What is sleep apnea
Snoring is a common disease. While under the age of 20, less than one in ten snores, 40 to 50% of people are affected by the age of 65. The so-called primary or simple snoring is characterized by loud breath sounds that arise in the upper respiratory tract. It is not a health hazard in itself and therefore does not need to be treated in most cases. Irregular, loud snoring, however, is not only a bothersome feature but can also point to serious respiratory disorders.
Sleep Apnea Syndrome
About 2 to 3% of the adult population suffers from sleep apnea syndrome. With increasing age, the likelihood of getting sleep apnea increases, affecting mostly men. Sleep apnea means “respiratory arrest during sleep”. In sleep apnea, the respiratory tract of those affected is so narrowed that breathing not only significantly more difficult but even completely suspended. Snoring can in some cases reach a volume of up to 90 decibels, which roughly corresponds to the volume of a jackhammer. The typical sounds of snoring, alternating breathing pauses with violent snaps of air, acoustically reflect the onset and onset of breathing. In sleep apnea, a distinction is made between an obstructive and central apnea.
Obstructive sleep apnea
Especially men of older age suffer from obstructive sleep apnea. About 20% of 40-60-year-olds and up to 60% of 65-70-year-old men are affected. Due to different anatomy in the neck area, women are usually spared until menopause. After that, the differences between the sexes decrease.
Central sleep apnea
The likelihood of having central sleep apnea increases with age. One in four of the over-60s suffer from sleep-disordered breathing. They are usually a result of cardiovascular disease.
Causes & Origin
In particular, while sleeping, the skeletal muscles of the body relax. This also applies to the respiratory support muscles between the ribs, but not to the diaphragm, which is mainly involved in breathing.
Snoring and/or sleep apnea can have many causes. In all cases, however, the air supply is reduced. This may be due to upper respiratory tract infections, such as colds, flushing with swollen nasal membranes, sinus infections, or allergic reactions. Other possible physiological causes include a deformed nasal septum, enlarged polyps or pharyngeal tonsils. In overweight, increased fat deposits in the throat and tongue area may promote apnea. Sleeping supine, drinking alcohol or taking sleeping pills or sedatives and medications (eg antihistamines) at bedtime may additionally aggravate the above factors. Other possible causes are mainly in anatomical changes of the jaw area or in a significantly enlarged tongue.
If the upper respiratory tract is narrowed due to the muscle slackened during sleep or another cause, the flow rate of the breathing air increases during inhalation and exhalation. As a result, the pressure in the throat decreases. The throat is a muscular tube that consists of more than 20 pairs of muscles. The reduced air pressure and the loosened muscles cause the soft tissue (sidewalls of the upper respiratory tract, tongue base, soft palate including suppositories), which are located in different places, to vibrate in the airstream. This creates the characteristic snoring sounds.
Obstructive sleep apnea
In the case of so-called aprotic snoring, complete occlusion of the pharynx occurs temporarily. The fact that the soft muscles of the palate relax and relaxes, it can come at various points in the upper respiratory tract by the inhalation generated negative pressure to complete collapse (collapse) of the trachea. The air can not flow freely then. Shortly after the respiratory arrest, the respiratory center is reported by special sensory sensors (receptors) to deviate from the standard, strongly negative pressures in the chest. In elderly patients, an increase in carbon dioxide in the blood can trigger a message to the brain. The respiratory center then causes an increase in respiratory effort, as well as an increase in blood pressure, heart rate and muscle tension: this is the so-called wake-up reaction. In particular, the increase in muscle tension (muscle tone) again leads to a partial opening of the respiratory tract, which is often accompanied by loud snoring. The respiratory arrest lasting between 10 to 90 seconds can be repeated a hundredfold in one night. Although the wake-up reactions are physiological, they do not cause the patient to wake up. Nevertheless, they regularly prevent the normal sleep process. As a result, especially important for the relaxation of sleep shares of deep sleep and dream sleep are extremely reduced or completely prevented.
Central sleep apnea
In central sleep apnea, the airways remain open, but the muscles in the chest and diaphragm are inactive. Since the respiratory drive is missing, the oxygen content in the blood drops so far until the wake-up reaction begins. While the adverse effects of central and obstructive sleep apnea are consistent, different treatment regimens need to be used for treatment.
