BY CELESTE RAFFIN, MD
Member
Los Alamos County Health Council

What do poorly controlled hypertension, palpitations, morning headaches and sore throats, brain fog, memory loss, difficulty concentrating, personality and mood changes, depression and anxiety, fatigue, sexual dysfunction, night sweats, and insomnia all have in common? They are all signs and symptoms of sleep apnea. Sleep apnea is very common; it is estimated that up to 9% of Americans suffer from it. Yet sleep apnea is frequently not considered by healthcare providers with one estimate stating that 80% of patients suffering from sleep apnea are undiagnosed.

Sleep apnea is a potentially dangerous sleep disorder in which a patient repeatedly stops breathing for at least 10 seconds at a time during sleep. There are three types: Central sleep apnea occurs because the respiratory center of the brain stops communicating with the muscles of respiration. One stops breathing during sleep. Obstructive sleep apnea is a result of complete airway obstruction during sleep. One tries to breathe but can’t. Mixed sleep apnea is a combination of the two. Because Obstructive sleep apnea comprises the lion’s share of cases (over 90%), it will be the topic of this article.

Obstructive sleep apnea (OSA) is caused by airway obstruction at the junction of the anterior and posterior pharynx. When one lies down and relaxes during sleep the muscles of the tongue and posterior pharynx relax as well. The tongue falls backwards and the pharyngeal muscles collapse inwards narrowing and then completely occluding the airway.

There are many risk factors for OSA. Obesity (BMI of greater than 30) is the number one risk. But please note, YOU DO NOT HAVE TO BE OBESE OR EVEN OVERWEIGHT TO SUFFER FROM OSA. Many slender people have OSA. Other risk factors include: family history of sleep apnea, large neck circumference (greater than 43cm in men and 41cm in women), male sex, age over 50, hypothyroidism, and menopause. Use of alcohol, sedating medications and drugs, and smoking round out the list.

What happens during a typical night of OSA? The patient goes to bed and falls asleep. As the patient relaxes the tongue falls backwards and the muscles and soft tissue of the pharynx collapse inward to the point where the airway is completely blocked. Respiratory effort increases with deeper and more frequent breaths but these are futile so the patient stops breathing. Because there is no air exchange in the lungs, blood oxygen (SP02) drops and blood carbon dioxide (SPC02) increases. The body senses that it is suffocating so the adrenal glands release catecholamines (epinephrine, norepinephrine, and dopamine) which increase the heart rate and blood pressure. The liver dumps glucose into the bloodstream and the body goes int a fight or flight response. Eventually rising SPC02 and decreasing SP02 trigger the respiratory center of the brain which then yells to the body WAKE UP! YOU’RE SUFFOCATING!! The patient arouses, gasps for air, hyperventilates to blow off CO2 and increase SPO2, and then falls back to sleep. But guess what: the patient relaxes, the airway collapses, and the cycle starts all over again.

How bad can these episodes get? In patients with moderate to severe sleep apnea it is not uncommon to see oxygen desaturations into the 50%’s (normal is greater than 90%), heart rates of over 150 beats per minute (normal 60-100), and markedly elevated blood pressures during apneic events. Someone with moderate to severe OSA can experience hundreds of these events per night. Yet amazingly enough, the patient has no recollection of respiratory distress or multiple awakenings, they just know that they don’t feel right.

The three Ss are considered very predictive of OSA. Snoring is the most commonly reported sign. The snoring is LOUD, chronic, and bothersome to others. It frequently stops, and then is followed by gasping, snorting, or choking sounds. There will be a pause and then the snoring resumes to its full splendor. Patients report that their bed partners will no longer sleep in the same room as them. Daytime Sleepiness is common in OSA. Patients cannot stay awake while watching tv, in movies or concerts, or as a passenger in the car. They take frequent naps and close their eyes and fall asleep at the dinner table or during conversations. Significant Other report: Often the best OSA historians, partners will report loud snoring, frequent gasping and
snorting, and tossing and turning throughout the night.

But the patient may not know if he/she snores, may not suffer from daytime sleepiness, or may not have a significant other. It may take a more thorough history, specifically asking for the signs and symptoms mentioned in the first paragraph of this article, to raise suspicion for OSA. Diagnosing OSA requires a trip to a sleep specialist who will order one of two types of sleep studies. The first is called a Polysomnogram. While considered the gold standard for diagnosing OSA, Polysomnograms are expensive, require an overnight sleep lab stay and specialized staff, and sleep labs can be booked for months. Fortunately, home sleep study tests are now available. One picks up the home testing system at the sleep specialist’s office and takes the test while sleeping in the comfort of their own bed. The device is returned to the office, the study read, and a diagnosis is made. If the test is inconclusive or central sleep apnea is suspected then a Polysomnogram will be ordered. Fortunately, about 90% of OSA patients can be successfully diagnosed with a home study.

