What A Patient Needs To Know
Sleep apnea is a common but serious sleep disorder. The muscles at the back of your throat relax too much so your airway becomes blocked. This prevents oxygen from entering your lungs so your breathing is stopped or there will be periods of shallow breathing. Both can last from a few seconds to a few minutes, and may happen many times a night. When this happens, your body wakes you up to resume breathing although you may not realize it.
These multiple sleep interruptions prevent you from sleeping well, leaving you feeling extra tired during the day. You may experience daytime sleepiness, slow reflexes, problems with thinking and concentration, and an increased risk of accidents. Sleep apnea can cause moodiness, irritability, and depression. It can also cause or worsen serious physical health problems such as diabetes, heart disease, stroke, or liver problems.
Types of Sleep Apnea
Obstructive Sleep Apnea is the most common type of sleep apnea. It occurs when the soft tissue in the back of the throat relaxes during sleep and blocks the airway, often causing you to snore loudly. Since sleep apnea only occurs while you are asleep, you may not know you have a problem until a bed partner or roommate complains about your snoring.
Central Sleep Apnea is a much less common type of sleep apnea that involves the central nervous system. In central sleep apnea, breathing can be interrupted when the brain fails to signal the muscles that control breathing. People with central sleep apnea seldom snore.
Complex Sleep Apnea is a combination of obstructive sleep apnea and central sleep apnea.
Who is at Risk?
Anyone can have sleep apnea, regardless of age, sex or body type. However, having any of the following factors may put you at increased risk:
Being older: Sleep apnea occurs significantly more often in adults older than 50. In the age range of 65-99, 70% of males and 56% of females are at increased risk for developing sleep apnea.
Gender: Sleep apnea is more common in men than women. This has been could be due to differences in hormones, anatomy of upper airways and fat distribution. Sleep apnea risks increase sharply for post-menopausal women. Hormonal changes can affect such things as airway openings and body fat.
Excess weight: Being overweight is one of the strongest risk factors for sleep apnea. Your risk of sleep apnea increases with the amount of excess body weight and can decrease by losing weight. At the same time, sleep apnea can cause weight gain.
Neck circumference: Men with a neck circumference of 17 inches or more and women with a neck circumference of 16 inches or more are more likely to develop sleep apnea.
Family history: Your risk of developing sleep apnea can be 50% greater if a parent or sibling also has sleep apnea. This may be a result of either inherited genetic traits or similar lifestyles.
Pregnancy: Sleep apnea increases during pregnancy, particularly during the third trimester or with extra weight gain.
Smoking: Smoking is associated with a higher risk of snoring and developing sleep apnea.
Alcohol: Drinking alcohol before sleep can cause the upper airways to relax and collapse during sleep, leading to apneas.
Muscle-relaxant medication: Medication such as sedative hypnotic drugs and opiates can make sleep apnea worse.
The following is a list of common symptoms or signs of sleep apnea. Some people have several and others have only one or two of these symptoms. Sleep apnea is not always recognized, so if you have any of these symptoms or problems it may be helpful to discuss your risk of sleep apnea with your doctor.
Information compiled by Kathy Page March 2019
For milder cases of sleep apnea, your doctor may recommend only lifestyle changes, such as losing weight or quitting smoking. If you have nasal allergies, your doctor might recommend treatment for your allergies. If these don’t improve your signs and symptoms or if your apnea is moderate to severe, there are other treatments available. Some people try several options before they find the one that works best for them.
Positive airway pressure
If you have moderate to severe sleep apnea, you might benefit from using a machine that delivers air pressure through a mask while you sleep. This helps to keep your upper airway passages open and can prevent obstructive sleep apnea and snoring.
CPAP (Continuous Positive Airway Pressure) is the most common method of treating obstructive sleep apnea that involves using a machine that provides mild, constant air pressure to keep your breathing airways open.
APAP (Automatically-adjusting Positive Airway Pressure) automatically adjusts the pressure required to keep the airway open based on the breathing of the sleep apnea patient.
BiPAP machines have two pressure settings: the prescribed pressure for inhalation (ipap), and a lower pressure for exhalation (epap). The dual settings allow the patient to get more air in and out of their lungs.
There are many PAP machines from different manufacturers. There are also many different masks available from nasal pillows (that deliver air pressure from a cannula you put in your nose), to partial masks (that cover your nose), to full face masks (that cover your nose and mouth).
You might need to try more than one type of mask to find one that’s comfortable and works best for you. Don’t stop using the PAP machine if you have problems. It takes persistence and practice to adjust to the mask, the headgear and straps, and the air pressure itself. Check with your doctor or sleep technician to see what adjustments can be made to increase your comfort.
Oral appliances that look like a mouth guard can help keep your tongue and jaw in a position to keep your airway open. CPAP is usually more effective than oral appliances, but oral appliances might be easier to use.
