Sleep apnea becoming more common

By JOAN PATTERSON

VIEW ON HEALTH

Stephen Crane has been snoring for a while but it wasn't until a conversation with a former roommate that he realized how bad it actually was.

When the roommate would come home after work and park his car in an alley adjacent their apartment, he'd be able to hear Crane snoring even before he walked through the door.

Once inside, "he said it sounded like there was a freight train coming through the apartment," said Crane, a 63-year-old former business executive, recounting the conversation.

"And it kind of startled me because I didn't know that I did that," he said.

In fact, like a lot of people with severe snoring, Crane learned to adjust to the lack of quality shut-eye by downing several cups of coffee every morning to cut through the fog of his daily fatigue and simply accepted the idea that he just wasn't a guy with a lot of energy.

But a visit to his primary physician finally led to a referral to a sleep clinic and in February, after an overnight stay at the Sleep Disorders Center at Sunrise Hospital, he was diagnosed with sleep apnea.

While it may always get some laughs in the movies, the idea of someone snoring so bad that even the family dog is running for cover, in real life it's not so much fun. In fact, snoring and sleep apnea can cause a spectrum of medical problems and affect everything from job performance to marital bliss. The vast majority of sufferers, in fact, are either unaware of their sleep disorders or simply learn to live with them.

According to Dr. William Kohler, a spokesperson for the American Academy of Sleep Medicine (AASM), it was once believed that three to five percent of the American population suffered from sleep apnea, but recent studies show it is closer to 20 percent. Chronic snoring that interferes with one's quality of life affects at least 30 percent of the population, he added.

Both of these conditions are the result of breathing that is impaired during sleep and therefore inhibits or prevents air from reaching the lungs. In snoring, it is due to anything that causes resistance in the airway, which begins at the nose, continues through the nasal passages, past the soft palate in the upper part of the throat and the tonsils, and down behind the tongue, according to Dr. Charles McPherson, director of the Sunrise Hospital Sleep Disorders Center which is accredited by the AASM .

"So it's anything that causes problems along the way, so narrowing of the opening of the nose, congestion of the nose due to allergies, increased tissue in the soft palate, increased tonsil size," he said.

"And then as people gain weight, they get more fat deposition in the soft tissues in the neck and throat area, and then (there's a reduction) of the inner diameter or inner dimensions of the throat, and so all those things are factors contributing to snoring."

Apnea is often accompanied by loud snoring yet goes even further because breathing is not just inhibited but actually stops, periodically, for what can be several seconds at a time, McPherson said. In the worst cases, it can be like someone standing over the bed and waking up the sleeper every few minutes over and over again.

There are three types of sleep apnea: obstructive, central and a combination of the two. Obstructive apnea is the physical blockage of the airway due to the collapse of tissue in the back of the throat.

Central sleep apnea, on the other hand, occurs when the brain is not getting the correct signals to control breathing as it normally would. It could be the result of a problem in the brain or the heart as the two work in conjunction with one another to control the depth and rhythm of our breathing.

Pinpointing these disorders, particularly apnea, means an overnight visit to a sleep clinic where technicians measure a multitude of physical signs with a polysomnogram during different stages of sleep. At the Sunrise center, for example, electrodes and sensors measure signs such as brain waves, heartbeat, leg movements, blood-oxygen levels, chin and eye movement, and breathing effort.

A look at the electronic records of a recent sleep study done on a 48-year-old male with severe sleep apnea, basically a series of squiggly lines filling the length and breadth of a large computer monitor, showed brain-wave activity and breathing effort, among other measurements, suddenly spiking up and down in seismic bursts during periods of apnea. At one point, the patient had stopped breathing for 44 seconds.

According to McPherson, the physiological responses during sleep apnea include the release of stress hormones which can eventually increase the chances of developing high blood pressure, heart rhythm problems, heart attacks and strokes. It can also put someone at risk for developing diabetes or worsen existing diabetes symptoms.

