THE MYSTERY. Many people stop breathing when they sleep, but it was only forty years ago that doctors began recognizing its dangers. Even today, doctors frequently fail to diagnose sleep apnea, a devastating disorder that can play havoc with a sufferer’s life—or even kill him or her.
The Case of the Farmer’s Daughter
One morning a fourteen-year-old and her father came to see me. She was a slightly overweight blonde with red cheeks who sat and stared at the floor through sad and tired blue eyes. She didn’t say much, though I noticed that her mouth was always a little bit open. She had grayish bags under her eyes, which is unusual in teenage girls. Her father, a farmer with overalls and calloused hands, did all the talking.
When I asked why they had come, the father said, “My daughter is a bit slow.” I could only imagine the embarrassment and shame this poor child felt hearing those words. He continued to tell me that she had trouble learning and that she was being treated with pills for depression but was not getting any better.
I told the father that I wanted to ask his daughter some questions, and I preferred that she answer for herself. Slowly, the extent of her tragedy emerged. For several years she had been doing poorly in school, and about a year earlier had dropped out because of bad grades. She had had difficulty concentrating and had frequently nodded off in class or fallen asleep during examinations.
I asked the father whether his daughter snored. He said that she had been snoring loudly for several years. I then asked if he had ever noticed that she stopped breathing while she was asleep. The answer was yes.
As I started my physical examination, I knew that I would find the cause of her problem with that simplest of medical instruments, a flashlight.
Sleep-breathing problems are so common that almost everyone knows a person who has one. The most common sleep-breathing problems are snoring and sleep apnea. Snoring, the less serious of the two, can cause conflicts in the home because the noise can be disruptive. But sleep apnea, a disorder in which people stop breathing during sleep, can ruin a person’s life as it did for my fourteen-year old patient. It can also cause death. Although snoring can be a symptom of sleep apnea, not everyone who snores has sleep apnea.
WHEN SNORING IS NOT A MEDICAL PROBLEM
Snoring, the loud noise people make while they are breathing in during sleep, usually signifies that the sleeper’s upper breathing passage is obstructed. Snoring results from vibration in tissues as the person tries to suck air in. As we saw in Chapter 6, a sleeper’s snoring can be so loud and disruptive that couples have to sleep in different rooms or even on different floors of the house. Couples in my office often get into arguments about whether one of them snores.
The vast majority of people who snore do not have a medical problem. If a snorer experiences no daytime sleepiness and has never been observed to stop breathing, and if his or her blood pressure is normal, then the snoring is not a medical problem (although it may represent a serious problem for the bed partner).
A snorer who has no other sleep-disorder symptoms or medical problems probably does not need an overnight sleep test. But snorers should consider having a medical assessment made, or at least a blood pressure check. In addition to doing a routine check, the doctor might find out whether the snorer’s nose is stuffy at night (perhaps the person is allergic to the feather pillow or the cat). The doctor will probably ask whether the snorer has ever had a broken nose or whether he or she wakes up with a sore throat (caused by mouth breathing). The doctor should inspect the patient’s breathing passage to make sure that no abnormalities such as a crooked or blocked nose, enlarged tonsils, or other lumps and bumps are present. The doctor should inspect the person’s jaw to see whether it is too small or set too far back. The doctor should also check the patient’s teeth for overbite. The tongue is attached to the lower jaw. If the jaw is too small or too far back, the tongue will also be too far back, and this can block the breathing passage behind the tongue. This may be a cause of children snoring. These checks may uncover a treatable cause of the snoring, which can improve the quality of sleep for bed partners and others in the household.
Women with no prior history of snoring sometimes start snoring during pregnancy, a symptom that can be related to several factors, including weight gain and the increased hormonal levels during pregnancy. Some women find that their nose becomes stuffed up because they have put on too much weight and the upper breathing passage has decreased in size. And some hormones that increase in pregnancy are believed to relax certain tissues and make the breathing passage floppier. In either case, the airway may become partially blocked and snoring may occur. Most of the time, snoring in pregnancy is not a problem, but the woman might want to discuss the symptom with her doctor to make sure it is not an indication of sleep apnea or a marker of preeclampsia (see Chapter 4). Progesterone, a hormone whose level is high in pregnancy, besides being involved in reproduction is also a breathing stimulant, protecting the pregnant woman from getting sleep apnea.
