Understanding Sleep Apnea
Sleep apnea is a disorder in which one or more pauses in breathing, or shallow breaths, occur while you sleep. Pauses in breathing can last from a few seconds to minutes and they may occur more than 30 times in an hour.
Sleep apnea effects millions of people and is a chronic lifelong disorder. Each pause in breathing is called an "apnea" which means "no breath".
When breathing is irregular, carbon dioxide builds up in the bloodstream which triggers the brain to wake up.
Left untreated, people with sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times. The brain and body may not get enough rest or oxygen in these cases.
Sleep Apnea Terms
- AHI - Apnea Hypopnea Index
- It’s the average number of combined apneas and hypopneas per hour. It is most often used to determine the severity of a person’s sleep apnea.
- RERA - Respiratory Effort Related Arousal
- An event that causes an arousal or a decrease in oxygen saturation, without qualifying as an apnea or hypopnea.
- RDI - Respiratory Disturbance Index
- This is your combined number of apneas, hypopneas, and RERAs per hour of sleep. Physicians who use this scale typically follow the same guidelines that are used for the apnea/hypopnea index (AHI).
- Apnea - An apnea is when your breathing stops for at least ten seconds while sleeping.
- Hypopnea - A hypopnea is a significant reduction in airflow while sleeping, but not a complete stop, that causes a drop in blood oxygen saturation and then an arousal.
Forms Of Sleep Apnea
- Obstructive Sleep Apnea (OSA) - a mechanical problem that can almost always be corrected with CPAP (continuous positive airway pressure), a mouthpiece or some other treatment
- This is the most common form and is caused by a blockage in the airway, usually when the soft tissues in the back of the throat collapse during sleep
- Can be: mild, moderate or severe sleep apnea
- Central Sleep Apnea (CSA) - the signal to the body to inhale is not being transmitted to the brain
- Sleep experts report that a large number of CSA patients also have OSA
- Complex sleep apnea syndrome - when the person has both OSA and CSA at the same time
Types Of Obstructive Sleep Apnea (OSA)
Not all types of sleep apnea are the same, some can be treated by mouthpieces. Many snoring mouthpieces have been cleared by the FDA for the treatment of mild to moderate sleep apnea.
These are the types of sleep apnea recognized by the American Academy of Sleep Medicine's definition of sleep apnea (based on AHI):
- Mild - sleep that’s interrupted 5-15 times per hour
- Involuntary sleepiness during activities that require little attention like watching TV or reading
- Moderate - sleep that's interrupted 15-30 times in an hour
- Involuntary sleepiness during activities that require some attention like meeting or presentations
- Severe - sleep that's interrupted 30 or more times in an hour
- Involuntary sleepiness during activities that require more active attention like talking or driving
Types Of Central Sleep Apnea (CSA)
- Primary CSA - which is the same as idiopathic CSA (an unknown cause) - the patient has no known related diseases
- Cheyne-Stokes breathing (CSB) CSA - which may be a product of heart failure, stroke or possible kidney failure
- Non-CSB CSA associated with other medical conditions - including heart and kidney problems
- High-altitude CSA - which often appears during sleep at altitudes above 15,000 feet, and induces a form of Cheyne-Stokes breathing
- This type usually disappears when the patient descents to lower altitude
- Drug use - typically, opiates which cause CSA
- This type can be treated by stopping use
Main Causes Of Sleep Apnea
- Enlarged tongue
- Jaw sliding back
- Enlarged tonsils
- Enlarged uvula
- Fatty tissue
- Soft palate sagging into the upper airway
- Small airway
Prevalence Of Sleep Apnea
The prevalence of sleep apnea has increased in the last two decades. In a study from 2013 in the United States, random men and women were checked for moderate to severe sleep apnea with the following results:
- 10% of 30-49 year olds
- 17% of 50-70 year olds
- 3% of 30-49 year olds
- 9% of 50-70 year olds
Why Does Sleep Apnea Occur?
When someone with sleep apnea goes to sleep, gravity and muscle relaxation allows the tongue and surrounding soft tissue to fall back into the throat area. This collapses the airway and obstructs air flow.
The airway collapses after the onset of sleep and this causes the breathing to stop. Sleep is disrupted when an apnea event occurs. The person with sleep apnea will then go back to sleep and repeat the cycle.
There are many contributing factors which can increase sleep apnea occurring but the basic process is the same, the airway is obstructed during sleep. A person with sleep apnea may not be aware they have it.
Being overweight, drinking alcohol before sleep and sleeping on one's back are some of the biggest causes for sleep apnea.
How Sleep Apnea Happens
Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.