A special form of central sleep apnea is the Cheyne Strokes respiration. It is characterized by a repetitive increasing and decreasing respiratory depth up to the respiratory arrest. Cheyne stroke breathing occurs in about half of the individuals who also have advanced heart failure.
Simple snoring is not harmful to health and usually does not need to be treated. However, increased mouth breathing may cause discomforts, such as a dry mouth, sore throat or heartburn. However, there are also indications indicating possible respiratory disorders, including obstructive snoring and sleep apnea.
So you should also consult a doctor if the loud snoring wakes you or disturbs the environment. Even if snoring occurs in anybody condition, or if you suspect that you have breathing difficulties during sleep (sleep apnea), which may be due to daytime tiredness, morning headaches, difficulty concentrating or frequent respiratory infections, you should seek medical attention.
Obstructive snoring, also known as Upper Airway Resistance Syndrome (UARS), is characterized by high airway resistance in the upper respiratory tract, the sleep-fragmenting wake-up reactions being caused by the large pressure fluctuations in the chest and may also cause daytime sleepiness. Obstructive snoring may be considered a precursor to obstructive sleep apnea. Therefore, the general rules of conduct listed in the chapter ” Therapy ” should be followed in order to prevent an increase of the complaints.
Obstructive sleep apnea
Obstructive sleep apnea is caused by obstruction of the airways, with the airflow to the mouth and nose completely stopped for at least 5 times within one hour for more than 10 seconds during sleep. In cases of obstructive sleep apnea, the person concerned snores loudly, irregularly and with significant breathing pauses. The wake-up reactions that occur as a result of the breathing pauses strongly disturb the sleep of those affected. As a result, they are tired during the day, have difficulty concentrating and are often absent or forgetful. Frequently, anxiety and depression also occur. In men, the nocturnal respiratory arrest often leads to potency problems. The classification of whether a mild, moderate or severe sleep disorder is present depends on how much sleepiness is during the day and how easily the person falls asleep during the day.
Central sleep apnea
The central sleep apnea is due to the suspension of respiratory movements due to relaxed respiratory muscles in the chest area, with the air flow to the mouth and nose at least five times within one hour for more than ten seconds in the sleep completely. The sequelae are the same as in obstructive sleep apnea. In many cases, mixed forms of obstructive and central apnea occur (so-called “mixed apnea”)
The nocturnal respiratory arrest and the resulting unfamiliar burden on the body can lead to further illnesses. To balance the temporary undersupply of the brain with oxygen, the heart must beat more often. The changing efforts of the heart muscle, which come about through the rise and fall of the pulse, lead to about five times as often to circulatory disorders of the heart muscle. Other comorbidities such as arrhythmia, other heart muscle diseases, and high blood pressure are detected in half of those affected. Also, the risk of a stroke getting about seven times bigger than healthy people. In many cases, the symptoms do not occur suddenly but intensify over several years.
Heartburn is a common side effect of snoring or sleep apnea. Gastric acid spills back into the esophagus due to the difficulty breathing and causes the characteristic burning in the chest area. In severe cases, gastric acid also returns to the mouth.
Patients with sleep apnea syndrome are more prone to accidents. Due to the numerous wake-up reactions, the sleeping pattern is greatly disturbed. The sufferers are then often tired during the day and tend to fall asleep suddenly. It has been shown that people with untreated sleep apnea cause more accidents (in traffic and at work) than healthy people.
Detail from a sleep log
A doctor will use targeted questions or questionnaires to clarify both the current state of health (including height and body weight), as well as trying to find out if and which respiratory disorder exists. He can also ask the respective bed partner. He will then examine the condition of the ear, nose and throat apparatus to determine if tumors or other space-occupying changes, such as edema (fluid retention in, for example, the lungs), may cause decreased airflow.
In individual cases, especially in severe cases, further investigations are connected. An oral-maxillofacial surgical examination of the bite status, sinusoidal imaging or an examination of the larynx and trachea by bronchoscopy can provide information on the cause of sleep apnea or respiratory disorders.
