A Guide to Sleep Apnea - Cross County Cardiology

sleep_apnea_doctor_njEvery night, millions of Americans go to bed and drift into an evening of sleep that is anything but peaceful. They snore and gasp for air throughout the night, causing chronic sleepiness and increasing their risk of heart disease, hypertension and Type 2 diabetes. This condition, known as sleep apnea, affects an estimated 22 million Americans. Yet most people who have it never get it diagnosed. They suffer night after night and jeopardize their health. Here’s what you need to know about sleep apnea, along with some of the best ways to detect and sometimes even cure it.

Are You Suffering From Sleep Apnea?

It can manifest itself in different ways. But some of the hallmarks of sleep apnea are easy to spot.

Because sleep apnea occurs when you’re unconscious, millions of people who have it are not even aware of it. So how do you know if you’re one of them? The American Sleep Apnea Association developed a brief quiz that can give you some insight. If you answer yes to any of these questions then you might have sleep apnea.

  • Are you a loud or regular snorer?
  • Have you ever been observed to gasp or stop breathing during sleep?
  • Do you feel tired or groggy when you wake up? Do you wake up with a headache?
  • Are you often tired or fatigued during the day?
  • Do you fall asleep while sitting, reading, watching television or driving?
  • Do you often have problems concentrating or remembering things?

    DO YOU HAVE ANY OF THESE?

    A History of Snoring: A lot of people snore, and the fact is that not every snorer has sleep apnea. Some people only snore once in a while, like after they’ve had a few beers or a glass of wine or two. That’s not exactly abnormal. But most people who have sleep apnea do snore. So it tends to be a marker of the condition. There are a few things that can distinguish normal snoring from pathological snoring: The intensity, loudness and frequency of it. If you snore once in a while then it probably is not a sign of a health issue. But if you snore loudly every night then the likelihood of it being sleep apnea is much greater. Some doctors call the snoring associated with sleep apnea “destructive snoring” because of its ear-rattling noisiness.

    “I’ve had patients whose kids are on a different floor of the house and they can still hear them snoring,” Dr. Malhotra said. “I’ve had patients whose neighbors will complain about their snoring from the next building.”

    Daytime Sleepiness: If you have to drink several cups of coffee just to get through the day then you might have sleep apnea. People who have it frequently fall asleep at the wrong time and place – while driving or while working for example – because they are constantly woken up in the middle of the night by their disrupted breathing.

    “Many people will say they’re not sleepy during the day but if you count the number of cups of coffee they’re drinking, it’s a lot,” said Dr. Malhotra. “While sleepiness is a common symptom, there are plenty of people who don’t fall asleep at inadvertent times because they’re pumped up on caffeine.”

    Witness Apnea: Some people who have sleep apnea only learn about it from their partners. Doctors call this “witness apnea.” “A common reason people get referred is because their bed partner is frightened – not by the snoring, but by the silence in between it,” Dr. Kryger said. “It’s very scary. It indicates that they’re actually stopping breathing. People see it and think, ‘My God, there is something wrong with this person. They’re not breathing.’”

    High Blood Pressure: There’s a well-known nexus between hypertension and obstructive sleep apnea. Some experts think the relationship is bidirectional: Sleep apnea predisposes you to high blood pressure, and having high blood pressure makes your sleep apnea worse. It’s a dangerous cycle. The two are so entwined that if you have hypertension, there’s a good chance you have sleep apnea too. More than half of all people with severe sleep apnea have hypertension. And in people with resistant hypertension, meaning their blood pressure remains high despite multiple medications, the prevalence of sleep apnea is greater than 80 percent. The bottom line: If you have high blood pressure, then sleep apnea might be present as well.

    Other signs that you might have sleep apnea:

    • Insomnia or frequent awakenings
    • Waking up with a sore throat
    • Frequent headaches in the morning
    • Daytime grogginess. Trouble concentrating. Forgetfulness

      GET IT CHECKED

      The most important thing you can do if you suspect you have sleep apnea is see an expert. Explain your symptoms to your primary care doctor or talk to a sleep medicine specialist. Your doctor will likely schedule you for a sleep test, which can be done at home or in a lab.

