Treating sleep apnea: what solutions for better sleep?

Why treat sleep apnea?

No, sleep apnea is not an Olympic discipline, nor even a breathing practice from yoga, and even less a nighttime activity consisting of holding one’s breath as long as possible. The reality of sleep apnea, its causes, but especially its consequences are unfortunately much more serious.

More than just the deafening noise of a snore as unattractive as it is annoying to its listeners, sleep apnea is known, but certainly not recognized enough. Knowing how to identify it means being able to treat it and thus protect oneself against its potentially dangerous health consequences. Why is it important to treat sleep apnea? Can one achieve a cure for sleep apnea? Let’s look at the impact of sleep apnea on health and what lies behind this noisy sleep disorder.

What is sleep apnea?

Sleep apnea is a breathing disorder characterized by a complete and involuntary stop of breathing, for at least 10 seconds, and which occurs at least 5 times per hour according to the INSERM definition¹. This phenomenon may last more than 10 seconds and repeat up to dozens of times per hour!

This involuntary respiratory stop is manifested by muscle relaxation of the pharynx and blockage of the trachea, which leads to airway obstruction. Breathing is prevented, air cannot circulate to the lungs. The individual suffering from it needs micro-awakenings during sleep, unconsciously, in order to resume breathing. These awakenings harm not only the quality of sleep but also the heart rhythm.

There are 3 types of sleep apnea :

• Obstructive sleep apnea ("AOS"): it is the most widespread and, as its name indicates, it results from muscle relaxation at the pharynx level and thus obstruction of the upper airways
• Central nervous system apnea ("ACS"): rarer, it is an abnormality of the respiratory control at the brain level, the "order" to breathe is no longer given by the brain (the airways are not necessarily obstructed)
• Mixed sleep apnea: it is the combination of obstructive apnea and central nervous system apnea

Whether it is obstructive sleep apnea syndrome ("SAOS", the most common form), central sleep apnea (much rarer), or mixed apnea, sleep apnea is a sleep breathing disorder.

Furthermore, the severity level of sleep apnea is measured by the number of apneas/hypopneas per hour of sleep. We then obtain the apnea/hypopnea index ("IAH"):

• Mild sleep apnea: between 5 and 15 apneas
• Moderate sleep apnea: between 16 and 30 apneas
• Severe sleep apnea: more than 30 apneas

Sleep apnea in numbers

According to INSERM², sleep apnea is "a common and rather male syndrome." For adults, it is estimated to affect:

• 7.9% of 20-44 year olds
• 19.7% of 45-64 year olds
• 30.5% of those over 65 years old

This sleep breathing disorder also affects babies and children. According to INSERM, 2% of children aged 2 to 6 years would be affected by OSA. For “The Lung Association of Canada³”, it would even be between “0.7 and 10.3%” of children suffering from sleep apnea. A study compiling cross-national data⁴ by homogenizing the factors considered shows that it would be between 2 and 10% of the world population affected by sleep apnea.

However, all these data on the prevalence of sleep apnea must be put into perspective due to its “underdiagnosed” nature. Indeed, the “French Federation of Cardiology⁵” notably points out that “80% of people who suffer from it are neither diagnosed nor treated…”. This fact is corroborated by INSERM. An American study⁶ reports that regarding severe obstructive sleep apnea, it would affect 9% of men and 4% of women.

Moreover, the “male” nature of this sleep disorder is also revealed in another study⁷, confirming here that parity between men and women is still not respected here, as in other fields!

What are the causes of sleep apnea?

The causes of obstructive sleep apnea are quite clearly established. Numerous studies⁸ agree and identify the following factors as the origin of OSA:

• obesity, overweight: excess fat in the neck reduces the caliber of the airways (fat deposit on the pharynx)
• age: the loss of muscle tone with aging promotes the relaxation of the throat and tongue muscles, thereby increasing the risks of upper airway obstruction, choking, or ventilation problems
• sex: men are twice as affected up to age 65
• nasal obstructions: surgical or ENT history, allergies...
• consumption of tobacco, alcohol or sedatives
• individual susceptibility, craniofacial anomalies and anatomical component: jaw size, reduced retro-lingual space, palate shape...
• magnesium deficiency

Furthermore, sleep apnea after anesthesia is also a risk factor to consider⁹ due to possible post-operative complications and risks related to anesthesia (increased muscle relaxation), whether the surgical intervention is related to OSA or not. At-risk individuals, whether undiagnosed or already treated for sleep apnea, should receive special monitoring before (polysomnography test) and after surgery.