TREATMENT OF SNORING
Snoring is not a disease, so I do not recommend any surgical procedures except as a last resort, and only then if the patient has something fixable, such as a deviated nasal septum. I do not consider surgery necessary as a primary treatment when there is no medical problem. I have seen many patients over the years who have had surgical treatment for their snoring, and it has failed to cure the problem. The type of surgery that is usually performed involves removing tissue of the soft palate. This will not solve the problem if the obstruction is somewhere else—for example, behind the tongue—or if the person has a small jaw. Some treatments that can help snorers who do not have a medical problem are losing weight, cutting out or down on alcohol and sleep medications, and various dental appliances and other gadgets.
Weight loss. Most snorers are overweight, and the most effective but difficult treatment for those snorers is to lose weight. We have seen dramatic examples of people who lost weight and cured their snoring. Sometimes a relatively small weight loss results in a dramatic improvement. Sometimes a larger weight loss is required.
This is not a diet book, but I will mention a couple of things patients might want to try that are often not mentioned in diet books. A report published in the Journal of the American Medical Association in 2003 on a study of women over a period of six years found that women who watched two hours of television a day had a 23 percent increase in risk of becoming obese and a 14 percent increase in risk of developing diabetes. The more they watched, the greater was their risk. If they watched four hours of television, the risk doubled to 46 percent for obesity and 28 percent for diabetes. The same study found that a brisk one-hour walk each day reduced the risk of obesity by 24 percent and the risk of diabetes by 34 percent.
Avoiding alcohol and sleep medications. One widely recommended treatment for snoring is to avoid alcohol, especially before bedtime. Alcohol, by reducing the tone of the muscles that keep the upper breathing passage open, worsens snoring. If possible, snorers should also avoid medications that might have a similar effect. Such medications might include sleeping pills and other sleep inducers such as certain types of antihistamines that are used for colds and allergies. If the label carries a warning about drowsiness, the medication will probably increase the tendency toward snoring.
Dental appliances and other gadgets. People who have a small jaw or an overbite can benefit from using an oral appliance. These appliances resemble the mouthpiece worn by a boxer or football player, but they have to be custom-made to fit the patient’s teeth and jaw precisely, and are only worn during sleep. The appliance brings the lower jaw up and forward, and this brings the tongue forward, enlarging the breathing passage behind the tongue. If the cause of the problem is obesity, the appliance is less likely to work.
Many gadgets are available to treat snoring, and many snorers have tried them. Some gadgets work for some people. The most commonly used are adhesive strips placed on the nose to flare the nostrils (Breathe Right) and valves applied to the nostrils (Theravent). Some gadgets are intended to keep the snorer off his or her back. However, I am not aware of any gadgets that are effective enough to be used by all snorers. Sometimes sleeping on the side reduces snoring, so a poke in the ribs by the bed partner can help.
What Is Sleep Apnea?
Sleep apnea is a serious sleep-breathing disorder. The symptoms can be a combination of snoring, pauses in breathing, waking up gasping, and severe daytime sleepiness. Until about two decades ago doctors thought that sleep apnea was primarily a disorder of middle-aged overweight males and that it was nonexistent or rare in females, especially young women. Certainly it was not something we thought a fourteen-year-old girl, such as the one I described in the beginning of the chapter, would have.
The reality is that obstructive sleep apnea is an extremely common condition in both males and females—as prevalent as asthma. The percentage of males with the disorder is roughly double the percentage of females, but it is not rare in females; it affects roughly 2 percent of adult women in North America. It is much more common in postmenopausal women; about 10 percent of postmenopausal women have sleep apnea. Based on 2015 estimates of the U.S. population, this means that there are roughly 4.9 million men and 2.5 million women with sleep apnea in the United States. We now know that obstructive sleep apnea can strike people of all ages, from newborns to adults in their nineties. And not all sufferers are overweight.
The stereotype of the middle-aged male victim of sleep apnea has resulted in a frequent failure to recognize the disorder in women and children. Not only were far fewer women with sleep apnea diagnosed and treated, but women with sleep apnea were frequently treated for the wrong condition. We found, for example, that women with sleep apnea were frequently treated for depression. One twenty-nine-year-old woman explained: “I was having anxiety attacks, sleepiness, and depression. I spoke with my doctor and she suggested that I begin taking an antidepressant. My doctor and I had tried another drug the year before, but neither was working for me. I started thinking that I was becoming overstressed at my job, and I wasn’t able to cope on some days without becoming ridiculously irritable. . . . I found I was in bed sleeping a lot and was never feeling refreshed. I was gaining weight and not feeling any better.”
Research from Harvard published in JAMA in 2003 shows that at age thirty men are five times more likely to develop sleep apnea over a ten-year period than are women. By age fifty the tables have turned; at that point, women are two times more likely to develop sleep apnea over a ten-year period than are men.
