Introduction

Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas, hypopneas, and/or respiratory effort-related arousals caused by repetitive collapse of the upper airway during sleep.  It is normal to experience some variation in breathing at night.  A diagnosis of sleep apnea is based on the presence of more than 5 disruptions in breathing per hour of sleep. 

It is estimated that 15-30% of men and 10-15% of women in North America suffer from sleep apnea.  Risk factors for sleep apnea include age, male gender, post-menopausal status in women, obesity, facial anatomy, smoking, nasal allergies, opioid pain medications, and use of certain sleep medications.

Sleep is accompanied by multiple physiologic changes in breathing.  The muscles that maintain the patency of the upper airway are less active during sleep.  This is of little clinical consequence in healthy individuals but can lead to repetitive airway collapse and closure in susceptible individuals.

Symptoms

Individuals with sleep apnea may experience problems with snoring, daytime sleepiness, gasping for air at night, morning headaches, difficulty initiating/maintaining sleep, increased irritability, reduced concentration/attention span, and problems with memory.  The prevalence of sleep apnea is also increased in patients with certain medical conditions including congestive heart failure, end stage kidney disease, chronic lung disease, stroke, acromegaly, hypothyroidism, polycystic ovarian syndrome, and Parkinson disease.  Sleep apnea may also develop in women during pregnancy.

Untreated sleep apnea is associated with an increase in risk for heart disease, high blood pressure, memory loss/dementia, atrial fibrillation, stroke, and motor vehicle accidents.

Diagnosis

A complete medical history, including a comprehensive review of medications, can help determine the risk of having sleep apnea.   Because sleep apnea is not a clinical diagnosis, objective confirmatory diagnostic testing must be performed.  A polysomnogram (PSG) is often the first step in establishing a diagnosis of sleep apnea.  This test evaluates how an individual’s breathing is affected while sleeping and how their breathing might affect their sleep quality. 

Treatment

The goals of obstructive sleep apnea therapy are to resolve signs and symptoms of the disorder, improve sleep quality, and normalize the disruptions in breathing at night.  Sleep apnea should be approached as a chronic disease that requires long-term, multidisciplinary management. The potential benefits of successfully treating OSA include clinical improvement (less daytime sleepiness), reduced and possibly, decreased cardiovascular risk and cognitive risk.  The following are options for treatment:

1. Weight loss and exercise – All patients with sleep apnea who are overweight or obese are advised to lose weight.  While this does not often lead to complete resolution of sleep apnea, weight loss has been shown to improve overall health and decrease the severity of sleep apnea.
2. PAP (positive airway pressure therapy) – PAP therapy is the mainstay of therapy for individuals with obstructive sleep apnea.  Simple and effective, PAP therapy treats sleep apnea by splinting the airway open and stabilizing it using pressurized airflow.  There is high quality evidence from randomized trials and meta-analyses that in most adults, including the elderly, PAP therapy reduces the frequency of respiratory events during sleep, decreases daytime sleepiness, improves blood pressure, lowers the risk of crashes, improves erectile dysfunction, and improves quality of life across a range of disease severities.  To precisely establish therapeutic settings, individuals seeking treatment may be required to complete a polysomnogram with CPAP titration (PSG w/ CPAP) prior to starting treatment at home.
3. Oral Appliances – An oral appliance may be a reasonable alternative for select patients with mild to moderate sleep apnea who are not candidates for, or are intolerant of, PAP therapy.  The efficacy of oral appliance therapy in patients with severe sleep apnea is highly variable and therefore it is generally not recommended in these cases.  Oral appliances protrude the mandible (jaw) forward to maintain the patency of the upper airway which improves airflow.  These appliances are fabricated and adjusted by experienced dentists with a special interest and qualification in treating patients with sleep apnea.
4. Hypoglossal nerve stimulator therapy (Inspire) - Hypoglossal nerve stimulation with an implantable neurostimulator device is a treatment strategy that may have a role in selected patients with moderate to severe OSA, who have failed PAP therapy with a body mass index <32 kg/m2, (BMI <35 kg/m2 is used in some centers) and no unfavorable collapse on drug-induced sleep endoscopy (determined by an ENT specialist).