In sleep medicine centers, sleep protocols are created to assess the quality of sleep. The person concerned spends one or two nights under the supervision of sleep medicine. Various measurement data (such as brain waves, heartbeat, eye movements, respiratory movements and sounds, blood pressure, etc.) are continuously recorded and evaluated during sleep. As a result, the individual sleep phases can be measured, occurring disorders can be identified and further therapies can be developed.
In order to optimally use precious sleeping labs, a so-called screening test is used. For this purpose, one can get a portable device with the pulmonologist, with which – similar to a 24-hour ECG – certain measurement data recorded during night sleep. Thus, the threat of sleep apnea can be assessed in advance. With several apneas per hour, a high urgency for the treatment is indicated, which can lead to a shortening of the waiting time. The costs for one night in the sleep laboratory are high but are also assumed to be justified by the health insurance as well as the subsequent therapy costs.
Sleep apnea therapy
To treat sleep apnea, general measures and special therapies are used. As long as there is no respiratory failure during snoring, treatment is not mandatory. However, there are general rules of conduct that can reduce the likelihood of snoring and have a positive effect on the volume. The following rules of conduct can help improve sleep quality. They apply to both people who snore and those who suffer from sleep apnea.
- Basically, good sleep hygiene should be respected: The environment should, for example, as quiet as possible and the bedroom is freshly ventilated. Furthermore, one should develop and maintain certain sleep rhythms.
- Obese should reduce their weight to normal weight. In the absence of overweight, the nocturnal breathing and sleep quality can already be significantly improved.
- Two hours before going to bed alcohol should no longer be drunk. Alcohol has a relaxing effect on the muscles – including the respiratory tract. Therefore, drinking alcohol may cause the upper airway muscles to relax more than normal, leading to complete collapse of the respiratory tract.
- Even late supper should be avoided as heartburn or acid regurgitation is less likely to occur.
- Whenever possible, medications such as antihistamines, but especially sleep aids and tranquilizers, should be avoided, since in many cases they reduce respiratory activity. However, medications that prevent nasal congestion (such as cold sores, or gels) can relieve both snoring and sleep apnea, and in some cases make sense.
- It is recommended to sleep on the side. In some cases, snoring or sleep apnea occurs only in the supine position. There are several tricks to get used to lateral sleeping. A cushion placed in the back or a tennis ball sewed in the back of the pajamas can prevent you from accidentally falling back into your usual position. If sleeping in a lateral position is not possible, at least an elevated position of the upper body should be taken into account.
In many cases, however, these general measures are not sufficient to remedy sleep apnea. Then, in consultation with a doctor, further therapy methods must be considered. For example, there are aids in the medical supply trade to influence the sleeping position, to fix the tongue or jaw (for example, chin bandages, bite splints) or to improve nasal breathing (for example, nose plasters). However, there is no evidence for their positive effect for chin bandages and nasal patches despite misleading advertising slogans for these products. Rather, they do not seem to benefit the least against respiratory disorders! It is similar to many bite splints. There are very few specimens that help with mild respiratory disorders. These can be tried for a few weeks,
In severe cases of obstructive or central sleep apnea, especially if concomitant diseases (see “effects”) have occurred, a respiratory therapy must be initiated. In the case of obstructive sleep apnea, airway pressure therapy (cognitive positive airway pressure = CPAP therapy) the means of choice. This is a constant treatment with overpressure and represents the most effective therapy method of sleep apnea syndrome. The associated therapy mask, via which the therapy device transmits the pressure to the respiratory tract, can and must be worn every night, especially the CPAP therapy unlike others Ventilation methods has no sustainable training effect. Without therapy, on the other hand, the previously described symptoms of sleep apnea immediately reappear. CPAP improves quality of life for at least 70% of patients, makes them feel refreshed when they wake up in the morning, and no longer sleepy during the day. In addition, heartburn decreases in three-quarters of people or even disappears completely. For others, however, wearing the mask is a big burden.