Women are also more likely to have a variant of sleep apnea called upper airway resistance syndrome (UARS), though the percentage of women with UARS is currently not known. Children may develop sleep apnea because they are born with abnormalities involving their face (for example, a small jaw) or enlarged tonsils and adenoids or because they are obese.
Even your dog might have sleep apnea. Sleep apnea occurs in several breeds of dog, especially those with a “flat” face (a short snout), such as bulldogs, boxers, and Boston terriers.
THE “DISCOVERY” OF SLEEP APNEA
What happened to people with sleep-breathing disorders before the 1970s? Doctors usually have some patients whose clinical history is permanently etched in their memory. I encountered one such patient when I was a medical intern at the Michael Reese Hospital in Chicago between July 1971 and 1972. (This hospital has since closed down.)
The Fat Boy (detail), Charles Dickens, The Posthumous Papers of the Pickwick Club (1836)
I was on a rotation on one of the medical wards, and one of the patients, a woman, had me completely stumped. The medical staff at the hospital was trying to determine the cause of her severe, incapacitating sleepiness. Almost every time I went to see her, she was sound asleep, and when she woke up, she still seemed sleepy. Yet in all other respects her health was normal. However, she was about a hundred pounds overweight, and this combined with the sleepiness indicated to me that she might have something I had learned about in medical school called the Pickwickian syndrome. In his first novel, The Pickwick Papers (1836), Charles Dickens had described the features of this condition in a character called Joe the Fat Boy, who snored and was constantly sleepy. In his first appearance: Joe is described as “a fat and red-faced boy, in a state of somnolency.”
I had learned that the Pickwickian syndrome was a disorder in which people did not take in enough air; they did not breathe enough. It was also widely believed that the reason people with this syndrome were sleepy during the day was that their carbon dioxide levels were too high when they were awake. But when we tested the patient’s carbon dioxide level, it was normal, as was the result of every other blood test for abnormal states of consciousness. Her results proved that she did not suffer from Pickwickian syndrome. Furthermore, her symptoms did not fit any other syndrome based on what I knew or had read about. I was as stumped as the specialists at the hospital who had consulted on her case. I remember thinking that if I had been a bit smarter or if we had known more, I would have been able to help her.
Roughly two years later, while I was a medical resident at the Royal Victoria Hospital in Montreal, I had a case that was nearly identical to that of my patient in Chicago. This patient was a man, and he had one additional symptom—he had seizures while he slept.
One night, as I was doing my patient rounds, I observed that he stopped breathing when he slept, and I wondered whether this was somehow related to his sleepiness and his seizures. My speculations quickly led to what I believe to be the first sleep-breathing study in Canada and the publication of the first paper I wrote in the sleep field.
In the study we found that when he slept, the patient’s breathing passage became repeatedly obstructed and he stopped breathing, and that when he stopped breathing, his heart rate dropped and at times his heart would stop for up to ten seconds. When the brain is deprived of blood because the heart has stopped pumping, seizures can occur. We now could explain both the patient’s sleepiness and his seizures. We treated the patient with a tracheostomy, a hole placed in his windpipe, which bypassed the obstruction. His sleepiness was cured, and he never had another seizure.
I had found a case of sleep apnea, a disorder thought to be extremely rare, which had only been described a few years earlier, in the mid-1960s, in obscure (at least to me) European medical journals. This was probably the disorder that should have been diagnosed in the Chicago patient as well.
If you were to search the National Library of Medicine databases on the internet for all the articles written that contain the keywords sleep apnea syndrome, you would find more than six thousand articles; yet not one of them is listed before 1975.
But sleep apnea is not new; though it was not recognized clinically until the 1970s, it has been around for thousands of years, as can be seen in Dickens’s Fat Boy and in historical figures from our earliest times. It has been around as long as there have been obese people.
In 360 B.C.E., the tyrant of Heraclea (now called Iraklion, on the island of Crete) was a man by the name of Dionysius, a contemporary of Alexander the Great. He was so overweight that during public appearances he allowed audiences to see only his head. Historical texts reveal that he had a tendency to fall into a very deep sleep, so he hired people to poke him with long, thin needles while he slept, presumably to keep him breathing. Apparently they did not do the trick; the same texts note that he eventually “choked” on his own fat.
The U.S. president William Howard Taft, who was elected in 1908, had sleep apnea while he was in office, although none of his doctors understood the cause of his problem. He was overweight, he snored, and he was sleepy throughout his four-year term. When he became professor of law at Yale in 1912 after leaving the White House, he was still obese, requiring extra-wide chairs. He soon lost much of his excess weight and apparently was cured of his apnea. Eight years later, he became chief justice of the U.S. Supreme Court, where he demonstrated none of the symptoms of apnea.
