Apnea de Sueño

Sleep apnea

The objective of this blog is to help the general population learn about various diseases related to Pulmonology. In such a way that whoever suffers from a respiratory disease can know it better and be able to promptly identify any symptoms that require medical evaluation and that this allows them to make broadly informed decisions with their doctor.

At the end of the post you can leave us your comments and questions, or if you wish directly to our email: neumologo.oc@breathbaja.com .

Today we will talk about SLEEP APNEA.

Definition

Sleep apnea means stopping breathing, and this happens while we sleep, which brings us to the literal translation of stopping breathing during sleep. However, sleep apnea is more than that simplified definition.

When a patient with OSA sleeps, there is an abnormal number of interruptions in breathing, which may be partial, generating snoring, of different intensity, but at the end of the day there is a general drop in the person's oxygenation. This snoring is caused by the collapse at some point in the airway which, by allowing only part of the breathable air, its vibration produces the characteristic snoring of this disease, but this causes the patient to reduce their oxygenation. At some point, complete collapses may occur, where the passage of air is zero, therefore, there will be no snoring, but oxygenation may decrease even more or even cause the patient to wake up (consciously or unconsciously). Fortunately, certain brain regions will “wake up” and allow breathing and, consequently, oxygenation to be reestablished. This cycle will be different in intensity and frequency, according to the severity of each individual.
 
 
With some frequency, the patient will go to the doctor at the suggestion of their partner who has disturbed sleep due to the partner's snoring or out of fear when observing a tremendous problem of suffocation in their partner. In other cases, when the condition is more chronic, there may be unrefreshing sleep, fatigue during the day, lack of energy and excess sleep mainly. Another number are referred by their trusted doctor, since unfortunately, OSA increases the risk of suffering and dying from cardiovascular disease. Later, I will explain it in more detail.
 
 
 

Symptoms of sleep apnea

We can divide these into those observable during the night or while sleeping, and those that will occur during the day as a consequence of the passage of time of this disease without being attended to.

Nocturnal symptoms:

  • Snore
  • Respiratory pauses
  • Shortness of breath at night
  • Nictura, that is, getting out of bed to urinate during the night
  • Excessive movements

Symptoms during the day:

  • Excessive sleep during the day
  • Fatigue
  • Headache in the morning
  • Decreased libido, in more severe cases erectile dysfunction
  • Problems with attention, concentration and memory
  • In children it can cause hyperactivity with poor school performance and be confused with other conditions.
 
 

But how common is this condition?

In Mexico it is found in 4.4% of men, but it is not exclusive to this gender, since 2.2% of women also suffer from it. Unfortunately, it has been estimated that up to 70-80% of cases remain without a proper diagnosis.

Health risks

Excessive daytime sleepiness is associated with 36% of vehicle accidents and patients with OSA (without treatment) are 3 times more likely to have a vehicle accident compared to the healthy population.

Additionally, this disease causes a greater risk of mortality. In fact, people > 40 years + OSA have more than double the risk of mortality than their counterpart without this disease. Likewise, they have a higher risk of suffering from systemic arterial hypertension, cerebral vascular infarctions, coronary heart disease, cardiac arrhythmias, heart failure and even sudden death.

 
 

Risk factor's

The prevalence of this disease increases with age, in fact, it is known that in Latin America 60% of the population >40 years old is a habitual snorer and 16% have excessive sleepiness during the day.

Men have 2 to 8 times more risk than women, although as they reach menopause their risk increases 4 to 7 times, equal to that of men.

Weight gain is highly associated with increased risk and progression of this disease, caused by an increase in neck circumference. However, there will also be thin patients with OSA, generally associated with craniofacial alterations that modify the lumen of the airway and consequently make it more susceptible to collapse when sleeping.

Other related factors are the consumption of alcohol, tobacco or the use of medications that can increase the intensity of snoring and the number of respiratory events during sleep.

In children it is highly associated with tonsillar and adenoid growth, however there may also be congenital craniofacial malformations that make them more susceptible to having this disease.

 

How is it diagnosed?

