If you feel tired in the morning, your sleep is not refreshing and you feel fatigued all day long, the reason may be sleep apnea. Sleep apnea is a sleep disorder that occurs when a person’s breathing is interrupted during sleep. Its backgrounds are not yet fully understood. Sleep apnea is not always detected in health care and it often remains untreated at first. Sleep apnea is accompanied by many misleading images that should be discarded, so that the person would be able to suspect that they might have sleep apnea and would seek medical attention.
Two out of three patients with obstructive sleep apnea syndrome are overweight. Sleep apnea is not just a discomfort for snoring middle aged overweight men, as it is easy to imagine. It occurs in all ages and both sexes.
There is no precise information on the number of sleep apnea patients. In any case, most of them are without diagnosis and treatment. Sleep apnea syndrome should be diagnosed and treated earlier, especially in the young and middle age, as sleep apnea often gets worse over time and carries the risk of a variety of diseases.
Identifying sleep apnea fatigue is sometimes difficult for the sufferer as the symptoms have progressed gradually, often over the years. Other causes of fatigue are easy to find, such as insomnia, high workload, work-related stress or shift work. The parents of small children often think that their fatigue is due to the sleep disturbance caused by the caring or sickness of the children.
Daytime fatigue experienced in prolonged chronic sleep apnea stabilizes, but at the same time, intellectual performance is significantly reduced. However, daytime fatigue and performance are not always directly related. Someone with sleep apnea may sometimes pay more attention to the loss of memory or feel strangely inadequate.
Sleep apnea is associated with a variety of symptoms and features. Fatigue and poor sleep in their various forms are the most important symptoms. Sleep apnea is a significant stress condition for the body, and sleep is often associated with loud and irregular snoring and breathing difficulties due to breathing breaks. Everybody with sleep apnea doesn’t snore, especially if they have gone through the removal of the tonsils and/or adenoids nor do all snorers have sleep apnea. Approximately every tenth of snorers have breathing problems
Sleep apnea sufferer has unusual breathing breaks of more than ten seconds during sleep or respiratory depression, due to upper respiratory congestion during sleep. The length of breathing breaks can vary from 10 seconds to minutes. The body suffers from lack of oxygen and carbon dioxide accumulation, which shows symptoms as a morning headache.
Types of sleep apnea
Three main forms are distinguished in the syndrome: obstructive, central, and mixed. In the most common, ie, obstructive sleep apnea, the upper respiratory tract is blocked and the normal flow of breathing air is prevented. Obstructive sleep apnea syndrome occurs when recurrent breathing is accompanied by sleep disturbance and daytime fatigue.
Central sleep apnea syndrome is rare and, in practice, obstructive sleep apnea is usually defined as sleep apnea. Central apnea is a central nervous system-related disorder where breathing breaks are caused by the disruption of the automatic regulation of the respiratory center of the brain, not by blockage of the airways. It is often associated with heart failure, cerebral infarction or kidney failure, ie uremia. Kidneys remove wastes and extra fluid from your blood. But when your kidneys fail, wastes and extra fluid can build up in your blood
People suffering from central sleep apnea usually do not snore. They are characterized by the so-called Cheyne-Stokes breathing, where breathing breaks and over-breathing are alternating. This type of breathing is common in patients with severe heart failure, but not all, even if the disease is severe. Central sleep apnea is treated with adaptive servo-ventilation machines (ASV), a specially designed dual pressure ventilator. The ASV device is able to treat breathing breaks and soothe the over-breathing. There are also mixed forms of obstructive and central sleep apnea.
Sleep apnea sufferers often sleep poorly and restlessly. Breathing breaks associated with sleep apnea are occurring especially during REM sleep, when the brain should be resting.
Sleep apnea, however, disturbs sleep even before the deep sleep stage, so the body can’t rest properly. When the quality of REM sleep diminishes, it is perceived as a complication of brain activity, such as concentration and memory problems, during the day. Often, a person with sleep apnea first notices concentration and memory difficulties.
Sleep is disturbed when the sleeper wakes up while breathing is intermittent. Many will wake up at breathing breaks and stuffy feeling so that they have to get to the sitting position on the edge of the bed. Sleep apnea can also be accompanied by severe shortness of breath that awakens. Sleeping on your back is bad for sleep apneic patient’s breathing, and it is better to sleep on your side. Sleep apnea patient is often sleeping with open mouth and therefore the mouth and throat are dry in the morning and the throat feels painful. Sleep is hampered by heartburn, sweating and the need for more frequent night-time urination, resulting in frequent sleep disruption. Despite these symptoms, many people feel that they are truly sleeping overnight and therefore does not necessarily come to think of any sleep disorder.