CAUSES OF SLEEP APNEA
Two types of problems lead to sleep apnea. The most common is an obstruction in the upper respiratory tract that can result in obstructive sleep apnea. Usually the breathing passage is kept open by muscles of the upper airway, but a variety of problems can impair the muscles’ ability to keep the passage open. Air going into the lungs usually travels through the nose, then makes a turn and moves behind the soft palate and down the throat (pharynx), before it finally gets into the lungs. A condition that interferes with the flow of air to any of these locations can result in sleep apnea. Thus, anything from a blocked nose to enlarged tonsils to a narrowed breathing passage due to obesity can lead to obstructive sleep apnea. For people with this disorder, the breathing passage is open while they are awake but obstructs when they are asleep; they cannot sleep and breathe at the same time.
In children apnea could be caused by enlarged tonsils and adenoids, obesity, and even an abnormal (often inherited) jaw or facial structure. Just as we now see a great deal of type 2 (adult type) diabetes in children as a result of the obesity epidemic, we now see a great deal of apnea caused by obesity in children.
In adults apnea is most often caused by obesity or, as in children, by abnormal (often inherited) jaw or facial structure.
In the less common type, the problem is in the central nervous system. This results in central sleep apnea, a reduction in the electrical impulses from the nervous system to the muscles used for breathing. This disorder sometimes occurs when there are abnormalities in the nervous system and can also occur in people with heart failure, in people who have had a stroke, or as a reaction to narcotic pain medications.
When people stop breathing, the level of oxygen in the blood goes down and the level of carbon dioxide goes up. The low blood oxygen level forces the cardiovascular system to work harder, and the changes in the heart rate and the autonomic nervous system can increase the blood pressure. The increases in carbon dioxide level also affect the circulation, particularly the circulation of the brain. As a result, patients may awaken with headaches. For breathing to resume, the brain needs to wake up and open the breathing passage. People with sleep apnea awaken many hundreds of times per night. These disruptions result in a lack of quality sleep, which in turn causes severe daytime sleepiness.
In upper airway resistance syndrome (UARS), the variant of sleep apnea more common in women, breathing passages are not completely blocked; the awakenings are caused by snoring or snorts.
When we study people with sleep apnea, we see that the worst episodes occur while they are dreaming (in rapid eye movement sleep). One of the reasons for this is that people are paralyzed in REM sleep, and so the muscles that keep the airway open are also paralyzed. In addition, the body’s defense mechanisms are inhibited in REM sleep. Normally, there are systems that protect us against low blood oxygen and high carbon dioxide levels. They make us breathe more deeply and will wake us up if necessary. These alarm systems seem to be suppressed in REM sleep; the defense mechanisms do not start to work until the oxygen level is very low and the carbon dioxide level very high. In some women with sleep apnea, the only time their breathing becomes abnormal is during REM sleep.
Recognizing Sleep Apnea
When I was a medical student, I was taught that if we could understand everything there is to know about syphilis, we would know all there is to know in medicine. Of course, this was an exaggeration, but the point was that syphilis is a disease that can affect many different organ systems, including the neurological system and the cardiovascular system. In addition, patients could have many different symptoms, so by understanding syphilis, a medical trainee could learn about all these systems and thus understand many aspects of internal medicine and microbiology.
I believe that the same thing is true of sleep apnea. If we knew everything about sleep apnea, we would know a great deal about medicine. Sleep apnea affects many organ systems. People with sleep apnea have a bewildering array of symptoms that take them to the doctor. Perhaps one of the reasons it took so long for medical science to recognize the disorder was its multitude of symptoms. Additionally, the symptoms in men and women are not always the same.
But another reason sleep apnea was missed was that sleepiness was never considered a symptom. It was not something doctors asked patients about; people with sleepiness were dismissed as either not getting enough sleep or lazy.
The most important cluster of symptoms of sleep apnea is sleepiness, snoring, and stopping breathing during sleep; for women, insomnia is also an important symptom.
People with sleep apnea often fall asleep in low-stimulus situations such as watching television, waiting at a doctor’s office, and traveling as a passenger in an automobile. Additionally, even small amounts of alcohol can dramatically worsen their sleepiness. They might fall asleep at times when it is dangerous to do so, such as when they are operating a motor vehicle or piloting an aircraft. The two most unusual circumstances in which patients of mine with apnea fell asleep were during their own wedding ceremony (the groom started snoring while still standing up) and during sexual intercourse. In both instances, the spouses insisted on immediate consultation!
