Sleep-Disordered Breathing

Introduction:

Obstruction in the upper airway results in decreased airflow through the nose leading to breathing disturbances while sleeping. Snoring, obstructive sleep apnea disorders, and central sleep apnea are common sleep-disordered breathing that affects people nowadays. Sleep apnea is a serious condition characterized by repeatedly starting and stopping breathing. Sleep-disordered breathing can affect both children and adults. However, it is more common among the male population and obese people.

What Is the Prevalence of Sleep-Disordered Breathing?

The prevalence of obstructive sleep apnea is around 0.1 to 13 percent among the general population.

What Is the Incidence of Sleep-Disordered Breathing?

• The incidence of sleep-disordered breathing is more common in males than females.

• Sleep-disordered breathing is more common in people with obesity.

• Sleep-disordered breathing most commonly affects people in the age group above 50 years old.

What Are the Types of Sleep-Disordered Breathing?

Sleep apnea is of two types:

• Obstructive Sleep Apnea (OSA): It is a more common disorder seen predominantly in males. Complete (apnea) or partial obstruction (hypopnea) of the upper airway repetitively during sleep is called obstructive sleep apnea syndrome.

• Central Sleep Apnea (CSA): Central sleep apnea is characterized by the inability of the brain to send a signal to the muscles to breathe due to an unstable respiratory control center. In this condition, the airway is not blocked.

What Are the Causes of Sleep-Disordered Breathing?

Different causes of sleep-disordered breathing are:

• Lifestyle: Sleep-disordered breathing is more common in people who are overweight. Alcohol and smoking are also contributing factors to sleep-disordered breathing.

• Structural Defects in the Upper Airway: Like a thicker neck, nasal obstruction, high arch palate, small jaw, deviated nasal septum, large tongue, and enlarged tonsils.

• Neuro-muscular Disorders: Like amyotrophic lateral sclerosis results in central sleep apnea.

• Hereditary: There is an increased risk of sleep-related disorders in persons with a family history of sleep apnea.

What Are the Signs and Symptoms of Sleep-Disordered Breathing?

Signs and symptoms associated with sleep-disordered breathing are:

• Loud snoring.

• Daytime fatigue.

• Dry mouth.

• Frequent urination at night.

• Morning headaches.

• Night sweats.

• Lack of concentration.

• Restlessness.

• Depression.

• Anxiety.

• Lack of sleep.

• Disorientation.

How Can We Diagnose Sleep-Disordered Breathing?

Diagnosis of sleep-disordered breathing is made by:

• History and Physical Examination: The patient's complete history for any underlying systemic disorders like hypothyroidism, neuromuscular disorders, and drug history is recorded. A physical examination of the person is done to rule out the basal metabolic index and tonsils size.

• Thyroid Function Test: It is done to rule out hypothyroidism in the patients as decreased thyroid hormone levels can lead to snoring problems.

• Polysomnogram (PSG): In this procedure, an overnight sleep examination is performed in the sleep laboratory. In this test, diagnosis of the electrical activity of the different body functions like the eye, brain, heart, breathing patterns, and oxygen saturation in the blood is recorded. This test is a gold standard but is quite expensive and time-consuming. This procedure determines apnea-hypopnea index episodes by dividing the number of apneas or hypopneas episodes by the total sleep time. Apnea- hypopnea index is divided as follows:

1. Mild: It involves 15 apnea-hypopnea episodes.
2. Moderate: It involves 15 to 30 apnea-hypopnea episodes.
3. Severe: It involves more than 30 episodes of apnea and hypopnea.

What Is the Treatment for Sleep-Disordered Breathing?

Management of sleep-disordered breathing is done by:

Conservative Management:

• Lifestyle Modification: Lifestyle changes like weight loss and avoiding smoking and alcohol four to six hours before bedtime should be followed to reduce sleep apnea episodes.

• Oral Appliances: Jaw-advancing and tongue-retaining devices reduce the severity of sleep-disordered breathing episodes like palatal lift appliances. Dental specialists provide these appliances after diagnosing the underlying cause behind sleep-disordered breathing.

• Follow Proper Sleep Hygiene: Following proper sleep hygiene protocols like avoiding too much caffeine before bedtime, indulging in physical activities, proper ventilation in the bedroom, and reducing noise in the bedroom while sleeping are some factors that help to reduce sleep-disordered breathing.

• Sleeping Postures: Avoid horizontal supine (lying on the back) position while sleeping. Try to sleep in a lateral (sideways) position.

• Continuous Positive Airway Pressure (CPAP): It is one of the best therapies used to maintain the patent upper airway. This procedure is mostly recommended for a patient who is not willing to do the surgical treatment. These devices are used as an oro-nasal or nasal mask during sleep after doing the recommended settings in the machine. Continuous positive airway pressure is mostly done in patients with an apnea-hypopnea index (AHI) of more than 15.

• Adaptive Servo-ventilation (ASV): It is a safe method used for patients with central sleep apnea to maintain a patent airway and ventilation.

• Hypoglossal Nerve Stimulator: In this procedure, an electric nerve stimulator is placed under the skin of the right chest, with electrodes placed under the hypoglossal nerve (the twelfth cranial nerve). The device is controlled by remote control to stimulate the hypoglossal nerve to move the tongue forward and outward to open the airway.

Drug Therapy:

• Dronabinol: These drugs are prescribed to the patient to reduce episodes of central apneas and AHI (apnea-hypopnea index).

• Modafinil: These drugs are given in doses of 200-400 milligrams per day in patients with daytime sleepiness even after continuous positive airway pressure therapy.

Surgical Management:

• Septoplasty: Deviated nasal septum (DNS) defects are treated by a surgical procedure called septoplasty to treat snoring or obstructive sleep apnea disorder.
• Uvulopalatopharyngoplasty: It is a surgical procedure performed to remove the extra tissues surrounding the throat to increase the patency of the upper airway.
• Tonsillectomy: It is the surgical removal of the enlarged tonsils to increase the free flow of air through the upper airway.
• Glossectomy: It is a surgical procedure to treat a large and broad tongue (macroglossia).

Conclusion:

Sleep breathing disorders are very common problems affecting the population nowadays. It affects the quality of life and deteriorates the health of a patient drastically. Sleep-disordered breathing is characterized by symptoms like loud snoring, dry mouth, morning headaches, daytime sleepiness, and depression. Early diagnosis and management of the underlying cause behind sleep breathing disorders are crucial for avoiding complications associated with sleep-related disorders.