Everything You (Never Knew You) Wanted to Know About Obstructive Sleep Apnea (OSA)

[McCamy Taylor]

Long post, huge health problem. Practically an epidemic, but you do not see any ribbons for this one. No rock stars doing benefit concerts—though I have no doubt that some of them have OSA. And if they have it, chances are they do not know it.


Intro. OSA, the Great Imitator

Once upon a time, in the pre penicillin days, syphilis was referred to as “the great imitator”. Syphilis did not merely make people break out in spots. It could lead to progressive neurological dysfunction (sort of like MS). It could make you crazy. At one point in the 19th century, the most common reason for hospitalization in mental facilities was syphilis. It could destroy your arteries and heart…

Now that the infection is easy to diagnose and treat, we seldom see these complications in this country. So, I would like to suggest that another common---and commonly unrecognized—disease be awarded the title “the great imitator.”

I. Obstructive Sleep Apnea 101

What is OSA? Put very simply, it is a condition in which the airway---nose, throat---close during sleep, cutting off the necessary flow of air. Almost anything that interferes with the diameter of the airway can worsen OSA. Allergies that make it impossible to breathe through the nose. A receding chin that falls back during sleep.An enlarged thyroid of other neck mass that pushes on the airway. Smoking, which causes swelling of the airway. Severe heart burn or gastroesophageal reflux disease, which allows acid from the stomach to back up into the throat, causing irritation. In addition, some things make the work of breathing more difficult. Certain neuromuscular disorders that weaken the diaphragm, the muscle that we use to breathe. Severe obesity, which puts a weight on the chest that makes the breathing muscles work harder. Conditions that cause swelling of the abdomen or stomach, such as certain tumors or cirrhosis of the liver, since the diaphragm has to push down against the abdomen when we take a breath. Medications and some recreational substances can interfere with breathing, by making the airway “floppier”. These include alcohol and sleeping pills such as benzodiazepines. Paradoxically, benzos like Ambien, Xanax and Valium are often prescribed to folks with OSA, who complain to their doctors that they are sleeping restlessly at night. Or folks may use alcohol at bedtime to smooth out their sleep. In both cases, if the underlying problem is OSA, they are actually making things worse.

Any list of causes of OSA must include genetics. The condition runs in families. One of the best ways to predict which snorers have OSA and which do not is to find out if Mom, Dad or the siblings have the disease. If so, then it is likely to be sleep apnea. I can not tell you why. It seems that some families lack the ability to keep their airways
open when they sleep.

How does this problem affect sleep? A couple of things happen. First, when the flow of air is cut off, the level of oxygen in the blood falls and the level of CO2 rises. At some point, the sleeping brain says “This is dangerous!” It triggers the adrenals to send out a surge of epinephrine, which makes it easier to breathe in conditions like asthma. Since epinephrine or adrenalin is a stimulant, it wakes the OSA sufferer up. Sometimes, it wakes him all the way up---and he complains of insomnia in the middle of the night, wakening up feeling anxious or restless. More often it does what is called a micro arousal. For a few seconds, the sufferer moves from deep sleep to very light sleep just verging on wakefulness. In the process, he is able to move his chin, reposition his head and neck and open the airway to get a few good breathes. Then, he drifts back to deep sleep. One or two of these micro arousals a night would be no big deal. However, people with severe sleep apnea may wake themselves up (without being aware of it) hundreds of times an hour. This means, they are getting very little refreshing restorative sleep in an eight hour night and they wake up feeling tired and sleepy. During REM or dream sleep, the bodies muscles (except for the diaphragm and the eye muscles) are paralyzed, which can make the problem worse during dreams----and the low oxygen and high adrenalin which results can affect the content of dreams, causing nightmares as the body senses that it is in danger and struggles to wake up. Since REM sleep is necessary for healthy mental functioning, anything that disturbs it on a regular basis can make it harder to learn and remember and even affect the emotions.

In addition to causing sleep deprivation, OSA also affects the body in a couple of other ways. First, if the condition is severe and if a lot of time is spent each night with dangerously low oxygen levels, this can damage the lungs and heart. More commonly, the oxygen level does not get that low that often, because the adrenalin kicks in a wake you up so that you can breathe again. There is a price to pay for all those hundreds or thousands of adrenalin surges. They raise the blood pressure. They contribute to something called insulin resistance, a factor in diabetes and heart disease. They act like chronic stress on the body, impairing the immune system, making folks feel anxious or nervous even during the daytime, for no apparent reason---

Because, keep in mind, all of this occurs when you are asleep. You will rarely catch yourself not breathing. By the time low oxygen forces your sleep deprived brain to a state of complete wakefulness, you have already cleared your airway reflexively and you are breathing alright again. That is why so few people go to the doctor and say “Doc, I think I need to be checked for sleep apnea”---unless a partner or family member has observed him choke, gasp and stop breathing at night. And very often, friends and family do not want to tell you about your noisy snoring/breathing since they do not want to sound critical and they do not understand that it can be a sign of disease.

