Dreaming about a good night's sleep?

1.770924-620990246 — Two of the most common symptoms of Obstructive Sleep Apnea (OSA) are loud and chronic snoring and fighting sleepiness during the day. Image Credit: Rex Features

Depending on who you talk to, snoring can either be comic or tragic. For those who suffer it silently, it is a menace.

For those who use examples of snorers to tell funny stories, it’s priceless comic relief. And for those who snore, it’s an alarming health problem. This sleep interruption is not taken as seriously as it should be in society. From little snorts and grunts to roaring, thundering bellows, snoring moves through various decibel levels but no matter where it’s at, it is a sign of an underlying health problem.

Two of the most common symptoms of Obstructive Sleep Apnea (OSA) are loud and chronic snoring and fighting sleepiness during the day. OSA not only robs an individual of deep, restful sleep, in its extreme form, it can lead to asphyxiation.

Take the case of W.A., a 35-year-old expatriate, who kept dozing off at work due to lack of proper sleep thanks to OSA. When he went out for lunch with his colleagues, he would often doze off in the back seat of his colleague’s car. Many a time his sleep would be accompanied by loud snores. In his own car, he would doze off at the wheel while waiting for the lights to turn green. His wife found her sleep repeatedly disrupted by his snoring cycles. His married life was fraught with tension and his work life a matter of ridicule.

In the case of 43-year-old S.T., snoring also destroyed his marriage. Obese and neglecting his health, he snored throughout the night. His wife’s pleas to seek medical advice fell on deaf ears. Often she would wake up with fear as his breathing grew strangled in his sleep.

Over a period of time, to her horror, she discovered that she too was putting on weight as her lack of sleep began to play havoc with her hormones. This miserable marital situation lasted for almost ten years until she decided to seek a divorce as she realised that living with her husband was damaging her mental and physical health.

“In the case of S.T.” says Dr Anil Chowdhery, ENT Specialist, Jebel Ali Hospital, “snoring turned out to be a very serious problem as it damaged the partner’s psychological and physical well-being. S.T. actually had a severely deviated nasal septum - the bone dividing the two nasal cavities was not straight, thus leading to an imbalanced flow of air through his nose. This led him to suffer from Obstructive Sleep Apnea [OSA.]

“W.A. too was suffering from OSA. While it is unfortunate that his wife left him, it is a highly probable occurrence in marriages where the husband does not seek medical help for his acute condition.”

What is OSA?

According to Dr Chowdhery, “OSA is a disorder which occurs due to the tongue and the soft palate partially or completely obstructing the pharynx [throat] which sends the air to the larynx. This results in a partial or complete blockage in air flow for a few seconds at a time which leads to recurrent episodes of cessation of ‘apnea’ or breathing.

In the event of either condition, sleep gets interrupted. Typically, the pattern of sleep in such cases is fitful and deep by turns. During the fitful phase, breathing is laboured and insufficient and in the deep phase, it returns to normal. If the cessation or stoppage of breathing lasts for more than ten seconds in adults and six seconds in children, it is classified as ‘apneic episodes’. Individuals with OSA may have such episodes many times during the hours of sleep.”

In OSA, there is a narrowing of the upper respiratory tract during sleep. The muscles of the tract are in a dilated state when awake and upright and therefore, breathing is normal. During sleep, especially in a supine position, the muscles relax thus narrowing the air passage.

“This narrowing leads to an increase in the carbon dioxide levels in the blood causing awakening from sleep,” says Dr Chowdhery.

The primary cause of OSA is obesity. “Obesity,’’ says Dr Chowdhery, “is a leading cause of OSA. Obesity leads to fat deposits in the throat and pharynx which thicken making the airway passages narrower. The fat deposits also render muscles in these areas lax, which means that the tongue and jaw then tend to fall back when an obese person is asleep in a supine position. This also obstructs the already narrow airway passage and leads to snoring.”

The height and the neck size of an individual is a good indicator of the propensity for snoring, says Dr Chowdhery. “Individuals with a short, broad neck with a lot of fat around it and with a circumference of more than 43cm may be more prone to the condition as compared to an individual with the ideal height-weight ratio.”

It has been incontrovertibly established by medical experts that a disruptive sleep pattern can wreak havoc with health. Research has established numerous times that lack of quality sleep on a continual basis could lead to excessive daytime sleepiness (EDS), impairment of cognitive functions and a diminished quality of life. What is disturbing also is that our current lifestyles increase the chances of sleep deprivation.

How can one identify OSA?

OSA can be diagnosed after assessing patient history, conducting a physical examination and polysomnography, also known as multi-parametric sleep studies (many parameters such as shallow breathing episodes, apneic episodes and oxygen levels are marked, recorded and analysed).

These studies are carried out while a person is sleeping to measure the apneic episodes. A sensor is used to track the breathing pattern through the night to measure the AHI (a numeric measure used to diagnose OSA and its severity). In this parameter, the ‘apneic’ or no-breathing episodes are measured over a period and an average per hour of such episodes is calculated to assess whether the person has OSA or not. Mild OSA is 5-15 apneic events per hour of sleep, moderate is 15-30 apneic events per hour of sleep and severe is more than 30 apneic events per hour of sleep.

Can one have asthma and not sleep apnea?

“Though OSA is pathologically related to upper airway obstruction,” he says, “and bronchial asthma is related to the lower airway, there is a fair chance that asthmatics are more prone to developing it.”

Says Dr Chowdhery, “Typically, someone suffering from OSA will display all of or some of the following symptoms depending on the severity: during sleep, a loud, cyclic snoring; snorting; choking/gasping; repetitive awakenings; thrashing body movements; reduction in heart beats; and apnea.” The typical apneic episodes occur more when the individual is lying on his back, that is, when he is supine.”

Other signs of OSA include EDS, systemic or pulmonary hypertension, lethargy, morning headaches and nocturia (frequent nocturnal urination). Children with OSA may be hyperactive and exhibit poor school performance.

Consequences if OSA is left untreated

As explained above, due to less oxygen in the blood as a result of improper breathing, various complications can arise in OSA. “Recurrent deficiency in oxygen in body tissue resulting from OSA may lead to changes in blood circulation, neurological conditions, metabolic and inflammatory changes,” says Dr Chowdhery.

“Various studies have also indicated that irregularities in heart beats called cardiac arrhythmias may lead to low blood-oxygen pressure, high blood-carbon dioxide pressure or pulmonary arteries constriction in patients with OSA. This in turn exerts pressure or stress on the heart and its pumping capacity, leading to a further risk of cardio-vascular diseases and stroke.”

Who is likely to have OSA?

“Studies have indicated that people over the age of 40 are more likely to suffer from OSA,” says Dr Chowdhery.

“The risk increases with age and the disorder occurs more often in men than in women [2:1 ratio]. Other risk factors for OSA include smoking, hypothyroidism, hypertension, and the consumption of alcohol or the use of sedatives before bedtime.”

Treatment

The current best form of treatment for OSA is through the CPAP (continuous positive airway pressure) contraption the patient wears on his face during sleep. “The CPAP machine is recognised as the gold standard for treatment of moderate-to-severe OSA in adults.

It is a mask which covers the nose and has a set of tubes which are attached to a pressure monitor. The machine automatically detects sleep apnea and immediately blows the appropriate volume of air into the respiratory tract through a ‘pneumatic splint’ that sits on the nose. The downside is that a patient has to wear it for six to eight hours each night during sleep and on a long-term basis.”

Apart from CPAP, there are other supportive treatments like the use of a nasal splint to dilate the nose, or wearing supporters on the jaws to prevent them from falling back during sleep.

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