Children’s sleep apnea
Every tenth child regularly snores and over a quarter snores occasionally. Snoring can be associated with a cold, the flu, or a sinus infection – if the nose is blocked, breathing is heavy. Snoring can also be caused by allergy symptoms. However, prolonged snoring and snoring for at least three nights a week should be followed.
In children, sleep apnea is mostly caused by tonsils and adenoids. Especially the large size of tonsils affects to the obstruction of the airways. Different structural issues affecting the volume of airways and allergies or hypersensitivity increase the risk of sleep apnea in children. In children, sleep apnea is equally common in girls and boys. The risk of sleep apnea in obese children is four times that of normal weight. Heavy night-time breathing, breathing breaks, restless sleep and abnormal sleeping positions increase the risk of sleep apnea. A typical symptom is to tilt the head back, which helps keep the airways open. Children also suffer from night sweats and nightmares, and then there is night terror, also known as sleep terror. Children’s daytime symptoms are different from those of adults. Strong daytime fatigue is usually not found, but sometimes unexplained tiredness can signal sleep apnea.
Sleep apnea may also explain the difficulty concentrating of children and the difficulty of learning and hyperactivity. Symptoms develop slowly, as in adults, so they can be difficult to identify and can often only be retrofitted to sleep apnea.
Sleep apnea in children is evaluated during an overnight sleep study. Treatment is often tonsillectomy ie. having tonsils removed. Despite the removal of tonsils, sleep apnea can later appear again.
The development of sleep apnea in children and adolescents can be influenced by proper orthodontic care, whereby the lower jaw is pushed forward to allow better space for breathing.
How do you know if you have sleep apnea
At least 4% of men and 2% of women suffer from obstructive sleep apnea, According to the latest studies, there are even much more. Sleep apnea is most common in people aged 40-65. There are more men in younger age groups, as hormones often protect women until menopause. After that, women have sleep apnea at least as much as men. In women, the symptoms are often also slightly different, which is why the sleep apnea is not so easily detected.
Facts about sleep apnea
- Sleep apnea is more common in people with hypothyroidism, especially if the patient has other risk factors for sleep apnea. Treatment of hypothyroidism may improve sleep apnea.
- Hormone treatment or a testosterone-secreting tumor may cause sleep apnea.
- Children with juvenile rheumatoid arthritis, who often have a small lower jaw, sleep apnea is more common than in the general population.
- A number of central nervous system drugs, such as benzodiazepines, make the upper respiratory tract muscles less sensitive.
- Drinking alcohol before going to bed will also lighten the upper respiratory tract muscles. After drinking alcohol, the likelihood and duration of apnea may increase. Increased total alcohol consumption appears to increase the risk of sleep apnea at least in men.
- Some of the medicines used to treat mental disorders increase appetite and may cause sleep apnea through obesity.
- Smoking increases the risk of sleep apnea.
- Sleep apnea occurs in families, but the genetic basis is still poorly known
What is sleep apnea
The most important cause of sleep apnea is overweight. More than half of people with BMI greater than 40 kg / m2 suffer from sleep apnea. Even mild waist obesity can cause sleep apnea. However, one third of sleep apnea patients are normal weight.
The cause of sleep apnea may be structural – a narrow nose or throat and short or thick neck or large tonsils can increase snoring and breathing breaks. In normal weight sleep apnea patients, breathing breaks are mostly due to abnormalities in the bones of the upper respiratory tract.
When a person falls asleep, the muscles supporting the upper respiratory tract relax. In structurally narrow upper respiratory passages, relaxation of the muscles during sleep can lead to the blocking of the air flow in whole or partially. The obstruction of the upper respiratory tract leads to recurrent breathing breaks and to end those breaks a person usually needs to wake up. In the partial upper respiratory tract obstruction, respiratory movements may continue for a long time, gradually intensifying, with the patient snoring loudly against the increased upper respiratory resistance.
Apnea can take up to a minute. During REM sleep, apnea and hypopnea tend to be longer than in other sleep stages, and oxygen saturation decreases with them. The diaphragm is the main inspiratory muscle during REM sleep.
How does sleep apnea feel like?