      The traditional sleep study, called a polysomnogram, requires you to spend a night in a sleep lab. There you’ll be hooked up to a variety of machines that track and record your brain waves, heart rate, breathing and blood oxygen levels while you sleep. If the study leads to a diagnosis of sleep apnea, you’ll be asked to return to the lab for a second time so you can be fitted for a device that gently blows air into your airway at night to keep it open, called a CPAP machine, for continuous positive airway pressure.

      The other method of diagnosing sleep apnea is through a home sleep test. The benefit of this is that instead of spending a night in an unfamiliar bed in a lab, you’ll be sent home with equipment that you can wear in the comfort of your own bed. It will capture data on your blood oxygen levels, airflow, and bodily movement. A home sleep test isn’t as accurate as a polysomnogram. But it’s cheaper, simpler and a lot more convenient.

      Sleep Apnea’s Toll

      Fatigue and frayed relationships are all too common consequences of sleep apnea.

      Because sleep apnea can cause you to wake up repeatedly throughout the night, it can worsen your psychological health. Experts say it is the single most important preventable medical cause of excessive daytime sleepiness and driving accidents.

      “If you’re lying asleep at night, and I came and shook you every minute or two you’d wake up feeling very tired,” said Dr. Atul Malhotra, the director of sleep medicine at the University of California San Diego. “With sleep apnea, your sleep gets fragmented. So you get sleepiness, lack of energy and an inability to concentrate.”

      Scientists at the Centers for Disease Control and Prevention have found that people with obstructive sleep apnea have a significantly higher risk of depression. They argue that when doctors diagnose either sleep apnea or depression, they should consider screening for the other condition as well. Sleep apnea can even throw a wrench in your sex life, causing erectile dysfunction in men and loss of libido in women.

      IT IMPACTS MORE THAN YOU

      But perhaps the most troubling consequence of the condition is that it can make you a danger to those around you. Uncontrolled sleep apnea makes you two and a half times more likely to be involved in car accidents, and it nearly doubles the rate of workplace accidents. In recent years a number of major train, bus and car crashes that resulted in multiple deaths and hundreds of injuries were blamed on untreated sleep apnea. In addition to being a public safety hazard, sleep apnea can make life miserable for your bedmate: Imagine sleeping next to someone who is constantly snoring and waking up throughout the night.

      “The spouses of people with severe sleep apnea are clinically sleep deprived,” said Dr. Malhotra. “They’ve got a jet engine next to them all night and they’re not sleeping properly.”

      Many people look at snoring as a joke or a minor nuisance. But for those who have to put up with it night after night, it is anything but. Experts say it is a common cause of marital friction and broken relationships. Many spouses have to sleep in separate bedrooms because of it. Studies show that at least half of people who have afflicted bed partners complain that their sleep is constantly disrupted. One study of women who live with heavy snorers found that they frequently experienced insomnia, morning headaches, daytime sleepiness and fatigue.

      “Plenty of patients get divorced over snoring because it can disrupt their partner’s sleep,” Dr. Malhotra said. “It’s shocking how common that is. I have patients saying my wife doesn’t want me in the bed at night so I sleep on the couch.”

      TREATMENT WORKS

      But treating sleep apnea can make a huge difference. It can put an end to loud snoring and fragmented sleep. It can alleviate depression in some cases and reduce the incidence of car accidents by up to 70 percent. “There’s very clear data that treating sleep apnea can make people feel better,” said Dr. Malhotra. “It causes people to have more energy and less sleepiness. They can think better, and they’re not falling asleep at the wheel anymore so the risk of car accidents goes down.”

      Understand It

      This is what is happening when you sleep with sleep apnea.

      The most common type of sleep apnea is known as obstructive sleep apnea. People who have it experience potentially dangerous pauses in their breathing while asleep, which can occur dozens or even hundreds of times a night, causing them to wake up or snore loudly as they struggle to breathe. These intermittent gaps in breathing are known as apnea episodes and they occur when your airway collapses in on itself, preventing air from reaching your lungs.

