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Tuesday, July 22, 2014
Risks of not treating sleep apnea
My best friend, a 53 year old male, was diagnosed with sleep apnea this year. He is of large build, at least 50 pounds overweight but quite active, and a snorer. He does not usually feel tired during the day and wakes up rested. He went for the night at the sleep lab anyway since it sounds like he is stopping breathing during sleep. He was definitely diagnosed with sleep apnea and they recorded how many times per hour he stopped breathing and how long each episode lasted. The sleep study also showed that even though he has sleep apnea, he does get a good amount of sleep. He tried the CPAP machine both with the full face mask and the mouth-only mask with the nasal pillows. The mouth-only mask did not work to correct the apnea so he went with the full face mask. He did not feel like he was getting restful sleep with the full face mask on--and also felt air was blowing out from under the mask and making his eyes water and look red. He is currently not using the CPAP at all, but may try to use another brand of face mask in the future to see it it`s more comfortable. Seeing that he does not feel tired during the day even when he does not use the CPAP device, is it worth trying to treat this sleep apnea? I have heard that it puts extra strain on the heart to stop breathing all those times during the night and am concerned and would like him to get back to using a CPAP again. Are there risks to not treating sleep apnea? Thank you for your reply.
Based on your question, I assume that your friend has obstructive sleep apnea (OSA) and not central sleep apnea. Assuming he has OSA, then there are a number of factors to consider in your question in addition to the issue of treatment.
OSA is a condition where the airway partially or completely collapses during sleep. This results in fragmentation of sleep and, in some individuals, low oxygen level during sleep. The consequences of this condition can be serious and range from a number of symptoms that may affect their poor quality of life (morning headaches, disabling sleepiness, poor concentration, irritability, etc) to problems with blood pressure control, heart disease and strokes. Generally, the more severe the OSA, the more likely a given person will be to have symptoms related to the OSA as well as the more likely they are to be at long term risk of developing bad cardiovascular outcomes.
Individuals with OSA may misinterpret or underestimate their symptoms related to OSA. Symptoms such as irritability or difficulty concentrating may be attributed to stress or anxiety, for example. Individuals with OSA may adjust their lifestyles to accommodate being fatigued and sleepy and thus may not realize just how sleepy they are until they are successfully treated. Likewise, keeping oneself busy or using caffeine to excess may mask some of the symptoms of sleep apnea. Thus, determining whether or not your friend truly has symptoms related to OSA may be important for realizing a treatment effect.
Having said that, OSA can exist in a mild form and this may or may not be associated with symptoms. While Sleep Specialists generally agree that mild OSA with symptoms should be treated, an argument has been made that mild OSA without symptoms does not require treatment. We know very little about the need for treatment in patients with mild cases who are truly not sleepy. For example, some patients may have very mild OSA and will be very sleepy due to the OSA. These patients would benefit from treatment with CPAP to alleviate their sleepiness. In other cases, patients may have mild OSA and are not very sleepy. These patients may not benefit from CPAP therapy. To complicate the situation further, some patients have severe OSA with other significant cardiovascular risk factors, and their OSA may be life threatening, but yet they may not feel significantly sleepy. These individuals should be treated regardless of their lack of symptoms.
There are a number of different treatments available for OSA. Which treatment is best for a given individual depends on a number of factors, including the severity of the sleep apnea, the patient’s size and airway anatomy, the patient’s co-morbid conditions and the patient’s willingness to accept a given treatment.
The primary treatment for OSA is the use of CPAP, which is very effective at keeping the airway open during sleep. It does this by “pressurizing” the airway to prevent it from collapsing. In a large number of well-done studies, CPAP therapy has been shown to be very effective at improving a number of measures of quality of life, including daytime alertness, improved concentration and improved mood. Individuals with OSA who can successfully use CPAP generally feel better! In addition, growing data suggest that CPAP may reduce some of the medical consequences associated with sleep apnea. The main problem with CPAP is that many individuals, such as friend, do not like sleeping with this type of device and, as such, alternative therapies must be considered. However, before giving up on CPAP, your friend should probably spend some time in the sleep lab trying the full range of options that may be available.
If your friend cannot tolerate CPAP, then alternative treatments for OSA could be considered – these really fall into 2 main categories: oral appliances and surgery. Oral appliances generally work to advance the lower jaw, hoping to open space in the back of the throat. They tend to work best in individuals with more mild to moderate OSA and in those who may have a small or more posterior positioned jaw. Individuals who use oral appliances during sleep often tolerate them, though they can have some annoying side effects (jaw achiness, pain with chewing in the morning, headaches, drooling). In addition, if there is a history of temporomandibular joint (TMJ) disease, these devices should be used with great caution as they put considerable stress on the TMJ and can worsen problems.
For some individuals, surgery is a reasonable option. Surgery tends to be most effective in those with clear anatomic problems that are amenable to surgery (such as large tonsils, deviated septum), more mild to moderate sleep apnea and who are not obese. There are a variety of surgeries that can be considered, though they are generally tailored based upon an individual’s anatomy. A tracheotomy (surgical tube placed in the neck) is usually curative for OSA, but because it is somewhat disfiguring, is reserved for severe cases that fail other treatments.
Other treatments that have been mentioned in the literature included weight loss for those who are overweight (in some cases, this can be curative), positional therapy (avoiding sleep on your back) and medications. Unfortunately, aside from treatment to help alleviate nasal congestion, almost all medications hoped to significantly impact OSA have failed when subjected to good scientific studies. Primary medication treatment for OSA is not recommended at this time.
There is extensive research looking into better and more effective ways to treat OSA. However, at present, none have been proven to be superior or better tolerated to those mentioned above.
I recommend your friend discuss his problems with his Sleep Medicine Physician. A number of specific factors in his case should be analyzed to determine if he should be treated and, if so, what treatment options would be best for him.
To learn more about sleep apnea, sleepiness, or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. The website Sleep Education.com also contains plenty of consumer friendly information about sleep and sleep apnea. Good luck and here's to better sleep!
Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University