Sleep apnea patients are generally thought to be sleepy all day long. In a study published by the international network of ESADA sleep apnea researchers in 2016, involving more than 6,000 sleep-secured sleep apnea from across Europe, only one-fifth of sleep apnea patients responded to this traditional image. A sleep apnea patient is not always sleepy, but can also suffer from insomnia.
One of the researchers says that a quarter of the patients in the study were tired during the day, but also suffered from insomnia, there was no daytime tiredness in the second quarter and no symptoms of insomnia, and one third suffered from insomnia symptoms, but not day fatigue. Thus, more than half of the participants report symptoms of insomnia, such as a long sleep delay and a short night’s sleep. Some sleep apnea patients again sleep reasonably well but wake up tired and have headaches.
Insomnia and sleep apnea are the two most common sleep disorders, both of which meet the criteria of national chronic disease. Given their prevalence, the likelihood of co-occurrence is high, but there is little research on the subject.
Although sleep apnea patients are thought to be predominantly sleepy, they may also have insomnia. It is then two simultaneous sleep disorders, or insomnia can be a symptom of sleep apnea.
Both sleep disorders have their own typical features, but they also have many common symptoms such as recurrent awakening, difficulty falling asleep, disturbed sleep, fatigue, daytime fatigue, concentration and memory problems, relationship problems, mood swings, lack of motivation, increased accident risk, impaired quality of life, and worry about sleeping. Sleep apnea includes snoring, breathlessness, feeling of choking and recurring awakenings due to breathing breaks. The characteristics of insomnia include hyperactivity, anxiety, and learned habits that disrupt sleep. So, when a person has these both disorders, they can suffer from all these symptoms.
Dangers of sleep apnea
Broken sleep causes daytime fatigue and carbon dioxide accumulation in the body followed by morning headaches. After a poorly slept night, the mind is easily irritated, which affects relationships at home and in the workplace. Concentration is often difficult during the day and the person might suffer from memory losses.
“Neurologists often meet middle-aged patients who come to reception because of memory problems.
However, the cause is often sleep apnea, not memory disease, ”says one neurologist.
Many of the sleep apnea patients have high blood pressure and some may also have swelling of the lower limbs as the fluid circulation becomes weaker.
After a poorly slept night, you will naturally be tired during the day, when sleeplessness and a broken night take effect. Many people fall asleep easily for a while – it may be at the desk, in a meeting, in a movie or in a theater – just as monotonous as in interesting occasions. Of course, falling asleep in the car is extremely dangerous for both yourself and others. Particularly dangerous sleep apnea is with professional drivers who actually have sleep apnea more than the rest of the population. There are probably many reasons for this: irregular sleep rhythm, immobility, overweight and unhealthy nutrition. Identifying sleep apnea is crucial for them, as a tired driver is a security risk in the traffic. However, with some drivers, fatigue can be so difficult that professional driving is no longer possible with it. Although not all sleep apnea patients feel tired during the day, the risk of getting involved in accidents is nevertheless higher than normal.
Sleep apnea snoring also complicates snorers’ bed partner’s sleep. A partner may prefer to go to a more peaceful place to sleep, even on the living room sofa than to stay listening to snoring and breathing breaks. Often, an initiative to investigate the causes of breathing breaks is made by a worrying partner. It is more difficult for people living alone, whose sleep and snoring are not attentive to anyone and who often do not know themselves as having trouble in their sleep.
Side effects of sleep apnea
Untreated sleep apnea increases the activity of the sympathetic nervous system, the risk of cardiovascular disease, the risk of injury, the need for healthcare services and premature mortality.
People with sleep apnea and partial sleep apnea often have many other illnesses at the same time. This is partly due to the same risk factors, such as overweight, but some of the illnesses are the result of a sleep disorder.
Sleep apnea and cardiovascular diseases are very common diseases. These diseases have common risk factors, such as overweight, and as untreated they worsen one another. Therefore, it would be important for at least diabetics and cardiovascular patients to find out about the possibility of sleep apnea and vice versa in order to be able to get treatment to the disease if necessary. The possibility of sleep apnea should also be investigated on all those who are considering bariatric surgery (or weight loss surgery). Many people with hypertension, coronary heart disease, atrial fibrillation, heart failure and diabetes also have high probability for sleep apnea. Untreated sleep apnea multiplies the risk of cardiac death compared to those who are not suffering from sleep apnea. Hypertension is also a risk for cerebrovascular disorders. If breathing breaks occur, the partial pressure of the arterial blood carbon dioxide is also increased and that leads to intrathoracic pressure and increased blood pressure variability.
