Sleep apnea and snoring

Information on Snoring, Sleep Apnea, and Treatment

Snoring and Society

  • One of the most prevalent and obnoxious human habits
  • Almost exclusively found in humans; common source of domestic conflict
  • Highest level of snoring recorded was 87.5 decibels! (about the level of heavy truck traffic)
  • Over 300 patented remedies in US to cure snoring
  • Famous snorers found throughout history (George Washington, Abraham Lincoln, Winston Churchill, Mussolini)
  • References in literature (Pickwick Papers by Charles Dickens)

Snoring

  • Snoring results from the vibration of loose tissues (soft Palate, uvula, posterior tonsillar pillars) in the oropharyngeal areas as air passes over them in inspiration
  • There is increased resistance to airflow due to narrowing of the airway

Prevalence of Snoring

  • Occurs in all age groups, but increases with age
  • Snoring in children usually due to enlarged tonsils or adenoids
  • 30-35 year old population: 20% of men and 5% of women
  • 40-65 year old population: 60% of men and 40% of women; remains stable after 65
  • Three times more common in obese person
  • Increased in certain races

Relationship Between Snoring and Obstructive Sleep Apnea

  • Snoring, alone, is a social/cosmetic problem, and is not associated with significant health problems
  • Obstructive sleep apnea (OSA) is a medical disorder, usually found in severe snorers, in which there are period of decreased breathing or complete cessation of breathing during sleep due to an obstruction of airflow
  • Most people who snore do not have OSA
  • However, almost all patients with OSA are heavy snorers, silent OSA can be found in some post-surgical patients
  • There appears to be a tendency for severe snorers to gradually progress to more serious forms of sleep disordered breathing (UARS;OSA) which are often, but not always, related to weight gain or aging

Definitions

  • Apnea-the cessation or near complete cessation (>70%) of airflow lasting for a minimum of 10 seconds
  • Hypopnea-a greater than 30% reduction of amplitude of thoracoabdominal movement or airflow as compared to baseline with >4% oxygen desaturation
  • Respiratory Effort Related Arousals (RERAs)-Episodes that include a clear drop in inspiratory airflow, increased inspiratory effort, and a brief change in sleep state (arousal) but which do not meet criteria for an apnea or hyponea
  • Obstructive Sleep Apnea-repetitive episodes of complete or partial airway obstruction during sleep resulting in the cessation of airflow despite continuing respiratory efforts
  • Central Sleep Apnea-the cessation of airflow during sleep in the absence of obstruction or respiratory efforts

Prevalence of Obstructive Sleep Apnea

  • In a large epidemiologic study using PSG, 2% of women and  4% of men met criteria for OSA (daytime sleepiness and AHI>5); 9% of women and 24% of men had an AHI>5 but without daytime sleepiness (NEJM 1993;328:1230-1235)
  • Conservative estimate of 12 million people in US (~4%) with OSA, 90% of whom have not been diagnosed
  • In a recent telephone survey of 1509 US adults, 26% of respondents (31% of men and 21% of women) met the Berlin questionnaire criteria indicating a high risk of OSA (Chest 2006;130:780-786)
  • The risk increased up to age 65
  • 57%of obese individuals were at high risk for OSA
  • Concluded that one in four adults could benefit from an evaluation for OSA

Medical Complications of Obstructive Sleep Apnea

  • Systemic hypertension
  • Stroke
  • Cardiac arrhythmias
  • Heart failure
  • Myocardial infarction
  • Pulmonary hypertension
  • Gastroesophageal reflux
  • Glucose intolerance neurocognitive impairment
  • Increased mortality with AHI>20

Sequelae of Disordered Sleep-Related Breathing

  • With the onset of sleep, some degree of obstruction to airflow occurs (resistance)
  • If resistance/obstruction is minor, snoring is the only result
  • If resistance/obstruction is more significant, breathing can completely or partially cease
  • Hypoxia and hypercarbia develop causing CNS activation
  • Arousals from sleep will occur to enable normal breathing to resume
  • If arousals are frequent, this leads to fragmented sleep of poor quality and of a non-restorative nature
  • Therefore, a common finding is excessive sleepiness during the day

Automobile Accidents and Obstructive Sleep Apnea

  • Being deprived of sleep for a 24 hour period produces the same cognitive impairment as having a blood alcohol level of 0.10%
  • Patients with OSA have a 3-fold greater chance of having an automobile accident
  • 12-fold greater chance for a single-vehicle accident!
  • Risk is highest in those who report sleepiness while driving or who score higher than 11 on the ESS

Primary (Benign;Simple) Snoring

  • Loud snoring
  • No gasping or cessation of breathing during sleep as reported by witnesses
  • No excessive daytime sleepiness
  • Normal sleep study (polysomnogram)

