"Sleep Apnea" By Allen Weiss, MD, MBA, President and CEO

Dr. ALlen Weiss, MD, MBA, FACP, FACR

October 1, 2008 - Sleep apnea affects over 12 million Americans, according to the National Institutes of Health. But what is sleep apnea, who is affected, and what are the symptoms and signs? And finally, what can be done about this under-diagnosed, under-treated disorder?

Sleep apnea causes a temporary cessation in breathing while asleep, which can last from a few seconds to minutes, and can occur five to thirty times an hour. When the breathing starts, there is sometimes a loud snort or choking sound. This chronic condition usually disrupts your sleep three or more nights per week. Typically, patients do not realize they have a problem until they experience the side effects of poor sleeping, namely daytime sleepiness and the inability to function normally.

Anyone, including children, can have sleep apnea; some of the risk factors include being over age 40, male, and overweight. In fact, sometimes sleep apnea is called Pickwickian syndrome, named after the “fat boy” in Charles Dickens' Pickwick Papers. This unfortunate lad was hugely overweight and probably had the most common form of sleep apnea—mechanical— which did not allow him to rest at night; consequently he was always falling asleep while sitting during the day.

Untreated, sleep apnea can be responsible for many problems, from falling asleep at the wheel and causing an auto accident, to a variety of medical problems. Functionally, think how you perform after a poor night of sleep. People suffering from this disorder sleep poorly most every night. Their day time functioning worsens, mental abilities deteriorate, and they may experience more weight gain which makes the condition even worse. These patients usually suffer from high blood pressure, headaches and depression, as well.

The most common form of sleep apnea, indicated in about 85% of cases, is called obstructive. The “mechanical,” temporary closing of any portion of the passages which allow air into the lungs, it causes the temporary pauses in breathing. Most often there is the sound of snoring; the loudness of the snoring, however, is not always proportional to the obstruction. In fact, if the passageways are really blocked very little air passes through and the snoring gets quieter.

The second most common cause of sleep apnea is a combination of obstructive and central. Central is when the brain's sleep center is not functioning properly. Normally the brain's receptors react to the amount of carbon dioxide and oxygen in the blood. Oxygen is necessary for life and carbon dioxide is the build-up by-product which is released into the atmosphere from the lungs when we breathe. The brain tells the lungs to breathe faster when either oxygen is in short supply, e.g. exercising, or when the carbon dioxide builds up -- the reason we cannot hold our breath beyond a certain amount of time. With central sleep apnea these two feedback mechanisms are not working well.

The final form of sleep apnea is pure central which is rare. This can occur after a stroke or other brain injury.

An accurate diagnosis can be made in a sleep lab. We are fortunate in Southwest Florida to have a few labs including one the downtown campus of the NCH Healthcare System. Patients remain overnight at the lab and are observed and monitored while they sleep.  Their breathing pattern, the oxygen concentration in their blood, and other parameters are recorded continuously while asleep. The records are compiled and a diagnosis made by an expert in sleep therapy who usually has had training in pulmonary medicine.

What can be done about sleep apnea? After a diagnosis is confirmed in a sleep lab any conditions contributing to apnea that can be removed should be removed. This includes losing weight and avoiding any alcohol or medicines which are contributing to the problem.

Depending on how successful the above changes are, the next step is to try continuous positive airway pressure. This involves a machine which is placed over a patient's nose and mouth while asleep and keeps the airways open with mild positive pressure. Nowadays the machines are light, quiet and efficient. Patients learn to tolerate them and then realize how much better they feel when they have a good night's sleep.

Finally, surgery can be considered to remove obstructions in the breathing passages. There are also some dental devices which are being used in Europe to relieve obstruction.

Knowing about a disease or condition is helpful in making a diagnosis. If you or someone you know is frequently sleepy during the day, you may be doing them a favor by sharing information about sleep apnea. Sweet dreams.




Dr. Allen Weiss is CEO & President of the NCH Healthcare System. He is board certified in Internal Medicine, Rheumatology and Geriatrics, and was in private practice in Naples, Florida from 1977 - 2000. Dr. Weiss is active in a variety of professional organizations and boards, and has been published in numerous medical journals, including the American Journal of Medicine and the Journal of Clinical Investigation.