Habitual snoring that is not apnea has its own set of problems, the most obvious being the fatigue and irritability that comes from not getting a good night's sleep and what Dr. Clifford Molin, medical director of the AASM-accredited Zeeba Sleep Center off North Tenaya Way, calls "spousal arousal" or sleep disruption in the non-snoring spouse. Of course, the snorer also faces the danger of getting poked in the ribs from a disgruntled partner.

On the serious side, it can lead to complications such as the increased risk of high blood pressure, heart failure and stroke. The continual inability to get a good night's sleep in both apnea and habitual snoring can also put someone at risk for depression.

While men are more likely to suffer from serious snoring and sleep apnea, women and children struggle with them as well. It used to be thought that the ratio of men to women was 10 to 1, but now statistics show it is closer to 3 to 2, Kohler said. These sleep disorders can also worsen with age.

In children, sleep apnea can be associated with hyperactivity, irritability and poor academic performance, he added.

People of every size and shape are affected by snoring and apnea, but there seems to be a high incidence among those who are obese, according to experts.

"The most important factor and the reason why we're seeing so much more sleep apnea, in part, is obesity, so that's obviously one of the most significant risk factors for obstructive sleep apnea, and we're starting to see a lot more sleep apnea in kids," Molin said.

While there is more awareness about sleep apnea than in the past, about 80 percent of those who have it go undiagnosed "so they feel lousy during the day but they just get used to it, they think this is normal," Molin said.

One of the biggest barriers to getting a diagnosis is that sleep issues are normally not something a patient brings up with their family physician and, in some cases, he or she may not even know there is a problem unless their bed partner at home points it out, Molin said. Nor are physicians likely to ask questions about sleep quality.

Yet patients need a referral from a doctor before they can go to a sleep clinic. Once the sleep issue has been documented at a clinic, insurance companies will usually pay at least a portion if not most of the cost for treatment.

In terms of dealing with snoring and sleep apnea, however, there are some lifestyle issues that can be addressed first. It is a good idea, for example, to lie on one's side while sleeping to help keep the airway passage through the throat open. Alcohol and sedatives also should be avoided before bedtime since they both tend to relax the throat muscles, according to experts.

Weight loss can sometimes be a way to diminish snoring symptoms, as well as treating nasal congestion due to allergies, although both should be done under the supervision of a physician. There are also mouthpieces that can be fitted by a dentist that adjust the position of the tongue and soft palate to help keep the airway open.

For snoring and obstructive sleep apnea, surgery is an option that might be recommended to address a deviated septum, for example, or increase the opening of the upper airway by removing or tightening tissue in the soft palate, McPherson said. Sometimes the removal of the uvula and/or large tonsils are also recommended.

But the success rate of surgery is highest when there is a definite obstruction that can be addressed, McPherson added.

In other cases, and when it comes to central sleep apnea, there is Continuous Positive Airway Pressure therapy or CPAP. In this instance, a patient wears a mask which blows air to the back of the throat so that it can then reach the lungs. There are also BiPAP or Bi-level Positive Airway Pressure machines which offer alternating air pressures based on a patient's inhaling and exhaling.

These air-pressure devices have a significant success rate among users and are considered the "gold standard" for treatment of apnea at this time, Molin notes. But success depends on making sure the devices are being used correctly and are comfortable for the patients, so it is a combination of "patient motivation and clinic support," he said.

When there is success, the change in a patient can be extraordinary, he said.

"It's a lot of fun to treat people with severe sleep apnea because they get better and they get their lives back, and they come into your office and they're just very appreciative," Molin said. "There's very little in medicine that we can do today that dramatically can change people's lives ... and treating sleep apnea does that."

Crane went back to the sleep clinic in April to be monitored overnight while he tried out his new CPAP device. At one point the technician had to dial down the air pressure to make it more comfortable for him and, in the end, it felt like "a constant pressure ... a light noticeable pressure," he said.

"I really thought at first I'd never be able to go to sleep, but sure enough in 15 minutes I was out," he said the next day. "At first it was intimidating but I'm one of those people who has had a lot of challenges ... so maybe I adjust faster."

Crane said he plans to stick with the CPAP and has done enough research on sleep apnea at this point to understand the rewards of a good, uninterrupted sleep. "I like the success rate of feeling better and getting my life back," he said.