The sleep studies look for episodes of apnea (breathing cessation) and hypopnea (decreased
airflow). Sleep apnea is diagnosed by the apnea hypopnea index (AHI) which is the number of times an hour one has either an apneic or hypopnic event. An index of 0-4 events per hour is normal, 5 – 14 indicates mild OSA, 15 – 29 is moderate OSA, and over 30 is considered severe
OSA.

Treatment depends on the severity of OSA and body habitus. In mild to moderate OSA lifestyle modifications can be tried. These consist of weight loss if applicable, sleeping on one’s side instead of back, no alcohol for at least 4 hours before sleep, and smoking cessation.

Oral appliances can also be tried. These are specialist fitted mouth pieces that either push the
mandible forward relative to the maxilla pulling the base of the tongue forward, or attach
directly to the tongue preventing it from falling backwards during sleep. Generally oral appliances are not tolerated very well and have a low success rate.

In moderate to severe sleep apnea CPAP (continuous positive airway pressure) is the therapy of choice. CPAP consists of a mask that fits snugly over the nose or nose and mouth. The mask attaches to a hose that attaches to a CPAP machine. The machine generates pressurized air which is blown continuously through the mask into the nose. The air pressure opens the collapsed airway and allows inspired air to flow in and out of the lungs. CPAP is put on when the patient goes to bed and is worn throughout the night. CPAP works extraordinarily well, is relatively inexpensive, and has few adverse effects. However, patient tolerance of CPAP varies wildly with anywhere from 20 to 60 percent of patients stating that they cannot tolerate CPAP. CPAP equipment is constantly evolving and improving with the goal of increasing patient satisfaction with the system.

There are alternatives to CPAP. Inspire consists of a surgically implanted electrode, which attaches to the hypoglossal nerve which enervates the tongue and a sensor that attaches to the intercostal muscle of the ribs. The system is turned on at bedtime. When the rib sensor detects decreased respiration it sends a signal to the hypoglossal nerve electrode which then stimulates the tongue causing it to retract opening the airway.

Several surgical procedures are available which focus on correcting any obstructive anatomy in the oropharynx and removing excess pharyngeal tissue to prevent airway blockage during sleep. Bariatric surgery for weight loss is also helpful in correcting OSA.

Finally, there are a couple of promising drug therapies. The first one is Tirzepatide (Zepbound).
This is one of the new injectable GLP-1 inhibitors for type two diabetes, which have been
effective in weight loss therapy. When studied it was found that Tirzepatide caused a 50%
reduction in the AHI (apnea hypopnea index) of obese OSA patients. This reduction is felt to be
secondary to weight loss caused by the drug, not the drug itself. The FDA has approved
Tirzepatide in combination with diet and exercise for treatment of obese patients with OSA.

There is another drug combination called AD 109 which works to keep the airway from collapsing during sleep. While the preliminary results are promising, the drug is still in clinical trials and is not yet available for therapy.

What are the risks of undiagnosed and untreated OSA? OSA is a disease of cumulative damage. Night after night of poor sleep, hypoxia and hypercapnia, resultant tachycardia and hypertension, and elevated catecholamines cannot be good for you. Repetitive hypoxia over time can cause brain cell death resulting in dementia. Constantly elevated catecholamines increase vascular tone causing medication resistant hypertension which we know is a major contributing factor to heart disease, stroke, and kidney failure. Repetitive catecholamine induced tachycardias can cause dysrhythmias such as atrial fibrillation. Nightly spiking catecholamine levels can cause severe anxiety. Sleep apnea induced blood glucose spikes are considered a precipitating factor for adult-onset diabetes. Night after night of sleep deprivation can cause or exacerbate depression and psychosis. And chronic fatigue resulting from sleep apnea is a major concern as fatigue greatly contributes to accidents especially in the automobile or at the workplace.

Because sleep apnea is underdiagnosed in this country, we do not know the true percentage of Americans who suffer from it. But we do know that heart disease, stroke, dementia, type 2 diabetes, and mental illness are epidemic in the United States costing inestimable amounts of money, suffering, and loss of happiness. It is a reasonable hypothesis that diagnosing and treating OSA could make a substantial difference.

Diagnosis and successful treatment of Obstructive Sleep Apnea is a game changer for most patients who suffer from it. If you suspect you might have undiagnosed Obstructive Sleep Apnea talk to your healthcare provider and start the steps to get tested and treated.

Unfortunately, New Mexico has a shortage of sleep specialists, but be patient, get in line, get your study, and get treated. You’ll be glad you did.

Dr Raffin is a retired board certified Emergency Medicine Physician who practiced for 30 years in emergency departments in Los Angeles, Ca,  Salt Lake City, UT, and Park City, UT