Secrets of the Sleep Apnea Annotated Resources Page

The “Annotated Resources Page: Sleep Apnea” page contains a list of resources (links) that have been taken from the National Library of Medicine.

So, each resource presented has been vetted by some of the best librarians in the world.

You may be wondering why we are reproducing someone’s else’s work?

That is a fair question 😉.

The short answer is that we have added some extra special information.

For instance, the page is a more user-friendly version of the original resources page:

  • On the National Library of Medicine page, all the links (resources) are shown with no further explanation.
  • On our version instead, you will get a glimpse of the linked pages. This will allow you to decide if the pages are worth a visit.

… a time saver, right?

But the unique extra bells and whistles that you will not find anywhere else are the … “What Google thinks about the page” sections.

These include:

  • Estimated monthly traffic from Google.
  • Estimated number of keywords for which Google ranks the page. In other words, for how many “searched terms” Google will show you the page.
  • Estimated most important searched keywords for which Google will show you the page. We will thus provide you with examples of some of the actual keywords.
  • Estimated number of links from other websites to the page. As you may know, links from other websites count as votes in Google eyes.

How will you use this information? …Well, you will be able to quickly understand:

  • what the page is about (most important searched keywords),
  • how important and authoritative the page is according to Google (estimated traffic, number of links and number of keywords).

Enjoy!

Chapter 5: Treating Obstructive Sleep Apnea (OSA) with Surgery.

Reviewed by Dr. Joseph Salim, DMD (written by the Sutton PDA editor)

How can surgery treat sleep apnea?

Last but not least comes surgery.

Why last?

Because it is usually considered the third line of treatment after CPAP and dental appliances.

Can surgery be indicated earlier?

Yes, when your doctor identifies abnormal anatomical structures that:

  • he can correct
  • and which hinder device use.

Now, you should know that there are many anatomical causes of sleep apnea.

Hence many surgical procedures exist to address each type of airway obstruction.

Each has its own risks and benefits.

Your surgeon’s choice will also depend on your age, whether you are overweight, obese or not.

Surgery can be targeted at soft tissues or/and skeletal structures. And your surgeon will choose the best procedure(s) for you.

Since surgery can improve your quality of life and survival …

… read on to discover the different techniques and success rates1.

Nasal obstructions

Let’s start with the organ responsible for our sense of smell.2

Surgery of the nasal cavity can:

  • reduce inferior turbinates
  • correct a deviated septum
  • etc.
Image comparing a straight and a deviated nasal septa.
Deviated and normal (straight) nasal septa

A deviated septum, as well as enlarged turbinates, tend to obstruct nasal airflow.

But is this surgery enough to help treat OSA?

Usually, not, you should not expect it to treat OSA on its own.

For this reason, correction of the nasal passage is often concurrent to that of oropharyngeal obstructions.

But, even on its own, it is far from useless.

Studies have shown that it is very beneficial since:

  • it improves sleep quality,
  • facilitates use of CPAP which in turn makes possible (a) more hours of treatment or/and (b) lower (CPAP) pressures.

Since we mentioned oropharyngeal obstructions, let’s dive deeper into the subject.

Oropharyngeal obstructions

These are redundant, flaccid and elongated tissues in the oropharynx.

Oropharynx: image showing the soft palate, tonsils, back of the throat and tongue
Anatomy of the Oropharynx

So you would expect surgery to focus on eliminating them, right?

Well, yes and no.

Pillar palatal implants, for instance, aim at local stiffening of the soft palate. They do not eliminate soft tissues to widen airway passages.

The procedure consists of:

  • the insertion of thin, narrow, polyester implants in the soft palate (which is the roof of the mouth)
  • with a modified syringe.

By reducing vibration and collapsibility, it can:

  • treat mild OSA with mild-to-moderate effects
  • reduce snoring with moderate effects3.

But these implants are not the most frequently used surgical procedure for treating OSA in adults.

The prize instead goes to Uvulopalatopharyngoplasty (UPPP).4

Human mouth: image showing the uvula, soft and hard palates, tonsils, teeth, gums, lips, and tongue
Anatomy of the Human Mouth

It is used to remove several soft tissues that may obstruct your airways at the back of the throat:

  • Part, or all, of the uvula,
  • parts of the soft palate and tissue at the sides of the throat,
  • tonsils and adenoids, if still present.

UPPP’s results with OSA vary a lot depending on the size of the tonsils and the patient’s body mass index.

It can improve patients’ compliance with CPAP by lowering CPAP pressure requirements (see also Chapter 4: Treating obstructive sleep apnea (OSA) with CPAP and dental appliances).

Detailed human throat anatomy: soft and hard palates, tonsils, hyoid bone, trachea, turbinates, adenoids, trachea, vocal cords …
Detailed Human Throat Anatomy showing Soft Palate, Hard Palate, Tonsils, Adenoids (etc…)

Let’s now move to study surgical procedures of the tongue to treat OSA.

Surgeries of the tongue

Your surgeon can use several procedures to treat obstructions due to the tongue.

And guess what?

All in all, symptoms of daytime sleepiness and quality of life are generally improved with all tongue procedures.5

But let’s understand how the tongue can obstruct the airways passage.

One possibility is that you can have more fat deposits at the back of your tongue. You will thus have a larger than normal base of tongue size.6

You could also suffer from an abnormally large tongue. Your surgeon will thus try to reduce its size.

But how? Well, let’s see…

Midline glossectomy

This is the name of a procedure that he may use.

It consists of removing the central part of the tongue base (at the back of the tongue).

The success rate can vary between 25-83%.7

Genioglossus muscle

Another approach involves your genioglossus muscle.

Genio… what?

This is the largest muscle of your tongue. It allows you to protrude it (or stick it out).

Surgery consists in moving its anchor point in the bone – the genio-tubercle – forward.

The result is less obstruction of the airways when sleeping as the tongue relaxes during sleep.

The success rate can vary from 39 to 78%.8 9

Radiofrequency

Radiofrequency ablation is also used.

This makes use of radio waves which create a certain amount of controlled damage in your tongue.

The resulting scarred repair tissue will shrink the tongue slightly.

The likelihood of the tongue falling back during sleep will also decrease.

It will be successful at improving snoring.

As for your sleep apnea, the surgical success rate will be in the order of 36%10

Hyoid suspension

Although it has a strange name, the hyoid is actually a little bone.

That’s right, just a little U-shaped bone, in the neck.

Image of the hyoid bone, also called tongue-bone, found at the root of the tongue in the frontal part of the neck.
Hyoid Bone or Tongue-Bone found at the Root of the Tongue

You can find it above Adam’s apple.

It is attached to several soft tissues and muscles in the throat and tongue.

It is free to move around which may lead to the collapse of the structures that attach to it during sleep.

This may, in turn, cause the airway to get blocked.

Your surgeon can suspend and advance it to increase space at the base of the tongue.

Results are variable, and it is performed as an adjunctive surgery for the treatment of OSA.11

Tongue suspension techniques

As the name suggests, your tongue base is pulled forward or suspended to reduce obstruction (at its base).

How?

Your surgeon will pass nonabsorbent sutures through your tongue and attach them to the jaw bone using a screw.

The technique is minimally invasive and can be performed along with other techniques (or on its own).

The success rate is approximately 33%.12

Let’s now look at a radical approach to treat your OSA: craniofacial surgery.

Craniofacial surgery

As you may have guessed already, this involves more complex surgical procedures.

Hence, it is usually the last phase of surgical treatment.

In some selected cases though, your surgeon may propose it as an initial approach. He can do this to avoid many surgeries.13

It is also proposed as an initial option when your OSA is not the result of soft tissues abnormalities.14

So what does craniofacial surgery consists in?

Different procedures which may include advancement:

  • of the inferior part of the jawbone and hard palate,
  • of the anterior jaw,
  • of the facial skeleton which will pull your soft tissues forward.

The end result is the widening of the entire pharyngeal space or posterior airway space. This will ease your breathing.15

What about the success rate?

With 43% positive results, the success rate is the highest among different surgical interventions.

Several studies have shown that it is equal in effectiveness to nasal CPAP.16 17

It is now time to look at a completely different type of surgery, which no longer involves your head’s tissues and structures: bariatric surgery.

It can help you lose weight (and in turn treat your OSA). Hence its accelerated growth, especially after the introduction of minimally invasive techniques.18

Weight Loss by Bariatric Surgery

Do you know how often OSA is present among very obese patients?

The answer is …almost half, that is 45%.19

Pause for a moment, and let that sink in.

Studies have shown that even mild-to-moderate weight loss benefits overweight patients.20 21

Very obese patients who have failed to lose weight via standard treatments like:

  • low-calorie diet,
  • behavioral changes,
  • exercise and activity,

may be advised to undergo bariatric surgery.22

Now, let’s see what the impact (of surgery) on OSA is.

Two authors report some interesting results:

  1. 101 patients who received bariatric surgery saw their AHI decreasing from 51 ± 4 (preoperatively) to 15 ± 2 (postoperatively).
    And this without them receiving any other treatment.23
  2. OSA patients showed remission rates of 40% after bariatric surgery.24

So, results are more than encouraging.

Last but not least, read on to discover how subsequent (staged) surgical interventions can treat your OSA.

Multi-level surgery and staged surgery

A quick question for you…

What percentage of patients suffer from OSA as a result of only one site obstructing the airways?

……. Only 25% whereas a vast 75% of patients have multi-level obstructions.25 So you are likely to have involvement of two or more of the following anatomical areas:

  • soft palate,
  • lateral pharyngeal walls,
  • and tongue base.26

If you suffer from many obstructions, single-site surgery will have a poor success rate.

Studies instead show that you can get success rates as high as 95% when different surgical approaches address many levels of obstruction.

Are surgical protocols all done in one event?

No, they are usually staged if there are many abnormalities present.27

Your surgeon will do the less risky procedures first. Meaning the ones less prone to complications will be prioritized.

Some examples of combined surgeries include:

  1. Advancement of your genioglossal muscle along with Uvulopalatopharyngoplasty (UPPP). The former will enlarge the airway at the base of your tongue.
  2. An oropharyngeal procedure and a nasal procedure.

All you have been reading until now was valid for an adult population.

But what about children?

….Well, check the next section to find out what happens with little patients.

Children and sleep apnea surgery

If you have children, you should be wary that obstruction of the upper airways is not without its effects.

This is true even in small patients.

It can:

  • Hinder the growth of their upper and lower jaws. This can, in turn, change their craniofacial structure which could worsen OSA once adults.
  • Create behavioral problems such as hyperactivity.
  • Lead to suboptimal school performance.28 29

So if you could avoid all that, then it would be hugely important, right?

But how do doctors decide whether your child suffers from OSA?

The criteria for deciding are stricter than in adults.

Some experts go as far as saying that an AH> 1 is enough to diagnose your child with OSA.30

Now, surgery to treat OSA in children is very different from an adult population:

  • it consists mainly in removing the tonsils if they are too large and obstruct the airways. (It is one of the most common surgeries in the pediatric population).
  • It is a first-line therapy unlike in adults, where CPAP or dental appliances are instead first-line (usually).31
Human mouth anatomy before and after surgical removal of infected tonsils. The image also shows gingiva, uvula, teeth, soft palate, lips and teeth.
Human Mouth Anatomy before and after surgical Tonsils Removal

Removing the tonsils is curative in 80% of children suffering from OSA.32

It is also worth noticing that tonsils tend to shrink as children grow.

So do not be surprised if your doctor suggests waiting some time before deciding for surgery.

That is all for pediatric patients.

Let’s briefly talk about results after surgery in the adult population, before we wrap up.

OSA results after surgery

So, by now you have probably understood that results can vary a lot from patient to patient.

Surgery is not the open-sesame to resolving OSA.

And this is because OSA has many different concomitant causes and factors.

These include varying patient characteristics such as the age or body mass.

Also, types of obstructions can be very different.

Though, surgery will still provide some important benefits for you:

  • reduction of early mortality risk and cardiovascular risk33
  • improvement in “reaction time, quality of life, and motor vehicle crash risk”34 35

But are results with OSA forever (like diamonds)?

The answer is awaiting you in the next section.

How long do results of OSA surgery last?

That is a good question.

Human muscles and tissues lose tonus as we get older. They become more collapsible.

Hence, the effectiveness of your surgery will likely decrease with time.

Also, we tend to become overweight as we become more mature 😊.

Now, weight gain seems to be one of the main factors making you more prone to losing the positive effects of the surgical treatment.36 37

Thus, it is advisable that you regularly see your treating doctor to get a long-term follow-up.

This is actually independent of the treatment you have chosen.38

If you have read until here, then you are almost an expert. Just one more section to go.

How well do Uvulopalatopharyngoplasty (UPPP), CPAP and weight loss treat OSA?

A study with 444 patients provided some interesting insights.

This group was made of patients with and without OSA.39

Those with OSA were either treated with UPPP, weight loss, CPAP or not treated at all.

Guess what?

The untreated group had higher mortality than the group not suffering from OSA.

But those treated, irrespective of the treatment, had survival rates similar to the healthy group.

And that’s all folks! We hope you have enjoyed the article.

Final remarks

Congratulations!

You have made it!

You have now reached the stage of “all-knowing” about OSA 😊.

In case you are almost there but not quite, make sure you read some of the previous articles (chapters) of the definitive guide to sleep apnea:


Bibliography

Chapter 2: Doctors Who Diagnose and Treat Obstructive Sleep Apnea.

Reviewed by Dr. Joseph Salim, DMD (written by the Sutton PDA editor)

Introduction

In this chapter we will try to answer a few questions you may have about:

  • which doctors first see patients,
  • prescribe tests,
  • diagnose sleep apnea,
  • decide treatments etc..

So, without preamble, here we go...

Who first sees a sleep apnea patient?

The closest doctor to you and your family initiates the process that may ultimately lead to a treatment,

… yes, you understood correctly….  your primary care doctor is usually the first one to suspect the presence of the disease.

Why?

First, it is very likely that he has known you, and hence your medical history, for a long time.

Second, sleep disorders affect an ever-increasing number of people. He has thus probably honed his skills.

He is usually knowledgeable about the symptoms, consequences, risk factors etc.

It is this doctor who will first gauge whether you may be suffering from sleep apnea. He will then decide whether you may need more exams and possibly treatment.

So, based on an analysis of your symptoms, he/she will then decide whether to refer you to a sleep specialist for a thorough examination.

But your dentist may also play a significant role… let’s see how.

Can a dentist diagnose sleep apnea? What is his role in OSA treatment?

A dentist cannot make a full diagnosis of OSA. Though, he can still identify whether you could benefit from treatment.

And that is because he can examine oral and anatomical structures playing a role in sleep apnea.

Also, he sees more than 50% of the population twice a year.

He can thus help identify many patients at risk.

So, what will he do if he thinks you suffer from OSA?

Simple!

Just as for your primary care doctor, a dentist will refer you to a sleep specialist, for a thorough examination. This will allow him to decide whether if you really suffer from sleep apnea.

But the role of dentists does not end there.

Your sleep specialist may send you back to your dentist.

That is, provided your dental specialist is certified by the American Board of Dental Sleep Medicine (ABDSM) (see below).

Typically, you will see a certified dentist after the failure of CPAP (see Chapter 4: Treating obstructive sleep apnea (OSA) with CPAP and dental appliances.).

CPAP is the first line of treatment for obstructive sleep apnea

But before stopping CPAP, you need to talk to your sleep doctor and/or supplier of a CPAP machine.

Why?

Because it often happens that minor fine-tuning of the machine or adjustments of the mask will be enough to make you want to stick to CPAP.

If CPAP is really not for you, then you should contact a dentist who makes dental appliances.

These are devices that keep your airways open during sleep and ease airflow.

After that, you are done, and no longer need to see anyone, right?

Well, not quite.

After starting to wear a dental appliance, consider follow-up visits with your dentist.

This will ensure that the device is well fitted and that it does not lead to:

  • teeth displacement from their normal alignment,
  • bleeding gums;
  • other gum diseases.
Different stages of human gum inflammation: healthy gum, gingivitis, periodontitis.
Different stages of human gum inflammation

We mentioned board certification for dentists. So that brings us nicely on to the next section.

Which dentists can treat snoring and sleep apnea?

Only a few actually.

I’ll hazard a guess, you are wondering why right?

Because sleep medicine is a young multidisciplinary science.

And also because, as we said above, your dentist needs to undergo specific training.

This is important since he will have to collaborate with other specialists.

Also, he must understand oral appliance therapy very well.

Interestingly, this training does not belong to the nine dental specialties recognized by the American Dental Association.

Instead, a dental specialist will receive certification:

  • by the American Board of Dental Sleep Medicine (ABDSM),
  • or by the Academy of Dental Sleep Medicine (USA).

The American Academy of Sleep Medicine (AASM) recognizes these degrees.

But only a few dentists have treated enough patients to be able to claim the necessary level of experience.

So, you may have to investigate a little further before deciding.

We mentioned the role of a sleep specialist several times already. So, you are probably curious to know more, by now.

Let’s thus look at this medical profile and see what he does.

Who is a sleep specialist and what role does he play?

Before we answer that, here is another quick question for you: how many sleep disorders do you think there are?

Anywhere between 70-100 according to different sources! (100 according to the Stanford Medical Center).

These include the following more common disorders:

  • sleep-disordered breathing, including obstructive sleep apnea,
  • snoring,
  • restless legs syndrome,
  • chronic insomnia,
  • narcolepsy/cataplexy and other forms of hypersomnia

and many more …

The 5 most common types of sleep disorders include: narcolepsy, sleep apnea, insomnia, snoring and restless legs syndrome
The 5 most common types of sleep disorders

And the numbers of people affected are equally impressive….…

………. 25-30% of all Americans across all demographic groups (children, teenagers, adults, elderlies).

That is a whopping 50-70 million Americans chronically suffering from a sleep or a circadian disorder.

And most of them go undiagnosed despite its proven negative effects on people’s health such as:

  • disabilities,
  • related diseases,
  • and even mortality.

No wonder that doctors are trained specifically to diagnose and treat people who have sleep problems.

These doctors are called… suspense … sleep specialists. What a surprise! 😉

Interestingly, Sleep Medicine has only recently been recognized as a specialty of medicine.

Board certification of practitioners dates to 1978.

This is because the physiology of sleep was fully understood only a few decades ago.1

For instance, REM sleep was discovered in the 1950s and circadian rhythm disorders in the 70s.

Hence standards were introduced in the seventies.2

Sleep medicine is now a sub-specialty within several medical disciplines such as:3

  • internal medicine,
  • anesthesiology,
  • psychiatry and neurology,
  • pediatrics,
  • family medicine,
  • otolaryngology.

So, to become a sleep specialist, you need further training in sleep medicine, and you will learn to:

  • diagnose,
  • treat,
  • manage,
  • help prevent,

the numerous sleep disorders we referred to above.

One of the reasons you need to become competent is the challenge due to the presence of many disorders with similar symptoms.

For instance, excessive daytime fatigue and sleepiness are always an observed symptom. This is true unless sleep deprivation is deliberate.

So, if you are a sleep specialist, you will be able to make a correct diagnosis of sleep disorders to identify the best treatments.

As explained above, a correct diagnosis will depend on:

  • a physical exam,
  • medical history,
  • and then some further tests or sleep studies such as a polysomnogram.

Technicians will perform some of these tests and sleep studies. Sleep specialists will then interpret the data.

Treatments may include:

You will find your sleep specialist working in sleep clinics, also called sleep laboratories or centers.

These can be privately-owned or affiliated with existing hospitals or medical centers.

Final remarks

We hope you have enjoyed this article.

By now you should have a good idea of which doctors are involved in the diagnosis and treatment of OSA.

Let us know whether you have any questions.

