Sleep apnea and related breathing problems during sleep are by far the
most common and dangerous sleep disorders assessed at nearly all sleep centers.

Everything that physicians used to think about sleep apnea was incorrect.

We once thought that sleep-related breathing disorders were rare, and that they occurred only in middle-aged men with severe obesity who snored like freight trains and who were always sleepy during the day.

We were wrong on every count!

We now realize that these disorders are extraordinarily common--and that they are more prevalent in men over age 40 than either diabetes or asthma.

We have learned that these disorders also occur frequently in slender, young individuals… and in both women and children. Sleepiness in any patient warrants exclusion of a sleep-related breathing problem.

We have also found that both the prevalence and severity of sleep apnea escalate in women following menopause--a problem likely to increase dramatically now that so many women are being taken off hormone replacement therapy. In fact, one study found that elderly women have a higher death rate from sleep apnea than do elderly men!

A recent large study revealed that the majority of patients with sleep apnea--even if extremely severe! --have no daytime sleepiness or other symptoms…such that if they have no bed partner to voice concerns about their breathing during sleep, they may never receive medical attention and hence may develop irreversible medical complications that could have been prevented. Perhaps such accounts for the fact that studies have shown that married people live longer than single people.

Of additional major importance is the fact that many patients with sleep-related breathing problems do not snore significantly. For example, many patients suffer from what is termed "upper airway resistance syndrome". They may never stop breathing but they must struggle on an ongoing basis to maintain air exchange through a narrowing upper airway. This relatively common disorder, which can cause high blood pressure and potentially dangerous sleepiness at the wheel, is particularly common in young women and children of normal body build--and they usually do not snore loudly!

Severe sleep apnea, if untreated, kills people.
And to make matters worse, it tends to kill them slowly.

Untreated severe sleep apnea has recently been shown by an NIH-funded study to increase mortality rates by a startling 46%!

Also, sleep apnea tends to kill its victims gradually and not suddenly during sleep: via such devastating complications as heart attack, heart failure and stroke.

For example, we now know that six of every ten men with stroke have sleep apnea. Untreated sleep apnea increases the risk of recurrent heart attack 23-fold. Furthermore, repeated drops in blood oxygen levels during
sleep cause an inflammatory reaction that accelerates development of coronary disease: such that afflicted patients are constructing their own "time bomb".

And approximately half of patients with chronic heart failure have sleep apnea, often without either loud snoring or daytime sleepiness. Failure to control their sleep apnea can render their heart failure untreatable and could accelerate worsening of heart function.

One must ask how many patients have died slowly, painfully and unnecessarily simply because their sleep-related breathing problems were never properly diagnosed and treated.

Sleep apnea and its variants are now readily treatable.

The leading treatment for sleep apnea is positive airway pressure (CPAP and its variants).

Why are other treatments less effective?

It is because we are dealing with both structure and function. Patients with sleep apnea and related disorders tend to have "floppy throats". The muscles that should pull throats open while sleep apnea patients breathe in during sleep fail to do their job. The end result is much like sucking on a balloon. Hence, if one enlarges the throat or nose surgically at one level, the upper airway tends to collapse at another level.

Dental appliances that pull the jaw or tongue forward to expand the airway sometimes work in patients with relatively mild sleep apnea, but not in all of them. These devices are not uniformly effective and typically fail to correct excessive drops in blood oxygen levels during sleep. Also, a quality dental appliance must be fabricated for a given patient at considerable expense and without any way of predicting whether it will control that person's sleep-related breathing problem. Dental appliances also can cause occlusive changes (change in the "bite" between the upper and lower teeth). Finally, they often cause TMJ (temporomandibular joint) pain, which can result in their not used on a consistent, nightly basis…which in turn can leave the sleep apnea patient at ongoing risk of potentially serious complications.

In contrast, CPAP and its newer variants are effective in nearly all patients. They are essentially blower units that use air pressure (delivered via the nose and/or mouth) to keep the upper airway open. They invariably work because it would not matter where a given patient's upper airway is collapsing. His or her throat and nose could be "blown open" at any level with air under gentle pressure. The machines are also safe: it is difficult to harm people with air. And they have become very small and quiet.

Tragically, though, some studies have shown that over half of the patients in the U.S. who were prescribed CPAP machines for treatment of their sleep apnea don't use them with any regularity!

And many patients with classic histories for obstructive sleep apnea are undergoing sleep testing, only to be told incorrectly that their sleep studies did not show any significant problem--such that no treatment was recommended when it should have been.

Why are so many patients with sleep apnea are being left
without an accurate diagnosis or effective treatment?