Upper Airway Resistance Syndrome

  • Loud snoring
  • Complaints of excessive daytime sleepiness
  • RERAs on polysomnogram

Obstructive Sleep Apnea

  • Loud snoring
  • Gasping, snorting, and periodic cessation of breathing during sleep as reported by witnesses
  • Complaints of excessive daytime sleepiness
  • Abnormal sleep study (polysomnogram)

Risk Factors for OSA

  • Obesity (predominately neck and abdomen rather than hips and legs); 
    BMI >30
  • Neck circumference > 17” or 40 cm
  • Age grater than 65
  • Male gender (3-9:1)
  • Risk for women increases with obesity and being postmenopausal
  • Positive family history (increases risk two-fourfold; risk is increased by 21-84% if first degree relative with OSA)
  • Craniofacial anatomy (high narrow hard palate, elongated soft palate, large tongue, retrognathia, tonsillar hypertrophy especially in children)
  • Alcohol ingestion around bedtime

Suggestive of Obstructive Sleep Apnea

  • Loud, intermittent snoring with gasping, chocking, or absence of breathing
  • Excessive daytime sleepiness
  • Restless sleep, and awakening tired
  • Morning headaches
  • Esophageal reflux
  • Mood, memory, attention problems
  • Impotence

Diagnosis of Obstructive Sleep Apnea

  • Obstructive sleep apnea is a medical disorder with potentially serious consedquences, therefore………
  • “The presence or absence of obstructive sleep apnea must be determined before initiating treatment with oral appliances to identify those patients at risk due to complications of sleep apnea and to provide a baseline to establish the effectiveness or subsequent treatment.  Detailed diagnostic criteria for OSA are available and include clinical signs, symptoms and the findings identified by polysomnography.  The severity of sleep related respiratory problems must be established in order to make an appropriate treatment decision” Practice Parameters; Sleep 2006;29(2):240-243

Treatment Options for Sleep Disordered Breathing

  • Self help measures; behavioral modification
  • PAP (Positive Airway Pressure)
  • Upper Airway Surgery
  • Oral Appliances

Self Help Measures

  • Weight loss
  • Avoidance of alcohol or sedatives before sleep
  • Stop smoking
  • Changing pillows or changing sleeping position

Positive Airway Pressure (CPAP; BiPAP, Auto-PAP)

  • Acts like a pneumatic stent to keep the airway open
  • Gold standard for treating OSA
  • Successful in ~95% of patients

PAP (Positive Airway Pressure)

  • Poor compliance (dropout rate 40-50%; typical use of 4 or 5 hours per night, 4 or 5 nights per week
  • Purchase cost varies from $600-$2,000
  • Complications common (nasal dryness and congestion, pain, leaks, eye irritation and dryness, pressure sores, claustrophobia, noise, cumbersome)

Types of Oral Appliances

  • There are more than 60 different oral appliances commercially available; only 30 have been approved by the FDA for the management of obstructive sleep apnea.
  • Two basic types:
    • mandibular repositioners (MAD); reposition and maintain the mandible and tongue in a forward position.
    • There are also variations in which the CPAP connector can be combined with an oral appliance, with or without protrusion, eliminating the need for head straps.
  • Tongue retainer; engage and hold only the tongue in a forward position without affecting the mandible or teeth (not FDA approved for OSA)

How Oral Appliances Exert Their Effect

  • They mechanically open the airway and reduce the collapsibility of the airway by:
    • Repositioning and maintaining the mandible (and/or tongue) in an anterior position.
    • Lifting the tongue (and soft palate) away from the posterior pharyngeal wall and increasing upper airway space, thus decreasing the resistance to airflow in the upper airway (analogous to the jaw thrust maneuver).
    • Increasing the resting tonicity in the genioglossus muscle.

Effects of Oral Appliances on Blood Pressure

  • Four recent studies have reported that Oral Appliances and CPAP have similar beneficial effects on blood pressure and improved oxygen saturation.
    • Barnes, Am J Respir Crit Care Med, 2004 (n=114)
    • Gotsopoulos, Sleep, 2004 (n=61)
    • Yoshida, Int J Prosth, 2006 (n=161)
    • Otsuka, Sleep Breath 2006 (n=11)

Oral Appliance and Effect on Driving

  • Hoekema, A, et al: Simulated driving in obstructive sleep apnea-hypones; effects of oral appliances and continuous positive airway pressure.  Sleep Breath, Jan 24, 2006.
  • In a controlled study of 20 patients with OSA and 16 controls, oral appliances and CPAP equally improved the performance of the OSA patients in a simulated driving test.
  • Click here to view some of the dental appliances >> (Adobe PDF)