Sleep Related Breathing Disorders

This group of sleep disorders is identified as abnormal breathing patterns during sleep. It results in an interrupted or poor quality of sleep. The most common subcategory of this class of sleep disorders is sleep apnea. OSA is linked to obesity, and cardiovascular and respiratory illnesses and must be treated as early as possible.

Identification of sleep-related breathing disorders is difficult because it shares symptoms with many other sleep disorders. Below is a broad classification of the subcategories of this class of sleep disorders

Obstructive Sleep Apnea Disorders (OSA)

OSA is the repeated closure (partial or complete) of the upper airway while sleeping. This occurs because your throat muscles relax. It leads to the airway temporarily narrowing or shutting down. This cuts of the oxygen to your brain, which wakes you up, so that your breathing can resume normally. This interrupted breathing (sleep-wake) leads to poor sleep and negatively impacts the quality of life.

The most common symptoms of OSA are, episodes in which you stop breathing for short intervals during sleep (usually observed by your sleep partner); gasping for air during sleep; loud snoring (though not all people with OSA snore when sleeping); difficulty staying asleep; irritability, and poor concentration; headaches and a dry mouth when waking up.

Under OSA there are two subcategories of OSA viz. adult, and pediatric sleep apnea.

Adult OSA usually occurs in the 40-60 age bracket; it is more common with males than females. Other causal factors include being overweight, having a large neck circumference, use of alcohol, sedatives, and tranquilizers, and having a family history of OSA.

Pediatric Obstructive Sleep Apnea (POSA), is also caused by the upper airway being blocked or narrowing down. In children, this also happens as a result of enlarged tonsils or adenoids, and obesity. In some cases, children with craniofacial anomalies and neuromuscular disorders may also experience sleep apnea. POSA if left untreated negatively affects the child’s physical and cognitive development, and can lead to serious medical conditions.

Diagnosis and treatment for OSA include the Polysomnography or the overnight sleep study. The person checks into a sleep clinic, and a sleep technician monitors and notes heart rate, oxygen levels, brain activity, sleeping pattern, and abnormalities. When there is no complicated medical history, an At-home sleep study can be done, which is a less detailed though. The results of the sleep study will be rated against the Apnea-Hypopnea Index (AHI) which will help in treatment.

Treatment for OSA includes machine related treatments, weight loss, surgery, positional treatment, and drug treatments:

Machine Treatments: CPAP therapy and BiPAP therapy are the most common treatments that use machines to relieve OSA. Both treatments apply positive airway pressure to ensure unrestricted airflow. CPAP applies airway pressure only one way, while BiPAP allows for positive airway pressure, both while exhaling and inhaling. It is best to let the physician decide the nature and course of treatment.

Surgery: Removes excess soft tissue that causes obstruction while sleeping.

Dental Devices are recommended for those who snore because of OSA. They facilitate an open airway by aligning the lower jaw or creating a tongue splint to avoid the tongue causing an obstruction.

Weight Loss – Where obesity is the primary causal factor or a contributing factor to OSA, weight loss is recommended to decrease the pressure on the airway. Weight loss is always done in conjunction with another treatment to ensure an immediate improvement in the quality of sleep.

Positional Therapy is the use of aids to prevent supine sleeping. The patient is encouraged to sleep on the tummy or on a side to avoid obstruction of the airway

Drug Therapy cannot treat OSA but can alleviate some symptoms. Drugs that prevent vomiting can open the airway passage. Drugs that treat high-altitude breathlessness can increase oxygen levels in the blood. Treatment with Melatonin can also improve the quality of sleep and oxygenate the blood.

Central Sleep Apnea Syndrome

Central sleep apnea also manifests itself as interrupted breathing during sleep. The differences between the two types of apnea are causal factors. Central Sleep Apnea is caused by other medical conditions like heart failure, or a stroke. It is caused by conditions that affect your brainstem and prevent it from sending messages to your body, reminding it to breathe. It could also be a result of high altitude.

There is no real difference in the symptoms of the two kinds of apnea. Only a trained professional will be able to effectively diagnose the type of apnea.