Regarding the causes of central sleep apnea, they are neurological and related to other pathologies that disrupt the brain's "respiratory commands":

• disorders following a stroke ("AVC")
• heart diseases
• neurological diseases (meningitis, Parkinson's...)
• morbid obesity

Finally, children are unfortunately not spared from sleep apnea. For them, the main cause¹⁰ of OSA is the swelling of the adenoids and tonsils. The same factors as for adults can be added, namely obesity, overweight, upper respiratory tract infections, asthma, as well as a soft palate or allergies.

Symptoms and diagnosis of sleep apnea

Sleep apnea is characterized by a very telling and... noisy! symptom. It is obviously snoring. In the case of sleep apnea, these are accompanied by interruptions in the breathing mechanism: the individual snores, and the snoring is punctuated by a respiratory pause of about ten seconds, whereas "simple" snoring is limited to vibrations of the pharynx. Like an alarm, snoring should alert the individual suffering from it, or the person who perceives it (partner, friend, family...), and thus allow the search for possible other symptoms. INSERM and most studies on this subject¹¹ have highlighted the main symptoms of sleep apnea, which are listed here:

• loud snoring
• breathing pauses
• daytime sleepiness
• difficulty concentrating and remembering
• fatigue, headaches, irritability, decreased libido
• frequent urges to urinate during the night

A consultation with a doctor as well as the implementation of an Epworth sleepiness test allow the diagnosis of sleep apnea by measuring the degree of daytime sleepiness, the latter being one of the main symptoms of this sleep respiratory disorder. Moreover, the use of nocturnal ventilatory polygraphy or, for more thorough screening, polysomnography allows precise diagnosis of severe or moderate sleep apnea. These tests can be performed in a clinic, a specialized center, or even at home.

 

What can be the consequences of sleep apnea?

Sleep apnea is not trivial! This respiratory disorder can have multiple consequences, from the mildest to much more serious, even dangerous health repercussions. As reported by several studies¹², the impact of OSA on health is very real:

• risks of cardiovascular disorders: hypertension, cardiac arrhythmia, atherosclerosis, type 2 diabetes
• hypoxia: activation of the sympathetic nervous system and metabolic disorders
• oxidative stress

Sleep apnea therefore causes cardiovascular complications that can lead to stroke, myocardial infarction, cardiac arrest, and thus result in premature death.

Moreover, the risk related to the phenomenon of "sudden death", as described in a 2013 study¹³, is dangerously increased for people suffering from sleep apnea.

Furthermore, OSA is also responsible for leukoaraiosis, a serious central nervous system disease characterized by a "fibrohyaline thickening" in a part of the brain (white matter). Leukoaraiosis and sleep apnea therefore cause cognitive disorders that can unfortunately manifest as dementia. This harmful consequence is highlighted in a report published in 2018¹⁴ in the "Journal of Thoracic Disease".

Thus, considering the various pathologies resulting from obstructive sleep apnea syndrome, it is clear that in the case of alarming symptoms, its screening through the different tests available as well as its treatment must be taken seriously. But then, how can sleep apnea be treated?

Treatments to cure sleep apnea

After observing the very negative impact of sleep apnea on our health, it is time to lighten the tone a bit because, fortunately, solutions exist to live with sleep apnea. Indeed, one can first try to reduce the symptoms, as recommended by INSERM and other health organizations¹⁵:

• weight loss in case of obesity or overweight¹⁶, engage in regular physical activity
• sleep on your side and not on your back
• stop smoking, avoid sleeping pills and alcohol
• having a good intake of magnesium to promote muscle tone
• tilting your pillow¹⁷ to 60° to give a more upright posture to the head
• acupuncture¹⁸ to improve anoxia (lack of oxygen)
• oxygen therapy¹⁹ for automatic oxygen supply during the night (via nasal cannulas)

