may decide they’re better off just living with the condition. After all, CPAP machines (1), dental appliances (2) and other treatment options can seem pretty intrusive. And in all honesty they are. Some consider surgery to correct the problem once and for all, but even surgery does not guarantee you will be free of the condition. So it’s understandable that some folks would choose “none of the above” and try to just tough it out. But there are consequences to doing nothing.

Untreated obstructive sleep apnea increases a person’s risk for a number of serious health conditions, including:

Heart Disease – The heart is a muscle. The most important muscle in your body. Muscles need oxygen to function. Obstructive sleep apnea reduces the amount of oxygen in the blood. This in turn stresses the heart muscle. Over time this stress can increase the risk of congestive heart failure and stroke. It can also pose an elevated risk to, and complicate treatment for, people being treated for atrial fibrillation (3).

High blood pressure – As we mentioned, sleep apnea reduces the amount of oxygen in the blood. This stresses the heart muscle. This constant stress on the heart muscle activates the sympathetic nervous system (4) which causes blood vessels to constrict. This constriction of the blood vessels causes an increase in blood pressure. The combination of elevated blood pressure, constant nervous system stimulation, and reduced oxygen saturation are all bad news for the heart.

Type 2 diabetes – There is a growing amount of data that suggests obstructive sleep apnea plays a role in the development of type 2 diabetes (5). Reduced oxygen levels in the blood due to interrupted breathing alter glucose metabolism, which seems to be the mechanism responsible for this elevated diabetes risk.

Metabolic syndrome – Metabolic syndrome is a complex condition linked to elevated cholesterol, elevated blood glucose levels, high blood pressure and an increased risk of heart disease. It is not entirely clear if metabolic syndrome is caused by sleep apnea, or if sleep apnea is a manifestation of metabolic syndrome (6). But the two are increasingly linked.

Liver dysfunction – There is a growing body of evidence linking sleep apnea with what is called “non-alcoholic fatty liver disease” (7). Recent studies suggest that people who suffer from sleep apnea who also have fatty liver disease may see their condition greatly aggravated by the sleep apnea. Other studies go so far as to suggest that sleep apnea may be a direct cause of liver disease, not just a complicating agent.

Unremitting fatigue – Because they suffer interrupted sleep, people with sleep apnea often drag themselves through the day, never able to feel properly energized. This unremitting fatigue can have a negative effect on their mood, their ability to concentrate, their ability to operate power tools or heavy machinery, and their ability to drive.

Nonsurgical Treatments for Obstructive Sleep Apnea

There are several nonsurgical, widely-used treatments for obstructive sleep apnea today. The most common are:

CPAP Machines

CPAP stands for “continuous positive airway pressure” which explains in a nutshell exactly what this device does. It increases pressure in the airway during the night that keeps it (the airway) from collapsing and interfering with breathing. The pressurized air is delivered through a face mask that is tethered to a compressor that typically sits on the nightstand. There are many different styles of face mask so you’ll need to find the one that fits you best.

The CPAP machine was first used for obstructive sleep apnea 40 years ago. While it was originally slow to be adopted (mostly because there were few companies that made the device) it is now universally accepted as an effective treatment for obstructive sleep apnea. And that is true whether a person has a mild form of the condition, a severe form or anything in between.

Although CPAP machines are generally considered effective they are not without their critics. Many people find it difficult to sleep wearing a mask all night. Others get claustrophobic with the mask attached to their face. Some people understandably think the CPAP mask will be a turn off to potential partners. The machine also makes a fair amount of noise so that might drive potential lovers away. And there is the inconvenience of traveling with a medical device.

Dental Appliances

Dental appliances take a different approach to treating obstructive sleep apnea. Instead of injecting pressurized air into the airway to keep it open, the dental appliance pulls the lower jaw forward and holds it there while the person sleeps. This prevents the soft palate at the back of the throat from collapsing into the airway.

Dental appliances are available in a variety of designs, but most of them bear some resemblance to a retainer used to keep teeth properly aligned after the removal of braces. They are considered a generally reliable treatment for people with less severe obstructive sleep apnea. Dental appliances don’t require use of a face mask, don’t require the person to be tethered to a machine and they don’t make any noise.

