[Nasional-e] A noisy, invisible threat: Waking up to sleep apnea

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 A noisy, invisible threat: Waking up to sleep apnea
  Jane E. Brody

The New York Times Thursday, September 19, 2002
NEW YORK John Holman is a very busy man, and he was not accustomed to having
to "let things go" because he was too tired to do them. But tired he was,
tired driving to and from work, tired during the day at the warehouse
company he runs, too tired some days to play his beloved game of tennis
after work, and really tired in the evening - in bed by 8:30 to arise at 6.
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But Holman, an average-size 67-year-old, did nothing about his fatigue until
his wife, Marna, threatened to move out of their bedroom because his snoring
was keeping her awake. It was she who suggested that he might have sleep
apnea. With it, breathing stops, often for a minute or longer, sometimes
hundreds of times a night and resumes each time with a loud snort or snore.
So at his wife's urging, Holman spent a night in the sleep laboratory at
Abbott Northwestern Hospital in Minneapolis. Her suspicions were confirmed.
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Holman now sleeps with a device that assists his breathing, and both he and
his wife, who feared he would fall asleep while driving and kill himself or
someone else, are feeling a lot better.
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The National Institutes of Health estimates that as many as 18 million
Americans, 6 percent of the nation, have sleep apnea. Following the
proliferation of sleep centers around the country and greater awareness of
the condition, the diagnosis of sleep apnea increased 12-fold from 1990 to
1998.
.
Still, experts estimate that fewer than 10 percent of people who have it are
aware of it. As a result, they risk their health and their lives and
possibly the lives of others.
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Apnea is Greek and means "with no breath." With obstructive sleep apnea, by
far the most common type, the airway repeatedly becomes blocked, usually by
soft tissue at the back of the throat. With central sleep apnea, no blockage
occurs, but the brain fails to signal the respiratory muscles to breathe. A
third type, mixed sleep apnea, is a combination of the two.
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In most cases of obstructive sleep apnea, the muscles of the soft palate
relax at the base of the tongue and the uvula, the small fleshy piece
hanging at the back of the throat, causing the tissue to sag and block the
airway. This is most likely to occur when sleeping on one's back, but it can
also happen in other positions. These involuntary breathing pauses may occur
as many as 20 or 30 times an hour all night long.
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Breathing resumes when the blood oxygen level falls low enough and the
carbon dioxide level rises high enough to stimulate the brain into action.
Although the afflicted person is unaware of what is happening, with each
apnea episode, the brain arouses from deep, restful sleep, resulting in a
night's sleep that is fragmented and of poor quality.
.
After spending up to 10 hours in bed, the sufferers may think they got
enough sleep, only to feel groggy in the morning and sleepy for much of the
day.
.
Sleep apnea is very common, as common as adult-onset diabetes. It is most
common among middle-aged men who are overweight, especially those with fat
necks. But it spares no age group or body size. Even some children have
sleep apnea, which is a suspected cause of some cases of sudden unexplained
infant death. It has been estimated that as many as 40 percent of elderly
residents in nursing homes have sleep apnea.
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In some cases, sleep apnea seems to run in families, suggesting that it may
sometimes have a genetic basis. But whatever its basis, the condition is
made worse by the consumption of alcohol or use of sleeping pills, which
impair the brain's arousal mechanism.
.
In addition to the obvious risks of falling asleep while driving or
operating dangerous machinery, life-disrupting consequences and serious,
even life-threatening, health hazards can accompany sleep apnea. Although
cause and effect are not well established, untreated sleep apnea is
associated with high blood pressure, an irregular heartbeat, heart attack
and stroke. The afflicted may experience headaches, weight gain, learning
and memory problems, depression, irritability and impotence.
.
Holman and others are among the lucky ones for having spouses or companions
who suspect something is wrong. Those who live alone may face a bigger
problem: Even when the snoring becomes outrageously loud, it does not fully
awaken the snorers. For them, it may be up to co-workers or friends to
notice that they fall asleep repeatedly at inappropriate times. Also, a
personal physician will sometimes ask the right questions to unveil the
possibility of a sleep disorder.
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The most accurate diagnosis is obtained by spending a night in a sleep
laboratory hooked up to instruments that measure electrical activity of the
brain, heart rate, muscle activity, eye movements, respiratory effort and
oxygen levels in the blood. This test, called polysomnography, can assess
the existence of sleep apnea and its severity.
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But even with the increase in the number of sleep centers, now some 2,200
across the United States, not everyone with a major sleep disorder has easy
access to one. Also, just one night in a sleep laboratory can cost $1,000 to
$2,500, and it is not always covered by medical insurance. If money is a
concern, be sure to check first with your insurance company. If necessary,
your personal physician may be able to intervene and obtain pretest approval
for insurance coverage.
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With improved technology, it may also be possible to perform polysomnography
at home through a remote connection to a sleep laboratory. There are also
some less involved diagnostic tests that can be done at home that are almost
as accurate as polysomnography.
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For example, the Food and Drug Administration just approved a device called
NovaSom QSG, developed by Sleep Solutions, for at-home diagnosis of
obstructive sleep apnea. It can be used to collect three nights of data more
conveniently and at lower cost than one night in a sleep lab. Another
validated FDA-approved device, the Remmers Sleep Recorder, can obtain the
necessary data in one night's use in the patient's home.
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Once diagnosed, sleep apnea should be treated by an expert. Administering
oxygen or medications does not eliminate the problem. Patients should be
advised to avoid alcohol, tobacco and sleeping pills, and those who are
overweight should be told to lose at least 10 percent of body weight.
.
The most common treatment - continuous positive airway pressure - involves
nightly use of a mask over the nose that transfers pressurized air from a
blower through the nasal passages. The pressure prevents the tissues in the
throat from collapsing.
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Most drastic are surgical procedures, including removal of tonsils and
adenoids or removal of excess tissue at the back of the throat - tonsils,
uvula and part of the soft palate - with a success rate of only 30 percent
to 50 percent.
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The National Center on Sleep Disorders Research cautions that while
laser-assisted surgery may decrease or eliminate snoring, it does not cure
sleep apnea itself or reduce its attendant risks.