Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten,M.D.
21 April 2004

THE IMPORTANCE OF SLEEP APNEA

     A patient recently came to the clinic indicating that he was so tired that he could not keep his eyes open.  He indicated that he went through his day having difficulty concentrating on his work.  He had previous problems with depression and he wondered if depression wasn’t the source of his symptoms.  He thought that he needed to restart an antidepressant medication that he had used in the past.

     On further questioning, I asked if he felt that he was sleeping restfully at night and if he awakened rested in the morning.  He laughed and stated that he was sleeping just fine but nobody else in the house was.  He said that his daughter slept in the basement, two floors below and she was kept awake by his snoring at night.  His wife had taken to sleeping in a downstairs bedroom at the far end of the house because his snoring kept her awake.  I asked if he knew that he snored to which he replied he didn’t have a clue.  He said that he was asleep and didn’t know if he snored.  He did acknowledge that his mouth was very dry in the morning and he often had a sore throat.  Several times he had come to the clinic in the previous years seeking attention to his concern that he had a strep throat.  He was slightly overweight but not inordinately so.  He was not a smoker and did not drink alcoholic beverages after supper or in the evening.  Based on the above story, it was suspected that his fatigue and sleepiness during the day was more related to sleep apnea than it was to depression.

     The problem with sleep apnea has to do with the structures around the mouth and the throat.  As a person ages and/or gains significant amounts of weight, the throat tends to close when a person lies on their back to sleep at night.  The jaw falls back onto the throat which then closes, obstructing air to the lungs.  The person then doesn’t breathe for 10 to 30 seconds.  A few people may not breathe for up to a minute before they squirm in bed, change position, reopen the airway and then breathe deeply for several seconds, not really waking up.  These episodes result in significant amount of time during which the patient doesn’t get enough oxygen.  Especially in the older age group, this can cause severe heart strain.  I have had several patients in whom atrial fibrillation (a kind of irregular heart beat) was directly attributed to obstructive sleep apnea.  Once the sleep apnea was corrected, the atrial fibrillation stopped.  It is very common that heart failure is made worse by obstructive sleep apnea and if this is not recognized and addressed, heart failure can become a major problem.

     When a person is suspected of having sleep apnea, the intensity of the evaluation and treatment depends upon the intensity of the problem.  There are four non-medical steps that can make a significant difference:

 1.  In those that are substantially overweight, effective weight loss can decrease the intensity of sleep apnea problems.  Effective weight loss being the difficult problem that it is makes this infrequently successful.
 2.  Avoidance of alcohol or other sedatives.  It may seem that these help would help with sleep but instead they lead to greater laxity of the jaw and can make the sleep apnea problem actually worse.  So many times a person comes in and asks for something to help them sleep, and in fact this is a counterproductive measure.
 3.  Methods to improve nasal patency can be a significant help. The use of Afrin nasal spray at bedtime to keep the nasal passage and sinuses open can be a tremendous help in avoiding mouth breathing.
 4.  Having the person learn to sleep on their side or on their stomach can sometime solve the problem.  The most common position for sleeping is lying on one’s back and this is the position most likely to generate snoring and sleep apnea.

     When the above measures are inadequate to deal with the problem, the next simplest step is to use a mouth guard very much like what football players use to protect their teeth.  The dentist can fit the person for a plastic mouthpiece that will hold the jaw forward, avoiding the collapse of the throat and shutting off the airway.  This may be effective enough in up to 80% of people who have sleep apnea problems.  The cost is between $200-$400 but well worth the price to allow the person to re-establish adequate rest and avoid the snoring problem.

     When the above measures are ineffective, the price of evaluation becomes very substantial.  The patient is brought to the hospital for a sleep study evaluation.  The person may then be provided with a CPAP machine (continuous positive airway pressure).  This device blows air into the pharynx with each breath the person takes and opens the airway so that the periods of cessation of breathing do not occur.  The workup for this machine and its use are very expensive although frequently necessary for some people with severe sleep apnea.

When the above measures are ineffective, surgery is sometimes recommended to alleviate the problem.  This is only for extreme problems and is variably successful.
The importance of adequate sleep to avoid heart strain, high blood pressure, and atrial fibrillation is poorly appreciated.  In addition, the excessive daytime sleepiness impairing intellectual function and potentially causing depression problems can be very disruptive.  If you or a loved one are aware that a person is snoring substantially, as the gentleman described above, it is in everyone’s interest to get this corrected before significant heart failure, and other problems occur.  The healthcare professionals at your local clinic are well aware of the sleep apnea syndrome, its consequences and how to care for it.