As is the case with all things, the dental appliance has its potential downside. First of all, some people find it causes pain in the temporomandibular joint (8). The pain is particularly acute when they’re eating. Dental appliances also don’t work well in conjunction with dentures, which is particularly vexing since obstructive sleep apnea tends to afflict older people more than young people. Finally, not all insurance plans will cover dental appliances.

Bi-Level Positive Airway Pressure (BiPAP)

This is a relatively new type of device that is similar to the CPAP machine in appearance but which functions in a slightly different way. With the BiPAP machine the person receives high pressure air on the inhale to keep the airway open. On the exhale, however, air pressure decreases, which makes exhaling seem much more natural. People who struggled with exhaling comfortably using a CPAP machine may prefer the BiPAP.

Behavioral Changes to Treat Obstructive Sleep Apnea

In some cases all that is needed to treat obstructive sleep apnea are behavioral changes. Those can take a number of forms based on the individual’s situation, including:

Sleeping on your side – Since most apneas occur when people are laying on their back they may see significant improvement by simply sleeping on their side. Mind you, this is not a cure for sleep apnea, but it can help some people sleep better with fewer episodes. The thing is, some people are more comfortable on their back and have a hard time adjusting to sleeping on their side. While others have a hard time staying on their side at night. But if you can pull it off, it may help.

Weight loss – Obese individuals are at much higher risk of developing obstructive sleep apnea. And among overweight individuals who already suffer from the condition, additional weight inevitably makes it worse. If you are overweight and afflicted with obstructive sleep apnea it is strongly advised that you consider losing weight.

Medication for Treating Sleep Apnea

Obstructive sleep apnea is primarily a physical problem where the airway collapses during sleep. It’s not like an infection that can be treated with antibiotics. As such, finding a medication that will yield positive results is not easy, although in some cases it may be possible. For instance:

• Nasal steroids may help some people with nasal airway obstructions.
• Some topical decongestants may also help alleviate nasal swelling.
• People whose apneas are caused by hypothyroidism (9) may benefit from thyroid replacement surgery.
• Other medications are being studied but none have demonstrated any significant effectiveness in treating the condition in most people.

Surgical Treatments for Obstructive Sleep Apnea

Although surgery should always be considered the treatment of last resort, there are several types of surgery available for people with obstructive sleep apnea.

Nasal Airway Surgery

Nasal surgery is usually indicated to remove nasal polyps or correct a deviated septum (10). Because this type of surgery will not typically solve the obstructive sleep apnea on its own, doctors will most often recommend it to help facilitate the effectiveness of CPAP therapy.

Palate and Pharyngeal Surgery

During this surgery – also known as uvulopalatopharyngoplasty or UPPP surgery – the surgeon removes all or part of the patient’s uvula, soft palate, pharynx and/or tonsils (11). The point is to remove those physical components that block the airway and cause apneas. This type of surgery is mostly recommended for patients that are not obese, and who have a long uvula and large tonsils.

Other Types of Surgery for Obstructive Sleep Apnea

• Upper airway stimulation therapy – This involves implanting a small generator that stimulates muscles of the airway while a person sleeps, thereby preventing the airway from relaxing and collapsing.
• Tongue reduction therapy – This is exactly what it sounds like and is only recommended for people whose apnea is caused by the tongue collapsing into the back wall of the throat when they sleep.
• Palate implants – Implants are inserted into the walls of the airway to stiffen them and prevent them from collapsing. This surgery has shown mixed results.
• Tracheostomy – A fairly radical surgical solution the tracheostomy is not for everyone. It is usually only recommended for those who airflow obstruction occurs above the larynx.

Central Sleep Apnea

Central sleep apnea is not as common as obstructive sleep apnea and has different causes. With central sleep apnea the brain does not send the necessary signal to the body to breathe. Until the brain resumes sending regular breathing signals respiration ceases. This can sometimes go on for 20 seconds or longer.

Central sleep apnea sometimes occurs in premature babies, but may occur in full-term infants as well. The baby stops breathing, their heart rate changes, they experience reduced oxygen in the blood and their muscles tend to relax, a condition known as hypotonia (12). For the record, central sleep apnea is not believed related to sudden infant death syndrome (13).

Babies, however, are not the only ones at risk for developing central sleep apnea. Older people have an elevated risk too, especially those who suffer from congestive heart failure and certain neurological conditions, as we will see in a moment.