Many people with obstructive sleep apnea believe they sleep well. Because they cannot hear their own snoring, they do not think that they do snore or that their snoring is disruptive to others. In our sleep clinic, we have patients look at a digital video of themselves sleeping that is taken during the sleep test. They often remark, “My God, is that me? What have I put my family through?”
Alcohol makes snoring louder and more severe. Someone who normally has no other symptoms of apnea than snoring might stop breathing while sleeping after drinking even small amounts of alcohol—alcohol can turn snoring into apnea.
The word apnea means “stopped breathing.” Though bed partners might be tempted to think that any silence emanating from a snorer would be a good thing, nothing could be farther from the truth. When a person who snores suddenly becomes silent, the listener usually waits with trepidation for the breathing (and the snoring) to resume. This can happen over and over again during the night. What is worse to the listener than the loud snoring is the hundreds of repetitive cycles of noise, quiet, noise, quiet. These apneic events make up the third of the main features of sleep apnea. However, there are other symptoms.
Stopping breathing affects several organs of the body, which can cause many other symptoms and be even more of a problem than the three main symptoms discussed so far. People with sleep apnea may complain of awakening with choking or headaches (either during the night or in the morning), loss of interest in sex, needing to take frequent trips to the bathroom at night, symptoms of cardiovascular disease, and heartburn.
In some patients, the clinical findings mimic a psychiatric disorder; people might complain of symptoms that are similar to those found in depression or other conditions. Women, in particular, are frequently treated for depression before their apnea is recognized.
The world is in the middle of a major epidemic of obesity that is affecting all age groups. It is estimated that by 2025, 18 percent of all men and 21 percent of all women worldwide will be obese. Currently, about two-thirds of American adults (compared to less than one-quarter forty years ago) are above their ideal weight, which is measured by the body mass index (BMI) and is defined as a BMI of less than 25. (The Centers for Disease Control offers a BMI calculator at its website, cdc.gov.) In 2016 the CDC reported that 35 percent of American men and 40 percent of women are obese (have a BMI of more than 30). The proportion of North Americans with extreme obesity increased more than sixfold between 1960 and 2012. Half of all people with extreme obesity are likely to have sleep apnea. They are also much more likely to have cardiovascular disease and diabetes. About 75 percent of sleep apnea patients at most sleep clinics are obese, and symptoms often started after a substantial weight gain. The average adult sleep apnea patient in our clinic has a BMI of 33. Even children are becoming obese, and many of them are now also suffering from sleep apnea.
Young, apparently healthy athletes who are overweight are subject to sleep apnea. For example, a study in 2016 estimated that 8 percent of college football players have sleep apnea, and a study in 2003 reported that about one-third of NFL linebackers have it. Another study in 2010 reported that about half of retired NFL players had sleep apnea.
RECOGNIZING SLEEP APNEA IN OTHERS
From the symptoms mentioned in this chapter, it should be relatively easy to recognize when a sleep-breathing problem is present. Listening to the loud, struggling snoring sounds—and the quiet periods when breathing is obstructed—is frightening. But often the symptoms come on so slowly that their significance is missed until something dramatic happens, an event that becomes a wakeup call to the family. This could include a patient’s falling asleep at the wheel, missing important appointments, or nodding off at unfortunate times. In general, if a bed partner snores, is observed to stop breathing while asleep, has had changes in personality (irritability, inability to concentrate, and so on), or falls asleep at the wrong time and in the wrong place, he or she may well have sleep apnea.
Many people, even those with severe apnea, might doubt that they have a problem and think that they are champion sleepers. Only when they see and hear themselves sleeping does the significance of their problem become apparent to them. The spouse or bed partner should persevere to make sure that the problem is evaluated—perhaps by making a video of the person sleeping.
As noted, sleep apnea can occur in people of any age, including children. The symptoms and causes of sleep apnea in children might be different from those of adults, and parents should keep a few general rules in mind. If a child snores loudly most nights and is observed to stop breathing, it may be a signal that he or she has apnea. If this symptom is associated with very restless sleep such as moving the neck or the jaw to open the breathing passage, that is another indicator. A child who has large tonsils, who is overweight, or who has a small jaw may have an obstructed breathing passage. Orthodontic evaluation and treatment can often cure the apnea if it is caused by abnormalities of the jaw.
Children who are sleepy may appear to have attention deficit hyperactivity disorder; in other words, they may seem hyperactive rather than sleepy. Sleep apnea is so common in children that in 2012 the American Academy of Pediatrics suggested that all children be screened for sleep apnea during routine office visits.
HOW MANY RISK FACTORS DO YOU HAVE?