II. OSA, the Statistics

For many years, if you took a sample of the population and performed a sleep study (a complicated overnight test in which breathing, oxygen and brain waves are recorded),
2% of women over the age of 40 and 4% of men over the age of 40 would have OSA. At least 80% of these people---4 out of 5—would not know that they had OSA. In recent years, those numbers have doubled. Now 8% of men and 4% of women over 40 have OSA---and 4 out of 5 of them still do not know it, despite all the recent developments in OSA diagnosis and treatment.

If you tack on a variety of risk factors---male gender, family history, obesity, smoker, alcohol or sedative use at bedtime, allergies---your personal risk goes up. African-Americans have a double risk of OSA. That does not mean that a lean nonsmoking European-American woman can not have OSA. But she is less likely to have it than her more obese, smoking African-American husband. Advancing age is a risk factor---but there is a subgroup of children with severe obesity or massively enlarged tonsils who are also at increased risk.

Now, a little math. There are an estimated 18 million people in the United States with OSA. Four fifths of these, or around 15 million do not know that they have sleep apnea To put this in perspective, there are around 23 million Americans with diabetes, only 6 million of whom do not know they have the condition. In 2003 the CDC estimated that 1 million were living with HIV. The number may be closer to 2 million now. There about 200,000 new breast cancer cases each year with about 40,000 deaths----

Maybe that is the problem. Maybe that is why there is so little public attention towards sleep disorders. No one ever died of not getting a good night’s sleep. Right? Wrong

III. OSA the Even More Alarming Statistics

Sleep apnea sufferers die on the road. They die from car crashes. A person with untreated moderately severe OSA drives with the about the same lack of care and attention as someone who is legally drunk.

People with undiagnosed OSA do not know that they are sleep deprived, and that is part of the problem. If you are driving home after working a 24 hour shift, you know to be extra careful and pay extra attention on the road. People with sleep apnea think they just got 8 hours of sleep. They do not realize that they are chronically sleep deprived. They drive the same way they did when they were 20---talking on cell phones, applying make up, eating breakfast. They go too fast and they hug the bumper of the car in front of them—just like the rest of us. But when something unexpected happens, say, for instance, another car tries to enter their lane or the car in front of them slows suddenly, their reaction time is poor. Accidents happen---not always the fault of the sleep apnea sufferer, but their poor attention contributes. People with OSA have been estimated to have a seven fold increased risk of motor vehicle accidents. And you do not have to be a sleep apnea sufferer to die on the road because of the disease. If a truck driver falls asleep behind the wheel, it may be you that suffers.

Untreated sleep apnea also jacks up the nation’s medical bills. If you review the medical histories of folks diagnosed with OSA, turns out that they have increased utilization of medical services---including hospitalization---for the previous five years . A study from 1999 found that these people spend an average of $1500 a year more than others without sleep disorder, and the nation may spend $3.4 billion extra a year on care that is not really necessary----since many of the secondary problems would resolve if the OSA was diagnosed and treated. That was 10 ten years ago. With the increased prevalence of the disease and rising cost of medical care in this country, the amount has probably increased.

http://www.ncbi.nlm.nih.gov/pubmed/10505820

Before you say “But people with obesity and other problems are just plain sicker in general” keep in mind that the medical costs incurred by people with OSA decline once they are diagnosed and treated.

http://www.ncbi.nlm.nih.gov/pubmed/15233955?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed

Before their OSA diagnosis, people are also more likely to report poor quality of life and problems with their work---which means that U.S. productivity is compromised, with more days off work, more people on disability and more mistakes on the job. If the OSA sufferer works with heavy machinery, drives a truck, runs a train or is in charge of a dangerous facility such as a nuclear power plant, their errors can be catastrophic—and costly.

Obstructive sleep apnea has been associated with a high risk for motor vehicle accidents, probably the highest of all risks due to medical conditions. Treatment of sleep apnea with nasal continuous positive airway pressure appears to reduce the risk of traffic accidents to the one of the general population. The risk for accidents may also be increased in untreated patients in the home and work environment. The increased risk seems unrelated to the symptom of daytime excessive sleepiness, and in many studies lacks a clear dose-response relationship with respect to the severity of apneas and hypopneas. The association of sleep apnea, chronic sleep deprivation and consumption of hypnotics or alcohol has not been thoroughly studied, although alcohol has been considered as a confounding variable in some studies. The cost of traffic accidents due to sleep apnea has been estimated to be so high that diagnosing and treating all drivers with sleep apnea in the USA would be cost saving and result in a decrease in society costs related to the disease.

http://www.ncbi.nlm.nih.gov/pubmed/19494476?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed

Scared yet?