Treatment with oxygen will only be used with concomitant lung tissue damage. If there are physical abnormalities or changes in the ear, nose, and throat, surgical interventions may help in some cases. A curved nasal septum, enlarged tonsils or polyps, as well as malformations of the jaw and soft palate can be surgically corrected. Another surgical procedure for the treatment of obstructive sleep apnea, especially in the overweight, is uvulopalatopharyngoplasty (UPPP)In about half of the patients, this measure is successful. In just as many, however, all the symptoms of sleep apnea often persist. In some cases, even side effects caused by the operation may be added, such as a nasal language or the backflow of fluids into the nose during swallowing and drinking.
Drug treatment is not useful in most cases since there are no long-term effective drugs. On the other hand, medications can be used to treat concomitant diseases such as cardiac arrhythmia, hypertension or residual drowsiness. For all drug therapies, however, it is essential to weigh their benefit against the disadvantage of possible side effects, which could limit the quality of life as well as sleep apnea, together with the doctor.
Sleep apnea forecast
If no respiratory failure occurs during snoring, treatment is not mandatory and does not pose a health risk.
Sleep Apnea Syndrome
Sleep apnea syndrome is a serious disease and should be treated. Breathing can cause a heart attack or stroke during sleep or even death. The mortality is four times higher in patients with sleep apnea syndrome compared to healthy people of the same age. At the same time, life expectancy in people with untreated sleep apnea is reduced by about 10 years.
Sleep apnea in children
About 7% of all children snore regularly at night and between 0.7 and 2% suffer from obstructive sleep apnea. In children with Zappel-Philipp syndrome (ADHD), every fourth child is affected. In infants and toddlers, slight snoring sounds may occur due to an unfinished mucosal fold in the throat. This snoring is harmless and usually passes after some time. Even children who have an infection of the respiratory tract(Cold, runny nose) may snore temporarily. If children continue to snore, or if they experience daytime tiredness, poor concentration, and frequent upper respiratory tract infections, parents should consult a doctor. It could be the sleep apnea syndrome.
Many babies, born before the 34th week of pregnancy, develop a so-called premature infant apnea. It is the more common the earlier the child was born and represents a central sleep apnea. The child’s breathing temporarily ceases for at least 5 seconds. It is believed that the respiratory center in the brain, which controls and regulates respiration, is not yet fully developed. The disease symptoms often occur in the first days after birth. The children often breathe regularly for a while, then short pauses for breathing occur. If the dropouts last longer than 20 seconds, the oxygen level in the blood drops, the child’s skin may turn blue and the heart beats slower.
By placing the infant on his back or on his side and holding the child’s head and neck stretched, it is possible to prevent blockage of the respiratory tract. In children born before the 34th week of pregnancy, the apnea seizures usually end at the time when the 34th week of pregnancy would normally have been reached. However, if the apnea attacks persist, medications may be given to the respiratory center to stimulate the respiratory center and provide continuous breathing ( theophylline or caffeine). In more severe cases, doxapram is also administered and the child is given a CPAP mask or needs artificial respiration.
Obstructive sleep apnea in children
About 0.7 to 2% of all children and 2% of 2- to 5-year-olds suffer from obstructive sleep apnea. In a study of 5,206 children in Dresden, it was shown that children suffer from snoring, paleness, daytime fatigue and concentration problems more often when more than 10 cigarettes a day are smoked in their families. Sleep apnea in children can often be manifested by a dull language or delayed speech development, mouth breathing, underweight and short stature, night sweats and motor hyperactivity.
Sleep apnea in childhood can also be related to weight. Obese children are more likely to have the syndrome than normal-weight children. In this case, consideration should be given to permanently reducing the weight of the child. Another cause may be enlarged tonsils or polyps. For this purpose, an ear, nose and throat doctor can examine the child. If necessary, the polyps or tonsils must be surgically removed, which will improve in three-quarters of the children. On the other hand, the problems persist, especially in children who have other underlying conditions, such as Down syndrome. In these cases, consideration should be given to CPAP therapy.
Sudden infant death
When a healthy child suddenly dies in the first year of life, doctors talk about SIDS (Sudden Infant Child Death ), whose causes and connections are still unknown. The research also addresses the question of whether sleep apnea could be associated with sudden infant death and to what extent respiratory misfires are the triggering factor.