It is important to comment that diagnosis only through questionnaires should be avoided. Which are useful since these are only useful to guide us about the condition and type of study it will require. A widely used one is the STOP-BANG which you can access by clicking here .
According to these scores, risk factors and physical examination, it will be established which type of study is most appropriate. Basically, there is the simple study and polysomnography, the latter sometimes known as a comprehensive sleep study. You can access the information we wrote about them by clicking here .
 

Treatment benefits

As previously mentioned, a patient with OSA has a higher risk of cardiovascular complications. In fact, the chances of dying from cardiovascular disease increase compared to the population without this disease.

It has been shown that, in treated patients, mortality decreases to values ​​very similar to that of the general population. This has been observed in coronary and cerebral vascular diseases.

Likewise, controlling this disease reduces the risk of traffic accidents, slightly lowers blood pressure, reduces the recurrence rate of an arrhythmia called atrial fibrillation, improves insulin resistance and could contribute to better glycemic control (although this last is not yet clearly demonstrated).

 

Treatment

The goals of treatment are to resolve the signs and symptoms of this disease, restore the quality of sleep, reduce the risk of complications, and improve the patient's oxygenation during sleep as much as possible.

Currently, treatment must be multidisciplinary in such a way that all available therapeutic options can be used.

  • The standard treatment for severe cases is the use of a device called CPAP, although currently we must not forget that in some cases other measures may be used:
  • Oral devices
  • Upper airway surgery
  • Myofunctional therapy
  • In overweight or obese patients, long-lasting strategic measures must be established, including hygienic-dietary measures, drugs and bariatric surgery in those with indication.
  • Treatment of reversible causes such as hypothyroidism and gastroesophageal reflux.
  • In case of severe tonsillar growth, the surgical option should be considered.
     
     
     

    CPAP is a device that is connected to the electrical current and generates pressurized air, which through a hose and in turn a mask that will be placed over the patient's nose when going to sleep will prevent the collapse of the pharynx, Consequently, snoring will disappear, and breathable air will freely enter the respiratory tract. The CPAP should be placed before going to sleep.

     
     

    When using CPAP, it is essential to properly adjust the pressure of the equipment and monitor compliance with the treatment. It is recommended that all patients have a review during the first month of treatment and then every 6 months. If the patient has an intolerance to the use of this equipment, other therapeutic alternatives should be considered.

    In sleep surgery , evaluation by a surgeon specialized in these procedures is necessary. Currently, it is advisable to perform an endoscopy using induced sedation (DISE) through which the person's sleep will be simulated, during which the doctor will check the patient's airway through an endoscopy. This will allow a precise and personalized treatment since it is common for a patient to present obstructions at different levels of the airway, so performing the DISE will allow combined procedures to be performed to achieve an optimal result.

     
     

    Mandibular advancement devices (MAD) are devices that are placed inside the oral cavity prior to sleep with the objective of moving the jaw forward, increasing the permeability of the airway. Its indication is mainly in mild to moderate OSA, who do not have an indication for CPAP. To prescribe these devices, it is necessary for a specialized dentist to carry out an adequate assessment and place them in coordination with the sleep unit.

     
     

    So, concluding the treatment should be based on the patient's characteristics so it is not always CPAP, but should be chosen based on the patient's lifestyle. MADs, sleep surgery and even bariatric surgery should also be considered. In cases of severe OSA, the initial treatment will be CPAP, but accompanied by additional measures that will be adjusted according to the multifactorial characteristics of each patient.

    I am Dr. Cecilio Omar Ceballos Zúñiga, specialist in pulmonology and internal medicine [National Institute of Respiratory Diseases (UNAM) and General Hospital of the State of Sonora (UNAM)] and basic training at the Mexicali School of Medicine (UABC) . Co-founder of Breathbaja.

    Ced. Prof. 4829126, reg. esp. 6119468 / 7440242

     
    We are members of:
    • American Academy of Sleep Medicine
    • Mexican Academy of Sleep Medicine
    • Mexican Society of Pulmonology and Thorax Surgery
    • European Respiratory Society
    • American Thoracic Society
    • Latin American Thorax Association
    • Latin American Society of Respiratory Physiology
    • Mexican Society of Internal Medicine. Mexicali Chapter

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