IV. Who Has Obstructive Sleep Apnea?

This is the $64,000 question. If there was a blood test that friends and family (who happen to own a glucometer) could administer to check for OSA, that 4 to 5 ratio would probably be much lower.

In order to confirm the diagnosis of OSA, you undergo an overnight sleep study in a lab. In the process, you are hooked up to so many machines, you look like the woman trying to give birth in Monty Python’s The Meaning of Life . All that equipment costs. Until very recently, many insurers including Medicaid, did not cover the test and/or treatment. Some plans still do not cover sleep studies. Rural communities do not have sleep labs, which means driving to the city for the test. Even if you live in the city, the waiting time to get an appointment can be months. And if you are one of the 40 million Americans who does not have health insurance you will be asked to fork over $1000 up front.

With so many barriers to diagnosis, it is no wonder that patients and doctors only think about OSA in the most extreme situation---the morbidly obese male who falls asleep on the couch and who keeps the family awake at night with his snoring. Your average family doctor and internist can spot these guys a mile away. They know that their sleep studies will be abnormal. That takes care of the one in five. Unfortunately, they miss the rest of us, even when we have conditions that should raise a red flag about possible sleep disorder.

V. Have You Considered the Possibility that Your ____ May Be Caused by Sleep Apnea?

Here are some people whose sleep apnea would usually be overlooked.

Tyrone, a slightly overweight African-American male in his 40s with severe hypertension. Though he no other significant health problems---he does not drink or smoke, he does not have diabetes, he exercises---his doctor has him on four or five different blood pressure medicines, all at their maximum dose, and he still had readings of 170/110 when he comes to the office for a check up. Tyrone needs to be asked about his sleep. Does he snore? Has be ever been told that he chokes or stops breathing in his sleep? When he checks his blood pressure first thing in the morning is it higher than it is later in the day? Note that people who get normal sleep have their lowest readings when they first wake up. Folks with OSA spend their nights riding a roller coaster of adrenalin, so they wake up with high readings.

Sally is a 12 year old child with migraine headaches. In a recent study, half of all children with doctor diagnosed migraine headaches also had sleep apnea. Sally’s mother, Sara, who also has really bad migraine’s along with fibromyalgia needs to be screened, too. Migraine’s run in families the same way that OSA runs in families. Often, the two occur in the same families.

Sally’s brother Jason, who has ADD and whose tonsils are the size of tennis balls needs to be screened, too, even if he is not overweight. Removing those tonsils may provide a cure for his behavior and learning problems. You would have a hard time paying attention in school, if you only got a few hours sleep at night. And a stimulant, such as Adderal, would mask your symptoms of sleep deprivation the same way that coffee keeps adults with OSA awake.

The same goes for fifty year old Bob, who wakes up to use the bathroom two or three times a night even though he is not on a diuretic (fluid pill) and even though his prostate is not enlarged and he does not have diabetes. Those adrenalin surges from low oxygen stimulate his body to produce more urine, in an effort to clear the lungs of imaginary fluid overload and raise the blood oxygen. Nocturia---having to get up one or more times a night with a full bladder---can be one of the most reliable markers of OSA, since it is less subjective than feeling tired or sleepy. Every doctor who suspects a sleep disorder should ask about the symptom. Older children who still wet the bed should raise a red flag, too. And speaking of genito-urinary problems, did you know that erectile dysfunction without an obvious cause can be the result of sleep apnea?

I mentioned fibromyalgia. Anyone with chronic muscle pain so severe that he or she is on narcotics should be screened for a sleep disorder. Especially if there is no obvious cause for the muscle spasms and pain. Add in tiredness and the other symptoms of chronic fatigue syndrome and OSA becomes even more likely.

Brenda, a 35 year old with a long history of intractable depression has tried every antidepressant on the market, she still lacks energy, feels moody, has a hard time getting her job and other daily tasks done and just does not feel like “herself”. Brenda is just as likely to have OSA as she is to have bipolar disorder without the manic component. I am amazed at how many psychiatrists think “bipolar” in folks who have never shown any symptoms of mania----reduced need for sleep, foolish spending and other irrational behaviors, pressured speech---and do not consider “sleep disorder”. I am appalled at how many of their patients end up on Abilify or some other atypical antipsychotic. Since the main side effects of these drugs is weight gain, they are only going to make an undetected sleep apnea condition worse.