These appliances have to be customized for each individual. Once you find the right fit of and appliance, you’ll need to follow up with your dentist repeatedly during the first year and then regularly after that to ensure that the fit is still good and to reassess your signs and symptoms.
Disposable nasal devices come in two different types. One is a patch that fits over the nostril and uses the patient’s own respiration to hold the airway open. (This device may need a prescription). The other is a device that fits inside the nostril to hold the nasal passages open. While easier to use, especially if traveling, they are not recommended for people who have severe sleep apnea and may or may not work.
Surgery is usually only an option after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. The different options available should be discussed with your doctor. Outcomes can be variable
(Positive Air Pressure) Machines Compiled – by Sarah Gorman
The term “CPAP” is often used somewhat generically, to refer to any of several types of machines used therapeutically to deliver Positive Air Pressure as a treatment for Sleep Apnea (a/k/a Sleep Disordered Breathing.)
But to get a little more specific, here’s a very brief description of the machines available in rising order of complexity, sophistication (and, usually, cost):
CPAP – provides Continuous Positive Airway Pressure. The machines are usually capable of providing between 4 and 20 centimeters of water (that’s the standard measure of air pressure) at a constant level. This is the most basic machine and was the first to be developed. It can provide only a constant level of pressure, which may not be optimal for those requiring different levels of pressure in REM and non REM sleep (which is most patients.) However, some models do provide lower pressures during exhalation known as expiratory assist.
APAP – The “A” stands for “adjustable” or “Automatic” This is a self-adjusting machine that operates on an algorithm designed to anticipate your pressure needs as they change throughout the night. The most recent generations of these machines are often offered in gender specific models, because research has shown that women usually benefit from a slightly different algorithm. Your sleep doctor or technologist will often set a narrower pressure range than the full 4 to 20 cm of water possible, because if you experience a large leak, the machine will automatically increase the pressure and, in that case, you may awake feeling as though you are trying exhale against a hurricane. (not dangerous, but annoying.) Often expiratory assist is also available.
Bi-Level – These are used by patients requiring higher pressures (usually large or heavy patients with a high AHI.) Bi-level is also sometimes used for patients who do not tolerate CPAP or APAP, for patients with COPD, and for patients with certain neurological diseases. Bi-Levels are designed to provide different pressure on inhalation and exhalation and may provide a higher range of pressures. These are a little less commonly used now that the APAP can provide expiratory assist.
ASV – The acronym stands for “Adaptive Servo Ventilator”- Essentially a machine with adaptive ventilatory function, used for patients suffering from central, or complex (combined central and obstructive) rather than purely obstructive, sleep apnea.If you are using a basic CPAP machine, or an APAP set for a single pressure, rather than a range of pressures, and find yourself waking several times a night with the mask off your face, or otherwise “fighting the mask”, you may require an APAP, rather than a CPAP machine to accommodate varying pressure requirements throughout the night.
Exploring Viable Options for Treatment
By Nancy H. Rothstein, MBA, The Sleep Ambassador® and Director of Sleep Health at Resonea
October 13, 2019
For many who suspect they or one they love is at risk for obstructive sleep apnea (OSA), the road to and fears about diagnosis and treatment are big enough impediments to keep them from taking steps to address the issue. In fact, OSA is a disease that when left untreated can result in significant health challenges and other diseases which have both short and long-term consequences.
With an estimated 26% of the adult population having OSA of which an estimated 85% remain undiagnosed nor treated, a public health crisis presents risks to individuals and to the public at large. From health care and other economic costs to safety risks, the impact of this disease looms large.
So what’s keeping individuals from taking charge of their health and taking action to get diagnosed and treated? One stark issue is the attitude, “I don’t want to wear that mask,” a reference to the gold standard of OSA treatment, CPAP (Continuous Positive Airway Pressure). While CPAP has excellent efficacy when used and the research to support it, many users jettison the treatment and put their CPAP in the closet. Be it due to lack of comfort or underwhelming support for use by the prescriber or provider of the CPAP, the fact is that not using treatment puts the OSA patient back at square one with significant, unaddressed health risks.
Unfortunately, people with OSA undergoing the progression from diagnosis to treatment are often not informed about alternative treatments, one of which we will focus on here: Oral Appliance Therapy (OAT). Usually administered by a dentist, one who should be trained and certified in Dental Sleep Medicine, OAT may offer a viable alternative to CPAP. Research suggests that the average CPAP user wears it significantly less than the recommended full night of use, whereas the average OAT user tends to wear the appliance most if not all of the night. Do you want to be treated ALL night or for just a portion, leaving you at risk for a significant part of your sleep, not to mention the impact on your sleep quality when OSA is left untreated.
Here are a few highlights to inform you about OAT:
In short, it behooves anyone at risk for OSA or already diagnosed but not compliant with treatment, such as with CPAP, to become informed about alternatives for treatment and to take action. Doing nothing is not a viable option for your health and well-being. If your physician is unresponsive to your treatment challenges, seek counsel elsewhere from a medical professional trained to care for OSA and well versed in treatment options.
