Dr Vikram Rathi is a successful chest physician who works with Rathi Chest Clinic, CARE Hospital and SEVEN STAR Hospital in Nagpur. Read one of his articles, where he speaks about one of the major sleep disorders – Sleep Apnea.
Sleep medicine did not even exist until the Japanese decided to save marriages. The story goes that about 30 years ago, a Japanese court granted divorce to a woman on grounds that her husband was snoring. The early work on sleep medicine therefore came from Japan and it was intended, even if not to save lives, to save relationships. Snoring, however, is just not a standalone. In most cases, about 90 per cent snoring is indicative of a condition called sleep apnea.
Sleep apnea is one of the many sleep disorders. Obstruction to breathing during sleep is defined as apnea, and its cardinal symptom is loud snoring. The prevalence in India is about 24 per cent of men (mostly over 40 years) and nine per cent of women.
Post 40’s, the body’s muscle loses its tonality, especially among men with little physical activity. During sleep, when the muscles relax, the base of the tongue completely obstructs the airway, causing the breathing activity to cease.
Sleep disorders represent a significant number in India, yet, it is an overlooked health problem Sleep apnea is a form of sleep-disordered breathing, in which the airway becomes narrowed as the tissues and muscles surrounding it relax. The brain corrects for this suffocation by jerking the patient between deep sleep and light sleep, and even momentary awakening, though the individual doesn’t necessarily remember it. Many of us are living with sleep apnea unaware and it is estimated that 80-90% remain undiagnosed
Untreated, OSA has been found to significantly raise the risk of developing diabetes, high blood pressure, heart disease, heart attack and stroke. It majorly impacts quality of life, patients are sleep deprived, feel sleepy all the time, there is dulling of the intellectual and emotional faculties of a person, often feel depressed and terrible. Many of the major industrial or transportation accidents in the past few years have been linked to sleep deprivation or OSA. It is crucial to treat this to protect your heart health.
Sleep apnea is recognised as a disorder in the West. In some countries, those with sleep apnea will not be issued driving licenses, or allowed to work with heavy machinery. That kind of awareness is lacking in India. There is a strong suspicion that Indians are genetically more predisposed to sleep apnea, research says. Sleep apnea among children is also growing. In them, while the causes relate to tonsils or adenoids, and removal is the recommended option.
What is the underlying cause of sleep apnea? There are a lot of different theories, but the general principle is that the airway gets narrowed due to tissue/muscle obstruction. Your body usually has a sense when the airway is being narrowed, but after a while the nerve endings can get less sensitive, especially as people get older, many people gain weight and lose muscle tone. Women are at higher risk post-menopause due to hormonal changes. Growing obesity, changing lifestyle patters, overeating, sedentary life, smoking, consumption of alcohol are few of the causes for Sleep Apnea
Research has identified a set of risk factors associated with sleep apnea. Major risk factors include being male, being obese, having a history of hypertension and diabetes, and having a family history of sleep apnea. People who snore loudly are also more likely to have sleep apnea.
Signs and symptoms:
One of the major red flags to be on the alert for is snoring.
Snoring is considered a partial obstruction or blockage of the airway, and many times it is only the bed partner who realises that the individual snores. Other warning signs are daytime tiredness, not feeling like you’ve gotten enough sleep when you get up, headaches, irritation, mood changes, frequent urination at night, morning headaches, inability to concentrate, and things related to sleep deprivation, like falling asleep at the wheel or falling asleep in meetings
Being Male, Overweight, Older, a Snorer and Excessively sleepy (MOOSE) are the typical risk factors for OSA. However, you can be thin and young female, who doesn’t snore and be sleepy, and still suffer from obstructive sleep apnea due to smaller jaw structures and smaller upper airways.
The diagnosis and management of this condition is rapidly evolving. Fortunately, with the proper tools, OSA can be diagnosed – and, with proper treatment, risks for conditions associated with OSA can be significantly reduced.
The Sleep Lab
When being evaluated for OSA, it’s recommended you see a sleep physician. Most sleep physicians will be pulmonologists or other physicians who undergo subspecialty training in sleep medicine.
Often, a sleep study will be suggested. However, for some, sleeping overnight in a strange place with wires hooked up can be a barrier to getting tested. Fortunately, there are other options. In some instances, simpler home tests can also be ordered.
If you’re found to have sleep apnea, there are a number of different, effective treatment options, including conservative methods, medical devices and, in some cases, surgery.
Initial Conservative Steps for Treating OSA:
- Lose weight. If you’re overweight, start by losing weight through a healthy diet and exercise regimen. While it’s been shown that lack of sleep can make it hard for someone to lose weight, losing even 5 to 10 pounds can help.
- Don’t eat late. Eating close to bedtime will increase acid reflux in your throat every time you stop breathing; this is due to a suctioning effect. It’ll wake you up more often and lessen your sleep quality.
- Breathe well nasally. Optimal nasal breathing is important so you don’t open your mouth, which causes your tongue to fall back more, leading to more obstructed breathing. Good nasal breathing also significantly improves your chances of doing well for more formal OSA treatment options. Chinstraps or mouth taping can sometimes help.
- Do tongue exercises. Researchers from Brazil found that a regimen of tongue exercises lowered the severity of OSA by about 50 percent.
- Don’t sleep on your back. Most people with OSA won’t be able to sleep on their backs since the tongue falls back due to gravity. When in deeper levels of sleep, the tongue and throat muscles become even more relaxed. If you’re a side or tummy sleeper and are suddenly forced to sleep on your back (due to an injury or surgery), try to go back to your previous sleep position as soon as possible.
If these conservative steps don’t work, there are other options to consider:
Continuous Positive Airway Pressure, or CPAP: Gold standard of therapy is CPAP. Gentle air pressure is passed through a mask over your nose (or nose and mouth), attached to a quiet and small bedside pump. This allows you to breathe properly at night. The best pressure is either measured in a second overnight sleep study (CPAP titration). With proper guidance from chest physician, most people can sleep much better at night.
Mandibular advancement device. These devices are recommended for people with mild to moderate OSA and can be considered as first-line therapy, in addition to CPAP.
Surgery. Before 1980, the only option available for OSA was a tracheotomy. Now, there are dozens of different surgical options for various areas and types of obstruction, from the tip of the nose to the voice box. However, surgery should be considered only after trying one or both the above options.
Since everyone has different levels and degrees of obstruction, there’s no one option that’s best. It’s important to work with your doctor to determine what’s most ideal for each individual situation. If you are at risk for OSA or exhibit any signs or symptoms, get tested.
Questions for your doctor:
There’s no harm in asking, “Am I at risk of sleep apnea?” If your partner complains about your snoring, then ask, “Am I a candidate for a sleep study?” If you are diagnosed with sleep apnea, the question becomes, “How severe is my sleep apnea?” and “What treatment options do I have?”
Sleep apnea and snoring can affect your day-to-day quality of life and your bed partner’s quality of life, apart from other health risks. “Having sleep apnea treated is crucial, both medically and in terms of your quality of life.”
Don’t ignore symptoms. And that includes feedback from your partner. “You can’t hear yourself snoring or when you stop breathing, but your partner can,” If you sleep alone, be alert for symptoms and don’t hesitate to ask your doctor if you are a candidate for a sleep study.
Take preventive steps. Maintaining a healthy weight, sleep hygiene, avoiding alcohol and other sedatives at night cuts your risk of sleep apnea.