      This sets off a cascade of problems:

      • When breathing stops, oxygen levels plunge, which activates the sympathetic nervous system that controls the fight or flight response.
      • Adrenaline levels soar
      • Heart rate climbs
      • Blood pressure rises, constricting blood vessels.
      • Snoring can occur as your body labors to pull in oxygen.

      Instead of being a period of restoration and relaxation, nightly sleep becomes a chaotic and often noisy struggle to breathe.

      “You’re not getting oxygen, you have this very high level of sympathetic activity, and to make matters worse you’re generating huge levels of pressure in the chest,” said Dr. Virend Somers, a cardiologist at the Mayo Clinic who specializes in sleep disorders. “You’re generating negative pressure inside the chest to pull in air, but the air isn’t coming in. You’re distorting the structures in the chest like the heart and the atrium and this is happening hundreds of times a night. When you repeat this insult every night over many years, you eventually get structural and functional changes in the body.”

      The severity of sleep apnea is determined by the number of times in an hour that a person has a cessation in breathing that lasts at least 10 seconds. Five to 15 times an hour is considered mild. Fifteen to 30 episodes is moderate. And more than 30 of these events is classified as severe. The prevalence of sleep apnea has been rising in recent years, and the consequences of not treating it can be devastating, said Dr. Meir Kryger, a professor at the Yale School of Medicine and the author of “The Mystery of Sleep: Why a Good Night’s Rest is Vital to a Better, Healthier Life.”

      Obstructive sleep apnea increases your risk of a host of metabolic diseases, including the following:

      • High blood pressure: When oxygen levels fall, your body responds by raising your blood pressure to boost the flow of oxygenated blood to your organs. That’s why high blood pressure and obstructive sleep apnea go hand in hand. Research suggeststhat up to 50 percent of people with high blood pressure also have sleep apnea. Although the evidence is mixed, many studies have found that the standard treatment for sleep apnea, known as continuous positive airway pressure, or CPAP, lowers blood pressure. Some clinical trials suggest that it can have a particularly significant  impact on sleep apnea patients with chronically elevated blood pressure, known as hypertension.
      • Cardiovascular disease: There’s a striking link between sleep apnea and heart disease, the leading killer of Americans. Obstructive sleep apnea increases the risk of heart disease by 30 percent and heightens your risk of having a stroke by 60 percent. According to the National Commission on Sleep Disorders Research, sleep apnea contributes to about 38,000 cardiovascular deaths annually and $42 million in related hospital costs.
      • Type 2 Diabetes: A growing body of evidence suggests that people with obstructive sleep apnea are more likely to develop diabetes, especially those who are overweight. One explanation for this is that chronic activation of the sympathetic nervous system impairs blood sugar control. Large studies have found that even after controlling for other risk factors, sleep apnea is “independently associated with glucose intolerance and insulin resistance and may lead to type 2 diabetes.” Studies have found that treating sleep apnea reduces insulin resistance and improves blood sugar control in people with diabetes.
      • Weight gain: While not everyone who has sleep apnea is obese, there’s a strong link between the two: About half of all people who are obese suffer from sleep apnea. One reason is that obesity promotes the development of soft tissue in the mouth and throat, which leads to a narrowing of the airway. But sleep apnea itself might cause you to gain weight because it disrupts your sleep, making you tired and fatigued. “In our studies, when people have apnea they tend to have put on a lot of weight in the year before their diagnosis,” said Dr. Somers. “If you’re sleepy, you’re not exercising enough and you’re eating the wrong things. You need energy so you’re eating a lot of carbohydrates. We think that having sleep apnea can potentiate the likelihood of you getting fat.”

        Recognize the Major Risk Factors

        Are you a prime candidate for sleep apnea?

        Obstructive sleep apnea may be one of the most overlooked causes of poor health in the country. According to the American Sleep Apnea Association, roughly 22 million Americanssuffer from it – yet an estimated 80 percent of the moderate and severe cases go undiagnosed. That number is particularly striking because so many of the risk factors are well known. Here are some of the most important things to look for.