Only you can take charge of your sleep. That said, for effective and healthy sleep, both quality and quantity, you may need the support of experts for OSA diagnosis and treatment. OAT may offer an effective pathway for you to adhere to treatment and honor your health…today and for your future.
 American Academy of Sleep Medicine, 2014, Rising presence of sleep apnea in the U.S. threatens public health, https://aasm.org/rising-prevalence-of-sleep-apnea-in-u-s-threatens-public-health/
 Harvard Health Sleep, Health Consequences, http://healthysleep.med.harvard.edu/sleep-apnea/living-with-osa/health-consequences
 American Academy of Dental Sleep Medicine, Oral Appliance Therapy, https://www.aadsm.org/oral_appliance_therapy.php
 Journal of Otolaryngoloty- Head & Neck Surgery, Trends in CPAP Adherence over twenty years of data collection: a flattened curve, 2016. https://journalotohns.biomedcentral.com/articles/10.1186/s40463-016-0156-0
 NHLBI, Sleep Apnea, https://www.nhlbi.nih.gov/health-topics/sleep-apnea
 See MyApnea.org (https://myapnea.org/) and The Foundation for Airway Health (https://www.airwayhealth.org/)
What is not being said about Compliance and Adherence?
By Patients Kathy Page and Sherry Hanes
You have received a diagnosis of sleep apnea. You haven’t felt well and have been tired for some time; now you have an answer as to why. You also have or will be given a remedy.
You may imagine that the future is going to be a life sentence of wearing an apparatus attached to your face while you sleep.
You may be feeling very vulnerable.
You may have a fear of being judged or what your bedpartner will think.
You may even be hesitant to comply with the recommended treatment and pretend that you never heard the diagnosis.
You may even think that it may be easier to just keep dragging yourself through life.
Compliance is what your doctor expects and what your insurance company demands If they are covering the cost of this therapy.
The insurance company will want to track your usage data. Both insurance carriers and sleep specialists can review CPAP usage by way of built-in monitoring technology in order to see if you are using therapy as needed.
There is either a data card inside the machine that measures usage, which can be uploaded at the sleep clinic for review or a wireless service that streams the same data live, directly to the clinic, through a modem.
Always, check the user manual to see the manufacturer’s instructions regarding the cleaning and maintenance of equipment. Use distilled water only in humidifier. Below are basic tips:
Make sure to unplug the CPAP from the power source before cleaning. Never immerse your machine in water.
These are recommendations only. Always check the manufacturer’s instructions. If the equipment is covered by insurance, check with their policy on replacing equipment.
HOW DO I GET USED TO WEARING A CPAP MASK?
Wear just the mask before going to sleep at night, while using the computer, reading or watching television. You can wear it with the hose disconnected from the mask itself if you are moving around.You can do the same during the day while doing work around the house.
Wear the mask every time you sleep, even during naps.If you wake during the night and the mask is off, put it back on and at least attempt to rest.MY CPAP MASK IS UNCOMFORTABLE AT NIGHT
It may take time to get used to wearing the mask. Unless it is causing pain or irritation, give it a little time.Make sure the mask type and style are right for you. It may take some trial and error to find the right one.Make sure you are shown how to adjust the mask. A mask that is fitted while you are sitting up will not fit the same as when you are laying down.Read all manufacturer instructions as they may help with proper fit ideas.
COULD I BE ALLERGIC TO MY CPAP MASK?
A slight redness or irritation is common when first using a CPAP mask.Most current masks are latex-free but older versions could contain latex.Making sure your mask is clean can keep skin irritations to a minimum.If the mask does not fit well, it can cause skin irritation.A leaky mask can also blow air into your eyes making them dry or teary.If the irritation becomes severe or the skin appears to be raw or blistered, stop using the mask and contact your doctor.