The Berlin Questionnaire shown in the figure below assesses a person’s risk of having sleep apnea. I have modified the questionnaire slightly to include not just overweight people but also those who might have other abnormalities such as small jaws that could lead to a sleep-breathing disorder. Like any tool that estimates risk, it could overestimate or underestimate. If you think you have a sleep-breathing problem, you should describe the symptoms to your doctor as accurately as possible, perhaps bringing a family member with you. Take a copy of this completed questionnaire when you go to the doctor to demonstrate your reasons for concern.
The questionnaire indicates the statistical likelihood that a person has apnea. Like most tools, it is far from perfect. Some people who score positive might not have apnea, while some who score negative might have it. The questionnaire has been weighted to be sensitive, so that it will miss the fewest number of people who might have sleep apnea. Using this tool and the other tests described above, your doctor will be able to determine whether you should see a sleep specialist.
Our Untreated Sleep Apnea Sufferers
As is true of most people who have sleep disorders, the average person who is diagnosed with sleep apnea will have seen many doctors before that correct diagnosis is made. One study showed that sleep apnea patients were seeing doctors more frequently than normal for as long as ten years before they were correctly diagnosed. Most doctors do not question their patients about how they sleep, whether they snore, or whether they feel sleepy in the daytime. Many doctors still believe the stereotype of apnea as a disease of obese middle-aged men; they often discount the symptoms of apnea in the women and children they see.
The Berlin Questionnaire
The best data available, based on studies done by the University of Wisconsin first reported in 1993 and continuing to this day, indicate that sleep apnea occurs in at least 2 percent of women and 4 percent of men in the United States; similar data suggest that these percentages also obtain throughout the Western world. This means that if a family doctor sees one hundred adult patients, fifty women and fifty men, each week, three of them (two men and one woman) will have sleep apnea. Imagine how many patients a single doctor is likely to miss in a year!
In our sleep clinic, the average age of patients being diagnosed with sleep apnea is around fifty, but many have had symptoms for five to ten years before they are diagnosed. Some of our patients have lost their jobs and homes because of the disorder. Many are being treated for conditions that they may not have, such as depression, and receiving unnecessary medications that could have serious side effects. Patients with sleep apnea are more likely to develop high blood pressure or suffer a heart attack, heart failure, or a stroke.
Many of my patients have fallen asleep driving—and some of those patients have been truck drivers, train engineers, and airplane pilots. Studies in several countries have shown that apnea patients are at much greater risk of having car accidents. Doctors need to make the connection that patients who fall asleep while driving could have a major sleep problem. In December 2013 a Metro-North Railroad engineer with undiagnosed sleep apnea fell asleep as he was driving a train in the Bronx, New York, resulting in a derailment. Four people were killed and sixty-one passengers were injured. As a result of this and other high-profile accidents, the public is increasingly demanding that locomotive engineers be tested for sleep apnea. Some trucking companies already screen and test their drivers for sleep apnea.
Management of Sleep Apnea
If your doctor suspects you have sleep apnea, he or she will ask about sleep and sleepiness during the daytime. If the doctor strongly suspects you have sleep apnea, he or she will probably refer you to a sleep clinic for overnight testing. This testing can also be done in the patient’s home, but the home testing is not usually as comprehensive as the testing done in a laboratory.
WHAT THE SLEEP TEST SHOWS IN SLEEP APNEA
To prove that apnea is present, the sleep test evaluates brain waves (via an EEG) to determine whether the person is sleeping; eye movements (by means of electrodes around the eyes) to see when the patient is in REM sleep; the heart rhythm (with an electrocardiogram); blood oxygen levels; measures of effort to breathe by the chest and abdomen; and whether the person is breathing from an airflow indicator in front of the nose and mouth. These measurements are monitored over an entire night.
The figure below shows a few of the measurements made in a sleep study. These measurements show that the patient has sleep apnea. The section on the left illustrates what we see when the person is awake. The section on the right shows what we see when the person is asleep. When the person is awake, breathing effort and airflow are regular and blood oxygen level is steady. When the person is asleep, although efforts to breathe continue, there are times when airflow is zero. The blood oxygen level drops to dangerously low levels with each episode of stopped breathing and the oxygen level is no longer steady; it now goes up and down with each episode. The episodes in this example occur about once per minute.
Measurements Made in a Sleep Study
Not included in the example is the EEG, which showed an awakening right before the patient started breathing again with each episode. The typical patient in our clinic stops breathing and wakes up about thirty to forty-five times every hour. Stopping breathing less than fifteen times an hour indicates mild apnea; between fifteen and thirty times is moderate; more than thirty times is severe. We also digitally video record the entire night and show patients their record and video the next morning. When they examine the results of their sleep study, they often become frightened and more aware of the dangers associated with these events, and realize that they must get treatment.