Sleep apnea usually is a ongoing condition that disrupts your sleep. When your breathing pauses or becomes shallow, you’ll often move out of deep sleep and into light sleep.
The quality of your sleep is poor with sleep apnea, which makes you tired during the day. Sleep apnea is a leading cause of excessive daytime sleepiness.
Symptoms Of Obstructive Sleep Apnea
- Snoring, mild to very loud
- Chronic fatigue
- Daytime sleepiness
- Morning headache
- Restless sleep
- Waking up with a very sore or dry throat
- A decreased interest in sex
- Recurrent awakenings or insomnia
- Weight gain
- Depression, mood swings or irritability
Symptoms Of Central Sleep Apnea
- Most of the OSA symptoms
- Difficulty swallowing
- Overall sense of weakness or numbness
Causes Of Central Sleep Apnea
CSA often occurs in people who are seriously ill from other causes such as:
- Heart failure
- Diseases or injuries to the brainstem
- Upper terminus of the spine (which controls breathing)
- Parkinson's disease
- Kidney failure
- Severe arthritis with degenerative changes to the cervical spine and base of the skull
- Users of opiates
- Unknown causes (idiopathic CSA)
Groups At Risk For Having Sleep Apnea
- Overweight people
- People with a BMI (Body Mass Index) of 25-29.9
- Obese people
- People with a BMI of 30 or higher
- Those over the age 40
- Post-menopausal women
- Certain ethnic groups
- A study showed Blacks and Hispanics/ Latinos are more prone to snore, even at the same BMI, than their white counterparts
- Hmong or Miao people descended from China are at high risk for sleep apnea
- Children and adults with Down Syndrome
- Those with a genetic predisposition (a family member with OSA)
- Those with an endoctine disorder such as Acromegaly and Hypothyroidism
- People with a large neck
- 17 inches or more in men
- 16 inches or more in women
- People with large tonsils
- People with a large tongue
- People who have a small jaw bone
- Those with gastroesophageal reflux, or GERD
- People who have a nasal obstruction
- A deviated septum
- Sinus problems
How Is Sleep Apnoa Diagnosed?
If you believe you may be suffering from sleep apnea, you should visit your doctor.
For sleep apnea to be formally diagnosed, you must undergo a sleep study. This is usually done overnight at a sleep clinic. Doctors will assess you overnight to see whether you have pauses in your breathing during sleep, and how frequent these pauses are.
Determining Sleep Apnea Type
Only a doctor can truly determine if someone has sleep apnea. A blood test cannot determine if someone has sleep apnea.
To determine what type of sleep apnea someone has, it is often recommended to do a sleep study (also called "polysomnogram"). During a sleep study a device is worn while sleeping that records brain activity. It can determine how many times someone wakes up during sleep due to not breathing.
The sleep study can indicate vital sign information such as brain waves, heart beat and breathing.
Quick Sleep Apnea Self-Test
The following questions can be used to help evaluate if you have sleep apnea:
- Do you snore more than 3 nights in a week? (2 points)
- Is your snoring so loud that it can be heard through a door or wall? (2 points)
- Has anyone ever told you that you briefly stop breathing or gasp for air while you sleep? (occasionally: 3 points, frequently: 5 points)
- What is your collar size?
- Men: more than 17 inches? (5 points)
- Women: more than 16 inches? (5 points)
- Do you have high blood pressure or are you being treated for it? (2 points)
- Do you ever doze off or fall asleep while you are not active during the day? (2 points)
- Do you ever doze off or fall asleep when you are stopped at a stop light? (2 points)
Score result indications
- 0-5: low probability of having sleep apnea
- 6-8: unclear, a doctor should determine if you have sleep apnea
- 9+: you may have sleep apnea
These results do not replace the advice of a medical professional, they only help in assessing your sleep apnea.
Sleep Apnea And Oxygen
When sleeping, people usually have less oxygen in their blood than when they are awake. For someone experiencing sleep apnea, the oxygen percentage in the blood is much lower than someone without sleep apnea.
By using a pulse oximeter, it is possible to measure the percentage of oxygen in the blood by using the finger.
According to ucsfhealth.org, if your oxygen level is normally 94 percent while awake, it is unlikely that your saturation during sleep will fall below 88 percent. Below 88 percent is considered the onset of sleep apnea at sea level.
Oxygen saturation at sea level according to harvard.edu:
- Normal awake level: 96-97%
- Mild to moderate sleep apnea: 80-89%
- Severe sleep apnea: less than 80%
Oxygen levels at high altitude (8661 feet/ 2640 meters above sea level) were conducted on people with severe sleep apnea. The results were:
- While awake: 85.2±6.6%
- Non-REM sleep: 83.1±7.7%
- REM sleep: 78.8±10.2%
- During apnea events: 75.1±9.1%
Sleep Apnea Without Snoring
It is possible to have sleep apnea without snoring, this is known as "silent apnea". Treating snoring will not fix sleep apnea. The only way to know if a person has sleep apnea is to do a sleep study.