MY NOSE IS STUFFY/MY MOUTH IS DRY AFTER WEARING THE MASK
Using a heated humidifier can help with nasal congestion or runny nose by allowing you to control the level of humidity.If you use a full-face mask, a humidifier can help with dry mouth.If you have nasal or mouth drying, talk to your doctor about using a nasal saline spray.Some people also benefit from medications that treat nasal inflammation.If your mouth is drying out and you use a nasal mask, try using a chin strap to keep your mouth closed.Make sure your mask fits well. A mask that leaks can cause a dry nose and/or mouth.If you find the heat uncomfortable, you can turn it off and use non-heated humidification.I AM CLAUSTROPHOBIC AND CAN’T TOLERATE THE MASK
Start by holding just the mask up to your face while you are awake without any other parts attached—maybe while watching television. Once that seems comfortable to you, try using the mask with the straps attached but not the hose.Or try holding the mask with the hose connected to your face, without using the straps. When you start to feel comfortable with that, you can try attaching the hose to the CPAP machine and running it with a low-pressure setting. After that you can work on wearing the mask with the straps and with the machine running while awake. After you’re comfortable with that, try sleeping with it on.It may help to get a different size mask or try a different style, such as one that uses nasal pillows. There are masks and pillows that don’t block your field of vision which could help.There might be certain relaxation exercises that can help.If nothing seems to work, talk to your doctor or sleep technician.I CAN’T GET USED TO THE FEELING OF AIR PRESSURE
Sometimes people feel like they are getting too much or not enough air either coming in or when they exhale. This may be a temporary sensation, or may mean that the pressure settings need to be adjusted. There could also be another medical problem that needs to be addressed.It might help using a machine with a “ramp” feature. This allows you to start with low air pressure. The machine then automatically and slowly increases the air pressure to your prescribed setting as you fall asleep. Your doctor can adjust its rate.If, after trying this for a couple of weeks, you still can’t get used to the air pressure, you may want to contact your sleep doctor about rechecking the pressure settings and consider alternativeI GET AIR IN MY STOMACH WITH PAINFUL BLOATING AND GAS (AEORPHAGIA)This can occur when the air from your CPAP enters the esophagus and stomach rather than the lungs.It can occur when your CPAP pressure is set too low or too high.It can also occur if you are a mouth breather but not wearing a full-face mask.Consult your physician if the problem is chronic and persistent.I’M HAVING HEADACHES FROM MY CPAP MACHINE
Sometimes issues with headaches and earaches can be caused by the pressure being too high or too low. Check this with your doctor or sleep technician to see if an adjustment needs to be made.An APAP machine should adjust automatically to the correct pressure. If it doesn’t, check with your doctor to find out why.Inadequate ventilation (breathing) also could build up carbon dioxide levels, which can cause headaches. Check with your doctor to make sure you are getting the right pressure to best support your breathing.Sinuses can sometimes become blocked from nasal congestion. Treatment of nasal stuffiness as described above and checking with your doctor to make sure you do not have a nasal infection may be helpful.Check the humidifier settings to see if the heated water is warm enough to help open sinuses.Headaches can be caused if your headgear straps are too tight. Try loosening the straps to see if that helps.I GET WATER IN THE HOSE
Heated, humidified air can sometimes cool as it travels from the humidifier through the hose causing condensation.You can try using a hose cover which is like a coat for your CPAP hose. It traps the heat inside the tube and prevents it from escaping. This keeps the moisture from condensing.You can also try placing the tubing under the bed covers instead of using a hose cover.Another option is a heated hose which uses heating coils to warm the air in the tube preventing condensation. I KEEP TAKING THE MASK OFF IN MY SLEEP
It takes time to get used to wearing a mask, but keep at it.Sometimes a mask will not stay on your face, especially if you move around in your sleep a lot. Check to see if a different mask or better fit helps with this. You may be taking it off because it isn’t fitting right. Using a chin strap can help keep the mask in place.Sometimes the CPAP tubing can get tangled so if you toss and turn at night, it could pull the mask off. CPAP tubing holders can help the tubing from getting tangled as it directs the tubing up and over your head.You can also try using a special CPAP pillow that is designed to hold the tubing away so it can’t create a drag on the mask, cause breaks in the seal, or remove it completely.You may be pulling off the mask because your nose is congested or your mouth is dry. Try using a humidifier and make sure there aren’t any mask leaks.Anytime you wake up and the mask is off, put it back on.If you don’t wake when the mask comes off, think about setting an alarm to check if it is on or off. When you find you are wearing the mask all night, you can stop using the alarm. Speak to your provider about trying an automatic setting (A-PAP) vs. a set pressure. The automatic setting will automatically adjust during your sleep cycles.THE NOISE FROM THE CPAP MACHINE KEEPS ME AWAKE
Most newer CPAP devices are almost silent but if the noise bothers you, check the filter. If it should be dirty or blocked, it may be causing some noise.Have your doctor or CPAP supplier check the machine to see if it is working correctly.Try wearing earplugs or use a fan to make “white noise” to cover the sound of the machine.
MY MASK CAUSES MARKS ON MY FACE
There are pads you can purchase that attach around the headgear straps with Velcro to create a cushion between the straps and your skin. You may need to readjust the straps for a better fit if you use these.There are mask liners available that can be used as a buffer between the mask and your skin that can also help with air leaks and skin irritation.Both of these can also make wearing the mask more comfortable.You may also consider wrapping your straps with a 100% silk scarf which will ease marks on your face and ease friction against your hair.