We repeatedly note the following deficiencies in our patients' prior assessments at other centers. Could any of these accounted for the poor results that you or a friend or family member experienced?

* A careful history was never taken.

* Observations of family members and bed partners were ignored whenever they suggested more serious problems than were documented during inadequate sleep studies.

* The patients slept less soundly during their overnight monitoring than at home: resulting in both underestimates of disease severity and inadequate guidelines for treatment. Both sleep apnea severity and treatment requirements increase with increasingly sound sleep. Hence, whenever patients sleep less well during testing than at home, the results and consequent treatment recommendations should be regarded as potentially inaccurate.

* The sleep center assigned multiple patients per technologist: such that inadequate attention was paid to detail and to the individual patient's needs during overnight testing.

* Limited testing capabilities resulted in failure to diagnose such potentially serious conditions as upper airway resistance syndrome, epileptic seizures and gastroesophageal reflux during sleep.

* There was a lack of meticulous attention to individual patient needs when prescribing treatments: whether CPAP, medications or other interventions.

• Central sleep apneas (which occur in some 15% of patients with obstructive sleep apnea when they are started on CPAP or "BiPAP", and in half of patients with congestive heart failure) were simply ignored because the sleep center did not offer the newer forms of therapy, such as adaptive servoventilation, that would have controlled them--and the repeated pauses in breathing then rendered PAP both intolerable and ineffective.

• When lack of attention to detail and lack of adequate follow-up support left sleep apnea patients unable to use CPAP or related therapies, the patients were simply referred for "second line" treatments such as painful surgeries that did not work--instead of the treating physician making any effort to render first-line treatments well tolerated and effective.

• Patients with potentially dangerous sleep problems were forced to wait for weeks or months before their sleep evaluations and even between their first and second overnight recordings, and then, they were left without the results of their tests--and without any treatment! --for weeks or months after completion of their overnight studies. Such delays in care--which are all too common--leave patients at an ongoing and inexcusable risk of such complications as heart attack, heart failure, stroke, and sudden death in sleep. Such delays should not be tolerated.

• There was no skilled follow-up care, support or responsiveness to patients' needs after completion of testing: such that patients were forced to abandon treatments that might have helped them.

• The responsible physician lacked adequate sleep medicine experience (and in many cases, practiced sleep medicine as a "sideline").

What can be done to increase the odds of prompt and effective care--
with good, lasting results?

The stakes are too high to settle for less, given the potentially catastrophic and irreversible complications that can result from untreated sleep apnea.

So, what can patients and their concerned friends and family members do to help ensure good quality care?

A logical approach would be to demand satisfactory answers to the following key questions before an initial appointment is even scheduled at a given sleep center. Evasive or unsatisfactory answers should lead patients to seek evaluation and treatment elsewhere--even if the center is convenient and "close to home".

• Do the physicians giving care at the center practice sleep medicine full-time?
• How many years of sleep medicine experience do they have?
• What are typical time intervals between: the initial office visit and first overnight recording, the first and second ("titration") overnight recording, and the second overnight recording and initiation of treatment for sleep apnea? Also, does the sleep physician consistently review completed recordings on the day after they are performed…or at some later date?
• How frequently after completion of testing are sleep apnea patients referred for second-line, less effective treatment with surgeries or dental appliances, instead of more effective treatments with positive airway pressure and its variants?
• Does the center have significant experience with the treatment of central and complex sleep apnea with adaptive servo-ventilation (not auto servo-ventilation)? And does it have experience with use of AVAPS to treat patients with inadequate breathing and low oxygen levels (a question of importance particularly when the patient is very overweight, has muscle weakness, spine deformity or chronic lung disease)?
• Does the sleep center often diagnose and treat upper airway resistance syndrome--since it should be?
• What type of follow-up care and support are provided by the sleep center? Also, in the event of significant problems, can patients reach the treating physician by telephone or e-mail and receive a prompt response?
• Does the sleep center rent and sell positive airway pressure machines (a potential conflict of interest) or does it refer patients to independent home care (durable medical equipment) vendors?

Knowledge is power. A well-informed patient is most likely to obtain the best care and the best long-term outcome.

The internet can greatly facilitate education of patients and those close to them. The Sleep Site (www.thesleepsite.com) provides extensive information on the entire spectrum of sleep related problems, including all forms of sleep apnea.

Finally, in the event of questions resulting from your reading this article, do not hesitate to contact the author at flamenco@netexp.net.

Author's Bio: 

Robert W. Clark, M.D., F.A.A.N.
The Columbus Community Health Regional Sleep Disorders Center
1430 South High Street, Columbus OH 43207
(614) 443-7800
flamenco@netexp.net

www.thesleepsite.com