Natural Treatments for Sleep Apnea
Options not using a mouthpiece, CPAP or surgery according to Dr. Axe:
- Look at your diet - support metabolism with protein, healthy fat and fiber
- Note: reducing fat may help reduce sleep apnea
- Avoid alcohol, caffeine, smoking and sedatives
- Note: caffeine keeps you awake more than asleep
- Treat acid reflux
- Note: this is more an effect of sleep apnea than a cause of it as described here
- Get a humidifier in your bedroom
- Note: this may not help much, a dry nose is a result and usually not a cause of sleep apnea
- Sleep on your side
- Note: this will not work for everyone, such as those with a deviated septum, a sleep study can help determine if sleep position can help
- Note: this is a preventative measure
- Use essential oils - peppermint, lavender, eucalyptus and chamomile
- Note: these may not have much of an impact, this may be a preventative measure at best
Effects Of Sleep Apnea
- Fluctuating oxygen levels
- Increased heart rate
- Chronic elevation in daytime blood pressure
- Increased risk of stroke
- Higher rate of death due to heart disease
- Impaired glucose tolerance and insulin resistance
- Impaired concentration
- Mood changes/ depression
- Increased risk of being involved in a deadly motor vehicle accident
- Disturbed sleep of the bed partner
- Erectile dysfunction
- Heart disease
- Pre-diabetes and diabetes
Sleep Study Scoring on Person with Severe Sleep Apnea and Snoring using Polysomnograph
Before and after CPAP in the patient:
Sleep Study Scoring on a patient with severe snoring and fragmented sleep from sleep disordered breathing and sleep apnea. This is an all night polysomnograph. This patient has a high AHI (amount of apena wake ups in the night). Sleep stages and respiratory scoring are reviewed in video. Video by: freecpapadvice.com.
Sleep Apnea Treatment
There are many different ways to treat sleep apnea. These solutions have helped people from around the world sleep better at night:
- Oral devices such as mouthpieces (mandibular advancement devices and tongue stabilizing devices) are an effective treatment for people with mild to moderate sleep apnea. They help maintain an open and unobstructed airway by repositioning or stabilizing the lower jaw, tongue, soft palate or uvula.
- Some mouthpieces are designed more for snoring and others more for sleep apnea. Compare snoring mouthpieces to determine the best mouthpiece for sleep apnea.
- An example of a sleep apnea mouthpiece is the SomnoDent.
- CPAP (continuous positive airway pressure)
- CPAP is the standard treatment for severe cases of OSA. It can also be an option for people with mild to moderate sleep apnea as well.
- CPAP is a steady stream of air provided through a mask that's worn during sleep.
- Surgery (when CPAP and mouthpieces are unsuccessful)
- Surgery to remove tissue from the soft palate, uvula, tonsils, adenoids or tongue
- Uvulopalatopharyngoplasty (UPPP) is surgery for treating snoring and obstructive sleep apnea. It removes excess soft palate tissue and opens the airway. In addition, the remaining tissue stiffens as it heals, which minimizing tissue vibration. The size of the air passage may be further enlarged when a tonsillectomy is added to the procedure.
- Thermal ablation procedures reduce tissue bulk in the nasal turbinates, tongue base, and/ or soft palate. These procedures are used for both snoring and OSA. Different methods of thermal ablation include bipolar cautery, laser, and radiofrequency. These procedures may be done in the operating room or during an office visit. Several treatments may be required.
- Methods to increase the stiffness of the soft palate without removing tissue such as injecting an irritating substance that causes stiffness in the injected area near the uvula. Another method is inserting stiffening rods (Pillar implants) into the soft palate.
- Genioglossus and hyoid advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway.
- Surgery to remove tissue from the soft palate, uvula, tonsils, adenoids or tongue
- Behavioral changes
- Weight loss benefits many with sleep apnea.
- Chaging sleep position from the back to side can help for those with mild sleep apnea.
- Position therapy can help patients not lay on their back
- Over-the-counter remedies
- Nasal dilators, nasal strips or decongestants may open the airway in the nose.
- These may hide the problem of sleep apnea for some.
- Nasal dilators, nasal strips or decongestants may open the airway in the nose.
Mouthpieces are a highly effective way to treat sleep apnea and often produce similar results to CPAP. See CPAP vs. mouthpiece comparison here. The following quotes are from Jagdeep Bijwadia, MD, SomnoMed’s chief medical officer, prove this point:
- "The outcomes of treatment for OSA depend on two factors: one is how effective the treatment is and the second is how compliant is the patient with treatment."