MY BED PARTNER COMPLAINS ABOUT THE AIR FROM THE CPAP MASK VENT HOLES
Many newer masks come with a type of vent diffuser that keeps the air from coming out as directly. Ask your CPAP supplier about this if your machine doesn’t come with one.I DON’T WANT TO HAVE TO WEAR MY MASK EVERY NIGHT
It’s perfectly understandable that you may feel wearing a mask every night (probably for the rest of your life) is annoying at best and depressing at worst.When you find yourself getting frustrated or upset with your CPAP equipment, don’t dwell on what the comfort the mask is taking away from you. Instead, remind yourself of the health benefits you are receiving, and the risks you are avoiding by wearing your mask.Work with your doctor and CPAP supplier to get the best fit, device and mask.Making regular visits to your sleep doctor can help troubleshoot any problems and adjust settings, if needed.It can take a while to find the correct settings and get used to the mask.It’s okay to ask questions or for help from your doctor, sleep technician or device supplier. This is your health and you should expect quality care.With time and patience, CPAP can positively affect your quality of life and health.
Travel can upset your sleep schedule so it is very important to get the best sleep you can while away from home.If you will be traveling for several days or especially if you are traveling out of the country, keep a copy of your prescription for your CPAP machine, mask, tubing, filters, headgear and humidifier in your wallet or purse. Accidents, lost luggage, or theft can cause real problems if you have no way to replace any of your CPAP supplies.Bring a back-up power supply in case there is an outage of some length or because you are in a location that may not provide electricity. There are portable batteries available that are designed for use with CPAP machines. Make sure to charge it fully before you leave and keep it charged during your trip.If traveling out of the country, you may want to invest in a universal power adapter. Power outlets may have a different voltage or your plug may not fit. Find out which adapters will work in the area where you are going.CPAP machines use distilled water in the humidifier. If distilled water is not available, you can use bottled water for a short time. Make sure to clean your machine thoroughly as soon as possible to get rid of any water deposits.AIR TRAVEL
CPAP machines are considered medical equipment.Check with the airline about rules for medical equipment such as CPAP. When possible, pack your machine and supplies as a carry on. Most airlines do not count medical equipment towards your personal carry-on item limit.CPAP machines are sometimes taken out of the case to run through the security checkpoint. Hoses, headgear and masks usually stay in your bag. Bring a clear plastic bag to put your CPAP machine in so that it does not come into contact with unsanitary bins or conveyors.If the security official need to make a closer examination of your CPAP, you can ask them to use a new pair of gloves and a new swab to check it over.You may want to check with your airline about using your CPAP. Some airlines require a notice of at least 48 hours if you will be using your CPAP during the flight. They need to verify that your model meets FAA standards and regulations. You may need to label your machine showing that it meets FAA safety regulations and is approved for use on an aircraft.If you will be on a long flight, check to see what electrical outlets there may be.ALTITUDE CHANGES
The CPAP machine is affected by a change in altitude, so it will operate differently at higher altitudes. At higher altitudes the air pressure decreases. With less air pressure, the CPAP machine delivers less pressure to open your airway.Newer CPAP machines automatically compensate for altitude changes. If your CPAP doesn’t have an automatic function, you may need to adjust it manually, but do this with your doctor. There are some calculations to be made for manual adjustment. In either case, discussing this with your doctor is a good idea.At higher altitudes some machines might record a false leak detection. The lower air pressure can cause the pressure sensor in the machine to shut itself off every few seconds.Compiled by Kathy Page June 2019
SLEEP DISORDER: A sleep disorder is a physical condition that keeps you from getting enough sleep and/or negatively impacts your quality of sleep. Sleep disorders are common, frequently unrecognized and usually require medical treatment.
APNEA: A breathing pause lasting 10 seconds or more during sleep, when airflow completely or almost completely stops.
HYPOPNEA: A period of breathing while asleep lasting 10 seconds or more when airflow gets shallow but does not completely stop.
CENTRAL SLEEP APNEA (CSA): A sleep disorder where breathing pauses during sleep due to inadequate signals from the brain to the breathing muscles. This commonly occurs with heart failure or after a stroke but can also occur as a result of genetic disorders or without any known cause.
OBSTRUCTIVE SLEEP APNEA (OSA): The most common kind of sleep apnea. During sleep breathing pauses as a result of narrowing or blocking of the throat. This is usually caused by a combination of a narrow throat, too much tissue within or surrounding the throat and abnormal breathing signals to the muscles in the throat during sleep.
MIXED SLEEP APNEA: A type of sleep apnea that happens when there is a combination of an “obstructive” apnea (when the throat collapses during breathing) and “central” apnea (when there is a breathing pause with no effort to breathe).
AHI – Apnea Hypopnea Index: The number of apneas and hypopneas per hour of sleep. This index, as well as measures of oxygen and sleep disruption, are used to determine how severe a patient’s sleep apnea is.
The Severity of OSA’s as defined by the American Academy of Sleep Medicine Task Force (1999) is:
AHI < 5 is NORMALAHI 5 to <= 5 is MILDAHI 15 to <=30 is MODERATEAHI 30 or higher is SEVERE
APAP (Auto-titrating Positive Airway Pressure: APAP therapy provides a variable amount of air pressure that is automatically adjusted (by the machine) to keep the airway open. For example, if a patient needs more pressure when sleeping on the back, the machine will sense this need and automatically increase the pressure.