Consider heading over to the natural continuations of this chapter, namely:

Though consider taking a peek at the following more introductory articles, if you have not already done so:


Bibliography

Chapter 3: Diagnosis of Obstructive Sleep Apnea (OSA).

Reviewed by Dr. Joseph Salim, DMD (written by the Sutton PDA editor)

Introduction

Did you know that many people are not aware of their sleep apnea's symptoms and do not get diagnosed?

10 million Americans are unaware they suffer from the condition.1

Fortunately, during the last decade, certain things have changed. A better knowledge of symptoms and clinical consequences have led to better screening methods.

But you should also be proactive.

There are many signs of sleep apnea.

Maybe you suffer from poor quality sleep, and your bed partner complains about your regular snoring.

Perhaps you:

  • make choking sounds at night,
  • suffer from restlessness during your sleep,
  • frequently urinate during the night,
  • and feel drowsy during daytime hours.

Or, possibly, you:

  • feel tired,
  • have headaches when you wake up,
  • struggle to concentrate during the day,
  • and suffer from sudden mood swings.

If you do, then take these symptoms seriously, and talk to your treating physician.

You may then have to see a sleep specialist for more in-depth exams.

That is right.

The diagnosis of sleep apnea requires specialized examinations.

Doctors use clinical symptoms, medical and family histories, and questionnaires.

You should inform your doctor if anyone in your family has had symptoms of this disorder or suffers from sleep apnea.

Diagnosis is not straightforward, and it will not happen during your first visit.

Let’s take a look at each step in detail.

Diagnosis of sleep apnea in children

If you have a child, then the diagnosis is simpler than in adults.

Why?

Because 80% of the time it is due to large tonsils.

So, what will your child’s doctor check first during the physical exam?

If you guessed the throat, then you guessed correctly.

The doctor will also check your child’s sleep history.

That is what he will usually begin with.

A physical exam and medical history may be enough to diagnose sleep apnea in young patients.

Medical history includes information about a person’s health such as:

  • allergies,
  • medications,
  • surgeries,
  • diet, etc.

In this case, it will be more focused on identifying symptoms related to sleep apnea, such as:

  • sleepiness during the day,
  • irritability,
  • choking at night, etc.

As the parent, you should inform the doctor about your child’s signs and symptoms.

But what about adults? ….. Just continue reading. 😉

First steps to diagnose sleep apnea in adults: sleep history and physical exam

The first step consists of a routine exam2.

Your doctor will begin by checking your sleep history.

That is about how you sleep, but also how you function at night.

He will ask if you:

  • snore,
  • suffer from daytime sleepiness.
Cow yawning in the meadows: probably suffering from sleep apnea!
Cow yawning and probably suffering from obstructive sleep apnea!

He will also consider factors that increase your risk of suffering from OSA:

  • obesity,
  • retrognancy, that is your upper jaw (maxilla), or lower jaw do not occlude well because one of them is more posterior than it should;
  • hypertension.

If your doctor’s findings are positive for this initial OSA screen, then it means you suffer from OSA, right?

Not quite, patience you must have, my young padawan.

What it means is that you are more likely to have OSA. In other words, you are at risk of suffering from OSA.

You will thus become a candidate for a more comprehensive sleep history and physical examination.

Curious to discover what these are, aren’t you? If so, then jump onto the next section.

More in-depths exams to diagnose sleep apnea

So, what do a more comprehensive sleep history and physical examination include?3

Many more things that your doctor will check, namely:

  • How often you snore, gasp, choke. Since you will likely not be aware of these, you will need help from your bed partner or a family member.
  • Excessive sleepiness that cannot be explained by other reasons.
  • Decreased libido.
  • Non-refreshing sleep.
  • Total sleep amount.
  • Measurement of sleepiness severity by the Epworth Sleepiness Scale (see the below section for explanations about this test).
  • Decreases in memory and concentration (cognitive functions).
  • Sleep fragmentation/maintenance insomnia.
  • Frequent urination at night (nocturia).
  • Morning headaches.

Also, your doctor should check conditions that may result from OSA such as:

  • Hypertension.
  • Stroke.
  • Myocardial infarction.
  • Decreased daytime alertness.
  • Motor vehicle accidents.

But there will also be an in-depth physical examination.

Your physician will look for the presence of extra or large tissues in your mouth, throat, and nose.

These include:

  • enlarged soft palate, which is the roof of your mouth in the back of your throat,
  • enlarged/elongated uvula,
  • enlarged tonsils,
  • large turbinates.
Image showing nasal cavity, mouth, sinuses and nose cartilage
Turbinates, soft palate and uvula can be seen in the image.

 

Besides signs of occlusion of the upper airway, he will also pay close attention to:

  • obesity,
  • increased neck circumference (> 17 inches in men, > 16 inches in women),
  • deviated nasal septum, nasal polyps, …
  • high arched/narrow palate

See also: Are you at risk of developing sleep apnea? What are the risk factors for sleep apnea?

Depending on the results, you may be more or less at risk of suffering from OSA.

If you belong to the second group (less at risk), the timing for further testing will depend on the level of risk and symptoms or daytime impairment.

Otherwise, your testing will be expedited (because you are more at risk).

You will then have to undergo one of two tests that can confirm whether you are indeed an OSA patient.

But before delving into these two exams, let’s briefly touch upon the Epworth Sleepiness Scale that we mentioned above.

Diagnosis of sleep apnea and the Epworth Sleepiness Scale

At first glance, it sounds complicated.

But it is actually quite simple.

The Epworth Sleepiness Scale4 is a questionnaire aimed at measuring your chance of dozing off during the day.

This sleeping sloth does not seem to be in a hurry
A sloth is so often asleep that he will not even be able to take the Epworth Sleepiness Scale questionnaire!

Depending on the result, it may justify seeing a doctor, and going through more in-depth exams to assess whether you really have sleep apnea.

Beware though! ... it is not a screening test for sleep apnea.

The Epworth scale only quantifies subjective somnolence irrespective of the presence or otherwise of a sleep disorder.

It assesses your level of sleepiness and amount of your quality sleep.

How does it work?

It calculates a score based on your “chance of dozing” in different situations such as when talking to someone or reading a book, etc.

Your “chance of dozing” can be slight, moderate, or high.

The higher the score, the lower the quality sleep you are getting, and the more tired you are.

Here below are some of the situations built into the Epworth Sleepiness Scale:

  • Sitting and reading a document.
  • Watching TV or at the movie theatre.
  • Sitting inactive in a public place (e.g., a theater, conference, waiting room, meeting, lecture)
  • As a passenger in a car or during public transport (train, bus, plane, underground) for an hour without a break.
  • Lying down to rest and relaxing in the afternoon when circumstances permit.
  • While sitting, during a conversation with someone close (also on the telephone).
  • Comfortably sitting after a meal without alcohol.
  • In a car, while stopped for a few minutes in a traffic jam.

You will have to analyze each of the above contexts.

Then you will need to decide what your odds of dozing are. These can be grouped as follows:

  • 0: no chance of dozing.
  • 1: dozing is possible but unlikely.
  • 2: the probability of dozing is moderate.
  • 3: it happens regularly, the likelihood of dozing is high.

What happens if your score is 6 or below?

Then you will be under the population average, which is 7 or 8.

If instead, it is 9 or more, then you have a problem, and should look for help.

This score is a strong indicator that you are likely suffering from OSA.

But to diagnose it with certainty, and to assess how severe the disease is, you need more than this.

In fact, your doctor needs to record:

  • the number of shallow breaths (hypopneas);
  • or breathing pauses.

You will be diagnosed with:

  • light sleep apnea when you have 5-15 events/hour;
  • moderate sleep apnea when 15-30 events/hours are recorded;
  • severe sleep apnea, if you show 30 events/hour or more.

But how do you measure and capture all this information?

Through sleep studies which measure the quality of your sleep and how your body reacts to sleep problems.

Two methods are currently accepted standard of practice5 to diagnose your sleep apnea.

This is because of their accuracy.

The approved methods are:

  • in-laboratory PSG;
  • or home testing with portable monitors (PM).

Poly ... what?

Jump to the next section to find out

What is a polysomnographic test?

It is a clumsy word for the most common sleep study.

This exam assesses if and which sleep disorder you suffer from.

Because there are many sleep disorders and OSA is just one of them, for instance:

  • Sleep apnea,
  • periodic limb movement disorder,
  • REM behavior disorder,
  • narcolepsy,

In the USA, the test usually takes place in a sleep center (within a hospital or elsewhere).

After your arrival, you will have to lie down and several wires will be connected to you.

But don’t worry!

The test is painless and takes place throughout your night sleep.

Trained staff will monitor you during this time while:

  • your scalp,
  • chest,
  • limbs,
  • and one finger,

will be attached to a bewilderment of wires and sensors.

Image of a man sleeping while connected to many probes, cables and recording devices which plot the data.
Polysomnography, sleep study test

But what exactly will they measure?

Your sleep specialist, or sleep technician, will capture numerous pieces of information, namely:

  • airflow through your nostrils and mouth by means of air-pressure gauges;
  • snoring;
  • oxygen levels;
  • breathing irregularities (mainly apneas and hypopneas);
  • upper abdominal wall movement and chest wall movement. This will allow the doctor to see whether you are making an effort to breathe;
  • blood pressure;
  • cardiac rhythm abnormalities, that is if your heart beats too fast or too slowly;
  • sudden shifts in brain activity (called arousals). They show sleep interruption due to your need to resume breathing. They may result from many factors, including:
    • breathing abnormalities,
    • leg movements,
    • environmental noises, etc.;
  • leg movements;
  • eye movements.

The constant presence of a trained individual will ensure that:

  • you follow the treatment,
  • and that the instruments and probes can capture all the information required.

A qualified physician should review and interpret the data collected during your sleep study.

But what will be the critical information that will enable your sleep specialist to decide if you suffer from OSA?

Stay with us and read on.

When will PSG testing confirm that you suffer from OSA?

So, now we want to understand how a doctor can decide whether you suffer from OSA or not.

Which type of PSG measurement is critical?6

The essential information is:

  1. the number of obstructive events (apneas, hypopneas + respiratory event related awakenings) is > 15 events/hour;
  2. or the number is > 5/hour, but you also show evidence of
    • unintentional sleep episodes during wakefulness,
    • daytime sleepiness,
    • unrefreshing sleep,
    • fatigue,
    • insomnia,
    • waking up breath holding, gasping, or choking,
    • or the bed partner describing:
      • loud snoring,
      • breathing interruptions,
      • or both,
    • occurring during the patient's sleep.

OSA, CPAP, and polysomnographic testing

After a PSG test, your sleep technician will be able to find out if you have OSA and decide your treatment (if needed).

If after a few hours of PSG testing, he thinks you suffer from OSA and that you need CPAP (check the following chapter Continuous positive air pressure), he may do a titration study.

A titra… what?

It is more straightforward than it sounds.

CPAP is the most frequently used treatment for sleep apnea. It handles moderate air pressures to keep your upper airway open during sleep.

Halfway through the night, your sleep technician may hook you up to a CPAP machine.

It is a way to take advantage of the fact that you are already connected to all sorts of sensors, to proceed with further testing.

The technician will spend the rest on the night gathering data to identify the best air pressure levels, possibly the optimal type of mask needed, etc.

You will be able to fall asleep comfortably because he will start at a low level and then gradually increase the air pressure.

Most CPAP machines come with a timed pressure “ramp” setting. Such a feature allows increasing air pressure up to the optimal level gradually.

What we described above is also referred to as a split-night sleep study:

  • the first part of the night helps determine whether you suffer from OSA, and how severe it is,
  • the second part is instead used to assess the best air flow from the CPAP machine.

Killing two birds with one stone!

A boy sleeping peacefully, while attached to multiple cables, during a sleep study
A boy attached to cables, undergoing a sleep study

A titration study is also used for sleep-related breathing disorders like:

  • central sleep apnea,
  • hypoventilation,
  • and hypoxemia.

Let’s now look at portable monitors.

When to use home testing for OSA with portable monitors (PM)

Did you know that your sleep specialist may recommend the use of a home portable device for the exam?

Let’s first address the elephant in the room: can you always use a home portable device?

Because that would be an important time saver, wouldn’t it? (no need to go and sleep over in a center).

When can you not use it?

Okay, that is many questions.

Let's check what guidelines say.

According to these7 you can use PMs to assess whether you suffer from OSA as part of a comprehensive sleep evaluation.

But this is only in patients with:

  • high probability of moderate to severe OSA,
  • and without other major associated diseases such as:
    • moderate to severe pulmonary disease,
    • neuromuscular disease,
    • congestive heart failure,
    • or those suspected of having a co-occurring sleep disorder.

The above notwithstanding, in some cases, PM testing may be the only solution for you.

When does this happen?

When you cannot be moved, such as when you are seriously ill, and in-laboratory PSG will not be a possibility.

Portable monitors will be effective at testing for OSA if they at least record:

  • airflow (as you breathe);
  • respiratory efforts like chest movements;
  • blood oxygenation;
  • your heart rate.

But that is not all…

According to the National Center for Biotechnology Information8 the same types of biosensors used for in-laboratory PSG should be used.

The results from your PM test should be assessed by a sleep specialist. For instance, he will verify whether you are making efforts to breathe etc.

In order to decide whether you suffer from OSA, he will need to do a comprehensive sleep evaluation and use the PM results.

The whole process may a take a few days or longer, after which he will contact you to discuss the conclusions.

But, but, but, … when compared to PSG testing …

... results from PM testing may underestimate the severity of apnea and hypopnea events9.

This is important to know.

How may that affect you?

Well, if you have:

  • a high pretest probability of suffering from OSA,
  • and your PM exam is not enough to diagnose your OSA,

then your sleep apnea specialist will request an in-laboratory PSG.

In other words, he will use a more thorough exam as a way to check the validity of the PM results.

Good data means better decisions!

Your sleep specialist may also request further in-laboratory PSG testing if the PM device did not collect enough data.

How does home testing for OSA with portable monitors (PM) work?

I guess the advantage of home testing for OSA is clear.

Is it not?

If not, let me explain ...

PM testing is very convenient since you will stay in the comfortable setting of your home.

You will also sleep while the instrument collects data.

The equipment will be delivered to your home, or you will have to go pick it up at your sleep specialist’s office.

Most of the times you will set up the instrument yourself, that is, after appropriate training by a technician.

Different PM devices come with various sensors and may differ slightly in what they measure.

You should make sure to ask the technician questions if you feel there is something you do not understand.

As for your daily routine, you should go to bed at your regular time but… don’t forget!

Before you lay down, you need to attach the sensors to different parts of your body as per instructions.

You will then have nothing else to do other than turn the machine on and go to sleep.

And that will be it.

In the morning, after detaching all the sensors, you will return the PM equipment (by mail or in person, to the sleep center).

Stay with us with you want to learn more about PSG and PM.

OSA, PSG or PM testing, surgery and dental appliances

If you suffer from OSA, what kinds of tests should you do before surgery?

According to guidelines10, you should undergo:

  • PSG or PM as part of a preoperative clinical exam, before you undergo upper airway surgery. This is true whether you suffer from snoring or OSA.
  • PSG as part of a comprehensive sleep exam to assess whether you suffer from OSA before you undergo bariatric surgery.
Different types of bariatric surgery procedures including sleeve gastrectomy, adjustable gastric banding, etc..
Different types of bariatric surgery procedures

What about monitoring results after OSA treatment?

If you have used non-CPAP treatments such as:

then you may use testing at home (unattended by medical personnel).

Dental appliances and pulse oximetry

How does your dentist measure your improvements?

He uses a simpler approach than PSG, called pulse oximetry.

Also, it is low cost, and you can do it at home.

Although not as precise as PSG, it provides useful information.

Provided your dentist has been trained sufficiently, oximetry results are very useful.

He will gauge whether you have decreased the number of:

  • complete cessations of breathing (apnea),
  • and/or partial obstructions of breathing (hypopnea),

occurring per hour of sleep.

You can use both wrist as well as handheld readings obtained continuously over the night.

If results are not satisfactory, you will have to pursue treatment.

Otherwise, you will have to go back to your sleep specialist for a more in-depth exam.

This will confirm whether sleep apnea has indeed been resolved.

If resolved, then that’s good news, actually great news!

And that is because your dentist will no longer have to re-align your oral cavity. Only routine yearly visits are necessary after that.

Final Remarks

You have completed reading Chapter 3, congratulations!

Now it's time to turn the treatment of OSA.

How?

By checking the following chapters:

Though, also consider taking a look at the previous articles (if you have not already done so):


Bibliography

Chapter 1: Obstructive Sleep Apnea (OSA) and its Health Effects

Reviewed by Dr. Joseph Salim, DMD (written by the Sutton PDA editor)

Introduction

We all know that after a night of poor sleep we tend to be temperamental, moody, struggle to concentrate and feel fatigued.

But what about the consequences of prolonged lack of sleep on your health?

How is your health affected?

Unfortunately, the answer is short: sleep apnea hurts your health.

And what is worse is that you will often not be aware of the extent of the issues.

The development of sleep apnea is gradual.1

But, a study has shown that moderate-to-severe sleep apnea increased mortality significantly.2

So, if you suffer from sleep apnea syndrome your quality of life as well as your life expectancy will decrease significantly.

Some studies have investigated the impact of lack of sleep on different diseases.

If left untreated, sleep apnea may increase the risk of:3

  • arterial hypertension,
  • heart attack,
  • stroke,
  • heart failure,
  • irregular heartbeat,
  • diabetes type 2,
  • obesity,
  • depression,
  • erectile dysfunction,
  • loss of libido,
  • concentration and memory loss,
  • risk of motor vehicle collisions,
  • work related accident,
  • Alzheimer disease,
Image showing multiple health effects related to sleep apnea: heart failure, diabetes type 2, Alzheimer, depression, stroke ...
Numerous health effects related to sleep apnea

Let’s take a closer look at each of these effects, one by one.

 

Are OSA and cardiovascular diseases related?

What should you do if you see that your bed partner or a family member frequently stop breathing for short moments?

There are no doubts!

You need to encourage him (or her) to seek medical advice straight away.

And that is because OSA can lead to premature cardiovascular death.

Why?

Because, according to the American Heart Association (AHA), it is associated with:4

  • high blood pressure,
  • arrhythmia or irregular heartbeat,
  • heart failure,
  • coronary heart disease,
  • and stroke.

Always according to the AHA, the evidence for a relationship between sleep apnea and high blood pressure is important.

And one should not forget that high blood pressure is a major risk factor for:

  • coronary heart diseases
  • and stroke.

Furthermore, the former is the leading cause of death in the USA. As for the latter, it is an important cause of disability and death.

Let’s try to understand better the relation between OSA and cardiovascular diseases.

How does OSA influence cardiac health?

Human circulatory system anatomy showing heart and blood vessels
Human circulatory system anatomy

If you have been diagnosed with OSA then you know that:

  • your heart,
  • your blood vessels (arteries, capillaries, veins),
  • and your brain,

will be exposed to periods of lack of oxygen (hypoxia) many times throughout the night.

(Note: your blood vessels and heart make up your cardiovascular system).

At night you will experience a below normal (negative) intrathoracic pressure.

Why?

Because you will struggle to breathe. You will experience pauses in your breathing due to a blocked airway.

Each sudden micro-awakening will lead to an increase in the arterial pressure and cardiac rate. This will result in a lot of strain on your heart.5

Here is that way it works:

  1. as your brain detects oxygen levels’ drops,
  2. it will “tighten” the vessels to increase blood pressure,
  3. to improve the oxygen supply.

You now understand why OSA will increase your risk of developing cardiovascular diseases.

The mechanisms via which the whole process happens, are not entirely understood. But treating OSA has the potential to diminish such risk.6

Let’s now look at hypertension.

Does OSA influence hypertension?

Different studies have focused on the connection between OSA and blood pressure.

Patients with OSA are often also obese and have other co-existing diseases as well.