The mechanism that triggers central sleep apnea is extremely complex and involves the brain’s response to blood carbon dioxide. It is typically characterized by cycles of breathing where a person breathes quickly for a time, then slowly for a time, then not at all (apnea).

Risk Factors for Central Sleep Apnea

As with obstructive sleep apnea there is no one-to-one direct correlation between any particular condition and the development of central sleep apnea. But the following conditions are thought to increase a person’s risk of developing it.

• Neurological conditions – Parkinson’s disease, Alzheimer’s disease, Lou Gehrig’s disease, epilepsy and other neurological conditions are considered a major risk factor for central sleep apnea.
• Age – People at both ends of the age spectrum (infants and older adults) have a higher risk of developing central sleep apnea.
• Being male – As with obstructive sleep apnea, men are at higher risk of developing central sleep apnea than women.
• Opioid use – Opioids are believed to significantly increase the risk of central sleep apnea.
• Congestive heart failure – People with congestive heart failure (14) are at greater risk of developing central sleep apnea than other people.
• Stroke – Central sleep apnea sometimes occurs in people who have suffered a stroke.

Treatments for Central Sleep Apnea

Unlike obstructive sleep apnea which is physical in nature, central sleep apnea can be traced to neurological causes such as:

• Alzheimer’s disease
• Parkinson’s disease
• Brain injury
• Encephalitis
• Cheyne-Stokes respiration
• Lou Gehrig’s disease (ALS)
• Congestive heart failure

Because of its neurological origins, treatment options often entail addressing the other condition that may be causing the central sleep apnea. This is especially true in severe cases. In theory, treating the underlying condition should (and often does) lessen the severity of the central sleep apnea.

In cases of mild central sleep apnea treatments may include lifestyle changes such as:

• Losing weight
• Cutting back on alcohol
• Determining if current medications are causing your apneas.
• Sleeping on your side instead of your back.
• Using nasal decongestants.

While it’s not common, CPAP therapy may be recommended in some specific cases.

Another thing to keep in mind if you have just recently begun to experience central sleep apnea is that, for reasons unknown, something on the order of 20% of all cases resolve themselves without treatment. In light of that fact you should consult your doctor before making any significant lifestyle changes.

Complex Sleep Apnea

If you have never heard of this type of sleep apnea you’re not alone. It was first uncovered by researchers in 2006. They were investigating why some people with what seemed like obstructive sleep apnea were not responding particularly well to CPAP therapy.

What they discovered was that most of these individuals were suffering from both obstructive sleep apnea and central sleep apnea. The new condition was named “complex sleep apnea” because it is indeed an extremely complex condition.

Risk Factors for Complex Sleep Apnea

Research into this condition is still in its infancy. But, as of this writing, researchers believe the following are risk factors for complex sleep apnea.

• Genetics
• Heart failure
• Being male
• Atrial fibrillation (15)
• Renal failure

Exactly what role these conditions play in the development of complex sleep apnea is not well understood, but one or more is often present in people with this condition.

Treatments for Complex Sleep Apnea

The fact that the condition was only recently discovered means that researchers are still concentrating their efforts on defining the parameters of complex sleep apnea and nailing down its causes. Truly effective, targeted treatment regimes cannot realistically be devised until both parameters and causes are better understood.

For the time being, most doctors are relying on established treatments for the other types of sleep apnea, tweaking therapies until they find the most efficacious route for different individuals. To that end, many doctors will recommend some level of CPAP or BiPAP therapy, although they will usually recommend using the machines at lower pressure to begin with and then gradually increasing air pressure until they find the optimal level.

Another therapy that has been gaining some traction is called “adaptive servo-ventilation therapy” (ASV). Similar to CPAP therapy, ASV therapy (16) uses an airway pressure device. This device monitors changes and disruptions to breathing. The difference between a CPAP and ASV machine is that the ASV machine can adjust air pressure automatically on the fly.

Conclusion

Sleep apnea is a vexing condition that can cause serious problems if left untreated. Because there are different types and many potential causes – ranging from the physical to the neurological – proper diagnosis is crucial in order to determine the correct treatment.

If you suspect you are suffering from sleep apnea it’s important to discuss the matter with your doctor as soon as possible. They will help put you back on the road to a good night’s sleep and better overall health.