ASV (Adaptive Servo-Ventilation): ASV is a highly sophisticated device used to vary airflow or pressure on a breath by breath basis aimed to maintain a certain breathing pattern. It may be used to treat complex sleep apnea or certain kinds of central sleep apnea.
Complex Sleep Apnea: also referred to as “treatment emergent sleep apnea” where development of central apneas happen after obstructive sleep apneas are treated.
CPAP (Continuous Positive Airway Pressure): CPAP therapy provides a constant amount of air pressure to hold the airway open. The goal is to maintain uninterrupted breathing during sleep.
BIPAP (Bi-Level Positive Airway Pressure): This therapy provides positive pressure while a person breathes in and lowers the air pressure when a person breathes out.
TITRATION: During a sleep study, the technician will vary the air pressure during the time of the study to see what pressure level will improve your breathing.
AROUSAL: An abrupt change from a “deeper” stage of sleep to a “lighter” stage.
REM (Rapid Eye Movement): One of the two basic sleep states where there are rapid eye movements, less muscle activity, more irregular heartbeats and heart rate. Dreaming often occurs in this state and this state of sleep is considered important for memory. Sleep apnea can be very severe in this sleep state because of less muscle tone.
CIRCADIAN RHYTHMS: An internal biological clock that influences many biological processes including when we sleep.
RDI (Respiratory Disturbance Index): Includes apneas and hypopneas, and may also include other respiratory disturbances such as snoring arousals, hypoventilation episodes, desaturation events, etc.
BRUXISM: Teeth grinding.
SLEEP STUDY (POLYSOMNOGRAM): An overnight diagnostic test for sleep apnea and other sleep disorders. “Poly” refers to the recording of several types of information, including the amount of REM and non-REM sleep, the number of arousals as well as breathing patterns, heart rhythms and limb movement.
DIAGNOSTIC SLEEP TEST: A sleep study done to look for the presence or absence of a sleep disorder. It is done without the use of CPAP.
MULTIPLE SLEEP LATENCY TEST (MSLT): This test is to evaluate how often and how quickly a patient falls asleep in quiet situations during the day how quickly REM sleep occurs. It is usually performed following an all-night sleep study and is specifically used to evaluate narcolepsy.
SPLIT NIGHT: This is an all-night polysomnogram that includes a “diagnostic” phase and a CPAP titration phase, all in one night.
HOME SLEEP STUDY: An overnight study done in your home, usually to check for sleep apnea and is focused on collecting a limited amount of information needed to evaluate breathing during sleep.
BMI (Body Mass Index): This index is a ratio of your height and weight to see if you are at your ideal weight, over or underweight for your gender.
COMPLIANCE (Also referred to as “adherence”): A description of how well you are following the therapy recommended for you and typically for sleep apnea, measures the number of hours per night you use CPAP. If you are compliant, then you are using your treatment as prescribed to gain the most benefit. If you are non-compliant, you are not using it for the best benefit. Patients who do not use their CPAP machines regularly may be required by their insurance companies to return their machines.
NASAL MASKS: A type of mask to treat sleep apnea using positive airway pressure. Nasal masks only cover the nose.
NASAL PILLOWS: These seal against the edge of each nostril rather than going around the entire nose. The pillows open into the nostril but are not inserted inside to seal.
NASAL PILLOW MASKS (nasal cushions): These masks rest right under your nostrils and they come with unobtrusive headgear. You insert your nasal pillow mask at the outer edges of your nostrils, rather than over your entire nose It rests right above your upper lip.
DENTAL DEVICE: A medical device for the mouth that is used when sleeping as an effective treatment option for sleep apnea.
RAMP: A setting on the CPAP machine where air pressure starts lower than prescribed and slowly increases or ramps until the full therapy pressure is reached.
OXIMETER: A small sensor that clips onto your fingertip that shows pulse rate and oxygen saturation.
LEAK: Refers to air that escapes or leaks from your mask. This can be caused by having the wrong mask size or fitting or because the mask is worn out and needs to be replaced.
This information was compiled by Kathy Page, March 2019
HOW DO I PREPARE FOR A SLEEP STUDY?
Sleep clinics want you to stay as close to your night-time routine as possible in order to get the best results. The sleep lab will give you check-in instructions a day or two before your study. This is the time to ask any questions you might have.
HERE ARE SOME WAYS TO PREPARE FOR THE TEST:
** If you work nights, some facilities are able to do testing during the day.
WHAT HAPPENS DURING THE STUDY?
To help you relax, the rooms are made to look more like a small hotel room instead of a hospital room. You can adjust the room temperature to your comfort. When you arrive for your sleep test, the process will be similar to checking in for any doctor’s appointment. There may be paperwork to fill out, including a consent form, and you may need to present your health insurance card and/or co-pay if you have one.