How does that pose a challenge?

Because you need to gauge which part of blood pressure increase is due to your:7

  • OSA,
  • obesity,
  • or to an interaction between these.

But, authors believe that there is a strong association between OSA and hypertension.8

An estimated 50% of patients with hypertension suffer from concomitant OSA.9

You will thus be much more likely to present OSA if your blood pressure is high.

And if you are in doubt, think about this for a moment. If you suffer from hypertension, then the American Academy of Sleep Medicine (AASM) advises that you be evaluated for sleep apnea.

The AASM suggests contacting a board-certified sleep medicine physician for this.

Do you understand why?

It’s simple! They consider the clinical evidence showing an increase in OSA amongst patients with hypertension, to be overwhelming.10

Let’s now look at the link between OSA and hypertension.

The mechanism via which it probably affects your blood pressure is not entirely understood.

But, the drops in your blood oxygen levels during your nightly apneas probably play an essential role.

Your brain detects these drops via appropriate receptors. It will then signal your vessels to constrict (via the nervous system).

And constriction helps to increase blood flow to:

  • the organs,
  • the brain,
  • and heart especially.

And that is easy to understand.

Unfortunately, often, your blood pressure will remain high also during daytime.

And this despite your breathing is back to normal.

That is more surprising, right?

This phenomenon is probably due to different mechanisms. These are triggered by the low oxygen levels you experience during your sleep.

Are you wondering if you need to treat your OSA to keep your hypertension under control? If so, then read Does treatment with CPAP continue to influence hypertension in OSA patients?

Let’s now delve into another specific cardiovascular disease… heart failure

Heart failure and OSA

But what exactly is heart failure?

Not exactly a minor issue, as you already know.

It is a condition in which the heart can’t pump enough blood to meet the body’s needs.

Image comparing a normal heart with healthy muscle to an enlarged heart with a weak muscle and thus prone to failure
Heart failure due to a weak heart muscle

In some cases, not enough blood can fill the heart.

In other cases, the heart can’t pump blood to the rest of the body with enough force.

Some people have both problems.

The relation between OSA and heart failure is well understood … right?

Wrong!

Unfortunately, this patient population suffers from other diseases. Hence, understanding the relation is difficult.

But some things are known. For instance, studies in populations have shown that, if you have heart failure:11

  • the chance of having OSA exceeds 50%,
  • OSA can worsen the course of the disease increasing associated illnesses and mortality.12

Now, let’s talk about coronary heart disease and OSA.

How are OSA and coronary heart disease related?

You probably already know what coronary heart disease is.

But if it is a bit fuzzy, here is a refresher explanation.

It is a disease characterized by:

  1. a slow process that hardens and narrows the arteries, which provide oxygen-rich blood to your heart muscle,
  2. via the build-up of a waxy substance called plaque,
  3. which gradually reduces the diameter of these vessels.

Narrow coronary arteries can become blocked, and lead to heart attacks.

Heart attack, atherosclerosis: healthy, damaged heart, blood vessel section with fatty deposit, narrowing, and final blockage due to blood clot.
Heart failure due to atherosclerosis, blood vessel narrowing, and blockage.

Studies (case-controlled) have shown that OSA was very frequent in patients with coronary heart disease.13 14

But, as if that were not bad enough, …

… patients treated with a stent for coronary heart disease had poorer results if they also had OSA.

This group of patients showed higher:15

  • cardiac death,
  • reinfarction,
  • re-narrowing of coronary arteries after stent implantation,

than those without OSA.

So, should you seek treatment for your OSA, if you are suffering from coronary heart disease?

Check: Is it beneficial to treat OSA with surgery or CPAP if you suffer from coronary heart disease (CAD)?

… to discover the answer.

Let’s now learn about OSA and stroke.

Does OSA influence your risk of a stroke?

16 17

Image of the blood vessels in the brain - cerebrovascular disease or hemorrhagic stroke.
Cerebrovascular disease or hemorrhagic stroke

Given the frequency of strokes, the relation between a stroke and OSA is well established (?)

Wait, it is not so simple.

It is still unclear how and if sleep apnea causes a stroke.

However, yes … unfortunately, sleep apnea does increase your risk of suffering from a stroke.

Large studies have shown that you will be more likely to suffer from a stroke in the future if you have sleep apnea.18

This is true even after discounting other factors that may increase your chances of having a stroke, like19:

  • high blood pressure,
  • smoking status,
  • diabetes mellitus,
  • high cholesterol,
  • atrial fibrillation (irregular heartbeat).

Read on to discover how OSA affects your chance of recovery from a stroke.

Does OSA influence the potential for recovery after a stroke?

The answer is a resounding yes20, unfortunately.

OSA may in fact:

  • Negatively affect the potential for recovery in stroke patients.
  • Increase the length of time spent in a hospital and the risk of death.

And what about sudden cardiac arrest?

Next…

Does OSA influence the risk of sudden cardiac death?

Again, the answer is … yes21.

Irrespective of whether:

  • You are obese or overweight,
  • or suffer from other risk factors,

OSA increases the risk of a heart attack.

Interestingly, people with OSA have a peak in sudden death from cardiac causes during sleeping hours.22

But what is so special about that?

Well, it is exactly the opposite of the rest of the population:

  • Here a heart attack happens mostly during the morning hours, after waking up.
  • The lowest risk is during sleep (i.e., from midnight to 6 a.m.).

Finally, a study in a population of 10,701 adults who underwent polysomnography showed worrying results. It showed that sudden cardiac death was much higher among severe OSA patients.

These were subjects who stopped breathing or had shallow breathing more than 20 times an hour during sleep.23

And now, last but not least among cardiovascular diseases, let’s look at irregular heartbeat and sleep apnea.

Does OSA influence irregularity of heartbeat?

Problems with the rhythm of your heart can be life-threatening.

And if you are apneic, how will that affect your heart’s behavior?

Normal and abnormal heart rates: activation of atria ventricle recovery wave; chart of normal, fast, slow, irregular heartbeats
Regular and irregular heartbeats

You have probably already guessed the answer.

If you suffer from OSA, then things get worse, and your risks of irregular heart behavior are higher.

You will be more likely to suffer from:

  • An irregular heartbeat,
  • and irregular traveling of electrical impulses through your heart (which cause it to beat).

This will be true for both:

  • Atrial fibrillation (irregular heartbeat),
  • and bradycardia (slow heart rate).

A study found that if you suffer from severe sleep-disordered breathing:

  • you will have 2-4 more chances of suffering from complex arrhythmias,
  • than if you don’t suffer from sleep-disordered breathing.

This was true after correcting (discounting) for other factors that could influence the observations such as24:

  • age,
  • sex,
  • concomitant coronary heart disease …

And, unfortunately, these are not good news since:

Also, if you undergo cardiac ablation, you will have a 25% higher risk of having your atrial fibrillation return, if you also suffer from OSA.25

Now dear reader, given what we just read, it makes perfect sense to treat OSA, in case you were suffering from an irregular heartbeat.

Wouldn’t you agree?

Learn more by visiting: Does treatment of obstructive sleep apnea (OSA) reduce cardiac arrhythmias?

Let’s now move out of cardiovascular diseases and learn about OSA and diabetes.

How are OSA and diabetes 2 related?

Before answering that, here is a brief recap of the difference between diabetes Type 1, Type 2 and impaired glucose tolerance:

  1. in diabetes Type 1, your own immune system attacks your pancreas (autoimmune disease). As a result, it stops producing insulin.
  2. Instead, if you suffer from diabetes Type 2:
    • your pancreas produces insulin to a certain extent;
    • these amounts may not be enough for your needs, or your cells may not use them efficiently (have become resistant).
Image showing diabetes 2 at cellular level: cellular receptor to insulin loses its sensitivity and the channel for glucose uptake closes
Absorption of glucose at cellular level for a healthy subject and for a diabetes 2 patient.

Diabetes Type 2 is often linked to obesity and concerns approximately 90% of diabetic patients26.

Finally, if you suffer from impaired glucose tolerance, then:

  • just like in diabetes Type 2, your body is less sensitive to insulin,
  • and your blood glucose levels are higher than normal but below those of a diabetes Type 2 patient.

Okay, it is now time to sharpen your mind to analyze the relationship between OSA and diabetes.

Studies have shown that:27 28 29

  • If you have OSA, you are more likely to suffer from impaired glucose tolerance and diabetes Type 2.
  • Respectively 50% and 30% of patients with OSA have impaired glucose tolerance and diabetes Type 2.

This is true independently of age and obesity.

Also, nondiabetic patients with OSA are at increased risk of developing:

  • insulin resistance
  • and diabetes.

Finally, most studies show that more than half of patients with Type 2 diabetes have some degree of OSA.30

Now, here is an interesting fact. A recent study of 131 patients diabetes Type 2, 70.2% of which had hypertension, showed that:

  1. Diabetes-related complications such as:
    • retinopathy,
    • neuropathy,
    • nephropathy,
    • or coronary artery disease,

    were present in 55.5% of the patients.

  2. Those with moderate-to-severe OSA were 3.05 times were more likely to suffer from these.

This relationship was mediated by the presence of hypertension.31

But before we go on, here is an important piece of information for you….

…. The American Academy of Sleep Medicine (AASM) considers that the clinical evidence showing an increase in OSA amongst Type 2 diabetes patients is overwhelming.

As a result, they advise anyone with Type 2 diabetes (or hypertension for that matter) to be evaluated for sleep apnea by a board-certified sleep medicine physician.32

But why these associations between diabetes Type 2, glucose intolerance and OSA?

Frankly, the reasons are not well understood though some explanations could be:

  • Because of sleep interruptions or intermittent sleep, OSA leads to a lack of oxygen (hypoxia) and poor rest.
  • This can alter the way your body processes glucose and increases your risk of developing Type 2 diabetes.

Just like obesity is a risk factor for OSA, it is also a risk factor for diabetes. This could be part of the explanation.33

You may also be interested to read: Can OSA treatment help diabetes type 2 patients or patients with abnormal glucose levels?

We touched upon hypertension, OSA and diabetes. It is now time to take a more in-depth look at how cardiovascular diseases are also associated with diabetes and OSA.

How are OSA, diabetes Type 2 and cardiovascular diseases related?

If you were to suffer from diabetes Type 2, the major potential causes of death would be?

If you thought cardiovascular diseases, you have the right answer.

They account for 50% of deaths amongst diabetic patients and lead to many types of disabilities34.

For instance, as a Type 2 diabetic patient, you would be twice more likely to have a heart attack or a stroke, than a healthy person.

Now, do you see the link with diabetes, cardiovascular diseases, and OSA?

OSA increases both the risks of:

  • Cardiovascular diseases (hypertension, heart failure, stroke, coronary heart disease, and arrhythmias).
  • Diabetes Type 2, which as we have just seen increases the risk of cardiovascular diseases.

Hence, if you suffer from sleep apnea, then you need treatment to prevent diabetes Type 2, and cardiovascular diseases, but….

…… even more so if you already suffer from diabetes Type 2 because you will be more at risk for cardiovascular diseases.

Unfortunately, the story does not end here. OSA is not only associated with increased risk for many diseases.

It is also associated with accidents.

And that is easy to understand right?

Sleepiness is a real threat to our safety when we drive.

Funny image of 2 chihuahuas driving a scooter. The co-pilot seems very drowsy but the pilot remains focused on the road.
Two chihuahuas driving a scooter. Fortunately, the pilot seems more awake than the co-pilot!

Does OSA increase the chance of a motor vehicle accident?

Driver sleepiness contributes to almost 20% of all serious car crash injuries. And that is independent of alcohol consumption.35

These statistics speak for themselves, don’t you think?

And if in doubt … a study in Spain confirms these findings. It shows that with untreated OSA, you will be six times more likely to have a traffic accident.36

The cause is most probably drowsiness, and lack of concentration.

This was also suggested by another study. It showed that, if you are sleep deprived, your driving performance will be akin to driving after alcohol consumption.37

Finally, one last study showed that fall-asleep crashes and alcohol-related crashes were comparable in terms of fatalities and serious injuries.38

Are you curious to learn how many motor vehicle accidents could be avoided by treating OSA? Is so, then continue reading.

You will see that the numbers are astounding.

How many lives would be saved if apneic patients were treated with CPAP?

This information is available to us, thanks to a 2004 study.

They estimated:

  • the number of OSA related collisions,
  • their costs in human lives and dollars.

But they did not stop there.

They also estimated the human lives saved and monetary savings, by treating apneic patients with CPAP.

Here is a quick summary of the year 2000 data in the United States:

  • 800,000 motor-vehicle collisions were OSA related.
  • 1,400 human lives were lost with a cost of 15.9 billion dollars.

Treating apneic patients with CPAP would:39

  • save 980 lives annually,
  • cost about 3.18 billion dollars/year,
  • but save 11.1 billion/year.

Now, OSA is also a cause of work-related accidents.

Curious to learn more?

If so, then jump over to the next section.

OSA and work-related accidents

OSA engenders daytime sleepiness.

You and I can easily infer that productivity at work will suffer.

Unfortunately, it does not stop there.

The injury rate or the chances of a work accident also increase.

By how much?

A review article, which analyzed 7 published studies, provides a useful answer. It concludes that “the odds of a work accident was found to be nearly double in workers with OSA.”

No wonder why the same authors strongly suggest that you should get screening for OSA in the workplace, in case your daily work is safety-sensitive.40

We talked about OSA and fragmented sleep.

But what about insomnia?

You may surmise that since OSA decreases the quality of your sleep, then there may be an association with insomnia.

If that is of interest to you, then stay with us and read on.

How are OSA and insomnia related?

According to sleep medicine dogma, insomnia is a sleeping disorder and so is OSA.

But did you know that the two often co-occur?

Research shows that 39%-58% of OSA patients also suffer from insomnia symptoms.

Likewise, 29%-67% of patients with insomnia also have OSA (apnea-hypopnea index > 5).41

Although cooccurrence does not imply a relationship of cause and effect, I am sure you are wondering about whether this link exists.

And if so, which comes first?

Does OSA cause insomnia or does insomnia cause OSA?

A 20 insomnia patients pilot study, run by Dr. Barry Krakow, sheds some light on this issue.

Patients’ selection excluded all those with signs or symptoms of sleep-disordered breathing (SDB).

The selection was based on physical traits or on patients’ answers to the Epworth Sleepiness Test.

Now, before the study, all patients identified their awakenings to:

  • uncertain cause (50%),
  • nightmares (45%),
  • nocturia (35%),
  • bedroom distractions (20%),
  • or pain (15%).

None of them identified breathing symptoms as a cause of their waking up.

Reason why the results of the study were startling:

  1. To everybody’s surprise, 90% of awakenings were preceded by:
    • sleep breathing events such as apnea,
    • hypopnea,
    • or respiratory effort-related event.
  2. 18 of the 20 patients woke up because of sleep-disorder breathing (SDB).
  3. Of these patients, 11 suffered from OSA since they had an average AHI of 14.4 (an AHI of 15 is a sign of moderate sleep apnea).42

Dr. Krakow explains, during an interview, that the number of insomniacs suffering from sleep breathing disorders is extremely high:43

  • >90% for those complaining that their sleep aids do not work.
  • Close to 100% for insomniacs with middle-of-the-night awakenings.

So, to conclude, if you are an insomniac who wakes up during the night then the cause may be OSA.

The good news is that OSA can be treated, and you stand an excellent chance of regaining a good quality sleep.

But OSA can influence the quality of your life in other ways… jump over to the next section to find out how.

OSA and erectile dysfunction (ED)

Not one, but several studies point to an important occurrence of ED among men suffering from OSA.

But how important is this occurrence?

The range is between 47,1% and 80%.

So, your partner’s snoring, or yours for that matter, may not be the only reason why OSA could influence your relation.

Also, the degree of severity of your OSA seems to play a role in the development of ED.

This seems to be associated with the importance of the decrease in blood oxygen levels. The frequency of apneas or hypopneas seems less important. 44

The exact mechanism, which could explain the association between OSA and ED, is unclear.

But studies have shown that testosterone drops with:45

  • an increasing number of apneic events during sleep (increasing AHI),
  • and decreasing oxygen levels in the blood.

We advise you to also read: Can treating OSA improve your erectile dysfunction (ED)?

Now, we are going to look at OSA and mood disorders.

How does OSA influence mood disorders?

Fatigue and depression may be associated with OSA.

And you know this is hugely important because depression is not just about feeling sad now and then.

Instead, the following symptoms may become pervasive, if you suffer from depression:

  • a feeling of anxiety,
  • loss of energy and pleasure for things you used to enjoy,
  • difficulty in concentrating,
  • sadness,
  • hopelessness.
Funny image of an alpaca with a bizarre hair.
An alpaca with funny hair. A good laugh is the best way to fight against sadness and anxiety.

But how exactly is depression related to OSA?

Although the mechanism is not clear, disturbed sleep is probably one of the reasons.

If you have read this guide until now, you know that OSA leads to a poor-quality sleep.

Now, we all know how grumpy we can become after a night without proper sleep.

It is not difficult to accept that chronic inadequate sleep can wreak havoc in our capacity to cope with daily stress. This leads to lifelong mood problems.

Good solid sleep is critical to coping with the stress of modern living’s accelerated tempo.

In the presence of poor sleep caused by OSA, your brain will be less and less capable of managing stress.

Like any other organ, it will feel more and more exhausted. It will show symptoms of fatigue and depression during the day.

If in doubt about the influence of lack of sleep on mood, an 800 subjects study46 provides some useful information.

Whilst ensuring an equal balance between genders, it suggests a link between insomnia and depression.

It shows that people with insomnia have:

  • greater depression levels by a factor of almost 10 than those whose sleep was normal,
  • greater anxiety levels by a factor of 17, than people not having insomnia.

Now, insomnia symptoms include:

  • struggling to fall asleep (onset insomnia),
  • difficulty in staying asleep (maintenance insomnia),
  • drowsiness during the day,
  • and unrefreshing sleep.

The authors report that depression is highest among subjects who suffer from the first two symptoms at the same time.

So, if you only suffer from one (or a mixed form), you are less at risk.

By now you are probably thinking this is intriguing, but you may also be a little skeptical.

After all, is there any reliable data pointing to a link between depression and OSA?

Yes, there is data, thanks to a 18,980 subjects study.

Those with depression were found to be 5.26 more likely to also suffer from SDB. Now, OSA is the most common form of sleep-disordered breathing.47

Investigate further by reading also Does treating obstructive sleep apnea (OSA) decrease depressive symptoms?

Let’s now move on to a widespread disease – obesity – and see how that is associated with OSA.

How does obesity influence OSA?

First things first. Before we look at the link between OSA and obesity, you need to know if you are obese or overweight.

To be classified as either one or the other, you need to weigh too much in relation to your height.

But how do you know how much is too much?

After listening to your spouse or partner’s pleas to lose some weight, do you want to know whether she or he is right? The Body Mass Index (BMI) can come to your rescue.

Body Mass Index formula where BMI is equal to one's weight in kgs divided by one's height squared (in squared meters).
Body Mass Index Formula

The BMI is quite simple to calculate

It is your weight (in kgs) divided by your height squared. So, the units are (kgs/m2).

You can use a simple smartphone’s app or surf the web to find a site that calculates it.

If you are an adult, then overweight is defined as IMC ≥ 25 Kg/m2 and obesity as IMC ≥ 30 Kg/m2.

BMI or Body Mass Index infographic chart showing values for normal, overweight, obese, and morbidly obese subjects
BMI or Body Mass Index

Now, let’s investigate the relationship between obesity and OSA.

The former is indeed a significant risk factor for sleep apnea.

Why?

It has to do with fat accumulating around your neck and pharynx. It will narrow your superior airways (nose and throat) when you sleep.

So, if you are not obese, then you have total peace of mind?

