OSA – The Not So Silent Killer

How Do I Know If I Have OSA?

If you or a loved one, snores, stops breathing at night, is overweight, has an enlarged neck circumference (larger than 16 inches for women or larger than 17 inches for men), has high blood pressure or diabetes, has had a heart attack, atrial fibrillation, congestive heart failure or a stroke, you may have OSA.

Obstructive Sleep Apnea (OSA) is a disorder in which patients snore and hold their breath during sleep. The reason for both the snoring and the breath holds or apneas is that patients with OSA have extra tissue in their upper airway (from the nose to the vocal cords). The airway of patients with OSA is also loose, floppy and more easily collapsible than the airway of persons without OSA.

Think of the airway of the apnea patient as a thin, flimsy straw and the airway of a person without apnea as a thick rigid lead pipe. The OSA patient has to “suck harder” to get air past the extra tissue and into the lungs. If you think of the straw analogy, what happens when you “suck hard” on a paper straw? It collapses! This is a simple explanation of what happens to the airway of a patient when they go to sleep.

When a patient stops breathing (because the airway is obstructed) the oxygen level drops, sometimes to very dangerous levels. Since our brain does not like to be deprived of oxygen, the brain sends out a signal to wake you up and start to breathe again. Once you awaken and return your oxygen level back to normal (usually within a few breaths) you quickly fall back asleep.

Most patients are not awake long enough to remember awakening. The problem is that many patients may awaken hundreds of times throughout their sleep with the result that their sleep quality is affected. This is why many patients with OSA complain of restless, non-refreshing sleep, daytime fatigue or daytime sleepiness, even in the face of a normal quantity of sleep. Daytime sleepiness contributes to difficulty with concentration and motivation, depression, poor job performance and a 4-7 fold increased risk of motor vehicle accidents. Untreated apnea also increased the risk for high blood pressure, heart attack, stroke, congestive heart failure, atrial fibrillation, diabetes and even sudden death during sleep.

How is OSA Diagnosed?

The first step is to have a comprehensive history and physical examination to determine if you have the signs and symptoms suggestive of OSA. During the course of taking your history, other disorders should also be screen for. The physical examination will focus on the presence of obstructing tissue in your upper airway and for the presence of complicating or co-morbid findings such as high blood pressure, an irregular heart rhythm or diabetes. This history and physical examination may be performed by your primary care physician but is preferably performed by a Board Certified Sleep Specialist at an Accredited Sleep Center.

Regardless of who performs your history and physical examination, your doctor can only be suspicious about the presence of OSA. A sleep study or polysomnogram (PSG) is the only definitive test to confirm the presence and severity of your OSA. It is the severity of the OSA which is the primary determinant of what treat option will be the most appropriate for you. Screening home sleep studies (HST) are starting to be paid by some insurers. However, they are only appropriate in patients with a high probability of having OSA and in the absence of other disorders which may affect your sleep such as heart disease, lung disease (asthma or COPD) or neurologic disorders. Patients with these other disorders are best studied in a sleep center.

If you are diagnosed with OSA, what are your treatment options? Treatment recommendations are based upon the results from your sleep. A brief listing of available options is outlined below:

Weight loss – sometimes as little as a 5-10 lb weight loss can make a difference. However, weight is only one factor. Even a “skinny” patient can have OSA if there is obstruction of the upper airway as discussed previously.
Positional therapy – some patients only have OSA when they sleep on their back. In such cases, learning to sleep on your sides may be all that is required. Sleeping with a couple of tennis balls sewn into the back of a T-shirt or the use of a belt or vest with built in balls may allow a patient to be “trained” to avoid sleeping on their back.
Continuous Positive Airway Pressure (CPAP) – is a medical air compressor. Remember the analogy of the upper airway being sucked closed like a paper straw (discussed above)? When we inhale, we generate negative airway pressure (the suction). CPAP blows positively pressurized air into the upper air airway to balance the airway pressure and “splint open” the airway, thus eliminating both snoring and OSA. CPAP is virtually 100% effective at eliminating both snoring and OSA when a comfortable mask and an appropriate pressure level are prescribed. CPAP is the “gold standard” for the treatment of OSA. As such, it is covered by most insurance plans.
Provent Therapy EPAP – this is a novel relatively new treatment option. It is similar to CPAP in that positive airway pressure is applied to keep the airway open. It is different from CPAP in that it does not require the use of a compressor or a mask. Positive airway pressure is applied only during expiration by applying a small adhesive bandage with a built-in-valve over each nostril. The valve allows the patient to breathe in effortlessly. During exhalation, the valve creates resistance to breathing out, causing pressure to back up into the airway (much like the CPAP does, but without the requirement for an air compressor or a mask). The effectiveness of Provent Therapy is somewhat unpredictable. However, in those patients who have a response, the snoring is typically eliminated or markedly reduced and the apneas are typically reduced from 50-90%. It is generally not as effective as CPAP, but is much less cumbersome and more readily accepted by patients. It is indicated in patients who either are intolerant to CPAP or refuse to use CPAP and studies have shown it to be effective across all severity levels of OSA. The down side, it is not yet covered by most insurers and runs between $60-80 / month.
Oral Appliances (OA) – these are medical devices made by dentists that fit into your mouth and over your teeth. Although there are numerous styles of OA there are basically 2 different methods by which they work. One method acts to pull the tongue forward, either with a suction device or a built-in tongue depressor. The other method pulls the lower jaw forward and as a consequence the tongue moves forward. Like the Provent Therapy, these devices are somewhat unpredictable as to whether or not they will improve your OSA. Typically, they will eliminate or markedly reduce your snoring and if they affect your OSA, the number of apneas will be reduced by 30-50%. They are indicated in patients who either are intolerant to CPAP or refuse to use CPAP and as an alternative treatment option in patients with mild to moderate levels of OSA. Insurances are starting to pay for these devices, but there is typically still significant out of pocket cost to the patients.
Surgery – A variety of surgical procedures have been developed over the years, all designed to remove or shrink the tissues that block the upper airway in patients with OSA. The success rates for the various surgical procedures can vary depending upon what procedure or procedures have been performed. Predicting who will respond and who will not respond is still problematic. As with the OA options, they will eliminate or markedly reduce your snoring and if they affect your OSA, the number of apneas will typically be reduced by 30-50%. They are indicated in patients who either are intolerant to CPAP or refuse to use CPAP and as an alternative treatment option in patients with mild to moderate levels of OSA. Insurance may or may not pay for these procedures, they are often painful, time is required to recover from them and there may be significant out of pocket cost to patients.
Combination treatment – sometimes various combinations of the above treatments are required to adequately control OSA.

What should you do if you believe you have OSA? See a Board Certified Sleep Specialist at an Accredited Sleep Disorders Center. Sleep well tonight for a better tomorrow.