- "The study found that our oral appliance was associated with similar health outcomes across a whole range of health outcomes—driving simulator, blood pressure, arterial stiffness, and quality of life."
- "The investigators found no difference in the mortality of the groups that used CPAP versus the ones that used oral appliances in terms of cardiovascular mortality—and both groups did much better than untreated patients."
- “CPAP may be extremely effective, but if the patient does not use the CPAP, it will not have impact on health outcomes. With the new microrecorder technology, we can now, for the first time, objectively measure compliance with the oral appliance.”
One important difference between CPAP and mouthpieces is their likelihood of being used. In a 2013 study, CPAP was more effective at reducing AHI (Apnea–Hypopnea Index, the quantity of sleep apnea wake ups at night), but more people are likely to wear a mouthpiece at night.
Sleep Apnea Mouthpieces
Sleep apnea oral appliances (sleep apnea mouthpieces or "sleep apnea mouth guards") work by moving the jaw forward, reducing the air resistance that leads to sleep apnea and snoring. Mouthpieces are often used as a substitute for CPAP or surgery.
Sleep apnea mouthpieces are usually custom fit by a sleep doctor or dentist. During this process an impression (mold) of the bite is taken and made into plaster. This enables the mouthpiece to have the best possible fit. An example of such a mouthpiece is the SomnoDent.
What makes a sleep apnea mouthpiece different from a snoring mouthpiece is generally the quality of the impression. The better the fit and the most adjustment it offers, the more it is considered specific to sleep apnea and not just snoring.
Many snoring mouthpieces are approved by the FDA for mild to moderate sleep apnea. This means you can buy one online yourself and see if it works for you. This can be useful information for a doctor.
Benefits Of Sleep Apnea Mouthpieces
- More likely to be used than a CPAP device
- Compact and portable
- Discreet when the mouth is closed
- Immediate results (usually the first night)
- No electricity required
- Often effective
Type Of Sleep Apnea Machines
If you are unable to see results using a mouthpiece, you can consider machines which help with breathing at night.
- CPAP - Continuous Positive Airway Pressure is a form of positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in people who are able to breathe spontaneously on their own.
- BiPAP - BiPAP stands for Bilevel Positive Airway Pressure, and is very similar in function and design to a CPAP machine. Unlike a CPAP machine which delivers a constant standard pressure, a BiPAP machine has two pressure settings.
- BiPAP is also sometimes called VPAP for Variable Positive Airway Pressure.
- APAP - Automatic Positive Airway Pressure; APAP machines use algorithms that sense subtle changes in your breathing and adjusts itself to the best pressure setting at any time of the night.
Steps To Take If You Think You Might Have Sleep Apnea
- If you believe you have only mild to moderate sleep apnea, you could try a snoring mouthpiece to see if this solves your problems. This is a good step to start with and can be useful for a doctor.
- If you believe you have severe sleep apnea, schedule an appointment with a sleep doctor.
- A sleep study will most likely occur to see how the brain is working at night.
- You may be advised to wear a snoring mouthpiece or you may be advised to buy a sleep apnea mouthpiece.
- You will probably be instructed to wear a sleep apnea or snoring mouthpiece every night for a days or weeks. In this process, you may need to incrementally adjust the device until the lower jaw is advanced as far forward as possible.
- After wearing the device, you will probably need an additional sleep study. This sleep study will likely evaluate you with and without using the mouthpiece.
- A conclusion will be made if the mouthpiece was effective at stopping sleep apnea events at night. If the mouthpiece is effective, it will be recommended to continue wearing it. If the mouthpiece is not effective, additional measures such as using a CPAP device may be recommended.
Sleep apnea often goes undiagnosed. Doctors usually can't detect the condition during routine office visits, it is usually recommended to do a sleep study because no blood test can help diagnose the condition.
Most people who have sleep apnea are unaware because it only occurs during sleep. A family member or bed partner might be the first to notice signs of sleep apnea such as gasping for air.
The most common type of sleep apnea is obstructive sleep apnea (OSA). In this condition, the airway collapses or becomes blocked during sleep which causes shallow breathing or breathing pauses.
Obstructive sleep apnea is more common in people who are overweight, but it can affect anyone. For example, small children who have enlarged tonsil tissues in their throats may have obstructive sleep apnea.
Consider treatment of sleep apnea using a mouthpiece, compare mouthpieces here. Doctors will often try to see if a mouthpiece is effective during a sleep study. Knowing how you react to using a mouthpiece is useful information before considering CPAP, in many cases.