Some side effects of sleep apnea:
- Patients with cardiovascular disease have sleep apnea 2 to 3 times higher than those who don’t have apnea, even though common risk factors are taken into account. Hypertension, type 2 diabetes, heart failure due to oxygen deficiency and stroke are more common among those who are also suffering from sleep apnea.
- In middle-aged overweight people, high blood pressure may be associated with snoring and sleep apnea can even triple the onset of high blood pressure. Sleep apnea patients under 50 years of age are more likely to have high blood pressure or chronic atrial fibrillation. The risk of premature death is higher for them than for older sleep apnea patients.
- Sleep apnea may multiply the incidence of coronary artery disease in middle-aged people and the risk of new myocardial infarction or premature death in patients with pre-existing coronary heart disease. Sleep apnea may increase the incidence of atrial fibrillation and the risk of stroke in middle aged and older people.
- The risk of sleep apnea patients getting a heart attack may be six times higher compared to the rest of the day, and the risk of a night-time myocardial infarction is almost five times higher than that of other myocardial infarction patients. Heart failure may be associated with obstructive sleep apnea in addition to central sleep apnea.
- Common risk factors such as overweight and smoking may explain the co-occurrence of sleep apnea and chronic respiratory failure. Snoring and sleep apnea may increase the risk of middle-aged people having type 2 diabetes.
- In some studies, reflux disease has been observed in people with sleep apnea more than average, but may be due to overweight.
Sleep apnea affects the body as a whole and it also involves the entire body’s inflammatory condition. Recurrent episodes of hypoxemia (abnormally low level of oxygen in the blood), and activation of the sympathetic nervous system are essential issues especially for cardiovascular diseases and diabetes. There are also indications of a link between cancer and sleep apnea, but there is still much to be researched about it.
Mood swings – depression or sleep apnea
In addition to the increased risk of individual diseases, sleep apnea is an insidious disease because it affects people so that they have less resources to take care of themselves and make sensible choices for their health. Sleep apnea and poor sleep quality both have a clear connection to mood. Poorly slept nights are tiring and a tired overweight person can’t move or exercise, even though he’d well know it is necessary and good for his health. In this situation, the person may become depressed and seek comfort from the delicacy, resulting in a further increase in weight and a worse general condition. This cycle must end at some point. If sleep apnea is being treated, many are able to take better care of themselves, eat more appropriately and move more, which in return improves mood.
Sleep apnea treatment itself does not eliminate overweight, but when it succeeds, it opens up the possibility of a lifestyle improvement refreshes and help with weight loss. There are good experiences with many sleep apnea patients. Unexpectedly, unfortunately, the overweight does not go away even after the start of sleep apnea treatment.
Depression occurs with sleep apnea according to various studies, between 7% and 63% and anxiety between 11% and 70%. Symptoms of sleep apnea, overweight and related diseases can explain the connection between sleep apnea and depression. The symptoms of depression and sleep apnea are often quite similar, so that the symptoms of one of the two illnesses can be misinterpreted as being only due to another. Because depression and sleep apnea are common, they often occur at the same time. Especially younger people with sleep apnea have experiences that they have been diagnosed with depression before sleep apnea has been studied. Low mood may be easily treated as a depression rather than to suspect the underlying sleep apnea.
If sleep apnea is treated, many will also be able to take better care of their lifestyle, which in turn will help in weight management and improve mood.
Symptoms of sleep apnea include impotence and low sex drive. Poor quality sleep and breathing breaks decrease sex drive. It has been suggested that sexual dysfunction is twice as common in women with sleep apnea as in healthy women. There is only limited data on the effect of sleep apnea treatments on sexual activities. Long-term, or one-year, CPAP device treatment, has been found to reduce sexual dysfunction.
In men, sleep apnea can be symptomatic of sexual dysfunction – lack of sexual desire, erectile dysfunction and orgasmic problems occur. CPAP treatment seems to improve men’s sexual function.
Many people who have had sleep apnea treatment have told that they have gained back their “desire for life“.
Sleep study and diagnosis of sleep apnea
The diagnosis of sleep apnea is based on the study of the symptoms and background data of the subject being studied, clinical research and sleep study made by a doctor.
In particular, depression, other sleep disorders, and hypothyroidism should be taken into account as the cause of fatigue. A symptom of sleep apnea can also be insomnia.
