By Dr. Tony Masri
Dr. Tony Masri is a neurologist who specializes in sleep medicine. He received his medical degree from the University of Toledo, Ohio, and completed a neurology residency at Case Western Reserve University. He then completed a sleep-medicine fellowship at the Stanford Sleep Center. Currently he is the medical director of the Sleep Health Program at El Camino Health.
What is Obstructive Sleep Apnea (OSA)?
Normal breathing involves inhaling and exhaling through the nose. However, when there's a collapse at the back of the throat, the brain sends a signal to take a deep breath. This signal can raise blood pressure and heart rate, contract respiratory muscles, induce heart acceleration, and even cause inflammation in blood vessels. Eventually, the airway reopens, allowing for normal breathing.
How is OSA monitored in a Sleep Lab?
In a Sleep Lab, individuals are closely monitored for signs of OSA. This involves measuring respiration, breathing patterns, and EEG (brain wave activity). During apnea episodes, blood pressure increases, oxygen levels drop, and the brain tries to compensate by elevating blood pressure. Also, inflammation happens where cortisol levels go up, and affects insulin, so it makes diabetes worse. Oxygen can drop low, as low as 60, compared to the normal level of 96. It can impair brain function and weaken the heart over time.
We measure how often someone slows down or stops breathing every hour. If they stop or slow down breathing fewer than 5 times an hour, that is generally considered normal. Five to 15 is considered mild. Over 30 times an hour is considered severe.
How common is OSA, and who has sleep apnea?
Approximately 10% of the general population has OSA, often undiagnosed. Individuals with a history of stroke, high blood pressure, or those taking multiple blood pressure medications have a higher risk of OSA. The risk is also elevated for those with heart failure and atrial fibrillation. OSA and hypertension often coexist, increasing the risk of stroke. Those with moderate OSA (15 or more episodes per hour) are three times more likely to develop hypertension in four years.
If you have moderate (not even severe) OSA, it’s important to treat it so you don’t develop high blood pressure. Your blood pressure can go up every time you have an apnea episode during the night.
If sleep apnea is not treated, how does it impact one’s health?
Untreated OSA can result in irregular heartbeats, heartburn, high blood pressure, and atrial fibrillation. The pressure from untreated OSA can stretch the walls of the left atrium, affecting atrial electricity. This is a crucial consideration for individuals with atrial fibrillation. If you have OSA, you should treat it before an ablation or another procedure on your heart for atrial fibrillation. This will reduce the likelihood of recurrent atrial fibrillation.
What are symptoms of sleep apnea?
Common symptoms include:
- Loud snoring
- Witnessed apneas (breathing stops during sleep)
- Excessive daytime sleepiness
- Non-refreshing sleep
- Atrial fibrillation
- Specific physical traits such as a narrow jaw or high arch palate
How is sleep apnea screened or identified?
Screening tools such as "STOP" and "STOP BANG" help identify potential apnea cases based on factors like snoring, tiredness, observed apnea, blood pressure, BMI, age, neck circumference (over 17 inches or 40 cm), and gender.
What are the treatment options for sleep apnea?
Treatment options for sleep apnea include:
- CPAP (Continuous Positive Airway Pressure): Highly effective, covered by insurance, and has minimal side effects.
- Bite Guard: Worn on the upper and lower jaws, it's less effective than CPAP but can help.
- Weight Loss
- Elevating Head: Elevating the head about 10 inches above your feet or 30 degrees during sleep can reduce apnea. Various surgical options are available but may have limited effectiveness. For example, nasal surgery, but just fixing the nose is not effective by itself. It might help 10-20%. Other options include soft tissue surgery, where tissue in the back of the throat is cut, or bone surgery, which involves breaking the upper and lower jaw and bringing it forward.
How Does Continuous Positive Airway Pressure (CPAP) Work?
CPAP uses pressurized air to keep airways open. It's essential to receive proper education, custom fitting for the mask, and ongoing monitoring to ensure successful CPAP use.
The traditional model where you are prescribed CPAP and handed a machine is not ideal because you won’t know what to do with it or how to use the machine. At El Camino Health, we provide education and custom fitting to find a good mask, we monitor how you’re doing with the machine, and solve adherence problems. There is a respiratory therapist and a sleep technologist. We monitor your machine remotely to see how you’re using it. We have 70-90% success in getting people to use CPAP, compared to 34% when someone is just handed a CPAP.
Questions About CPAP
Q: If someone starts on CPAP, do they have to stay on CPAP for life? How can we travel with CPAP?
A: Once you start on CPAP, the expectation is to be on it for as long as possible. But if you lose weight, have surgery or some other treatment, you might not need CPAP afterwards.
CPAP is small and easy to travel with. It can be taken as an extra carry-on since it's considered a medical device.
Q: Is it normal to feel excess air in the stomach while using CPAP?
A: That happens maybe 10% of the time. One option is to reduce the pressure and slowly increase it again. Another option to reduce air swallowing is to elevate the head of the bed a little bit. If you have heartburn or reflux, it’s a good idea to your doctor about getting treatment.
Q: I am afraid to put on my CPAP. What if it stops my oxygen in my sleep?
A: There is no risk. Even if the machine is off, you can still breathe in and out. It doesn’t stop air flow.
Q: Why is it hard to breathe with CPAP?
A: You are getting continuous positive airway pressure, which can make it harder to breathe. But that’s usually when first started. There is a comfort feature with the machine that can help. That feature makes the pressure drop when you breathe out, so it feels much easier to breathe. I recommend using that and using the lowest pressure at first, then slowly increasing it to make sure that you can use it.
Q: How many hours should CPAP be worn at night? Do we need to wear it when we take a nap?
A: A minimum of 4 hours is recommended, but 6 hours is better. If you going to take a nap, you will have a better nap if you use CPAP.
Q: Can CPAP be used during a cold or cough?
A: Yes, and the humidifier feature can help.
Q: I can’t fall asleep, and wearing CPAP makes it even worse. How should I handle that?
A: At El Camino Health, we also help with other sleep disorders, such as insomnia. We would treat your insomnia separately from apnea to help you be able to fall asleep with CPAP. Treatment for insomnia usually involves medication or cognitive behavioral therapy.
Q: How often should sleep apnea be monitored?
A: Regular monitoring is recommended. At least once a year or when significant changes occur, or if there's weight gain or weight loss of five pounds or more. If you've had surgery on your nose or airway, you should check back in with your doctor.