Jill, who has been told for years that she suffers from chronic anxiety, even though she has nothing in particular to feel anxious about, also needs to be screened for OSA. All those adrenalin surges act on the body the same way that being in combat does. If you test the sympathetic nerves of someone with sleep apnea (sympathetic referring to the “flight or fight” nervous system that makes us take off running if we see a tiger) you will find that the nerves are revved up compared to a normal person. It takes only a minor fright---say a car pulling in front of you on the freeway---to activate a full blown panic attack. That is because nature wants people who live lives of danger to be ready to respond at a moment’s notice. But what if your life is not dangerous at all and the only thing you have to fear is your own exaggerated response to everyday situations? You need to consider the possibility of a sleep disorder. And also consider the possibility that the Valium your doctor has you taking at bedtime, so that you can sleep may be making your OSA worse. And the coffee you drink by the gallon during the day to stay awake is not helping your anxiety.

Bill, a young man who has been to the ER a number of times for SVT---a particular type of rapid heart beat or tachycardia could have underlying heart disease and needs to be tested. He also needs to have his thyroid checked and if there is any doubt, a drug screen. These things are routinely done. But how often is Bill asked about the signs and symptoms of sleep apnea? Grandma, who keeps going into atrial fibrillation, a different more serious type of arrhythmia that can lead to strokes, should also be checked for a sleep disorder.

Patrice, who was just involved in a single car motor vehicle accident and who ended up in the hospital , will be checked for drug and alcohol abuse, diabetes, seizures, stroke, heart disease. Too bad that no one will think to check her for sleep apnea.

Tony, a youngish 40 year old who has always had perfect health comes in complaining that he is developing early Alzheimer’s. His memory is not what it used to be. If he does not write everything down, he forgets. And it is harder for him to concentrate on tasks, especially those that are boring. He makes a lot more mistakes on the job than he used to and he is afraid that he is going to get fired. Tony could have a rare, progressive disorder that is destroying his brain. But he is more likely to be chronically sleep deprived and not know it.

Latonya, a 29 year old from Texas with severe allergic rhinitis, who gets tired, depressed and anxious every year during September and then January through March but who is fine the rest of the time and who feels much better if she can leave Dallas and go down to a Mexican beach during these spells is not suffering from seasonal affective disorder. That does not happen in September. What does happen in September is rag weed bloom. And in Texas, the winter months are notorious for mountain cedar. The severe obstruction of her airway during high pollen seasons may be enough to tip her over the edge of sleep apnea.

Chin is worried because all the men in his family develop premature coronary artery disease, despite a good diet and healthy lifestyle. In addition to checking Chin’s cholesterol, his doctor should ask about his sleep, especially since Asians have an increased incidence of sleep disorders.

Rachelle, in her mid 20s, who suffered pre-eclampsia with her first pregnancy and premature delivery with her second should pay attention when told that she snores during her third pregnancy, especially if her mom has OSA. Because of the effects of pregnancy on the body, sleep apnea may be unmasked at an early age and then disappear after delivery only to pop up again later in life. And all those episodes of low oxygen and high adrenalin are not good for the baby.

Sylvia has hypothyroidism, She still feels tired even though her doctor says that she is on the perfect dose of thyroid supplement. Hypothyroidism, especially with a goiter is a risk factor for OSA.

Juan woke up in the middle of the night with stroke symptoms. It was a “passing” stroke. He regained full use of his left arm. But he does not want the same thing to happen again. Guess what can cause strokes, especially at night.

We then performed laboratory studies and were able to show that OSA could elicit excessive sympathetic and parasympathetic activation that would lead to respective surges in blood pressure (up to 230/130 mm Hg) and bradyarrhythmias with a complete heart block. It seemed rational to hypothesize that vacillating blood pressures with hypoperfusion and hypoxia may predispose OSA patients to cardiovascular and cerebrovascular catastrophe.

http://www.uihealthcare.com/topics/medicaldepartments/neurology/apneaandstroke/index.html

That’s some pretty severe blood pressure elevation. Maybe Henry, who keeps getting chest pain at three in the morning should ask his wife whether or not he snores, since blood pressure elevations are one of the causes of angina and heart attack.

Manuela, 22, is being treated for polycystic ovary disease. This is a condition which is associated with infertility, weight gain, abnormal hair growth and insulin resistance. Her doctor has her on medication that has made her cycles regular again and which has stopped her facial hair growth. She has been told that she made need “fertility pills” in order to get pregnant. She probably has not been told that she has a 5 fold increased risk of having OSA. Oh, and her severe cramps with her periods---they are associated with OSA, too.