Once you’re checked in the sleep technician will take you to your bedroom for the night. You will be shown the bathroom and where you can put your things. You can settle in, put on your sleepwear, brush your teeth, take medications and do your usual nighttime routine.
The technician will then spend about 45 to 60 minutes setting you up for your sleep study. Each disc or electrode will be put in place with a special sticky paste. This keeps the electrodes in place. Some of the wires on your face may be taped in place. If you’re sensitive to or allergic to medical tapes or glues, let the technician know ahead of time so that she can use a type that won’t affect you.
Small cups and wires will be attached to your scalp that will measure your brain activity so the technician will know if you are sleeping and what stage of sleep you are in.Wired electrodes are taped around your eyes and chin to measure movements. Eye movements can help show sleep stages while chin movements might show that you grind your teeth.Two elastic belts will be placed around your chest and stomach to measure breathing.Small plastic tubing (like oxygen tubing) will be placed in your nose to also measure breathing.Wire electrodes will be attached to your legs to monitor movement.A monitor will be placed on your finger to show your oxygen levels during sleep.EKG monitors will be placed to show heart rate and rhythm.Once you’re set up, the technician will leave you alone in your room. You can read, watch television, or listen to music. It’s important not to fall asleep until it’s your usual bedtime or you feel drowsy enough to drift off. Let your technician know when that happens. (She will have instructed you as to how to contact her.)
The technician will then help you into bed and connect the wire box to a computer so that she can monitor you from another room. You may be asked to open and close your eyes, move them side-to-side, take breaths in and out and move your arms and legs. If something comes loose during the night or you need to use the bathroom, the technician will come in to take care of the wires.
If the monitors show sleep apnea issues, the technician may try a CPAP device and different types of nasal or face masks.
SLEEPING DURING A STUDY
It isn’t easy to get to sleep or stay asleep with all the wires and monitors hooked to your body. It also isn’t easy to sleep knowing that someone is watching you. It might feel like you didn’t get any sleep at all! Even if you don’t sleep much during the study, it will be enough for the monitors to collect and return data.
WHAT HAPPENS AFTER A SLEEP STUDY?
The sleep technician will wake you early the next morning as you are only monitored for seven to eight hours. They will remove the monitors and have you do any final paperwork. Most sleep clinics have showers and changing rooms to use so you don’t have to hurry home before starting your day.
The sleep technician will not be able to share your results with you. If a sleep doctor is available there to read your results, you may be able to start any needed treatment quickly. Otherwise, results can take a week to 10 days to be reviewed and sent to your doctor. Just one test can produce around 1,000 pages of data. If a sleep disorder such as sleep apnea is found, your doctor will discuss with you the treatment options available or suggest you do another sleep study to try CPAP while being helped by the sleep technician.
WHAT ABOUT AT-HOME SLEEP STUDIES?
In some cases, at-home sleep studies may be used. Before the study, you should be contacted by a sleep clinic to pick up the equipment needed. They should provide instructions on how to use the home equipment and test and be able to answer any questions you may have. You should also discuss any medication you are taking to know if you should or should not take it for that day.
Avoid napping during the day before the test.Follow your normal routine as much as possible.Avoid caffeine and alcohol after lunch.You can go to bed at your regular time.When ready to go to bed, attach the sensors as instructed. You may need to press a button on the device when you get into bed and may be asked to keep a sleep diary.
The sensors usually include an oxygen and heart rate monitor that is placed over your index finger. There will be other sensors you will strap to your chest to monitor breathing. A small tube placed in your nose will measure air flow.
Make sure the machines are working like they should and that all the sensors are in place. If something gets disconnected during the night and isn’t reconnected, there won’t be enough data for a study and the test will have to be done again.
When you wake up in the morning, you can remove the sensors and return then to the sleep clinic. An appointment will still need to be made with your doctor in order to find out what the test results were and to discuss diagnosis and treatment options.
Cost and Health Insurance
Sleep studies like the overnight polysomnogram used for sleep apnea can cost a lot of money. If you have insurance or Medicare they might cover most of the expense. What it finally ends up costing you will depend on the type of insurance you have and your deductible. Your insurance may also require that certain symptoms are present before the study will be covered. These are some of the examples of sleep apnea symptoms that might be required to cover sleep studies: excessive daytime sleepiness, snoring, sleep apnea episodes seen by a bed partner or gasping or choking during sleep.
Check with your insurance company before you have a sleep study done. The sleep center can give you an estimate of expenses before your test. If you don’t have insurance or a way to pay for it on your own, check with the sleep center to see if they have any discounts or financial help.
You can also have a home sleep apnea test done which is less expensive and often covered by insurance. Again, be sure to check with your insurance company first to see if it is covered or if there are any pre-requirements.
Note: At-home test devices focus on measuring breathing patterns, air flow, and oxygen levels. They also record pulse rates and sleep position. Home sleep apnea testing is better when testing for sleep apnea that is moderate or severe and if the test is inconclusive, you may have to do an in-lab test anyway.