Not so fast, because OSA is also observed in non-obese patients, for instance, those with enlarged tonsils.

But obesity remains an important risk factor for OSA.

Another explanation about why OSA and obesity are related is poor sleep quality.

There may even be a vicious circle between obesity, OSA and sleep deprivation.

How?

Let me explain.

Studies have shown that there may be a link between sleep deprivation and obesity. And we know that OSA causes sleep deprivation.48

This happens because disturbed sleep influences the hormonal mechanisms that regulate hunger and fullness.

Although further studies are required, poor quality or insufficient sleep may:

  • Stop you from feeling full.
  • Lower your daily energy expenditure by decreasing a hormone called leptin.
  • Increase unnecessary food cravings (e.g., for sweet snacks) may result.
  • Boost your appetite by increasing a hormone called ghrelin.
  • Decrease your likelihood of exercising, because you will feel tired.
  • Lead your body to secrete more insulin after a meal, which will increase sugar storage and thus your weight.

So, all this may lead to a vicious circle since:

  1. obesity affects OSA,
  2. which leads to fragmented sleep,
  3. and poor sleep may, in turn, affect obesity.

Before reading on, you may also want to check Weight Loss by Bariatric Surgery

In the next section, we will analyze the link between OSA and cancer. This is the second leading cause of death globally.

How does OSA affect the risk of cancer?

For those used to read about OSA and its associated diseases, hearing about a potential link with cancer may come as a surprise.

As we have seen above, several studies have shown an association of OSA with:

  • depression,
  • hypertension,
  • early death cardiovascular disease,

but never with cancer.

That is, until Dr. F. Javier Nieto, an expert in sleep epidemiology, published an important paper (in 2012)49.

The publication is about sleep-disordered breathing and cancer mortality.

The lead author was less surprised than his readers by the findings, which showed:

  • a 4.8 higher incidence of cancer deaths in patients with severe SDB (AHI ≥ 30) versus a healthy population,
  • and 2.0 increased risk for moderate SDB (15 ≤ AHI ≤ 29.9),

in a 22-year mortality follow-up of 1,522 subjects chosen randomly from Wisconsin state employees.

The author’s reactions can be easily explained. Previous studies done in animals (and in vitro as well) had indicated that intermittent lack of oxygen promoted tumor growth.

It is still very early to say OSA causes cancer or contributes to its growth. More research is needed for this. Though the study is important because it shows a correlation for the first time.

Let’s now look at how OSA may affect your mental capacities such as:

  • concentration,
  • memory,
  • and problem-solving.

How does OSA affect you’re your mental capabilities (cognitive functions)?

Even mental processes are affected!

We know how you feel: OSA seems to have pervasive health effects.

If you think about it though, OSA implies a fragmented sleep. So common sense tells us that it must impact our mental functioning somehow.

A review sheds some light on how OSA negatively impacts mental processes.50

OSA results in:

  1. attention/vigilance deficits;
  2. delayed long-term visual and verbal memory;
  3. disturbed visuospatial/constructional abilities such as:
    • assembling different parts of an Ikea furniture,
    • or building something with Lego,
    • making a bed,
    • buttoning a shirt,
    • drawing, …;

    Funny image of a dog with glasses, wearing a tie and reading a newspaper.
    Dog with strong mental capabilities

  4. impaired executive function such as:
    • gathering information,
    • evaluating or changing behavior in response to the environment.

Language ability and movement during conscious mental activity (psychomotor functions) were instead found to be unaffected by OSA.

CPAP treatment of OSA appeared to improve:

  • executive dysfunction,
  • delayed long-term verbal and visual memory,
  • attention/vigilance,
  • and global conscious mental processes (cognitive functioning).

Another study supports the theory that disordered breathing accelerates memory loss.51

A study with a group of 2500 Alzheimer patients, aged between 55 and 90 years, showed interesting results. Memory declined 10 years earlier among those who had breathing problems such as snoring or sleep apnea.

How bad was the memory loss? Was it enough to prevent daily routine activities?

Albeit noticeable to their surroundings, fortunately, the loss was only mild.

It translated into forgetting recent events for instance.

Those who had been treated by CPAP instead behaved like those without breathing problems.

Their mental decline was as the same as the group non-affected by breathing disorders.

Also, Alzheimer development occurred 5 years earlier amongst untreated patients with breathing problems.

Lower oxygen is not the only factor that can explain these observations.

Lack of sleep could also cause an earlier onset of Alzheimer disease.

How?

By preventing the brain from eliminating toxins.

This is a process, which can only occur during deep sleep.

Since we talked about Alzheimer, let’s now look at its relationship with OSA.

How are OSA syndrome and Alzheimer disease related?

Did you know that Alzheimer and OSA show considerable overlap in the population?

What this means is that:

  • if you suffer from one of the two,
  • then you are more likely to also suffer from the other.

Although some suggest a link between the two, the mechanism is not understood.52

An article reviewing many published studies (meta-analysis) reports some interesting facts. It reveals a potential mechanism.53

Let’s analyze the facts.

The review shows that if you are a patient with Alzheimer disease, then you will be five times more likely …

Yes, you understood correctly,

… five times, more likely of presenting OSA than individuals of similar age with normal mental functions.

By mental functions we mean:

  • memorization,
  • processing thoughts,
  • decision-making,
  • learning,

The authors highlight that approximately half of the patients “have experienced OSA at some point after their initial diagnosis.”

They conclude by saying that if you are an Alzheimer patient, changes in:

  • sleep quality and structure,
  • cerebral blood flow,
  • the presence of unstable molecules that damage cells (oxidative stress/free radicals),

may contribute to a decline in your mental functions worsening your disease.

Final Remarks

If you have found this article interesting, or if you want to learn more, then ….

… Do not stop here!

Instead, consider also the following readings:

These are all in-depth articles of several thousand words, all based on the most recent scientific findings.


Bibliography

Obstructive Sleep Apnea: The Definitive Guide for 2019.

Reviewed by Dr. Joseph Salim, DMD (written by the Sutton PDA editor)

Introduction

Do you ever ponder about your breathing or sleep?

Usually not, right? Because these are automatic activities for someone in good health.

But if you belong to the 18 million Americans suffering from sleep apnea, according to the National Sleep Foundation, then you probably do.

The term apnea describes breathing pauses of ten seconds or more.

Sleep apnea is an ever-increasing issue in modern society.

Can you think why?

If you thought obesity and overweight, then you guessed right.

The medical community recognizes that there is a clear link between excess weight and sleep apnea.

The stereotype snorer, in comedy routines and silly cartoons, is someone overweight with a short and sturdy neck.

And may I hazard a guess? You are probably thinking that if this overweight, sturdy neck person snores very loudly, then he is likely an apneic patient.

This may not be true though, and obstructive sleep apnea (OSA) can also affect thin people who do not snore.

So, you should feel concerned, whether you do or do not have the "physique du role", especially if you often feel drowsy during the day.

And this is because daytime sleepiness is not the only consequence of obstructive sleep apnea (OSA).

A study over 18 years, in 1522 individuals from the general population, reported some shocking results.

People with severe, untreated sleep-disordered breathing died 3.8 times more often than those without.1

And these results, while alarming, may not be so surprising after all.

Untreated OSA deprives your brain, organs, and tissues of oxygen as you sleep.

Yes, oxygen! Nothing else!

No wonder, so many serious health effects are associated with OSA.

The decreased blood oxygen levels can affect how some internal organs’ function. They can also worsen other pathologies.

Read on to understand OSA, as well as the consequences of oxygen deprivation and fragmented sleep on your body.

 

Of snoring and sleep apnea

What is snoring?

When you rest at night, your uvula and soft palate tissue relax, become flabby and lose their tone.

Because of your horizontal position, gravity pushes them against the rear part of the mouth, along with your tongue.

Your snoring results from the vibration of your soft tissues:

  • uvula,
  • soft palate,
  • pharynx,

as you inhale air, like sails flapping in the wind.

The vibration of partially obstructed respiratory structures during sleep results in snoring
Snoring

How frequent is snoring?

According to the American Academy of Otolaryngology-Head and Neck Surgery, your chance of being a habitual snorer is 25% percent.

Interesting fact: this number goes up to 45% if one also includes occasional snorers.2

And if you have children, then consider that 10% of them snore regularly.3

But what about its impact on your health? … Read on to find out.

Is snoring a health issue?

Good news...
….. it is not a health issue per se and rarely does it occur with sleep pauses.

So, when should you seek medical advice?

If your sleeping shows alternate periods of snoring and moments of silence lasting a few seconds up to a minute where you stop breathing.

Then you may be suffering from sleep apnea, and if you do, your health may be affected.

The louder the snoring, the higher the chances that you may suffer from sleep apnea.4

Check the next sections to learn about sleep apnea.

Is snoring the same as sleep apnea?

Nope, they are different.

And that's true, despite the loud snoring of most people with obstructive sleep apnea (OSA).

Sleep apnea consists in an obstruction of your upper respiratory airways. This can be either complete or partial.

And obstruction implies breathing efforts!

In other words, your body will start struggling to maintain the airflow. This will be either absent or significantly reduced.

As explained above, snoring instead can happen without sleep apnea.

Your snore could be loud even without any obstruction.

So, do not confuse the two!

How many types of sleep apneas are there?

The most common form is Obstructive Sleep Apnea (OSA). Hence, throughout this web site, we will use the term "sleep apnea" to refer to OSA.

However, there exist two other forms, albeit less frequent, called central or mixed apnea.

Let's take a closer look at their different characteristics.

What is obstructive sleep apnea (OSA)

OSA is a sleep disorder where you have involuntary breathing difficulties that disturb sleep.

Apnea means "no breathing."

Yes, nothing else!

Just by judging from its name you know it is a serious disease.

OSA is an ongoing condition (chronic) where you suffer from an abnormal high number of:

  • reductions of respiration (shallow breaths) also called hypopneas,
  • repeated interruptions of breathing during your sleep (hence the name "apnea"),

that occur during your sleep.

Muscles always relax when you fall asleep.

But as a sleep apnea patient, this leads to your soft palate narrowing or blocking of the airways at the back of your mouth.

During your sleep, this repetitive process causes:

  • a partial decrease in airflow (hypopnea)
  • or a complete airflow cessation.
Image comparing a woman's free respiratory airways to her blocked airways. The obstruction leads to sleep apnea.
Obstructive sleep apnea results from obstructed respiratory airways

Also, it will invariably lead you to snore more loudly, and even make choking sounds as you attempt to breathe.

Interesting facts:

  • These breathing pauses last 10 to 30 seconds or more … even 1 minute!
  • They can happen hundreds of times a night despite your breathing efforts.

And so, if you are guessing that your sleep will be lousy ... well, you guessed correctly!

You will indeed suffer from poor quality sleep because of repeated short sleep disruptions.

Because of shallow breathing or breathing interruptions, you will repeatedly switch from deep into a light sleep.

The quality of your sleep will plummet.

Throughout the night, you will awake partially to resume breathing.

You may find yourself with:

  • your heart beating faster,
  • sitting in your bed,
  • making an effort to free your upper airways.

Your respiratory reductions or interruptions will cause a lack of oxygen. This will lead your brain to trigger a reaction to overcome the problem.

The breathing pauses, and shallow breaths will generate sudden drops in your blood oxygen concentration. This could be down to 40% if you suffer from severe OSA.

Also, surprising fact, you usually won't recall the events on the following morning.

Why?

Because you were usually not fully awake.

But, you will not feel refreshed and rested because of the repeated sleep interruptions throughout your sleep cycle.

As you may be surmising already, this will impact your daily life and health.

Check the next sections to discover how.

What are the likely consequences of OSA on your daytime activities?

It is unfortunate, but it is a fact: OSA will significantly affect your daily life.

Poor quality sleep will make you doze off during the day. You will struggle to concentrate, losing out on efficiency.

At times, you will also be unable to avoid falling asleep.

Your risk of having car accidents will also be seven times higher versus those who do not suffer from OSA (see Does OSA increase the chance of a motor vehicle accident? if you want to learn more).

Hence, it is important to understand how severe your OSA is.

But how do doctors assess its severity?

Jump to the next section for the answer.

What is the apnea-hypopnea index (AHI)?

It is a score used to assess the severity of your obstructive sleep apnea.

It captures:

  • the number of apneas or hypopneas (also called partial apneas or shallow breaths),
  • during 1 hour of sleep,
  • measured via a polysomnographic machine.

The results are expressed via an index called apnea-hypopnea index [AHI].

And it is quite useful.

Do you know why?

Doctors will use this index to assess the severity of your disease.

For instance, the American Academy of Sleep Medicine states that you will be diagnosed with OSA provided some criteria are met.

And these criteria include your AHI.

To be diagnosed with OSA, your apneas, hypopneas (and sleep-interruptions with breathing efforts), must be:

  • at least equal to 15 events/hour,
  • or at least equal to 5 events/hour provided they occur at the same time as certain symptoms.

Doctors must use a polysomnographic machine to measure these events.

Image of a dog looking very drowsy and about to fall asleep
Daytime sleepiness

The criteria referred to above, also include5:

  • falling asleep against your will during times when you are awake,
  • daytime sleepiness,
  • waking up with choking or suffocation sensations,
  • insomnia,
  • description (e.g., by one's spouse or partner) of significant snoring or breathing interruptions during sleep,
  • tiredness.

The severity of OSA depends on the measurement of the combined number of apneas and hypopneas per hour of sleep. This is also referred to as the apnea-hypopnea index (AHI), if6:

  • AHI is between 5 and 15, then obstructive sleep apnea is mild;
  • AHI is between 15 and 30, then it is moderate;
  • if AHI > 30, then apnea will be severe.

Let's now talk about the less frequent types of sleep apnea.

How do central, mixed or OSA differ?

As explained above, during OSA, your respiratory tract will collapse or get blocked during your sleep.

This slows down or interrupts breathing.

When you try to breathe, the air flowing through the obstruction will cause you to snore.

But how does central apnea differ?

Well, central sleep apnea is caused by a nervous system dysfunction. So, it is very different from OSA.

The area of the brain controlling breathing will transiently stop functioning. It will cease sending the correct nervous signals to the muscles in charge of your breathing.

Hence your body "will forget" to breathe during some very short instances.

If you suffer from central apnea, your pauses in breathing will occur without any effort to breathe.

Now, your likelihood of suffering from central apnea will increase if you:

  • suffer from certain pathologies like cardiac insufficiency, stroke, and renal insufficiency,
  • and if you take certain medications.

If you have central apnea, you will not suffer from frequent, ongoing snoring.

Why?

Simple! Because there is no airflow whatsoever.

Pure central apneas are rare.

OSA most often accompanies them, hence the term mixed apnea.

We said that pure central apnea is rare, but how frequent is OSA?

You will find the answer in the next section.

How frequent is OSA amongst adults?

To begin with, here is an interesting fact: out of 10 people suffering from apnea, 9 actually suffer from OSA.

You understood correctly.

OSA is much, much more frequent than all other apneas.

Reason why, during the rest of this article, we will focus on OSA.

But how many individuals does OSA affect in the population at large?

According to a recent source, those with moderate to severe OSA (with an apnea-hypopnea index ≥15 events/hour) are

  • 10% among 30-49-year-old men;
  • 17% among 50-70-year-old men;
  • 3% of 30-49-year-old women;
  • and 9% among 50-70-year-old women.

The statistics speak for themselves.

They show with clarity that it is more frequent in men and in older age groups.7

And these numbers are higher among obese subjects.

A surprising fact is the underdiagnosis of the majority of OSA sufferers!

The findings from a 1997 study are revealing.

These showed that8:

  • out of a sample of approximately 5000 patients employed adults,
  • 93% of women and 82% of men with moderate to severe sleep apnea
  • had not been clinically diagnosed.

This is probably because:

  • no blood tests exist to diagnose sleep apnea,
  • and it is not easy for your general practitioner to detect it during regular medical check-ups.

We have seen the statistics for adults, but what about children?

Next ...

How frequent is OSA amongst children?

Luckily, little patients are less affected than adults.

1%-4% of this population suffers from the disease.

But OSA is more frequent amongst boys than girls.9

Is OSA observed irrespective of age, within this young population?

Nope. OSA is more frequent among 2-8 years old children, and 12-16 years old adolescents.

But it affects all ages somehow. All the way from few-month-old babies to 18 years-old young adults.


Obstructive sleep apnea (OSA): signs, symptoms, risk factors and health impact

Are you at risk of developing sleep apnea? What are the risk factors?

Quick question: what are some of the characteristics, easy to identify, that will quickly let you gauge whether you are at risk for OSA?

…. Increased waist circumference and a large and short neck.

A short neck will tend to have a reduced airway passage.

And as for its size, it depends on your gender:

  • if you are a man with a circumference of 17 inches (43 cm) or more, then your airways will be narrower;
  • if, instead, you are a woman, a neck circumference of 16 inches (40 cm) or more you will make you more likely to present OSA.

Another neck related risk factor is excessive skin between your chin and neck. This is also known as turkey neck.

close-up portrait of a turkey with large flaps of red skin hanging off its chin
Turkey neck with large flaps of red skin

But, really, anybody can suffer from OSA.

Let's now look at the rather long list of risk factors. These may interfere with the smooth functioning of your upper respiratory tract:

  1. If you are overweight or obese, your chances of presenting OSA will increase.
    Why is that you may wonder?
    Because the deposits of fat down the back of your throat, around the neck or chin.
    These increase if you are obese, and they will tend to obstruct your breathing.
    Obesity is considered the most important risk factor.
    Even a modest weight loss can improve the quality of your sleep.10 11
    If you are obese or overweight, you have 50% chances of suffering from sleep apnea.
    But there also many thin people presenting this syndrome, because they may have other risk factors – see below.
  2. Gender: if you are a male, your chances of presenting OSA are also higher. And even more so if you are older than 40.
    If you are a woman instead, the risk of suffering from sleep apnea will be half that of a man.
    Now, what happens with age?
    Well, this difference will decrease.
    During menopause the ratio will be almost the same: "Disordered breathing during sleep is more common among postmenopausal women than among their premenopausal counterparts. ... This is possibly due to the decline of levels of estrogen and progesterone."12
  3. As we have just seen, Age is also a factor irrespective of your gender.
    OSA is much more frequent in a population aged between 45 and 64 years.
    The risk further increases as you get older.
  4. A family history of OSA or snoring will also increase your risk of suffering from the same syndrome.
    Yes, there is a hereditary component for OSA!Unique genetic features determine the size and position of:
    • your jaw,
    • tongue,
    • soft palate,
    • tonsils,
    • or uvula.

     

    Anatomy of the human mouth showing the hard/soft palate, pharynx, uvula, tongue, lips, tonsils, nasal cavity.
    Anatomy of the human mouth (showing soft/hard palate, uvula ...)

    For instance, an undersized lower jaw (versus the upper jaw) is a risk factor that may lead to OSA.

    A small lower jaw will remain in a posterior position, and the upper respiratory airway will be narrower.13 14

  5. Your ethnic group will also play a role. Asians and Afro-Americans have a higher risk of sleep apnea15
  6. It is obvious that obstructions can also have an impact. These can be due to:
    • diseases of ear, nose, and throat (otorhinolaryngologic disease),
    • allergies,
    • past surgeries.

    All this leads to small airways and increased risk of OSA.

    For instance, a study showed that if you suffer from allergic rhinitis, then this will influence your OSA.

    OSAs will be longer and more frequent during a period of significant nasal obstruction than when symptoms are absent.16

    Results suggest that a high nasal resistance may influence the development of OSA (pathogenesis of OSA).

    Image comparing healthy versus inflamed sinuses. The inflammation of the mucous membrane and the accumulation of watery fluids block the airways.
    Rhinits: inflamed sinuses lead to an accumulation of watery fluids that block the airways.