        • Family history: Your risk of developing sleep apnea is 50 percent greater if you have a first-degree relative, such as a parent or sibling, who has a history of sleep apnea or snoring.
        • Obesity: Being overweight is one of the strongest risk factors for sleep apnea. In fact a majority of people with the condition are overweight. Increases in bodyweight can exacerbate sleep apnea, and conversely, losing weight can dramatically improve it. That goes for both children and adults.
        • Gender: Men are several times more likely to develop sleep apnea than women. It’s not entirely clear why, but experts believe it’s more common in men due to inherent differences in hormones, upper airway anatomy, fat distribution and other factors.
        • Neck circumference: One of the variables that is very strongly associated with sleep apnea is neck collar size. People who have a neck collar size greater than 17 inches, particularly men, are at much greater risk for sleep apnea, said Dr. Kryger at Yale. “A neck collar size greater than 17 inches in a male is certainly something that should point toward the possibility of sleep apnea in someone who snores,” he said.
        • Alcohol: A large body of research has found that drinking alcohol, especially at night, makes you about 25 percent more likely to develop sleep apnea. Alcohol reduces muscle tone in your upper airway, making it more likely to collapse as you sleep. Some experts think alcohol might also contribute to sleep apnea because it can increase the amount of food you eat, leading to a higher body mass index, which itself makes sleep apnea more likely.
        • Anatomy: Your risk of developing sleep apnea is much greater if you have certain anatomical features that can obstruct your airway at night. These include large tonsils, a large neck and a small lower jaw.

        DON’T OVERLOOK IT

        Obstructive sleep apnea is most frequently seen in middle-aged men, especially those who are overweight or obese. For many decades it was thought that the condition was essentially a disease of men. But many people who have sleep apnea do not fit the stereotypical profile. In fact the condition afflicts many women, children and men who are not overweight. Even if you don’t fit the classic profile, you might still be at risk.

        Normal Weight Adults: You don’t have to be overweight to suffer from sleep apnea. Studies have found that at least one in four people afflicted by it have a body mass index that is within the normal range. “I have plenty of patients who are skinny,” said Dr. Malhotra at U.C.S.D. “The message here is to avoid the stereotype. About 60 to 70 percent of sleep apnea patients are obese. So that means about 30 to 40 percent of patients are not obese.”

        Women: Large studies suggest that about 17 percent of women and 22 percent of men have obstructive sleep apnea. But it tends to be underreported in women for a number of reasons. One is that women often report different symptoms than men. Women who have the condition frequently complain of insomnia, restless legs, depression, nightmares, palpitations and hallucinations, while men are more likely to report snoring and trouble breathing at night. Women are at particularly high risk of developing sleep apnea during the following two stages of their lives.

        • Pregnancy: Many of the changes that occur during pregnancy can affect nighttime breathing. During pregnancy women gain weight and experience an increase in neck circumference. The growing uterus can press up against the diaphragm, reducing lung volume. Many women also experience higher levels of nasal stuffiness and engorgement of soft tissue around their airways. All of this illustrates why pregnancy increases the risk of sleep apnea. Women should be on the lookout for it especially beginning around the second trimester. “It can be relevant not just because their number of breathing pauses goes up, but also because it can have negative consequences for maternal fetal outcomes,” said Dr. Grace Pien, an assistant professor of medicine at the Johns Hopkins University School of Medicine.
        • Menopause: One of the other times when sleep apnea risk rises sharply for women is during menopause. The hormone progesterone helps prevent the upper airway from becoming obstructed. But it declines after menopause. Other hormonal changes can influence the distribution of body fat. And since postmenopausal women tend to have a higher fat mass compared to the period prior to menopause, their apnea risk climbs. “A number of large epidemiological studies have shown that there’s a two to three-fold greater risk for sleep apnea among women who are postmenopausal, with some of that risk occurring during peri-menopause,” said Dr. Pien. “So if you have two women who are the same age or body mass index, the woman who is postmenopausal is clearly going to have an increased risk compared to the pre-menopausal woman.”  Dr. Pien said that women who undergo surgical menopause, where they have their ovaries removed, can undergo abrupt hormonal changes that lead to sleep apnea. They also have a greater risk than women who undergo natural menopause. “Menopause is a time of risk for women,” she added. “We definitely see women who start snoring while they’re going through menopause, who don’t sleep well, and they think it’s just another manifestation of menopausal changes. But it can be a physiological issue.”