High blood pressure: When you wake up often during the night, your body responds by sending your hormone system to go into overdrive which raises blood pressure. Blood pressure also rises when the level of oxygen in your blood drops because you aren’t breathing well. Sleep apnea increases the risk of high blood pressure, especially the type that is difficult to treat (resistant hypertension).People who get help for sleep apnea can often see their blood pressure improve. Some people may be able to cut back on their blood pressure medications, but you should never stop or change your dose without talking to your doctor first.
Heart disease/Stroke: Sleep apnea can increase your risk of heart disease by 30% and risk of stroke by 60%. Atrial fibrillation is also common in people with sleep apnea. Untreated sleep apnea can reduce the effectiveness of treatments for atrial fibrillation. In fact, many cardiologists test their patients who have atrial fibrillation for sleep apnea and make sure sleep apnea is treated as part of the plan for their treatment.
Type 2 diabetes: 80% of people with Type 2 diabetes also have obstructive sleep apnea. Being overweight raises the risk for both sleep apnea and Type 2 diabetes. Lack of sleep can keep your body from using insulin properly which leads to diabetes.
Weight gain: When you are tired all the time, it is harder to resist carbs and sweets or to exercise as you should. Your body may not change the food you eat into energy as efficiently and that can lead to weight gain.
Cognitive problems: Sleep apnea can cause both disturbed sleep and low oxygen levels during sleep—both of which may lead to problems with brain health and may increase the risk of developing dementia.
Dr. Judith Owens
Since the 1970’s, it has been recognized that sleep apnea* can occur in children as well as adults. It is estimated that 2-4% of children overall have sleep apnea, but these percentages are likely much lower than the reality. As in adults, sleep apnea often goes unrecognized, undiagnosed and untreated in children, with equally, if not more severe, consequences to health, development and well-being. Below are some basic facts about sleep apnea in children of which all parents should be aware.
While any child may have sleep apnea, there are certain conditions that increase the risk. These include:
Large tonsils and adenoids Being overweight or obeseAsthma and environmental allergiesA family history of sleep apnea Premature birthSome ethnic/racial groups (African-American, Latino, Asian)Certain medical conditions (Down syndrome, Pierre-Robin syndrome, Prader-Willi syndrome) that may result in a smaller size face and upper airway or obesity
Symptoms of sleep apnea in children may be similar but differ in some important ways from those in adults:
Loud frequent snoring (not just with colds)Breathing pauses (less frequent than in adults)Mouth breathing during sleepChoking, gasping in sleepRestless sleepSweaty in sleepNeeding to sleep with several pillows
Feeling sleepy, dozing off, starting to take naps again (this is more common in older and obese children, and those with more severe sleep apnea)Difficulty waking in the morning in spite of getting enough sleepHyperactivity, poor attention span, impulsivity, aggressive behavior (these are common signs of poor sleep, especially in younger children, and maybe mistakenly diagnosed as attention deficit hyperactivity disorder (ADHD))Mood swings, irritability Difficulties performing in school; decrease in gradesIf parents have any concerns related to the above, they should speak to their pediatrician.
The next steps in terms of diagnosis typically include:
An overnight sleep study in a sleep lab to monitor breathing and oxygen levels and confirm a diagnosis of sleep apnea**
Treatment (depending on risk factors and severity of sleep apnea) may involve “Watchful waiting”:
Some children may outgrow the symptoms of mild sleep apnea over timeSurgery (removal of the tonsils and adenoids); this requires consultation with an ENT (Ears Nose and Throat) specialistWeight loss Drug treatment of inflammation on the nose and throat (Flonase and Singulair)Dental appliances (to increase the size of the upper breathing passages)Exercises to improve the function of upper breathing passages (myofunctional therapy)Breathing assistance: the most common treatment for sleep apnea in adults is CPAP (continuous positive airway pressure) using a device that delivers air under pressure to open the airways; this treatment can also be successful in children who are appropriate patients. Special masks and CPAP units are available for children to make this treatment more acceptable.
Sleep apnea in children has different causes and presents with different symptoms compared to adults. Parents are usually the first ones to recognize the symptoms, and so should alert their child’s healthcare provider about their concerns. There are many effective treatment options available, so the importance of early recognition and diagnosis is critical to prevent the important potential consequences of sleep apnea on brain development. behavior. mood, health and well-being.
*A distinction should be made between obstructive sleep apnea, in which there is some blockage to breathing and central sleep apnea, which especially in infants may be related to immature control of breathing
** Parents should ask if the sleep lab is equipped to study children and has accommodations for parents
Dr. Judith Owens is Director of Sleep Medicine at Boston Children’s Hospital in Boston Massachusetts and a Professor in Neurology at Harvard Medical School. She is an internationally-recognized authority on pediatric sleep and the author of over 175 original research and review articles in peer-review journals, chapters, and books on the topic.