WEIGHT LOSS AND GENERAL MEASURES
Treatment of sleep apnea includes the measures used for all people who snore (weight loss, avoidance of alcohol and certain drugs, use of dental appliances), described earlier in this chapter, along with specific treatments to open the airway that becomes blocked during sleep.
When I diagnose patients with sleep apnea, I also point out to them something that I have observed many times. The forty-five-year-old sleep apnea sufferer is still mobile and might be in reasonable health. The fifty-five-year old sleep apnea sufferer who is overweight will probably have already had a major cardiovascular event such as a heart attack and frequently has developed diabetes. Arthritis in the knees or the hips may also be present. The hips and knees are particularly vulnerable because those joints are under the greatest amount of stress when a person is overweight. With knee and hip problems, the patient is no longer as mobile as he or she once was, and so exercises less, causing the weight to balloon upward. I often hear patients use the excuse, “I can’t lose weight because I can’t run or walk on the treadmill or use the bicycle. There is no exercise I can do.” I tell them to go to their local swimming pool. Exercise programs are available or can be designed for these patients. Walking in the water, which removes pressure from weight-bearing joints, is excellent exercise. Other, supervised exercises in water can also be beneficial. Along with regular exercise, the patient needs to normalize his or her food intake. It is beyond the scope of this book to focus on dieting, but if a person cannot lose weight, there may be another medical condition underlying his or her obesity; such patients should seek professional help. In cases of extreme obesity bariatric surgery might be an option.
OPENING THE BLOCKED BREATHING PASSAGE
When obstructive sleep apnea has been confirmed by testing, the treatments mentioned earlier for snoring are usually recommended. In cases that don’t respond to these treatments, if severe obesity or apnea is present, or for very severe cases we recommend more aggressive treatment, especially continuous positive airway pressure (CPAP).
CPAP. With this treatment, the patient wears a mask, usually over the nose, but sometimes over the nose and mouth. This is attached by a hose to a device the size of a toaster which generates pressure that opens the breathing passage. CPAP treatment usually gets rid of snoring, effectively reestablishing regular breathing. This type of treatment does not work for everyone because some patients have difficulty getting used to the pressure in the nose or develop symptoms of a blocked or runny nose. Sometimes, humidification is added to the system, but some people still have difficulty. CPAP seems to be tolerated and effective in about 70 percent of severe sleep apnea cases. For bed partners concerned that the noise of the machine is going to replace the noise of the snoring patient, with no net gain in quietness, the machines widely available in 2017 are fairly quiet—rather like a very quiet air conditioner.
Other PAPs. The CPAP machine creates a single effective pressure. Machines are also available that continually adjust themselves (these are called autotitrating or AutoPAP), as well as machines that deliver two pressures (called Bilevel or BiPAP). Some machines help the patient breathe in addition to opening up the breathing passage. The sleep specialist will generally recommend the machine type and settings, as well as the mask type. We can now monitor remotely how well the patient is doing on treatment by communicating with the machine wirelessly. Patients can also monitor how they are doing by using a smartphone that communicates with their PAP device.
Dental appliances. In addition to helping with snoring, custom-fitted (by a dentist or orthodontist) oral appliances can be very effective for some people with apnea. The appliances are worn at night only, and they bring the lower jaw up and forward. Since the tongue is attached to the lower jaw, moving the jaw forward moves the tongue forward, thus increasing the size of the breathing passage behind the tongue.
Provent. This treatment was introduced about 2010. It consists of a miniature disposable one-way valve inserted into the nostrils and attached to the nose by an adhesive strip.
Surgery. If apnea is caused by an obvious problem, such as enlarged tonsils or an abnormal structure of the jaw, surgery might cure the problem. In very severe cases that do not respond to CPAP, the patient might require a tracheostomy, as my Canadian patient did. The patient breathes in and out of a hole cut in the front of the neck rather than the mouth or nose. Until the mid-1980s, this was the only treatment available, and it was usually effective, although highly invasive. This is the treatment of last resort for people severely affected with sleep apnea.
Another type of operation that has been performed for snoring and apnea is to remove tissue from the back of the soft palate including the uvula, the tissue that hangs down at the back of the throat. This type of surgery has been done using scalpels, lasers, radio waves, and most recently robots. As mentioned earlier, many people do not respond well to such surgeries; thus most sleep specialists (myself included) do not recommend surgery as the first treatment.
In 2014 a new surgical treatment that involves stimulation of a nerve that goes to the tongue was approved in the United States by the FDA. The stimulation is achieved by the same type of device that is used in heart pacers. It is implanted under general anesthesia by an ear, nose, and throat surgeon. This is only recommended after other treatments have been exhausted and is not recommended if the patient is too obese (has a BMI of greater than 30).