Sleep study results and symptoms reliably determine sleep apnea. When making a diagnosis, a number of relevant factors must be taken into account. The condition of the patient may be affected by the fact that he sleeps too little or does not appreciate sleep. Shift work, stress, family circumstances, menopause and depression are important things to consider. Anemia, hypothyroidism, diabetes, neuromuscular diseases, epilepsy, brain tumors or inflammation, dementia and chronic pain are often found in the background of sleep apnea. Also, the side effects of drug treatment, increased urinary frequency, overweight and poor physical condition are often associated with sleep apnea.
Sleep apnea examination is usually started at a health center or at the reception of an occupational physician or a private doctor. The doctor interviews the patient and tries to find out the background of fatigue and sleep disorder. Nasal and pharyngeal structures are also studied. Particular attention is paid to nasal congestion and its causes. Allergic rhinitis, polyps, nasal obstruction, or possible damages at the nasal area will be investigated. The size of the tonsils and the tongue are of interest. The length of the soft palate is also considered. Stretched, thickened and swollen uvula are often signs of snoring.
Abnormalities in the face and jaw, as well as their relationship and bite problems are mapped, especially the lower jaw or the position of the lower jaw as usual (retrognathia), the very small or enlarged height of the lower face, large overbite, or open bite provide information about the possibility of sleep apnea. The neck structure is also examined.
The patient’s profession and shifts are also discussed. If necessary, the patient is directed to a specialist in lung diseases or ear, nose and throat, or to a dentist for further examination.
The actual sleep apnea examination, ie sleep study, can be done in a hospital as a polysomnography or a test can be made at home and is called a home sleep study or a home sleep test. In sleep labs, the quality of sleep can be studied more thoroughly. Also, motion sensors and sleep mattresses, can be used to provide information about sleep, for example.
Often, sleep apnea is usually examined at home by overnight home polysomnography. Everyone usually sleeps better at home than at the hospital. The person to be examined is to borrow a device from a health center, with two body-mounted belts that measure breathing movements.
Respiratory flow is measured through the nose. Blood oxygen level and heart rate is measured from a finger. The measuring device has a position sensor that records the person’s positions during the night. The measuring devices are easy to setup and do not cause much difficulty in sleep. The data recorded during the night is processed in the treatment unit and it provides information about possible sleep apnea and its severity. Night polysomnography is useful even if there is no information on snoring or breathing breaks but there are other symptoms.
Comprehensive night polysomnography is done in a hospital, when more accurate information on sleep quality is needed. It includes the EEG of the brain, and the study also records respiratory movements and airflow, snoring, and oxygen saturation in the blood. Night polysomnography also measures eye movements (EOG) and muscular muscle tension (EMG). The same method can also be used to diagnose restless leg syndrome. Wider sleep studies are used, for example, in the diagnosis of epilepsy or other sleep disorders, such as sleepwalking or sleep terror.
When investigating the ability to work, for example, with professional drivers, testing includes how alert the patient is during the day and if they are capable of staying awake (MWT, Maintenance of Wakefulness Test, or Osler test). These studies can also monitor the effectiveness of sleep apnea treatment. A health-based driving test is often used to determine the capability of a professional driver. Non-sleep apnea test include a multiple sleep latency test (MSLT) to investigate narcolepsy or daytime fatigue.
Actigraphy is a wristwatch-like device that records sleep time movements. Based on the movements, specialists can study daily activity, circadian rhythm, sleep delay and the quality of sleep. The device is usually used for about a week at home.
Severity scale of sleep apnea is called AHI (apnea hypopnea index), ie the number of complete breathing breaks per hour, that is, apnea and partial loss of breath, hypopnea.
If AHI is 0-5, the situation is normal, ie there is no sleep apnea.
Sleep apnea by AHI:
• 5–15 = mild sleep apnea
• 16-30 = moderate sleep apnea
• over 30 = severe sleep apnea
Sleep apnea prevention and self-care
- If you are overweight, lose weight. In mild sleep apnea, losing weight can be an adequate treatment.
- Limit the use of alcohol and sedatives, especially before bedtime.
- Stop smoking as it increases the swelling of the respiratory mucosa.
- Avoid sleeping on your back.
- Treat your stuffy nose.
- Use the compression socks during the day. This prevents fluid from accumulating in the lower extremities, from where it enters the neck area at night and obstructs the upper airways