  7. Sleeping with the mouth open is a sign.
    Are you surprised? Well, you should not.
    It is a sign of obstruction of the nasal airway.
    Nasal obstruction causes the jaw to drop. This reduces the diameter of your pharyngeal airway. As a result, your likelihood of presenting OSA will increase.
    Take this piece of advice: check with your family or bed partner if you are a sleeping mouth breather.
    You may indeed be suffering from OSA.
  8. Substances causing relaxation of your throat's muscles, such as:
    • alcohol consumption,
    • sedatives,
    • anti-anxiety medications,
    • sleeping pills

    These exacerbate sleep breathing issues and worsen your OSA symptoms.

    They will also increase the frequency and length of OSA events you may experience.

  9. Smoking If you are a smoker and you ascribe your OSA to be due to something else, then think twice! Because smoking also plays a role.
    You will be at higher risk for sleep-disordered breathing than if you do not smoke or if you have quit.17
    Smoking increases your likelihood to suffer from OSA by a factor of 2.5 or 3 versus non-smokers.18
    This may be due to an inflammation of the airways as well as fluid retention. They lead to a reduction of the volume available for smooth flow through the airways.
  10. You suffer from diabetes type 2 you are at risk for OSA.
    But if you expect a clear explanation, then you will be disappointed.
    The reasons are not well understood yet, but obesity most likely plays a role.
  11. Last but not least, enlarged tonsils and adenoids are also a risk factor for OSA.... And, you may have already guessed the reason ... decreased airways passage.

This leads us nicely onto the next section.

What are the risk factors of developing OSA for your children?

Enlarged tonsils or adenoids are the most frequent causes in a pediatric population.

As their size increases, the flow through the respiratory airways becomes more difficult.

But the good news for your children is that airflow can resume after removal of these tissues.

It is the best option to solve the problem, and the surgical procedure is quite standard.

Image of a man breathing freely and then suffering from respiratory failure du to large adenoids
Large adenoids obstruct airflow

Other risk factors for your children include:

  • obesity or being overweight,
  • a narrow face shape.

We have looked at the risk factors for OSA, but what about symptoms and signs?

You just need to read on to find out.

What are the symptoms and signs of OSA in adults?

Surely, you should be able to tell with ease if you have OSA … right?

…. Wrong!

Your relatives or your bed partner are usually the ones who can help you do so.

You will probably not realize you have breathing difficulties during your sleep unless you identify the symptoms.

The same goes for gauging how severe your sleep apnea is.

And, when it comes to symptoms, you can divide them into 2 groups: major and minor.

Major symptoms

The main one is frequent and loud snoring.

It is the most common symptom occurring in 70% to 95% of patients. 19 20

You may stop breathing during sleep. These pauses may interrupt your snoring. After the pauses, you may be panting or gasping for air.

When you sleep on your back, the pressure on your respiratory airways will be more important than if you sleep on your side.

Image of a puppy sleeping on its back
Puppy sleeping on its back

Hence, sleeping in a fetal position (on the side) will make your snoring less loud.

But, it cannot end your snoring if this was initially loud.

Will you snore every night?

Nope. Though it is likely that, with time, your snoring will gradually worsen and increase both in frequency and intensity (louder).

Another major sign of OSA is fatigue and feeling sleepy during your daily activities (work, travelling, etc.).

You will also find yourself struggling to avoid falling asleep during quiet times of the day.

Interesting facts:

  • Drowsiness will permeate and increase during the day while taking a nap will usually be of no relief.
  • You may even wake up more tired after a nap if apneic events interrupt it.

Minor signs and symptoms include:

  • a morning headache,
  • memory or learning problems,
  • struggling to concentrate,
  • irritability,
  • depression,
  • mood swings,
  • personality changes,
  • frequent nocturnal awakenings to urinate,
  • (as you wake up) sore-throat or dry mouth,
  • drowsiness and uncontrolled daytime sleepiness when you work or drive.
Symptoms of obstructive sleep apnea: fatigue, morning headache, insomnia, depression, mood swings, personality changes, dry mouth, sore-throat, ...
Symptoms of obstructive sleep apnea

Let's now see what the symptoms are in a younger population.

What are the symptoms and signs of OSA in children?

Little patients have somewhat different symptoms than adults.

Unlike them, they do not show sleepiness. Instead, they display restlessness and overactive reflexes.

As a parent you will also observe behavioral disorders that characterize a "real problem child" like:

  • hostile or angry behavior,
  • sudden mood change,
  • a tendency to cry easily.

Other issues will be present like:

  • Lack of attention at school, and poor school performance,
  • a tendency to breathe through their mouths (instead of their noses) during the day,
  • struggling to remember things they learned at school.

On the good side though, you will not have to worry about:

  • cardiovascular complications such as high blood pressure,
  • and excessive weight gain.

Final remarks

Since we broached the subject of health effects, let's now see how OSA can impact your health.

Jump over to Chapter 1: Obstructive Sleep Apnea (OSA) and its Health Effects, to delve into this fascinating subject.

However, you may also find our other chapters interesting:

Enjoy!


Bibliography

Annotated Resources Page: Sleep Apnea

(Note: this is not just another page of annotated resources - available on the web - about sleep apnea. It is somewhat special because we have added some extra data and information. Are you curious? ... Then continue reading to discover our secrets.)

Sleep apnea: a brief introduction

They say that life in a couple falls into two categories: delights or annoyances.

If your partner suffers from sleep apnea, then sleeping together …. well you know into which category it falls.

Sleep apnea is also called sleep-disordered breathing.

And that is for a reason since this disease is characterized by repeated shallow breaths or interruptions.

The most frequent type is called obstructive sleep apnea (OSA) where your upper airways collapse or become obstructed during sleep. This slows down or interrupts your breathing.

If your partner suffers from OSA, he will tend to snore and make choking sounds as he will try to breathe through the reduced or obstructed airways passage.

But if you or your partner snore, you do not necessarily suffer from OSA.

OSA is characterized by breathing pauses that can last between a few seconds and few minutes, and that can be quite frequent, up to 30/hour. After which, breathing usually resumes normally but is accompanied by loud snoring.

Guess how will all this affect your sleep's quality?

It will plummet as you move out of deep sleep into light sleep throughout the night.

No wonder you will feel so tired during day hours.

Sleep apnea is one of the major causes of daytime drowsiness.

As a result, you will be at a higher risk for car crashes, work-related, accidents and a number of associated diseases:

  • Abnormal heartbeats (arrhythmias),
  • Stroke,
  • Depression,
  • Alzheimer
  • Diabetes
  • ….

Sleep apnea is underdiagnosed because it is not possible to diagnose it via a medical check-up or with blood tests.

Besides your physical exam, your medical and family history, your doctor will also use data collected during a sleep study for a proper diagnosis.

What are the risk factors?

Well, if you are obese, overweight, male and if you have a family history of small airways then your risks will increase. Likewise, your children will be at a greater risk if they have enlarged tonsils or adenoids.

But, after this long list of worrisome information, here are some good news…. yes sleep apnea can be treated in different ways:

  • by lifestyle changes,
  • by dental devices,
  • by breathing devices,
  • and by surgery.

Enjoy!

 

Resources: getting started

Overview

Last seen: November 2018

Here below is a brief summary of the page.

The text provides a succinct overview of the main types of sleep apnea (obstructive, central and mixed) and of their:

  • symptoms
  • causes
  • risk factors
  • complications

How popular is this page according to Google?
Overview

Last seen: November 2018

Here below is a brief summary of the page.

The text is divided into the following sections:

  1. Introduction
  2. How sleep apnea occurs
  3. Sleep apnea symptoms
  4. Sleep apnea consequences
  5. Sleep apnea diagnosis
  6. Sleep apnea treatment
  7. Where to get more information
    1. several links are provided for patients, but you need to be an UpToDate subscriber
    2. you will find links to the following organizations which provide useful information for patients:

How popular is this page according to Google?
Overview

Last seen: November 2018

Spanish version: Apnea del Sueño

Here below is a brief summary of the English page.

The text is divided into the following sections:

  1. Definition
  2. Treatment
  3. Prognosis
  4. Clinical Trials
  5. Patient Organizations
  6. Publications

How popular is this page according to Google?
  1. Estimated monthly traffic from Google: 70/month
  2. Estimated most important keywords for which Google sends searchers to this page: 20/month
  3. Estimated number of keywords for which Google will show you the page:
    • neurological sleep apnea,
    • neurology sleep apnea,
    • neuro sleep apnea,
    • sleep apnea neurological
  4. Estimated number of links to the page (these count as votes in Google’s eyes): 29
Overview

Last seen: November 2018

Spanish version: ¿Dificultad para dormir?

This short text offers a quick overview of the different types of sleep apneas, their symptoms, diagnosis, and treatment

How popular is this page according to Google?
  1. Estimated monthly traffic from Google: 3/month
  2. Estimated most important keywords for which Google sends searchers to this page: none
  3. Estimated number of keywords for which Google will show you the page: 11
  4. Estimated number of links to the page (these count as votes in Google’s eyes): 5
Overview

Last seen: November 2018

Spanish version: ¿Apnea del sueño?

Here below is a brief summary of the English page

The text shows an expandable/collapsible menu with some main topics. Clicking on each topic will lead to several subtopics. For instance, clicking on “Causes” will show “Obesity”, “Large tonsils”, “Endocrine disorders” ….

  1. Causes
    1. Obesity
    2. Large tonsils
    3. Endocrine disorders
    4. Neuromuscular conditions
    5. Heart or kidney failure
    6. Genetic syndromes
    7. Premature birth
  2. Risk Factors
    1. Age
    2. Unhealthy lifestyle habits
    3. Family history and genetics
    4. Race or ethnicity
  3. Screening and Prevention
    1. Screening for sleep apnea
    2. Healthy lifestyle changes to prevent sleep apnea
    3. Look for
  4. Signs, Symptoms, and Complications
    1. Signs and symptoms
    2. Complications
    3. Look for
  5. Diagnosis
    1. Medical history
    2. Physical exam
    3. Sleep studies
    4. Ruling out other medical reasons or conditions
    5. Reminders
  6. Treatment
    1. Healthy lifestyle changes
    2. Breathing devices
    3. Mouthpieces
    4. Implants
    5. Therapy for mouth and facial muscles
    6. Surgical procedures
    7. Look For
  7. Living With
    1. Using and caring for your breathing device or mouthpiece
    2. Monitor your condition
    3. Repeat sleep studies
    4. Learn the warning signs of some CPAP side effects
    5. Learn about other precautions to help you stay safe
  8. Research for Your Health
    1. Improving health with current research
    2. Advancing research for improved health
    3. Look for
  9. Participate in NHLBI Clinical Trials
    1. Do you have an adolescent or young adult with sleep apnea and Down syndrome?
    2. Are you an adult with sleep apnea who wants to help understand this disease by using an oral appliance?
    3. Are you an adult with sleep apnea who would like to try a new treatment with facial exercises?
    4. Are you an adult with sleep apnea and type 2 diabetes?
    5. Are you an adult who recently was diagnosed with sleep apnea?
    6. Are you a Minnesota resident with hypertrophic cardiomyopathy?
    7. Do you have a child with sleep apnea who is interested in a new treatment with a nasal spray?
    8. Are you an adult with sleep apnea who finds it hard to use your CPAP machine?
  10. More Information
    1. Related Health Topics
    2. Our Publications
    3. Other Resources

How popular is this page according to Google?
  1. Estimated monthly traffic from Google: 26,000/month
  2. Estimated most important keywords for which Google sends searchers to this page:
    • sleep apnea,
    • what is sleep apnea,
    • apnea,
    • sleep apnea symptoms,
    • sleep apnea test,
    • signs of sleep apnea,
    • symptoms of sleep apnea,
    • sleep apnea causes,
    • what causes sleep apnea
  3. Estimated number of keywords for which Google will show you the page: 2400
  4. Estimated number of links to the page (these count as votes in Google’s eyes): 2370

Resources: how to diagnose sleep apnea

Overview

Last seen: November 2018.

Here below is a brief summary of this page.

It will provide you information about:

  • which doctors to go see in order to get a diagnosis,
  • the importance of a sleep study for a definite diagnosis of sleep apnea,
  • a list with those sleep centers accredited by the American Academy of Sleep Medicine,
  • the data collected during a sleep study with special emphasis on the AHI index (along with an explanation),
  • a brief mention of sleep studies as an alternative to polysomnography,
  • and finally, some comments about costs of treatment and diagnosis.

How popular is this page according to Google?
  1. Estimated monthly traffic from Google: 1600/month
  2. Estimated most important keywords for which Google sends searchers to this page:
    • sleep study results,
    • how to get a sleep study,
    • arousal index,
    • sleep apnea doctor,
    • pulmonary sleep study,
    • sleep apnea test results,
    • …..
  3. Estimated number of keywords for which Google will show you the page: 1100
  4. Estimated number of linksto the page (these count as votes in Google’s eyes): 56
Overview

Last seen: November 2018.

Here below is a brief summary of the page.

The text contains the necessary information to understand your sleep study.

The content also provides explanations about the nature of sleep, for instance, sleep stages, arousals, and awakenings ….

The page is divided into sub-sections:

  • A Guide to Understanding Your Sleep Study
  • Quantity of Sleep
  • Sleep Efficiency and Latency
  • Sleep Stages
  • Arousals and Awakenings
  • Respiratory Parameters
  • Implications
  • Addenda

How popular is this page according to Google?
  1. Estimated monthly traffic from Google: 758/month
  2. Estimated most important keywords for which Google sends searchers to this page:
    • sleep study results,
    • arousal index,
    • sleep apnea test results,
    • sleep efficiency index,
  3. Estimated number of keywords for which Google will show you the page: 588
  4. Estimated number of links to the page (these count as votes in Google’s eyes): 18
Overview

Last seen: November 2018

The page provides a very short and limited overview of sleep studies.

How popular is this page according to Google?
  1. Estimated monthly traffic from Google: 513/month
  2. Estimated most important keywords for which Google sends searchers to this page:
    • Sleep study
    • Sleep studies
    • Sleep research
    • Sleep apnea study
  3. Estimated number of keywords for which Google will show you the page: 118
  4. Estimated number of links to the page (these count as votes in Google’s eyes): 23

Resources: treatments and therapies

Overview

Last seen November 2018

(The Spanish version: ¿Está siempre cansado? Usted podría tener apnea del sueño.)

Here below is a brief summary of the English page.

The text is divided into two parts:

  1. “What is sleep apnea”. Here you will discover general information about the different apneas, their risk factors, associated diseases…
  2. “Getting treatment”

You will learn about:

  1. the behavioral approach (e.g. losing weight),
  2. use of continuous positive airway pressure,
  3. an implantable medical device called the “Inspire Upper Airway System (UAS)”,
  4. oral appliances,

How popular is this page according to Google?
  • A. Estimated monthly traffic from Google: 178/month
  • B. Estimated most important keywords for which Google sends searchers to this page:
    • Sleep apnea tired
    • Airing cpap fda approval
    • Sleep apnea always tired
    • Oral sleep apnea appliances fda approved
  • C. Estimated number of keywords for which Google will show you the page: 687 keywords
  • D. Estimated number of links to the page (these count as votes in Google’s eyes): 76
  • Overview

    Last seen November 2018

    (The Spanish version: Dispositivos de presión positiva continua: consejos para evitar 10 problemas frecuentes)

    Here below is a brief summary of the English page.

    You will find here the 10 most frequent problems encountered when using a CPAP machine and useful tips about how to overcome them:

    1. The wrong size or style CPAP mask
    2. Difficulty tolerating forced air
    3. Dry, stuffy nose
    4. Feeling claustrophobic
    5. Leaky mask, skin irritation or pressure sores
    6. Difficulty falling asleep
    7. Dry mouth
    8. Unintentionally removing the CPAP device during the night
    9. Bothersome noise

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 0/month
    2. Estimated most important keywords for which Google sends searchers to this page: none
    3. Estimated number of keywords for which Google will show you the page: none
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 3

    Resources: associated diseases, related issues

    Overview

    Last seen November 2018.

    Here below is a brief summary of the page about Obesity Hypoventilation Syndrome (OHS - also known also known as Pickwickian Syndrome).

    The text provides the following information about this breathing disorder characterized by an excess of carbon dioxide and too little oxygen in your blood:

    • OHS’ symptoms
    • how OHS can be diagnosed
    • how OHS can be prevented and treated

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 2100/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • obesity hypoventilation syndrome
      • Pickwickian syndrome
      • hypoventilation syndrome
      • hypoventilation
      • obesity hypoventilation
      • pickwickian sydrome
      • obesity and shortness of breath
      • ….
    3. Estimated number of keywords for which Google will show you the page: 146
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 17
    Overview

    Last seen November 2018.

    Here below is a brief summary of the page.

    You will find an overview of sleep apnea and its association with hypertension, stroke, arrhythmia and heart failure. But it is very short.

    The text then provides general advice and information about the different types of sleep apnea, treatments, etc …

    The information is divided as follows:

    • Sleep Apnea and Heart Disease, Stroke
    • A Common Problem
    • Listen to Those Snoring Complaints
    • Getting Proper Treatment
    • Getting Good Rest

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 1300/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • Sleep apnea heart failure,
      • Sleep apnea heart,
      • sleep apnea and heart failure
      • sleep apnea heart attack
      • sleep apnea effects on heart
      • sleep apnea and heart
    3. Estimated number of keywords for which Google will show you the page: 1900
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 255
    Overview

    Last seen December 2018

    Here below is a brief summary of the page.

    The text is focused on the rarer type of sleep apnea: central sleep apnea.

    It is divided in the following sections:

    1. Overview,
    2. Symptoms,
    3. Symptoms: when to see a doctor
    4. Causes
      • Cheyne-Stokes breathing.
      • Drug-induced apnea.
      • High-altitude periodic breathing.
      • Medical condition-induced central sleep apnea.
      • Idiopathic (primary) central sleep apnea.
    5. Risk Factors
      • Sex
      • Age
      • Heart-disorders
      • Stroke, brain tumor or a structural brainstem lesion
      • High altitude
      • Opioid use
      • CPAP
    6. Complications
      • Fatigue
      • Cardiovascular problems
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 0/month
    2. Estimated most important keywords for which Google sends searchers to this page: none
    3. Estimated number of keywords for which Google will show you the page: none
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 1
    Overview

    Last seen December 2018

    The page is divided into the following sections

    1. What is OSA?
    2. Treatments
      • Uvulopalatopharyngoplasty (UPPP)
      • Hyoid Suspension
      • Genioglossus Advancement (GGA)
      • Maxillomandibular Advancement (MMA)
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 47/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • Myoms
      • Sleep apnea surgery
      • Sleep apnea jaw
      • ….
    3. Estimated number of keywords for which Google will show you the page: 208
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 21
    Overview

    (Spanish version: Apnea obstructiva del sueño),

    Last seen December 2018

    Here below a brief summary of the English page about obstructive sleep apnea.

    The page is divided into the following sections:

    1. Overview
    2. Symptoms
      • When to see a doctor
    3. Causes
    4. Risk factors
      • Narrowed airway.
      • Excess weight
      • High blood pressure (hypertension).
      • Chronic nasal congestion.
      • Smoking.
      • Diabetes.
      • Sex.
      • A family history of sleep apnea.
      • Asthma.
    5. Complications
      • Daytime fatigue and sleepiness.
      • Cardiovascular problems.
      • Complications with medications and surgery.
      • Eye problems.
      • Sleep-deprived partners.
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 0/month
    2. Estimated most important keywords for which Google sends searchers to this page: none
    3. Estimated number of keywords for which Google will show you the page: none
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 5

    Genetics

    Overview

    Last seen December 2018

    Here is a brief summary of the page which provides many links to further resources.