Because people with untreated sleep apnea stop breathing and then awaken repeatedly when they sleep, they do not find naps refreshing; they usually wake up feeling groggy. Some people find that they sleep best when resting upright, and these people may benefit from naps.
The treatment for the sleepiness of sleep apnea is to open the blocked breathing passage. A patient with apnea who is on CPAP should use the CPAP every time he or she sleeps, including naps. The FDA has approved the use of the wake-promoting drug modafinil (known as Provigil, or Alertec in Canada) and armodafinil (Nuvigil) to treat patients who are still sleepy even after using a CPAP device.
OPERATING MOTOR VEHICLES
In many parts of the world, a person diagnosed with sleep apnea will not be allowed to operate a motor vehicle until she or he has been treated. In most places, driving a car is considered not a right but a privilege—and that privilege can be withdrawn or suspended. This applies not only to people who have sleep disorders but to those with any medical problem that might endanger themselves or the public. This would include people with epilepsy and those who have had a recent heart attack or stroke. Since the regulations vary from place to place, people with sleep apnea should check with their doctor about the regulations in their state.
In many places, commercial drivers (for example, those who operate buses or tractor trailers) are screened by questionnaire, BMI, and neck size. If they are deemed to be at high risk, they will be given a sleep test. If they are found to have sleep apnea, they must be treated and be able to prove that they are using the treatment.
I am reminded of a patient who finally sought help, but not until he fell asleep driving and crashed his station wagon with three of his grandchildren in the backseat. Luckily, they all survived. Sometimes the symptoms come on so slowly—over a period of years—that the person is not aware of them and believes that he or she has a normal sleep-wake pattern.
I was once invited to give a lecture to a group of family physicians about sleep disorders. The room was small, and the doctor who invited me to speak, a thin young man, promptly fell asleep when my presentation began. I awakened him to demonstrate to the rest of the audience how to do an interview with a patient who might have a sleep disorder. When I asked him whether he fell asleep while driving, he said, “Doesn’t everybody?” This doctor had been falling asleep while driving his entire adult life and believed that this was a normal state of affairs. He had a classic history of obstructive sleep apnea caused by a small jaw, and his symptoms disappeared when he was fitted with an oral appliance, which he now wears at night.
SLEEP APNEA DURING PREGNANCY AND EARLY MOTHERHOOD
For some pregnant women apnea is present before the pregnancy begins, while in other women it can come on if there is a massive weight gain during pregnancy. Pregnant women with apnea should be evaluated and treated because they might be prone to high blood pressure or a more serious problem, preeclampsia (see Chapter 4). There is medical evidence that suggests that babies born to pregnant women with sleep apnea could be smaller than average. If the blood level of oxygen is too low in the mother when she sleeps, it will be too low for the baby. If the woman is not treated, the symptoms and the sleep quality will tend to worsen as the pregnancy progresses. If she is working and accommodations such as working a reduced number of days or a shortened workday are not possible, she may need to consider taking a medical leave. It is best for pregnant women who have untreated sleep apnea to not drive a car.
After the baby is born, the mother must be alert to take care of it. Mothers diagnosed with sleep apnea should thus be started on CPAP (or at least sleep sitting in a 45-degree position) as soon as the diagnosis is made and continue using it after the baby is born. Mothers with apnea should continue using the CPAP until they have lost weight and the apnea is cured.
After the onset of menopause women are about three times more likely to develop sleep apnea. There are several reasons for this. The levels of the sex hormones that protect the women against apnea decrease during menopause; additionally, many women put on weight at this time. But not all menopausal women with sleep apnea are obese. Research reported in mid-2003 showed that hormone replacement therapy seemed to improve sleep apnea in some postmenopausal women. This is currently an area of active research.
Back to the Farmer’s Daughter
When I examined the girl’s throat with my trusty flashlight, I saw a giant set of tonsils, each one almost the size of a golf ball, meeting in the middle of her throat and virtually blocking her breathing passage. They were the cause of her apnea, and I referred her to an ear, nose, and throat surgeon. After removal of her tonsils and her adenoids, her breathing became normal. Her alertness returned, and she went back to school. I wish every medical problem had such a happy ending, but I also wish that my young patient had not had to suffer needlessly for so long.
What happens during sleep, which makes up roughly a third of a person’s life, has enormous importance. A good night’s sleep can energize a person for daytime activities, but a bad night’s sleep, or a bad sleep disorder, can put a person’s life in danger. Both patients and doctors need to be attuned to their sleep so that the symptoms of sleep apnea do not go untreated.