        Children: Sleep apnea is increasingly common in kids as a direct result of the childhood obesity epidemic. Compared to their peers who are not overweight, obese children have a 46 percent greater risk of developing the condition. They also have more than a six-fold increase in metabolic syndrome. Kids who have sleep apnea have are more likely to develop heart disease later in life, particularly if they’re overweight. But children can develop sleep apnea for reasons that are unrelated to their weight. They can inherit unique features for example that obstruct their breathing at night. “Very often if I see an adult patient in the clinic who has an anatomical reason for sleep apnea like a smaller jaw, I’ll ask them if they have any kids and whether they snore too,” said Dr. Kryger at Yale. “You’d be amazed how often their kids snore – and snoring and stopping breathing is not normal in kids.”

        Treat It

        Is sleep apnea stalking you? Here’s how to stop it from ruining your health and your sleep.

        Don’t despair if you have obstructive sleep apnea. An array of medical treatments, devices and lifestyle changes can help you alleviate or reverse it. Some people try multiple strategies before they land on one that they can live with. The trick is to find the approach that works for you. Here are some of your best options.

        MEDICAL OPTIONS

        Continuous Positive Airway Pressure (CPAP): The gold standard treatment for sleep apnea, CPAP, delivers pressure through a mask to keep your airway from collapsing . For many people CPAP can lead to dramatic health improvements. Clinical trials show that it improves blood sugar control in pre-diabetics, lowers blood pressure in people with uncontrolled hypertension, and reduces daytime sleepiness. It also lowers the risk of type 2 diabetes. About 70 percent of people who use CPAP find it very effective, said Dr. Kryger. But some people find the mask so uncomfortable that they simply cannot tolerate it. “For most patients it works really well,” he said. “But a lot of people have trouble with it. And we have other options.”

        Oral appliance: A popular alternative to CPAP is an oral appliance that resembles a mouth guard. It works by keeping your tongue and jaw in a forward position, which keeps your airway open while you sleep. One drawback is that they have to be customized for each individual. But they have a lot of advantages. Studies show that they have higher adherence rates than CPAP and fewer side effects. They can reduce blood pressure and snoring. And they’re small and easy to pack when traveling.

        Nasal patches: One of the least intrusive options is a nasal patch that fits over the nostrils. Called Provent, the patch contains two small plugs, one for each nostril, that create pressure in your airway to enable easier breathing. A clinical trial found that people who used the patch saw their apnea episodes fall sharply. They’re available by prescription and in some cases are covered by insurance. Like the oral appliance, they’re also convenient and easy to pack when traveling.

        Surgery: When all else fails, one of the less common treatments for apnea is surgery. It’s risky and more invasive, but for some people it cures their condition. If you go down this route, you have many different options. The most popular procedure is one that removes excess tissue from the sides of the throat, which widens the airway. Another procedure moves the upper and lower jaws forward to make the airway larger. And a third option involves a surgeon inserting implants into your palate to stiffen the tissue and prevent it from collapsing at night. It’s best to talk to a sleep medicine specialist to figure out if one of these operations makes sense.

        BE WARY OF INSURANCE PITFALLS

        Health insurers will typically cover some or most of the costs of one of these procedures if your doctor deems it necessary. But not surprisingly, dealing with insurance can be a minefield. Medicare, the government insurance program, requires patients to use their CPAP machines for a minimum of four hours at a time for at least 70 percent of the nights in each of the first three months after they receive them. People who don’t abide by the rule can lose their machine. And it’s not only people on Medicare: Many private insurers have adopted the same criteria. As ProPublica and NPR recently reported, the machines can track exactly how often patients use them and send that data to insurers, who in turn can deny coverage. “I can’t tell you how often patients have their equipment taken away from them,” said Dr. Kryger. “The monitoring of the equipment is being used to deny patients therapy.”