If you have been told that you have a life threatening condition called pulmonary hypertension then I assume that you have also been screened for OSA, since pulmonary specialists are very aware of the effects of OSA.

VI. Doctors Are Blind to Sleep Disorders So You Have To Be Extra Vigilant

If you think your situation resembles one of the above, do not wait for your primary care doctor to ask about your sleep and diagnose a sleep disorder. Physicians are very bad about overlooking OSA. In part, this is because they are not trained to ask about sleep in medical school. One study found that almost no residents included a sleep history when they admitted someone to the hospital. Also, many residents train at facilities where diagnosis and treatment of OSA are not high priorities. If you are up to your neck in people with gun shot wounds and if your population includes a lot of homeless or extremely poor folks who would not be able to get OSA treatment even if the condition was diagnosed, you will not be encouraged to look for the disorder. If your public clinic does not have the money to pay for sleep studies and your patients are too poor to pay for themselves, you will definitely think about any disease other than OSA.

Physicians develop their practice patterns early on. They look for diseases which they have experience diagnosing and treating. If they have witnessed cardiology success stories---people with incipient heart attacks averted with stints---they will be very good at detecting folks who need interventional cardiology. If they have never actually diagnosed anyone with OSA or witnessed people getting better with treatment, OSA is not going to cross their minds most of the time. Oh, they will pick up the 300 pound man who falls asleep during the medical examination. But for the other 4 out of 5, sleep apnea will never even cross their minds.

Worse yet, if the doctors does happen to think about OSA and if he asks a question about it---“Do you snore or stop breathing at night?”---the patient may not know that he snores or chokes. Especially if he lives alone, and no one has witnessed these events. He tells his doctor “no” and the doctor dismisses the possibility of a sleep disorder. In a perfect world the doctor would then go on to ask “Does anyone in your family have sleep apnea? Does anyone in your family snore or choke? Do you get up at night to use the restroom? How many times? Do you feel tired when you wake up in the morning? Do you have a morning headache? Do you fall asleep easily when sitting on the couch? Do you feel sleepy even after a good night’s sleep? Do you wake up a lot at night or toss and turn? Is there a family member you could ask about snoring or choking?”

If the patient answers “no” to all these questions, he could still have a sleep disorder, but it is very unlikely. If he answers “yes” to most of them, then he probably needs a test. What kind of test? It depends. If he has obvious OSA, then a trip to the sleep lab to get him fitted for CPAP---the special breathing system that helps most but not all OSA sufferers. If the diagnosis is unclear, a simpler test is an overnight pulse oxymeter. The patient wears an oxygen monitor overnight while he sleeps at home. That test will pick up the more severe forms of OSA, though it can not rule out a mild sleep disorder, and if the patient fails that test they need to go on to get a formal sleep study. For those who do not want to spend a night away from home or for whom money is an issue, there are now home sleep studies which can be performed at a reduced cost.

VII. Ok, So Now I Know. What Should I Do Next?

I am not going to spend a lot of time on treatment. Most of the battle, in our current health care climate, is getting a correct diagnosis. Once you know that your have OSA, you will be able to see doctors who will know how to treat you----

Assuming you have insurance or money. Here are a few things that will help, if you are forced to wait for treatment.

1. Sleep on your side! Use pillows to prop yourself up. If you think about your airway, when you are on your back the tongue and jaw have a tendency to fall back, making it more difficult to breathe. On your side, they fall forward.
2. Control your allergies. Use antihistamines and decongestants at bedtime. Try one of those nasal strips. Keep your bedroom dust and pet free. Consider a HEPA filter.
3. Avoid certain sedatives such as valium and others of that class at bedtime. They will relax your throat and make it easier for you to choke. Avoid alcohol at bedtime for the same reason.
4. Lose weight. If you are overweight and you can lose some of those extra pounds, there will be less fat around your neck and airway.
5. Stop smoking.
6. Dental guards---a special kind of retainer that pulls the lower jaw forward while you sleep are relatively inexpensive and many dentists make them. In some studies they work as well as CPAP.
7. CPAP does not really cost all that much for what you get. And if you absolutely can not afford it, there may be a local charity that will help.
8. If you have insurance, there may be some surgical procedures, including some that can be performed in the office, that will help. Tonsillectomy can cure some kids.
9. Most important of all Be careful when you drive! Make sure you are rested. Do not let anything distract you. Stay many car lengths away for the car in front of you. If you are not rested, take public transportation or get someone else to drive. No one wants to become a road safety statistic because they could not get a good night’s sleep.

Good night and sweet dreams