There are various types of Central sleep apnea

Central Sleep Apnea with Cheyne-Stokes Breathing

Abnormal breathing pattern associated with heart failure. The breathing pattern is fast breathing, with increasingly deep breaths, a slowing down of breaths and a brief stop. Each cycle can last from about half a minute to a couple of minutes

Central Sleep Apnea Due to High Altitude Periodic Breathing

Also called periodic breathing is experienced by some people at an altitude of 2500 meters and by almost all people at over 4000 meters. It manifests itself as apnea (interrupted breathing), insomnia and sleep fragmentation

Central Sleep Apnea Due to Medication or Substance

Long term use of certain medications, abuse of opioid (pain relief) medications can lead to sleep disturbance and central sleep apnea. The main way to resolve this issue is to be weaned off these medications.

Primary Central Sleep Apnea of Infancy

Central sleep apnea in infants is usually caused by a developmental problem such as an immature brain stem. The periodic breathing can result in hypoxemia (low oxygen levels), a slow heartbeat and sometimes loss of consciousness

Primary Central Sleep Apnea of Prematurity

Central sleep apnea in babies born prematurely is often due to the body not being fully developed. But it can also have multiple other causes from medical conditions to infections to fluctuations in external temperature. Rubbing the child’s body gently can get the breathing to resume normally. Most children will outgrow this apnea but need to be carefully observed and treated by a specialist when going through it.

Treatment-Emergent Central Sleep Apnea

Also called complex sleep apnea, sometimes occurs during the initial stage of CPAP therapy.

Diagnosis and Treatment of Central Sleep Apnea

The diagnosis is the same as for OSA (see above). Central related sleep apnea is very complicated because of other coexisting factors. Therefore it is important to understand that any treatment must be recommended and monitored by your doctor, for your own safety.

Treatment includes treating the existing medical condition/illness causing the apnea, stopping of opioid medication, delivering supplemental oxygen directly to the lungs through various devices, and use of medications to stimulate breathing

Treatments specific to central sleep apnea are Adaptive servo-ventilation (ASV), which adjusts breath by breath air pressure during inhalation; Bilevel positive airway pressure (BPAP) has fixed amounts of air pressure for your inhalation and exhalation.

Sleep-Related Hypoventilation Disorders

Hypoventilation means breathing at an abnormally slow rate which allows for a buildup of carbon dioxide in the blood. Hypoventilation disorders can occur at any age, for both males and females.  It usually occurs with other sleep disorders and medical conditions (hypothyroidism, obesity, asthma). All hypoventilation sleep disorders can be progressive and chronic and they can lead to other more lethal ailments including heart and lung failure and blood and brain disorders.

Symptoms include insomnia and daytime sleepiness, reduced capacity to exercise, difficulty in breathing, lightheadedness. The most common subcategories of sleep-related hypoventilation are obesity hypoventilation syndrome, congenital central alveolar hypoventilation syndrome, hypoventilation due to hypothalamic disorders, and hypoventilation due to medication or substance use.

Snoring

Snoring is noisy breathing while asleep. It affects people of all ages, genders, everywhere across the globe. Snoring is dangerous as it can lead to weight gain, impaired cognition, and heart disease. Age, obesity, alcohol and muscle relaxants all can lead to snoring. For some sleeping on the back rather than on the tummy on the side causes snoring. Treatment differs from person to person. Sometimes surgery helps, sometimes a dental device will lessen or eliminate it. Lifestyle changes are needed. Eating small meals earlier rather than later in the evening, no alcohol or muscle relaxants late evening, etc. are all known to help.

Catathrenia

Catathrenia is the groaning sound that some people make during exhalation of breath while sleeping. This groaning sound occurs during the REM stage of sleep. A typical groan can last anywhere from 2-20 seconds, and there have been instances of it lasting 40 seconds! Catathrenia does not seem to have any negative effect on the person who has it, but it disturbs the sleep of the bed partner tremendously. CPAP has some effect on Catathrenia. Since it affects the bed partner more than the person who is groaning, it is important to find a way to ensure the partner sleeps well and does not acquire a sleep disorder. So earplugs, creating white noise or even sleeping separately might be worth exploring to cope with Catatherenia.

Sleep-Related Hypoxemia or Hypoxia

Extremely low levels of oxygen (below 90 percent) in the blood is a direct result of sleep-related breathing apnea and hypoventilation. Symptoms include shortness of breath, rapid heart rate, shallow breathing and in some cases, especially with children there may even be some drooling. In extreme cases, the person may be unable to speak, be much disoriented and can even slip into a coma and the absolute worst case can die as a result. Sleep-related hypoxemia is treated by treating the sleep-related breathing disorder that is causing the primary problem.