        Another potential pitfall: Some insurance companies require patients to rent their CPAP machines, paying a monthly fee that can eventually add up to more than the cost of the machine itself. To save money, some patients skip the insurer and buy their machines on the black market. The downside is that a machine you find online might not be working well, it could need expensive replacement parts, or it could be difficult to get it serviced. And ideally a doctor should be monitoring you and tracking your progress. “Buying equipment off the web is a gray area,” Dr. Kryger said. “But I’ve had a lot of patients that have done it, just like I’ve had patients who have gone to Canada or overseas to buy their medications.”

        MAKE BEHAVIORAL CHANGES

        Some of the best antidotes to sleep apnea are lifestyle changes. A number of free or low-cost behavioral approaches can reduce your apnea episodes and ensure a better night’s sleep. Some of these changes can lead to marked improvements, and the great thing is that they can be combined with medical remedies to get maximum benefit. Here are some critical lifestyle changes to consider.

        Lose weight: There is no way around it. If you’re overweight or obese and you have sleep apnea, then shedding some pounds is an absolute necessity. Gaining weight can promote soft tissue development in your throat that restricts your breathing at night. Losing weight can solve the problem. A large study published in the Archives of Internal Medicine in 2009 found that obese people who lost weight through diet and exercise experienced “significant and clinically relevant” improvements in their sleep apnea. The researchers found that the greatest improvements occurred in people who had the most severe apnea and who lost the most weight. But people who did not lose weight during the study saw their sleep apnea get progressively worse.

        Sleep on your side: About half of people who have sleep apnea have what is technically known as positional sleep apnea. That means that they snore and stop breathing most frequently when they sleep on their backs compared to their sides. The reason for this is not entirely known. But it’s thought that it has to do with gravity. When you sleep on your back, it causes your tongue and other soft tissues to fall in a way that obstructs your airway. A number of studies have found that sleeping on your side can reduce apnea episodes.

        The problem is that people often sleep in different positions throughout the night. But a number of devices can keep you on your side. One that I use and find very effective is called the “sleep positioner belt,” which you wrap around your waist. The belt has several balls that you can adjust so that they’re positioned on your back. This keeps you from rolling onto your back while you’re asleep. Since I started using it this year, I no longer roll onto my back at night. It forces me to lie on my side, and my snoring and apnea episodes have mostly disappeared (according to my wife, who had to listen to my snoring). You can purchase the belt on Amazon for about $40. You can also find a wide array of other gadgets to stop you from lying on your back, including special pillows, a bumper belt, and even a T-shirt with a tennis ball attached to the back.

        Avoid alcohol before bed: Drinking alcohol causes your throat muscles to relax, which can cause or exacerbate sleep apnea. One meta-analysis found that higher levels of alcohol consumption significantly increase the risk of sleep apnea. This doesn’t mean that you have to stop drinking altogether. But it does mean that you should avoid alcohol for at least a few hours before you go to bed.

        Try throat exercises: One way to prevent obstructed breathing at night? Try building up the muscles around your airway. In one study published in the American Journal of Respiratory and Critical Care Medicine, researchers trained a group of people with obstructive sleep apnea to do 30 minutes of daily throat exercises for three months. The routine included swallowing and chewing motions, pronouncing vowels quickly and continuously, and doing an exercise that involves brushing the tip of your tongue against the front of your palate and sliding it backward. At the end of the study, the subjects snored less, had reductions in neck circumference, and reduced the severity of their condition by 39 percent compared to a control group that was trained to do breathing exercises. Perhaps exercise truly is the best medicine.

        About the Author

        Anahad O’Connor is a bestselling author and staff reporter for The New York Times who writes about nutrition, medicine and consumer health and wellness.  Original article appeared in the New York Times.

        At Cross County Cardiology, we want you to be the most informed about this common condition.  If you or a loved one suspect you may be suffering, call our offices at 201-299-4479 to speak with one of our specialists.  Here to help you get the rest you need.  Call us today!

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