On the other hand, for severe obstructive sleep apnea, treatment with continuous positive airway pressure ventilation ("PPC", or "CPAP" in English for "Continuous Positive Airway Pressure") is effective and very common. A device sends air (or pure oxygen) during the night to prevent the pharynx from closing. Wearing a mask is then necessary all night (nasal mask, frontal mask, oral mask, pediatric mask). One can expect a significant improvement in sleep quality thanks to a PPC device, however some side effects related to the device used to treat sleep apnea may appear:

• nasal dryness
• throat irritation
• discomfort caused by the harness mask
• noise from the PPC device

Nevertheless, some types of PPC/CPAP devices include humidifiers to prevent side effects such as nasal dryness or throat irritation. Moreover, the variety of masks available on the market is quite substantial. Several manufacturers notably offer harness-free masks, and new devices that are increasingly innovative, comfortable, and efficient are emerging

Regarding the treatment of sleep apnea in children²⁰, it mainly consists of surgical intervention to increase airway flow by removing soft tissues (adenoidectomy, tonsillectomy), orthodontic therapy (narrow jaws), and an appropriate diet in case of obesity.

Thus, sleep apnea and its most common form, OSA, prove to be a respiratory disease in its own right, responsible for sleep disorders but with potentially very serious health consequences. Fortunately, effective treatments exist, and the diagnosis of obstructive sleep apnea is possible thanks to fairly easily identifiable symptoms, provided one pays attention.

We might even be grateful for some snoring, certainly unpleasant for the partner or family (or even the neighbors!), but lifesaving by its preventive nature in making this sleep disorder more identifiable and not to be taken lightly!

Additionally, and for a more "geek" approach: discover through this video titled " The geek approach to sleep apnea ", published by Koichi Nakayama (TEDxFukuoka), how IT innovation, through a new device, can help manage sleep apnea!

Sources:

[1] and [2] Sleep apnea: a source of fatigue, but also cardiovascular diseases, site « INSERM », October 2015 [3], [10] and [20] Obstructive sleep apnea in children, site « Fondation Sommeil », 2020 [4], [8] and [12] Obstructive sleep apnoea: definitions, epidemiology & natural history, J.C.M Lam, S.K. Sharma et al, « The Indian Journal of Medical Research », February 2010 [5] Sleep apnea significantly increases cardiovascular risks, site « Fédération Française de Cardiologie », January 2015 [6] Epidemiology, risk factors, and consequences of obstructive sleep apnea and short sleep duration, N.M. Al Lawati, S.R. Patel et al, "Progress in Cardiovascular Diseases", February 2009 [7] The Epidemiology of Adult Obstructive Sleep Apnea, N.M Punjabi, "Proceedings of The American Thoracic Society", February 2008 [9] Risks of general anaesthesia in people with obstructive sleep apnoea, C. den Herder, J. Schmeck et al, "The BMJ", October 2004 [11] Obstructive Sleep Apnea: A Growing Problem, K.K Motamedi, A.C. McClary et al, "The Ochsner Journal", 2009 [13] Obstructive Sleep Apnea and the Risk of Sudden Cardiac Death: A Longitudinal Study of 10,701 Adults, A.S. Gami, E.J. Olson et al, "HHS Public Access", August 2014 [14] Clinical physiology and sleep: highlights from the European Respiratory Society Congress 2018 presented by early career members, I. Almendros, A. Aliverti, "Journal of Thoracic Disease", January 2018 [15] Sleep Apnea, site "Ameli-Assurance Santé", 2020 [16] Interactions between obesity and obstructive sleep apnea: implications for treatment, A. Romero-Corral, S.M. Caples et al, "Chest", March 2010 [17] New and Unconventional Treatments for Obstructive Sleep Apnea, Jose Angelo A. De Dios, Steven D. Brass, "Neurotherapeutics", October 2012 [18] Effect of acupuncture on blood oxygen saturation in patients of obstructive sleep apnea-hypopnea syndrome, Jia Xu, Yan-Xia Niu et al, "Clinical Trial", January 2009 [19] Home Oxygen Therapy for Sleep Apnea, Dr B. Peters for the site "VerywellHealth", June 2020