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FirstHealth of the Carolinas
Losing zzzzzzzs (and quality of life) with sleep apnea By Mary Griffin

One night a few years ago, while Gene was driving home late from work, he fell asleep behind the wheel and went off the road. The cause of his risky drowsiness wasn’t a long day’s work, but a restless night’s sleep—a symptom of obstructive sleep apnea.

As many as four in 100 middle-aged men have obstructive sleep apnea (OSA), and most remain undiagnosed and untreated. The condition causes a person to stop breathing during sleep because his airway collapses, preventing air from getting into the lungs.

These breathing pauses can last for several seconds and sometimes as long as a minute. With each event, the brain rouses the sleeper in order for breathing to resume.

Several factors can lead to airway collapse and, as a result, sleep apnea: extra tissue in the back of the throat, such as enlarged tonsils or uvula; lack of muscle tone holding the airway open; nasal obstruction; certain jaw or facial structures, such as a recessed chin; and obesity.

Symptoms include snoring, gasping or choking for breath while sleeping, daytime fatigue, weight gain and, as Gene found, falling asleep while driving. If untreated, OSA can lead to increased risk for high blood pressure, heart disease, heart attack, stroke and fatigue-related accidents, as well as decreased quality of life.

Clyde O. Southwell, M.D., who specializes in pulmonology and sleep medicine at Pinehurst Medical Clinic, sees at least two to four patients a day because of OSA. The most obvious physical sign and risk factor is obesity, he says.

“Some 40 percent of obese individuals, defined as anyone with a body mass index of more than 30 percent fat, have the sleep disorder,” he says.

According to Carl W. Berk, M.D., an ear, nose and throat specialist with Pinehurst Surgical, most OSA patients would notice marked improvement to their sleep with just a 10 percent to 15 percent loss in body weight.

Sleep studies
Being diagnosed with OSA is as simple as sleeping. After Gene’s doctor discussed his symptoms—his snoring, his daytime drowsiness and his weight gain—with him, he arranged for him to visit a sleep clinic for further testing.

“OSA is a very common problem,” says Dr. Berk. “And treating it begins with a sleep study. You’re hooked up to a couple of machines that monitor brain waves, breathing patterns, blood oxygen levels, and we’ll record snoring and movement of legs.”

The results are back within a week, and the patient comes in to review them with his doctor.

Clyde Southwell, M.D., is the medical directorfor the Sleep Disorders Centers at Moore Regional, Montgomery Memorial and Richmond Memorial hospitals.

“We counsel patients on weight reduction and the impact of alcohol consumption on OSA, and the risks of untreated OSA, like secondary hypertension or even safety,” says Dr. Southwell, who is the medical director for FirstHealth's three Sleep Disorders Centers. “Motor vehicle accidents increase by two to seven times, for instance.”

Treatment depends on the degree of the patient’s OSA, and can range from simple use of a CPAP (continuous positive airway pressure) device to surgery.

“We always try the use of medical therapy before surgery,” says Dr. Berk. “Positive airway pressure acts like a splint to keep the airways open for us. If it’s tolerated well, it works.”

Through CPAP therapy, breathing becomes regular and snoring stops. Blood oxygen levels become normal, restful sleep is restored, and all the associated risk factors decrease. “CPAP, or BiPAP (bi-level positive airway pressure), has been, and is the gold standard,” says Dr. Southwell.

While many patients resist the idea of wearing the CPAP through the night, Dr. Southwell counsels them about overcoming their reservations.

“The main issue of CPAP and BiPAP is compliance with therapy,” he says. “We give them ways of learning to live with it. Many not only live with it, but their lives are greatly improved.”

For patients who have difficulty tolerating the CPAP, Dr. Southwell suggests that they put on the gear while they are awake—starting with the mask itself and wearing it for an hour before bed.

“The pressure could be turned on next, and they can wear it for an hour, while watching television in the evening,” he says. “Then maybe they could wear it for a couple of hours at night until they are wearing it for the whole night. The more benefit they see, the more inclined patients are to use it.”

The surgical option
If surgery is required to correct obstructive sleep apnea, “We evaluate the airway, from the nasal cavity all the way to the larynx, looking for areas of obstruction,” says Dr. Berk.

He looks at the surgical option in two phases. “Phase I surgery deals with correcting the nose, then working on the palate through surgery that eliminates the extra tissue around the back part of the palate and tightens it,” he says. “In conjunction with that, we’ll try to address the back of the tongue with somnoplasty equipment, radio frequency waves that heat and shrink the base of the tongue.”

After surgery, patients go in for follow-up sleep tests to see if the OSA has been corrected, or whether the severity has been reduced enough for them to tolerate CPAP therapy. If it’s not, phase II surgery involves more invasive surgery. In the most severe cases, patients may have to undergo a tracheotomy.

Although surgery has become relatively common as OSA is diagnosed more, CPAP remains the best way to treat OSA for many patients. Gene noticed immediate improvement.

“Wearing the CPAP just wasn’t a big problem for me,” he says. “I slept better, and woke up fully rested. The air that’s pumped into my nose is even warmed, so it’s not a shock, and the pump itself is very quiet. By putting it on the floor next to my bed, I didn’t even hear it. And my wife didn’t have to listen to my snoring anymore.”

There is a Sleep Disorders program at each of the three FirstHealth hospitals. For more information, call (800) 213-3284 toll-free.

The Greek word “apnea” literally means “without breath.” There are three types of apnea: obstructive, central, and mixed. Of the three, obstructive is the most common.

Despite the difference in the root cause of each type, in all three, people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer.

Obstructive sleep apnea (OSA) is caused by a blockage
of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. In central sleep apnea, the airway is not blocked, but the brain fails to signal the muscles to breathe. Mixed apnea, as the name implies, is a combination of the two.

With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality.

(Information from the American Sleep Apnea Association)