    The text is divided into the following sections:

    1. Description
    2. Frequency
    3. Causes
    4. Inheritance Pattern
    5. Diagnosis & Management Links
      • Genetic Testing Information (2 links)
      • Research Studies from ClinicalTrials.gov (1 link)
      • Other Diagnosis and Management Resources (4 links)
    6. Other Names for This Condition
    7. Additional Information & Resources
      • Health Information from MedlinePlus (2 links)
      • Additional NIH Resources (5 links)
      • Educational Resources (9 links)
      • Patient Support and Advocacy Resources (2 links)
      • Scientific Articles on PubMed (1 link)
      • Catalog of Genes and Diseases from OMIM (1 link)
      • Medical Genetics Database from MedGen (1 link)
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 279/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • is sleep apnea genetic
      • is sleep apnea hereditary
      • sleep apnea genetic
      • sleep apnea genetics
      • obstructive sleep apnea
    3. Estimated number of keywords for which Google will show you the page: 53
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 22

    Statistics and research

    Overview

    Last seen December 2018

    Here below is a brief summary of the page.

    It lists 20 facts about sleep apnea, some of which is statistical information:

    • “Sleep apnea affects up to 18 million Americans.”
    • “Officials estimate 10 million Americans have the condition but have not been diagnosed.”
    • “The condition affects about 4 percent of middle-aged men and 2 percent of middle-aged women.”
    • ….
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 0/month
    2. Estimated most important keywords for which Google sends searchers to this page: none
    3. Estimated number of keywords for which Google will show you the page: 0
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 2
    Overview

    Last seen February 2019

    On this page, with the following filters applied:

    • Recruiting,
    • Not yet recruiting,
    • Available,

    you will find 418 studies for Sleep Apnea Syndromes.

    You can change the filters (recruiting, not yet recruiting, available) to:

    • active not recruiting,
    • suspended, …

    You can also view all the clinical trials identified for your search terms:

    • As a list
    • Or on a map and you can then click on a specific country to precisely view the trials done in a country.

    Consider browsing many medical conditions under “By Topic” and use them to search for related trials by including them in the filters.

    Finally try fishing for related terms under “Search Details” and add or remove terms and synonyms.

    How popular is this page according to Google?

    The above page represents an extraction from a database, so it does not make sense to talk about “Google popularity”.

    The home page (www.clinicaltrials.gov) is instead very popular:

    1. Estimated monthly traffic from Google: 630,000/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • clinical trials
      • clinical trials.gov
      • clinicaltrials.gov
      • ….
    3. Estimated number of keywords for which Google will show you the page: 1.8M
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 44.2K

    Academic Articles – References and abstracts from MEDLINE/PubMed – National Library of Medicine.

    Overview

    Last seen December 2018

    You can either read the 230 words long abstract, or the full 4000 words article.

    Discover our opinion and explanations.

    Our advice: this article requires solid medical knowledge and the non-initiated will find it difficult to understand.

    In a nutshell it talks about Percutaneous Coronary Intervention (PCI) in patients with OSA.

    PCI is a non-surgical procedure that uses a thin, flexible plastic tubing to position a small device called a stent. It is used to open blood vessels that have narrowed as a result of plaque formation (atherosclerosis).

    This review article concludes saying that if patients already suffer from OSA and undergo PCI, then they will have significantly increased incidence of:

    • all-cause death (4 studies),
    • cardiovascular death (4 studies),
    • and repeat PCI (7 studies).

    So, patients with OSA are at greater risk of subsequent cardiovascular events after PCI.

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 0/month
    2. Estimated most important keywords for which Google sends searchers to this page: none
    3. Estimated number of keywords for which Google will show you the page: none
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 1

    We did not include other articles selected by the National Library of Medicine (NLM) specialists. And that is because they are too difficult for the average reader and require good medical knowledge.

    But, if you feel ready to take on the challenge then go the following page

    Find an Expert

    Overview

    Last seen December 2019

    On their "Sleep Apnea Information for Individuals" page, the American Sleep Apnea Association provides you with the following useful links:

    • Find a Sleep Doctor
    • Find a Sleep Dentist – the link on the page is broken, here is the correct “Find a Sleep Dentist Page"
    • Find a Sleep Lab
    • Find a Behavioral Sleep Specialist with a search by last name https://my.absm.org/listing.aspx. But our team has also found a page where you can look at a list of individuals who have earned certification in behavioral sleep medicine.
    • Find Home Sleep Testing.
    How popular is this page according to Google?

    Since there are multiple resources, providing you this information is difficult.

    Overview

    Last seen February 2018

    The AASM’s directory includes all the sleep centers which it accredited.

    Accreditation is granted to a center because it has shown the “highest quality of care in the diagnosis and treatment of sleep disorders”.

    One criterium, for instance, is to have a board-certified sleep medicine physician, who leads a sleep team of trained health care professionals.

    All the centers in the directory have also been accredited to provide home sleep apnea tests.

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: none
    2. Estimated most important keywords for which Google sends searchers to this page: none
    3. Estimated number of keywords for which Google will show you the page: none
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 80
    Overview

    Last seen February 2018

    We did not find any useful resources on this page to help you identify sleep centers and sleep specialists.

    We think the National Library of Medicine specialists have erroneously included this resource.

    Children

    Overview

    Last seen February 2018

    (the Spanish version is “Apnea del premature”)

    The page, reviewed by a medical doctor, provides an overview of apnea of prematurity and related treatments.

    The text is divided into the following sections:

    • What Is Apnea of Prematurity?
    • What Happens in Apnea of Prematurity?
    • How Is Apnea of Prematurity Treated?
      • Medicines
      • Monitoring Breathing
    • If Your Baby Is on a Home Apnea Monitor
    • How Can I Help My Baby?
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 542/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • Apnea of prematurity
      • Baby apnea
      • Apnea in newborns
      • Newborn apnea
      • Ab monitor
      • Premature baby heart rate drops
    3. Estimated number of keywords for which Google will show you the page: 923
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 62
    Overview

    Last seen February 2018

    This page serves as a gateway to content in the other sections of the website.

    You will find the below navigation menus:

    Pediatric Conditions:

    • Pediatric Hearing Loss
    • Pediatric Sinusitis
    • Pediatric Sleep-disordered Breathing
    • Pediatric Thyroid Cancer
    • Swimmer's Ear
    • Tonsillitis
    • Tonsils and Adenoids

    Halfway through the page you will find a section called spotlight with some interesting articles. Currently this section features three articles:

    Last but not least, at the bottom of the page you will find a useful resource called “Find an ENT

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 1/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • healthent
      • ent health
    3. Estimated number of keywords for which Google will show you the page: 5
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 739
    Overview

    Last seen February 2018

    The page provides information about obstructive sleep apnea in a pediatric population.

    The text is broken up in the following subheadings:

    • What Is Obstructive Sleep Apnea?
    • What Causes Obstructive Sleep Apnea?
    • What Are the Signs & Symptoms of Obstructive Sleep Apnea?
    • How Is Obstructive Sleep Apnea Diagnosed?
    • How Is Obstructive Sleep Apnea Treated?
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 5200/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • Sleep apnea
      • Sleep apnea in children
      • Apnea
      • Toddlers sleep apnea
      • Sleep apnea toddlers
      • ….
    3. Estimated number of keywords for which Google will show you the page:
      • Sleep apnea
      • Sleep apnea in children
      • Apnea
      • Toddlers sleep apnea
      • Sleep apnea toddlers
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 166

    (The Spanish version is “Cómo detectar el síndrome de apnea del sueño”)

    Last seen February 2018

    Overview

    This brief page provides some information about:

    • sleep apnea detection
    • sleep apnea treatment

    Links to further resources are provided throughout the text.

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 13/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • sleep apnea in babies symptoms
      • baby sleep apnea
      • sleep apnea detection
      • ….
    3. Estimated number of keywords for which Google will show you the page: 151
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 37

    Patient Handouts

    Overview

    Last seen February 2018

    (The Spanish version is “Apnea central del sueño”)

    The English page features a “Click to Keep Reading” button via which you will access the whole (500-600 words) text.

    This is divided into the following subsections:

    • Causes
    • Symptoms
    • Exams and Tests
    • Treatment
    • Outlook (Prognosis)
    • Possible Complications
    • When to Contact a Medical Professional
    • Alternative Names
    • References

    The page has been classified under “Patient Handouts” because you can easily print it (see the special icon in the upper right corner).

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 1500/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • central sleep apnea causes
      • central sleep apnea
      • central sleep apnea cause
      • causes of central sleep apnea
      • what causes central sleep apnea
      • central sleep apnea causes
    3. Estimated number of keywords for which Google will show you the page: 290
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 40
    Overview

    Last seen February 2018

    (The Spanish version is “Tratamiento de presión positiva en las vías respiratorias”)
    The English page is divided into the following subsections

    • Who should use CPAP
    • How CPAP works
    • Getting used to the machine

    The information is clearly laid out and structured in bullet points.

    You will find some embedded links throughout the text to pathologies of patients needing CPAP, like:

    The page has been classified under “Patient Handouts” because you can easily print it (see the special icon in the upper right corner).

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 393/month
    2. Estimated most important keywords for which Google sends searchers to this page:
    3. Estimated number of keywords for which Google will show you the page: 415
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 46
    Overview

    Last seen February 2018

    (The Spanish version is Síndrome de hipoventilación y obesidad (SHO).)

    The “Click to keep reading” button will show the full English page. This is divided into the following sections:

    • Causes
    • Symptoms
    • Exams and Tests
    • Treatment
    • Possible Complications
    • When to Contact a Medical Professional
    • Prevention
    • Alternative Names

    Several links are provided throughout the text for further reading, for instance:

    The page has been classified under “Patient Handouts” because you can easily print it (see the special icon in the upper right corner).

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 816/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • obesity hypoventilation syndrome
      • ohs medical
      • obesity and shortness of breath
      • ohs medical term
      • hypoventilation syndrome
      • ……
    3. Estimated number of keywords for which Google will show you the page: 235
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 27
    Overview

    Last seen February 2018

    (The Spanish version is “Los adultos con apnea obstructiva del sueño

    The “Click to keep reading” button will give you access to the full English page

    This is divided into the following subsections:

    • Causes
    • Symptoms
    • Exams and Tests
    • Treatment
    • Outlook (Prognosis)
    • When to Contact a Medical Professional
    • Alternative Names

    You can easily print the page by using the special icon in the upper right corner.

    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 1900/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • Stop breathing while sleeping
      • Obstructive sleep apnea
      • Throat closing up at night
      • Stop breathing when you sleep
      • Stop breathing while you sleep
    3. Estimated number of keywords for which Google will show you the page: 2100
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 217
    Overview

    Last seen February 2018

    (The Spanish page is “Apnea del sueño infantil”)

    The “Click to keep reading” button will allow you to see the full English page which is divided as follows:

    • Causes
    • Symptoms
    • Exams and Tests
    • Treatment
    • Outlook (Prognosis)
    • Possible Complications
    • When to Contact a Medical Professional
    • Alternative Names
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 13/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • Pediatric sleep apnea
      • Sleep apnea in children symptoms
      • Pediatric apnea
      • Sleep apnea kids
      • Sleep apnea pediatric
    3. Estimated number of keywords for which Google will show you the page: 69
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 4
    Overview

    Last seen February 2018

    (The Spanish page is “Uvulopalatofaringoplastia (UPFP)”)

    The “Click to keep reading” button will open the full English page for you.

    The text is divided into the following subsections:

    • Description
    • Why the Procedure is Performed
    • Risks
    • Before the Procedure
    • After the Procedure
    • Outlook (Prognosis)
    • Alternative Names
    How popular is this page according to Google?
    1. Estimated monthly traffic from Google: 321/month
    2. Estimated most important keywords for which Google sends searchers to this page:
      • uppp
      • uvulopalatopharyngoplasty
      • uppp in
      • uppp surgery
      • uppp procedure
      • uvulopalatopharyngoplasty uppp
      • uvulopalatopharyngoplasty (uppp)
    3. Estimated number of keywords for which Google will show you the page: 58
    4. Estimated number of links to the page (these count as votes in Google’s eyes): 10

    Chapter 4: Treating obstructive sleep apnea (OSA) with CPAP and dental appliances.

    Reviewed by Dr. Joseph Salim, DMD (written by the Sutton PDA editor)

    Treating obstructive sleep apnea (OSA)

    OSA is the most common type of sleep apnea, and it is no laughing matter.
     
    Or rather, it is a “no-breathing matter” since that’s what apnea means.
     
    Have you just been diagnosed with OSA and you want to understand what therapies are available?
     
    Or maybe you only want to learn about this common disease’s therapeutic strategies and which ones are more effective?
     
    Whatever your motivation for being with us today, I assure you that you have come to the right place.
     
    With over 10,000 words and 49 sections, this article will cover every single lifestyle treatment that currently exists.

    This includes also dental appliances and continuous positive airway pressure.

    If you want to learn about surgical treatments instead, check Chapter 5: Treating Obstructive Sleep Apnea (OSA) with Surgery.

    If you are an OSA patient or some people dear to you suffer from this disease, you will be relieved to know that several strategies exist that can treat OSA.

    So, without further ado, let’s dive into the article.

    Table of Contents

    1. Treating obstructive sleep apnea (OSA)
    2. How do you treat obstructive sleep apnea (OSA)?
    3. What are the objectives of treating sleeping apnea?
    4. What lifestyle changes can you implement to treat mild sleep apnea?
    5. Dental appliances
    6. Are dental appliances behavioral treatments
    7. How do mouthpieces treat sleep apnea?
    8. Different types of dental appliances
    9. Over-the-counter (OTC) dental appliances
    10. Over-the-counter (OTC) dental appliances: less than optimal fit
    11. Poor to no adjustability of OTC dental appliances
    12. Longevity of OTC dental appliances
    13. Can I use Medicare approved over-the-counter (OTC) dental appliances?
    14. What are the advantages of dental appliances versus CPAP masks?
    15. What are the disadvantages of dental appliances used to treat OSA?
    16. Of sleep apnea, teeth grinding and oral appliances
    17. How effective is a dental appliance to treat sleep apnea and snoring?
    18. Dental appliances: how does treating snoring differ from sleep apnea?
    19. How can I know if using an oral appliance will decrease my sleep apnea?
    20. Can you always use an oral appliance if you suffer from sleep apnea?
    21. Dental health problems to consider before using a dental appliance for OSA
    22. Which dental devices for OSA patients with insufficient dentition?
    23. Oral devices to treat sleep apnea: technological advances
    24. Continuous positive airway pressure (CPAP)
    25. What is continuous positive airway pressure (CPAP)?
    26. How long should I use CPAP for?
    27. How often should I use CPAP?
    28. How good are results obtained with CPAP?
    29. Does treatment with CPAP continue to influence hypertension in OSA patients?
    30. Is it beneficial to treat OSA with surgery or CPAP if you suffer from coronary heart disease (CAD)?
    31. Does treatment of OSA reduce cardiac arrhythmias?
    32. Does night treatment of OSA reduce the need of a pacemaker?
    33. Can treating OSA improve your erectile dysfunction (ED)?
    34. Does treating obstructive OSA decrease depressive symptoms?
    35. Can obstructive OSA treatment help diabetes type 2 patients or patients with abnormal glucose levels?
    36. What are side effects with CPAP and what are the solutions?
    37. Air leaks
    38. Skin irritation, sores or blisters
    39. Dry Mouth
    40. Dry, stuffy, runny nose
    41. Pressure is perceived as too high, difficulty in exhaling
    42. Feeling claustrophobic
    43. Difficulty getting used to the CPAP device
    44. Too noisy
    45. What are the effects of CPAP therapy on your jaws and teeth?
    46. CPAP and dental appliances: results and comparisons
    47. How do sleep apnea results obtained with CPAP compare to those obtained with mouthpieces?
    48. Do dental appliances or CPAP cure sleep apnea?
    49. What happens when you stop using CPAP or dental appliances?
    50. Final Remarks

    How do you treat obstructive sleep apnea (OSA)?

    Quick: are medicines the most frequently used treatment of OSA?

    …. Yes?

    Nope, they are only rarely used.

    Sleep apnea is typically treated with:

    • lifestyle changes such as losing weight, quitting smoking, …. These may be effective in mild forms of sleep apnea;
    • mouthpieces such dental appliances, which may relieve mild sleep apnea;
    • breathing devices, such as continuous positive airway pressure, which are more suited for moderate or severe sleep apnea;
    • surgery that is used for moderate or severe sleep apnea.
    Image of a continuous positive air pressure machine showing nasal-mouth mask and air hose
    Continuous positive air pressure (CPAP) machine

    What are the objectives of treating sleeping apnea?

    If you thought that the treatment’s purpose is to make breathing more comfortable, then you guessed right.

    Indeed, the objectives of treating sleep apnea are always the same: hold open or increase the size of the upper airways’ opening during sleep.

    The goals are two-fold:

    • improve the quality of your sleep, eliminating apneas and hypopneas and thus increasing blood oxygen levels;
    • reduce symptoms like snoring, sleepiness, enhancing the quality of life.

    Treatments may also improve other medical issues associated with sleep apnea such as:

    • High blood pressure,
    • stroke,
    • heart disease,
    • and diabetes.

    and they can also reduce the risks of suffering from these diseases.

    Let’s now look at what you can do.

    What lifestyle changes can you implement to treat mild sleep apnea?

    If you suffer from mild forms of sleep apnea, then it may be possible to treat it merely with some lifestyle changes:

    1. If you are obese or overweight, your risks of suffering from sleep apnea increase. Even a mere 10% weight loss can be beneficial and relieve your symptoms

      Experts believe that excess body weight may contribute significantly to sleep apnea.1

      Image of a fat man chased by a pizza, a coke, a hamburger, a chicken, and a beer
      Losing weight is not easy!

      Studies have shown that if you are obese or overweight, going on a diet (and losing weight) will be beneficial since:

      • your apnea frequencies will decrease;
      • your Apnoea–Hypopnoea Index (AHI) will improve compared to controls.2
    2. If you are a smoker, you also need to quit tobacco consumption. Smoking irritates your throat and makes you cough at night.
    3. Avoid alcohol, sleeping pills or painkiller drugs. They make it harder for your throat to stay open while you sleep since they relax throat muscles.
    4. Sleep on your side instead of your back. This may reduce sleep apnea symptoms.

      Sleeping on your back in fact stretches your throat and neck’s tissues thus narrowing or blocking your upper airways.

      You can learn to sleep on the side by placing a pillow so that it may support you (on the side).

      You could also use the ‘tennis ball trick’: sew a pocket onto the back of your pajama top and put a tennis ball in it.

      The pressure from the ball will make you roll back to your side.3

    5. Practice sports regularly.

      Also, try to have regular sleep patterns by going to bed and waking up more or less at the same time.

      This will improve the quality of your sleep.

    6. Do you have a runny or stuffed-up nose, because of an allergy or a cold?

      If so then consider using some nasal sprays or allergy medicine.

      Check with your treating physician what is the best treatment for you

    We will now look at the use of medical devices that can help your OSA.

    Dental appliances

    Are dental appliances behavioral treatments

    You can consider mouthpieces, also called dental appliances, as behavioral treatments.

    Why?

    Because they have to be worn regularly to re-align the oral cavity. Hence, they lead to a change in your behavior.

    The American Academy of Sleep Medicine (AASM) recommends them as:

    • A first choice therapy in mild or moderate forms of sleep apnea.
    • Severe forms when CPAP has failed or where patients prefer alternative therapies. But they are not the first choice for severe forms because they may not be enough for a challenging airway4

    They are also used:

      1. Concomitantly with CPAP to lower the air pressure levels, if you do not tolerate higher pressures.So there is hope if you struggle with CPAP!With the help of a dental appliance, your airway will present less resistance. Your CPAP machine will, therefore, blow air with lower pressure and more timely;
      2. if you have refused or failed surgery (such as tonsillectomy, adenoidectomy, …).

    Your doctor may recommend them if you snore loudly, even if you do not have sleep apnea.

    Let’s now look at how dental appliances can treat your sleep apnea.

    How do mouthpieces treat sleep apnea?

    Image of 3 orthodontic retainers
    3 Orthodontic Retainers

    To understand how they work, let’s see how you wear them.

    Can you picture an orthodontic retainer or a sports mouthguard?

    Dental appliances to treat sleep apnea look similar.

    Most of them rely on the principle of mandibular advancement.

    OTC dental appliances are made out of two parts:

    • one latches onto your upper teeth,
    • the other, onto your lower teeth.

    The bottom part maintains your lower jaw in an advanced position making your breathing more comfortable.

    Your tongue is also adjusted to keep your upper respiratory airways, in the back of your throat, open.

    This facilitates airflow and reduces snoring and OSA.

    Image of an over-the-counter dental appliance
    OTC Dental Appliance

    Dental devices made ad-hoc by your dentist, to treat OSA, differ somewhat from their OTC counterparts since:

    • the part fitting over the upper teeth and over the lower teeth connect via metal hinges, with a piston and tube;
    • they are usually adjustable so that your dentist can gradually change your advancement to get the best results;
    • when your muscles relax, the piston and tube limit the tendency of the jaw to move backward;
    • When you fall asleep, and your muscles relax, your chin is kept forward, and your airways stay open.

    Another type of dental appliance is also used where your tongue protrudes instead of your lower jaw.

    It will maintain your tongue forward by suction, preventing it from occluding your upper airways.

    But, since they are not well tolerated, they are not part of the current recommendations for oral appliance treatment5.

    Let’s now learn about the different types of dental appliances available in the market.

    … jump on to the section to find out!

    Different types of dental appliances

    Quick, how many different types of dental appliances are there in the market?

    ….. hundreds of over-the-counter models are available.

    To that, you need to add the custom fitted devices.

    Who can make ad-hoc dental appliances?

    A dentist or an orthodontist who is a doctor specialized in improving your bite by correcting teeth or jaw problems.

    And they can make appliances for all types of patients, for all sorts of oral anatomies including patients without teeth.

    Even though many models are available, their underlying principle is the same:

    • they exert traction on soft tissues,
    • to free the upper airways,
    • and ease airflow.

    Move on to the next sections, if you wish to learn more about the pros and cons of the different dental appliances used to treat OSA.

    Over-the-counter (OTC) dental appliances

    Price!

    Yes, that is the only main advantage of over-the-counter dental appliances.

    Image of an over-the-counter dental appliance
    OTC Dental Appliance

    But that comes with other types of costs because prefabricated oral appliances:

    1. May fall out at night and your snoring will continue.
    2. Have to fit different anatomies and tend to be bulky.
      To understand how they work, let’s see how you wear them.What a paradox! A bulky dental appliance in a small airway!Indeed, it will be challenging to improve your snoring and sleep apnea.
    3. May mislead you, or rather, their results may mislead you.If you are successful at eliminating snoring symptoms and think that your sleep apnea has been cured….you may suffer from the complications of an untreated sleep apnea later on.

      And OSA is no laughing matter since it is a life-threatening disease.

      Also, your jaw position may actually be worse and increase occlusion of the airway without you realizing it.

    4. may force you to clench to keep the dental device in place.

    But a sleep medicine trained dentist will immediately identify these issues, and help you avoid them.

    The ease with which you can buy OTC appliances may fool you into thinking that:

    • you can diagnose your sleep apnea,
    • and manage its side effects on your own.

    Fortunately, some of the above issues, namely lack of comfort (and even pain), limit their use somewhat.

    And this despite that they have been around for approximately 20 years.

    One of the paradoxes of their lack of effectiveness and discomfort is that …..

    ………they discourage patients who would otherwise be excellent candidates for custom-fitted appliances.

    Let’s see how you can use them, to better understand some of the issues.

    OTC dental appliances: less than optimal fit

    Many of these OTC appliances are crudely made with thermoplastic polymer materials.

    When you buy them, you often need to boil them.

    No! No sauce needed 😉 (we are easily amused with simple jokes here at SPDA).

    They are softened by boiling so that they mold and adapt to your oral anatomy when you bite the softened material.

    You will do this with a somewhat advanced jaw position.

    No wonder these appliances are also called “boil and bite.”

    The appliance is then placed in a bowl of cold water to “set up.”

    The end result is a device that may somehow fit, but it is not always a very good fit.

    Now let’s analyze how an optimal fit is ensured when a qualified dentist gets involved:

    1. he will take an impression and send it to a lab;
    2. once the oral appliance is received, your dentist will make the necessary, delicate adjustments to achieve an optimal fit;
    3. these adjustments will depend on your OSA symptoms and oral condition.

    These are all chair-side steps which need time and engender costs.

    It is important to note that, in New York, a dentist has to:

    • attend courses
    • and receive training

    to make custom appliances for sleep apnea and snoring.

    Doctors have to follow with rigorous standards ensuring good success rates.

    It is thus preferable to contact your dentist to have a dental appliance really adapted to your anatomy (teeth and gums).

    Let’s now study what happens as you get older.

    Poor to no adjustability of OTC dental appliances

    How will your sleep apnea evolve as you age?

    It is likely not be shocking if I tell your that your sleep apnea will get worse.

    That happens because muscles lose their tone, and tend to occlude your airways.

    Though it is true that you may compensate for this process by losing weight, for instance.

    This may improve your OSA.

    But, the prevalent trend shows an increase in the severity of sleep apnea as you get more mature, so to speak.

    Now, one of the significant benefits of your custom-made device is that it can be adapted.

    You will thus be able to incrementally advance your jaw over the years as the aging process takes its toll.

    This also comes in handy when you are just beginning to use the device.

    The first few weeks your dentist will gradually move your jaw forward. This will help to avoid pain from a sudden and abrupt advancement.

    But OTC models do not offer this benefit.

    Longevity of OTC dental appliances.

    Is there a difference in durability of a prefabricated dental appliance versus a custom made one?

    The answer is a definite yes, and the difference is significant:

    • The former lasts only a year approximately,
    • the latter has a lifespan of 2-5 years. The time depends on whether you clench and grind your teeth during your sleep.

    Finally, the AASM and the AADSM guidelines also advise that:

    …… “a qualified dentist uses a custom, titratable appliance over non-custom oral devices.”6

    This means that an adjustable (titratable) oral device should be used.

    Can I use Medicare approved OTC dental appliances?

    Yes!

    Do you definitely want to try an OTC dental appliance instead of one made ad-hoc for you? If so, then go for a Medicare-approved one.

    They have been tested clinically and also stand the test of time.

    It will be a safe choice that may protect you from some of the issues explained above.

    What are the advantages of dental appliances versus CPAP masks?

    Amongst the pros …..

    1. Dental appliances can significantly reduce sleep apnea, if used over an extended period.
      And, you will show better adherence to treatment because mouthpieces are more comfortable to use than CPAP masks.
      Unlike CPAP masks, they:
      • are portable hence you can travel with them;
      • allow you to talk and drink water.

       

    2. You will not have any dry, itchy nose issues due to air pressure from a CPAP mask.
    3. Emoji holding a flower that makes its nose itchy
      Itchy Nose

      Oral appliances are less cumbersome to use than CPAP equipment:

      • If you move a lot in your sleep, there no risk of getting entangled with the tubing because there is none;
      • a dental appliance will stay in place until the end of your sleep. That is unlike CPAP masks which you may unintentionally remove;
      • finally, a dental appliance does not need a machine.

    Let’s now take a look at the cons of oral devices.

    What are the disadvantages of dental appliances used to treat OSA?

    To begin with … These can be permanent or transient.

    I know what you are thinking!

    You would prefer the side effects of oral appliance therapy to be transient only and not permanent.

    But do not worry.

    The benefits of oral appliance therapy outweigh the adverse effects.

    This is what the majority of patients have said7.

    Permanent effects include dental changes that occur over the long term due to the pressure exerted by your dental appliance.

    They won’t have a significant impact on your chewing, and you will not even be aware of differences to your bite.

    Though, tooth movement is observed in 85,7% of patients according to a 5 years analysis8

    The types of tooth movement that you may experience include, for instance, a decrease of the overlap of your lower teeth by your upper teeth (aka overbite).

    Images of a healthy bite, overbite, underbite and open bite.
    Malocclusion problems, bad bite

    And this may not always be a bad thing 😉 !

    Other observed changes include:

    • A decrease in the number of contacts between teeth’s surfaces (occlusal contacts);
    • forward inclination of the lower incisors and backward inclination of the upper incisors;
    • Etc.9

    Exercise caution though, if you have been recently treated by an orthodontist these changes may be more noticeable.

    While the above is true, you can prevent these issues with proper preventive jaw exercises.

    You should do them in the morning.

    They will decrease the risk of teeth displacement.

    Also, worthy of notice is that CPAP masks as well, may displace teeth via the pressure exerted on the upper teeth (see What are the effects of CPAP therapy on your jaws and teeth?)

    Let’s now look at transient side effects.

    Their frequency varies significantly amongst patients.

    They occur during the first two months of the therapy and include:

    • Headaches
    • A toothache
    • Gum inflammation
    • The pain of the muscles that move the jaw (temporomandibular joint discomfort)
    • Dry mouth
    • Excessive salivation10

    Your situation may worsen if:

    • you already suffer from jaw pain,
    • or from pain in the temporomandibular joint (TMJ)

    before starting the treatment.

    Though, do you want to know the best part?

    Interestingly, you will discover that, against expectations, improvements are sometimes observed from the start.

    How is that possible?

    … jump to the next section to find out.

    Of sleep apnea, teeth grinding and oral appliances

    So, why may jaw pain or pain in the temporomandibular joint (TMJ) improve when using a dental appliance to treat sleep apnea?

    This has a simple explanation!

    If you observe relief of pain after using the appliance, then it came from your teeth’s grinding. This is also called bruxism and occurs during your sleep.

    Image showing teeth wearing down as a result of teeth grinding
    Effects of teeth grinding (bruxism)

    And it does not come by chance.

    It is related to your sleep apnea.

    Let me explain that.

    It is your body’s instinct to trigger a back and forth motion (associated with teeth grinding) to keep the airways open when your muscles relax during sleep.

    Hence the cause of your grinding and excessive use of the jaw muscles is sleep apnea.

    Treating sleep apnea with a dental appliance may solve all these issues.

    Now, teeth grinding and clenching comes at a cost:

    • poor quality sleep,
    • jaw popping,
    • headaches,
    • gradual teeth erosion and destruction,
    • jaw pain,
    • neck aches.

    So I am sure you agree, treating it will be quite a relief.

    As a side note, be wary of nightguards!

    Does that surprise you?

    It should not!

    These are prescribed to protect your teeth from erosion during grinding and clenching (bruxism).

    But what if your bruxism is not due to stress but rather to a small airway passage?

    Then the following will probably happen:

    • your small airway will become even smaller,
    • its blockage will increase,
    • so will your teeth grinding,
    • and your sleep quality will further deteriorate.

    So, make sure your dentist rules out sleep apnea before prescribing a nightguard.

    If you suffer from sleep apnea then you doctor should focus on its treatment first.

    One last word of caution.

    While the above holds true, the relationship between OSA and sleep bruxism is not always clear.

    Sometimes, patients successfully treated for sleep apnea with a dental appliance may continue teeth clenching and grinding.

    In these cases, your dentist should consider a reinforced adjustable mandibular device. It will avoid breakage of your oral appliance.

    Some patients have been reported to break their oral device during sleep bruxism11

    Okay, it is now time to talk about the clinical results of oral appliances therapy.

    How effective is a dental appliance to treat sleep apnea and snoring?

    If you snore, you will be happy to know that response rates are high, almost 95%!

    And that is really good news!

    Because snoring either disappears entirely or it decreases to acceptable levels.

    And if you suffer from sleep apnea, you have approximately a 67% chance of seeing a significant improvement of your sleep apnea12.

    There is substantial evidence that the majority of patients benefit from dental appliances. This also includes some with more severe disease.

    But it is not possible to predict in advance whether treatment will be successful.

    Studies show a range of positive responses between 50-80%.

    Why this difference?

    It really depends on13:

    • the study,
    • the criteria used to assess responses,
    • patients’ selection criteria.

    For instance, if you are a patient who can breathe well through the nose, then you will be able to use your dental appliance more efficiently, and the results will improve.

    The results obtained with a dental mouthpiece also improve if you are a woman because women respond better.

    European studies tend to include thinner patients than USA ones. And it is well known that your weight directly influences response to a dental appliance.

    Also, if you are thin, you will respond better to dental appliances.

    Why do you think?

    Well, because your neck’s size is smaller and your lower jaw bones don’t sit too far back.

    Let’s now take a peek at how treating sleep apnea and snoring differ.

    Dental appliances: how does treating snoring differ from sleep apnea?

    Freeing your airways by moving your jaw forward …

    … That is the purpose of dental appliances whether you snore or you also suffer from sleep apnea.

    Comparison of the flow of air when breathing freely and when snoring due to the tongue's root retracting
    Breathing through a free or partially occluded airway

    At the start, treatments are similar, and your dentist may even use the same appliance.

    But that’s where the similarity ends.

    Treating snoring is shorter and less complex than treating sleep apnea.

    Often, if you are a sleep apnea patient, you may be relieved from snoring symptoms while still suffering from sleep apnea.

    If you suffer from sleep apnea, your dentist will continue to use the dental appliance to re-align your oral cavity until:

    • You feel better, are less tired, etc..
    • or until you reach the maximum advancement you can tolerate.

    How can I know if using an oral appliance will decrease my sleep apnea?

    Knowing if you are likely to respond would be a considerable time and cost saver … I am sure you would agree.

    And surely it would be a highly desirable outcome because:

    • The success of treatment with dental appliances is lower than that of CPAP;
    • the process is also more time consuming and costly than CPAP.

    But life is not always easy!

    Despite many studies, no standardized parameters or procedures exist to gauge response before manufacturing a dental appliance14.

    While the above remains true, some factors are associated with treatment success, these include:

    • OSA observed during supine sleep,
    • low apnea-hypopnea index,
    • young age,
    • female patients’ compliance,
    • obstruction area mainly involving the oropharyngeal region,
    • small neck circumference,
    • low body mass index.

    Though, beware! … none of these factors, either singly or in combination, can predict a positive outcome when treated with a dental appliance15

    So, oral appliances are not the be and end all of OSA treatments.

    Now, let’s investigate when you can, or cannot, use them.

    Can you always use an oral appliance if you suffer from sleep apnea?

    Unfortunately not!

    Although this may seem surprising, the reason is simple: you require a healthy dentition for dental appliances therapy.

    Your oral health may thus be a barrier to the use of such devices.

    So, what is the solution?

    Well, there are three possibilities:

    • You may have to delay the use of an appliance. You should do that until you have received appropriate dental treatment and your oral health has improved.
    • Or you may start oral appliance therapy while requiring close supervision and follow-up. This will avoid worsening of previous dental or temporomandibular joint issues.
    • You may also not be a good candidate for it16.

    This is especially true for older patients.

    Let’s look at some examples of oral health issues.

    Dental health problems to consider before using a dental appliance for OSA.

    Just like taxation is a certainty in life, some dental health issues will invariably affect your use of dental appliances.

    Let’s look at these dental health concerns.

    Tooth loss

    It is associated with sleep apnea.

    If you are an edentulous patient, you will be more likely to suffer from sleep apnea17. A study found that if you were a patient aged 25-65, your risk of developing OSA would increase by 2% for each additionally lost tooth18.

    So, your dentist will have to carefully consider restoring your missing teeth, before an appliance is made.

    This will create a more balanced occlusion.

    Likewise, use of dentures is associated with a higher apnea-hypopnea index (AHI>15)19.

    Chronic periodontitis

    Chronic what…

    Here below is a brief explanation and some useful images.

    It is the inflammation of your periodontal tissues. They include:

    1. the gum tissues covering your alveolar bone;
    2. the alveolar bone which supports your teeth. If it is unhealthy, then it will no longer support them, and you will suffer from tooth loss;
    3. your periodontal membrane which can be found between your teeth and your alveolar bone.
    Image showing a tooth's crown, root, enamel, dentin, pulp, cementum, periodontal membrane, nerve and blood supply.
    Cross section of a human tooth
    Periodontal Tissues
    Periodontal Tissues

    This disease is a significant issue among patients undergoing oral appliances therapy. This is because teeth may be pulled out as your appliance protrudes your lower jaw forward.

    A study found that you are more likely to suffer from periodontitis if you also have OSA20.

    Dry mouth

    As you may have already guessed, it results from an insufficient salivary function.

    It is a frequent symptom among sleep apnea patients.21 22 23

    It is also a sign of poor oral health.

    How do we know that?

    Because these same patients also have:

    • more pain associated with dentures,
    • fewer teeth,
    • more caries,

    than the normal population24

    Indeed, saliva is not just your precious ally if you play the chatterbox, for it regulates pH in the oral cavity. Acidic compounds are thus less likely to damage your teeth.

    Also, you may not know that …

    …. saliva production is lowest during sleep and it will be worse if you are an OSA patient.

    Why?

    Because OSA patients tend to breathe through their mouth.

    Teeth grinding and clenching

    Last but not least comes bruxism.

    Can you guess when and why your dentist will be very concerned?

    When you have dental prosthesis – that answers the first question.

    And for the second question, the reason should be obvious after reading the first answer….. bruxism damages prosthesis.

    That is why he will prescribe a bite guard covering your superior dental arch.

    Unfortunately, this is mostly done without a sleep study despite the frequent concomitance of sleep apnea and bruxism25

    A study analyzed the impact of such guards on patients with sleep apnea and the results found were worrying:

    • the apnea-hypopnea index increased by >50% in 5 of 10 patients
    • the sleeping time with snoring increased by 40%.

    So, the risk of aggravation of your sleep apnea is a reality when you wear a dental guard (see also Of sleep apnea, teeth grinding and oral appliances)26.

    Which dental devices for OSA patients with insufficient dentition?

    If you have been an avid reader of the previous sections, then you will probably conclude that:

    • if you suffer from poor dentition,
    • if you suffer from OSA,
    • and if CPAP is not the right treatment,

    then surgery is the only treatment left?

    Not so fast! You can use a different approach that does not need teeth for retention: a tongue retaining device.

    This comes in handy if:

    • you are receiving dental treatment,
    • and if you do not have enough dentition to use a mandibular advancement device.
    Tongue Stabilizing Device

    So, what does it do and how does it work?

    • It manages to maintain your tongue in a forward position by suction.
    • It looks a bit like a pacifier with a flexible bulb positioned in front of your mouth.
    • First, you need to protrude your tongue so that it goes into the anterior bulb.
    • Next, you have to give the bulb a little squeeze.
    • This results in a suction that holds the tongue in a forward position.

    Some of these appliances are prefabricated, like the tongue-stabilizing device (TSD). Others are custom made instead.

    But what about if your tongue does not extend beyond the lips?

    Good call!

    Then, unfortunately, this solution will not be suitable27

    Let’s now take a look at how technology is being used to innovate.

    Oral devices to treat sleep apnea: technological advances

    Indeed, technology is here to surprise you!

    During the last few years, remotely controlled mandibular positioners have been introduced.

    They can:

    • identify whether you are a responder
    • assess the degree of mandibular advancement necessary for you. This requires a polysomnography test during one night.

    Also, some new generation dental appliances feature some small temperature sensors. They assess your adherence to treatment.

    Let’s now delve into the most frequently used treatment of sleep apnea.

    Continuous positive airway pressure (CPAP)

    What is continuous positive airway pressure (CPAP)?

    Before oral appliances came into use, CPAP was the only medical device available.

    And it is still the most popular and also the primary treatment of sleep apnea.

    It prevents your upper airways collapse during your sleep.

    But how does it work?

    By providing a constant flow of pressurized air that is gently blown into your respiratory airways. This serves to keep them open while you sleep at night.

    Image showing unoccluded airflow when wearing a continuous positive airway pressure (CPAP) mask
    Unoccluded airflow with CPAP mask

    The mask must ensure a good seal.

    If this is not the case, air leaks may lead to insufficient air pressure with suboptimal results. Your airways may not open because of insufficient air pressure.

    You can use both a mask, fitting over your nose and mouth, or a nosepiece (only) fitting over your nose.

    Flexible tubing is connected to the mask and to a machine. This tubing is long enough to ensure you are comfortable (you can turn or move easily).

    When you use a CPAP machine, you will see that these devices:

    • are portable hence quite small (the size of a tissue box)
    • can be easily placed next to your bed, for instance on your nightstand
    • blow ambient air into your trachea
    • are equipped with a humidifier to moderate air
    • are also equipped with a chip card. This serves to record events occurring during your sleep (micro-awakenings etc..).

    CPAP types of equipment have improved and continue to improve.

    They are becoming more and more user-friendly, less cumbersome, quieter and less intrusive.

    Though, being hooked up to a machine… well, it is not very attractive, is it?

    That leads on nicely to the next question.

    How long should I use CPAP for?

    Let’s address the elephant in the room.

    You are wondering, and that is only human, whether you will have to use it forever.

    Indeed, the thought of having to use CPAP for the rest of your life is not very reassuring. It is not the most appealing treatment for sure!

    But you may not have to.

    It really depends on the cause of your sleep apnea, and that is person dependent.

    Factors that lead to sleep apnea include:

    1. loss of muscle tone due to aging, for instance, menopause.
    2. As you get older, teeth position may also change. These may affect the airway and how well you can breathe during sleep.
    3. Reversible factors where you will experience sleep apnea in specific contexts or where it is aggravated by others:
      • Sleeping on your back,
      • REM sleep,
      • after alcohol consumption,
      • becoming overweight since the accumulation of fat at the base of the tongue narrows your airway,
      • nasal congestion due to a cold or allergies,
      • pregnancy especially for women who are overweight or obese, or who gain excessive weight during pregnancy.
    4. Anatomy of the structures within your throat, nose, position of your tongue and jaw:
      • Inflammation of your turbinates (tissues within your nose) due to infections, allergies, weather, and temperature changes …
      • A broken nose can lead to a deviated septum and increase the chances of suffering from sleep apnea.
    Anatomy of the nose and upper respiratory system, with nasopharynx, oropharynx and laryngopharynx.
    Anatomy of the nose and upper respiratory system

    As you can see, some of these causes can be corrected.

    For example, if you lose weight, your sleep apnea may likely improve.

    The same is true if you undergo surgery to correct a deviated septum or get treatment for your allergies.

    Hence doing CPAP is not like serving a life sentence.

    How about the frequency of use?

    Should you use it every time you doze off?

    Move on to the section to find out.

    How often should I use CPAP?

    Unfortunately, the answer is short and clear: you should use it every time you sleep.

    It is a lifestyle change.

    Why such frequent use?

    Because the more you use it, the better you will feel and you will decide it is worth putting up with the inconvenience.

    One night without CPAP can:

    • Negatively influence your quality sleep
    • increase your blood pressure
    • decrease your daytime alertness and function
    • etc.

    But how effective is CPAP at treating sleep apnea?
    Let’s see…

    How good are results obtained with CPAP?

    CPAP does work!

    It will reduce or eliminate:

    • Sleep apneas or hypopneas, so that you will no longer snore or make choking sounds when you sleep.
    • Fragmented sleep due to micro-awakenings because of lack of oxygen.

    But that is not all!

    By eliminating sleep apnea, you will also have many other health benefits:

    1. less sleepiness hence better daytime alertness,
    2. better memory and thinking skills, better concentration throughout the day,
    3. lower risks of motor vehicle accidents (see also Does OSA increase the chance of a motor vehicle accident?),
    4. lower risk for diabetes (see also How are OSA, diabetes Type 2 and cardiovascular diseases related),
    5. you will feel emotionally more stable, and your risk of depression will be lower.

    And, using CPAP therapy over an extended period can protect you from cardiovascular problems. Hence, your risk of dying from:

    • Stroke,
    • congestive heart failure,
    • coronary artery disease,
    • irregular heartbeat,

    will decrease (see also Chapter 1: Obstructive Sleep Apnea (OSA) and its Health Effects).

    Now gentle reader, maybe that after reading this you are leery that there is a price to pay for these positive effects.

    And you are right because CPAP has some adverse effects.

    But before we look at its side effects, let’s learn about the results obtained with some of OSA’s associated diseases.

    Does treatment with CPAP influence hypertension in OSA patients?

    Several studies have been done to answer this question.28 29 30 3132

    Now, despite variations of CPAP’s effects, results seem significant. A decrease in arterial pressure will be more important if you:

    • have a severe OSA,
    • are obese,
    • are treatment compliant, in other words, if you stick to treatment.

    Let’s now talk about how CPAP’s treatment of OSA affects associated coronary heart disease.

    Is it beneficial to treat OSA with surgery or CPAP if you suffer from coronary heart disease (CAD)?

    This time, a study on 54 CAD patients provides some interesting answers.33

    Are you curious?

    Here we go.

    The study included patients with coronary artery stenosis ≥70% and OSA (apnoea-hypopnoea index ≥ 15).

    It showed that the treatment of OSA was associated with a decrease in the occurrence of cardiovascular events in CAD.

    Examples of cardiovascular events included:

    A group of patients was treated with CPAP (21 patients) or upper airway surgery (4 patients).

    And another group (29 patients) refused treatment.

    Interestingly, the two groups were similar regarding other characteristics that may have influenced coronary heart disease such as:

    • age,
    • body mass index,
    • smoking history,
    • hypertension,
    • hypercholesterolemia,
    • diabetes mellitus,
    • number of diseased vessels,
    • left ventricular ejection fraction,
    • and coronary heart disease therapy.

    What was finally observed?

    The treatment of OSA led to:

    • a decrease in the occurrence of new cardiovascular events,
    • an increase in the time to such events.

    So, the results were encouraging.

    Let’s now talk about another cardiovascular disease: irregular heartbeat (cardiac arrhythmias).

    You may be interested to discover how CPAP affects your arrhythmias when you are treated for OSA.

    Just scroll down.

    Does treatment of OSA reduce cardiac arrhythmias?

    Only studies can answer such questions.

    And a study indeed there is.

    What does it show?

    That if you suffer from OSA, then your risk of arrhythmias decreases with CPAP therapy.

    Even if you suffered from frequent occurrences of irregular heartbeat, this would decrease quite fast.34

    Another study also showed that:

    1. if you suffer from atrial fibrillation and OSA,
    2. and if you get treated for your arrhythmia,
    3. the return of your cardiac atrial fibrillation will decrease from 80% to 40% if you are on CPAP35.

    Worthy of interest is also the fact that among patients with a pacemaker, the prevalence of undiagnosed sleep apnea is 59%.36

    Since we spoke about pacemakers, do we know whether treatment by CPAP affects their use?

    Next …

    Does night treatment of OSA reduce need of a pacemaker?

    You have seen that arrhythmias decrease after CPAP treatment of sleep apnea.

    What about the use of a pacemaker to control arrhythmias?

    Can its use be decreased if OSA gets treated?

    Unfortunately, there are currently no data to answer this question.37

    Image showing a heart with an implanted pacemaker
    Heart with an implanted pacemaker

    As we wait for science to progress, let’s look at other effects of OSA.

    Erectile dysfunction (ED), for instance, affects your quality of life.

    It is also linked to OSA.

    With that in mind, let’s roll right in.

    Can treating OSA improve your erectile dysfunction (ED)?

    If you have stayed with us all the way from the beginning of this guide, then you are almost an expert on OSA therapies 😉.

    So, you know that the established first-line therapy for OSA is CPAP.

    It is thus no surprise that most of the studies on OSA patients suffering from ED have been done using CPAP.

    And what about the results?

    Unfortunately, they are inconsistent:

    • Some studies show improvement in ED and hormonal levels (e.g. testosterone).
    • Others instead show improvement in ED only.
    • Finally some show neither improvement in testosterone levels nor in sexual function38.

    Some preliminary encouraging results come from uvulopalatopharyngoplasty (UPPP).

    This surgical procedure has shown encouraging results.

    The outcomes are actually better than both CPAP and mandible advancement procedures. But more studies are required.39

    Another way CPAP can improve your quality of life, is by treating your OSA when you suffer from depressive symptoms.

    Read on to find out.

    Does treating OSA decrease depressive symptoms?

    A 2007 study showed encouraging results.

    Patients suffering from OSA and treated with CPAP showed a marked improvement in their symptoms of depression.

    This was both true at short-term and long-term follow-up periods, indicating that results were lasting.40

    Diabetes Type 2 is the last OSA associated disease we want to touch upon.

    Stay with us if you want to learn how CPAP affects its symptoms.

    Can OSA treatment help diabetes type 2 patients or patients with abnormal glucose levels?

    If you suffer from these 2 diseases, you will be relieved to know the news are somewhat good.41

    Several studies show that CPAP can improve your cells’ ability to use glucose especially if:

    • You are compliant with the treatment meaning that you correctly follow medical advice,
    • and if you use CPAP >4 hours per night.

    But, these studies focused on individuals with:

    • normal blood glucose concentrations
    • or patients with pre-diabetes.

    Unfortunately, strong evidence is lacking for the impact of CPAP on glucose levels, in patients with Type 2 diabetes.

    Now that we have completed this detour through OSA’s related health effects.

    Let’s now go back to CPAP.

    We had mentioned that it has some side effects.

    Curious?

    Then jump right in!

    What are the side effects with CPAP and what are the solutions?

    Despite its effective use in treating sleep apnea, CPAP can create some frustrations

    Although serious side effects are extremely rare, there are minor problems which are quite frequent:42 43

    • machine noise,
    • pressure from masks or straps,
    • air leaks from mask,
    • air leaks from your mouth,
    • cold face or nose,
    • claustrophobia,
    • dry mouth or throat,
    • air pressure is too high,
    • skin irritation on your face,
    • mask coming off your face,
    • chest discomfort,
    • difficulty breathing,
    • nosebleeds,
    • a dry nose,
    • a stuffy nose,
    • a runny nose,
    • a headache,
    • bloating.

    It will thus not come as a surprise that the main problem with CPAP is…

    …low acceptance and adherence to treatment.

    In other words, although it is very effective, the risks are high of you not complying with what your sleep specialist advises.44 45

    And you will be likely to use it irregularly and/or stop using it after a few years. …. and guess what?
    ….This will decrease its effectiveness.46

    The next sections will look in more detail at:

    • Some common problems that may influence your acceptance
    • and also check some possible solutions.

    But before we do that, remember that it may take some time to:

    • find the right settings
    • and to get used to wearing a mask at night.

    Your sleep doctor will help you identify and correct any issues and adjust settings.

    Let’s look at the first culpright of low compliance.

    Air leaks

    One frequent issue is air leaks.

    You need to address this problem if:

    • you complain about them,
    • the machine cannot maintain enough pressure,
    • they exceed the machine’s threshold,
    • your eyes are dry or teary due to some of the air leakages.

    Some solutions include:

    • cleaning the mask since the softer and cleaner the silicone, the better its skin adhesion;
    • changing type of mask if the above solutions are not satisfactory, if the mask is worn out or if it’s the wrong size;
    • checking and adjusting mask’s positioning, as well as its straps, with air pressure on.
    Image of a man holding and examining his CPAP mask
    A man holding and examining his CPAP mask

    If you are without teeth then wearing your dentures at night is important.

    If you feel significant discomfort from a dry mouth, then a likely cause is mouth leaks.

    You can try to use a chin strap.

    You should consider that everyone has different face shapes. Hence, changing mask may be a good solution.

    When changing mask, you should seek help from your doctor and supplier to find the best mask for you.

    Let’s now check another source of discomfort.

    Skin irritation, sores or blisters

    CPAP masks exert prolonged pressure on the skin.

    So here is the (expected) kicker..

    … skin pain and adverse effects

    Since pressure is the cause, then:

    • ensure that the mask is properly fitted over your face by adjusting pads and straps;
    • most masks are adjustable, so take advantage of this;
    • clean the mask daily. A cleaner silicone ensures a better seal and you will not need tightening the straps too hard;
    • consider also changing your mask especially if your weight has changed considerably;
    • think about using a nose patch;
    • if you have sores, blisters or your skin has deteriorated significantly, tell your doctor and stop CPAP until skin healing.

    Dry Mouth

    Breathing through your mouth a whole night is not pleasant because it gets dry.

    But it gets worse with some CPAP devices.

    Consider:

    • switching to a mask covering your mouth and nose,
    • use a CPAP-heated humidifier.

    How does the latter work?

    Simple… it connects to the air pressure machine to increase the level of moisture in the air.

    Dry, stuffy, runny nose

    A dry nose can be due to a leaky mask.

    Ensure that it fits well. A good test is to see whether you need (or not) to tighten your straps.

    If you have to tighten straps too often, then consider changing your mask. It may not fit properly.

    Use a humidifier. This is connected to the CPAP machine. Increase the level of moisture if the problem persists.

    Change from a nasal pillow to another type of mask to reduce the flow of direct air.

    A nasal saline spray before falling asleep may also help.

    Pressure is perceived as too high, difficulty in exhaling

    You will require some time to adapt to CPAP.

    So that will need …. yes, you know …. a good deal of patience.

    Though, you can also address the pressure issue via the ramp feature. This is present on individual devices.

    It allows you to fall asleep with a lower pressure level. This is then gradually increased during the night, up to a final level set by your doctor.

    If you wake up at night, you can also turn the machine off and on, so that the process starts all over again.

    If this does not help, there are other solutions that you can discuss with your doctor.

    An example is a bi-level positive airway pressure (BPAP) machine.

    A bi … what?

    It is a sophisticated word for a device that:

    • continuously adjusts the pressure it delivers,
    • so that air pressure is higher when you breathe in than when you breathe out.

    Feeling claustrophobic

    You can deal with this issue if you approach it gradually.

    You will see that it usually decreases over 3 months.

    Try to use the mask regularly, even for a short time, so that your tolerance threshold increases.

    At first, you can use it while you are awake without the straps.

    Then you should try wearing it with the straps on.

    Finally, you will have to add the hose to the mask, at first without the straps.

    You should then try to use the CPAP machine and once you will feel more comfortable also use the straps.

    Finally, the last step….. you have probably guessed already.

    Image showing sleeping man with nasal CPAP machine
    Sleeping man with nasal CPAP machine

    …….. you need to sleep with the mask on, straps attached and CPAP machine turned on.

    If this approach does not yield good results, then talk to your doctor or CPAP supplier.

    There exist other types of masks, coming in different sizes and shapes such as nasal pillows.

    These could be a solution because they make you feel less claustrophobic than a full face mask.

    Why?

    Because they do not cover your mouth. Albeit they also have straps that stretch across your forehead and cheeks.

    Difficulty getting used to the CPAP device

    Just as with claustrophobia, try to get used to the CPAP mask by wearing it when awake.

    Do not force yourself to wear it for a long time right from the start.

    Increase the amount of time gradually.

    Then begin using the device turned on, connected to its tubes when awake and then when napping.

    Finally, begin using it during your night’s sleep.

    You may temporarily take some sleeping pills to ensure falling asleep more quickly. Else consider going to bed somewhat later (for the same reason).

    After some time, you will feel whether mask and pressure are right for you or not.

    Too noisy

    Since most new generation devices are almost silent, this should not be a frequent occurrence.

    So, when it happens, what may it be due to?

    Here are some causes:

    • improperly closed humidifier,
    • clogged device air filter (it should be clean and unblocked)
    • punctured tubing,
    • defective engine,
    • leaks around the mask,

    Try to find a solution by liaising with your sleep specialist or CPAP supplier to:

    • understand how to clean your mask and hose,
    • ensure that the whole device is working as it should.

    Also, consider placing the machine:

    • as far as possible from the bed (you may need extra tubing for that),
    • on a surface that can reduce noise levels: a mousepad, a strip of cloth …

    Other solutions entail:

    • Wearing earplugs,
    • using a white noise machine to mask the noise. So, the device would make a random pleasant sound (called white noise). Examples include wind blowing through trees or a rushing waterfall.

    If all else fails, then consider changing the machine.

    What are the effects of CPAP therapy on your jaws and teeth?

    Once you have fine-tuned your CPAP therapy to decrease the sources of discomfort, then you are all set, and there is nothing else to worry about, right?

    Wrong!

    A study over 2 years showed that CPAP therapy can affect the position of your jaws and teeth.

    For instance, some patients had less prominent lower or upper jaws (“reduced maxillary and mandibular prominence”).47

    Close-up of molars showing malocclusion
    Close-up of molars showing malocclusion

    Another study showed a decrease in the premolar region’s occlusal points. These are the contacts points between opposing teeth’s surfaces.

    In this study, patients had also been using CPAP over 2 years48.

    Hence it is important that you see your sleep specialist regularly. This will ensure optimal results with your CPAP therapy.

    CPAP and dental appliances: results and comparisons

    How do sleep apnea results obtained with CPAP compare to those obtained with mouthpieces?

    Head to head studies comparing the two therapies during overnight sleep studies provide the answers to this question.

    And so, the answer is that…

    ……… although CPAP shows greater efficacy, and can reduce AHI by 6 events/hour49, final results are comparable.

    Also, a study with 103 patients using (randomized to) either CPAP or dental appliances, showed that quality of life improved significantly and similarly irrespective of the treatment.50

    Feeling a little puzzled by these findings?

    The explanation is that patients use dental appliances more easily. So, they end up wearing them for more extended hours during their night’s sleep.

    Even if you show better response when using CPAP, this will be offset by your tendency:

    • to stop using it
    • or using it less regularly51.

    Patients are twice less likely to discontinue using oral appliances than CPAP52.

    Now, assuming that your compliance is excellent, do the above therapies put an end to your concerns?

    Next…

    Do dental appliances or CPAP cure sleep apnea?

    A short answer is … no, unfortunately

    That is because neither dental appliances nor CPAP:

    • Can address the main causes
    • or bring about the structural changes

    that may resolve your sleep apnea.

    These include:

    • correcting your deviated septum by undertaking surgery
    • treating your allergies
    • weight loss because you go on a diet
    • ….
    Image saying: I am trying to lose weight, but it keeps of finding me.
    Losing weight is not easy

    So, they are not cures since your sleep apnea will return as soon as you stop using them.

    The predisposing factors are still there.

    But, as long as you use them, both dental appliances and CPAP can help you:

    • maintain your airways open
    • and improve or fully resolve your sleep apnea.

    In a way, CPAP and dental appliances are like a pair of glasses. They can improve your quality of life without changing the underlying problem.

    What happens when you stop using CPAP or dental appliances?

    Symptoms like fatigue, daytime sleepiness will return more or less rapidly

    Why not immediately?

    Because the use of CPAP or dental appliances may have decreased the swelling in your airways.

    As snoring and sleep apnea gradually return, so does the swelling, leading to a vicious circle.

    The circle is vicious ☹ because:

    1. as the swelling worsens,
    2. so do the snoring and sleep apnea,
    3. which in turn increase the swelling.

    And that’s all folks!

    Final remarks

    To reach omniscience about OSA, you have one more chapter to read.

    This is “Chapter 5: Treating Obstructive Sleep Apnea (OSA) with Surgery.”

    It will walk you through a more invasive approach to treating sleep apnea.

    Now, if you have not seen the previous articles, then check the links here below. They are also important on your path towards OSA wisdom 😊.


    Bibliography