The clock says you slept for eight hours, so why are you so tired during the day? It could be that you have sleep apnea, a sleep disorder where you stop breathing periodically at night, which affects 17 percent of the United States population.
“People with sleep apnea stop breathing repeatedly during their sleep because the tissue around the neck relaxes and falls back, blocking the airways,” said Dr. Andres Santiago Endara-Bravo, director of the Cleveland Clinic Indian River Hospital Sleep Center.
“When people snore it’s a sign that the airways are blocked and preventing enough air to flow in and out. It only happens at night because during the day we keep the muscles tight and the airway open. When we sleep we are relaxed, and all of the tissue falls behind, causing people to snore and to have the airway be obstructed.”
If it’s not treated, sleep apnea creates a higher risk for hypertension (high blood pressure), stroke and heart attacks, and the possibility of being disabled. Excess weight is one of the primary causes of sleep apnea, but it can occur in people of ages and body types.
Certain physical traits like a large neck and structural abnormalities that reduce the diameter of the upper airway – such as nasal obstruction, a low hanging soft palate, enlarged tonsils or a small jaw with an overbite – also are contributing factors.
When you stop breathing, your heart rate drops, and your body is deprived of oxygen. As your involuntary reflexes wake you, your heart rate accelerates, and your blood pressure rises. If your body experiences chronic effects of sleep apnea, your heart walls thicken and become stiffer and less flexible. These changes increase the risk that you can develop atrial or ventricular arrhythmias and reduce the efficiency of the heart to pump blood.
“Men are more at risk of developing sleep apnea than women but the risk for women increases after the age of 50 when they stop producing hormones,” Dr. Endara-Bravo said. “My patients will come in because they feel tired and sleepy during the daytime even after a good night’s sleep, or in many cases the apnea has been witnessed by their partner.”
The most common form of sleep apnea is obstructive sleep apnea which occurs as repetitive episodes of airway blockage during sleep. During an apneic episode, the diaphragm and chest muscles work harder as the pressure increases to open the airway. Breathing resumes with a loud gasp or body jerk.
The second form of sleep apnea is central sleep apnea, which is related to the function of the central nervous system. It occurs when the airway is not blocked but the brain fails to signal the muscles to breathe due to instability in the respiratory control center. Oftentimes, prescription medications cause the disconnect between the brain and the lungs, blocking the signal to breath.
Dr. Endara-Bravo shared a simple screening acronym used in his office. It is called STOP-BANG: S- snoring, T-tiredness, O-observed apnea, P-pressure (history of high blood pressure), B-body mass index (BMI above 30), A–age (greater than 50), N-neck (greater than 17 inches in diameter), G-gender (men are at a greater risk).
Patients who score 3 points out of the 8 are at high risk of having sleep apnea. The higher the score the more severe the condition. Someone who scores 8 out of 8 has severe apnea.
“Family doctors are generally the ones who hear the initial complaint from a partner who says they can’t sleep because their partner is snoring or gasping for breath,” Dr. Endara-Bravo explained. “That will trigger an evaluation. The first thing we do is a sleep study and there are two types of studies that we can do. The majority of my patients prefer a home base evaluation where we provide the patient with a small machine they sleep with for one night. They return the next day and that gives me all the information I need to determine if the patient has or doesn’t have sleep apnea.”
The Home Sleep Test records airflow, breathing effort, blood oxygen levels and snoring.
“The second method is conducting the study at the sleep lab,” he continued. “Usually those are reserved for patients with pre-existing conditions who feel they can’t do these tests themselves.
We have four private rooms with private baths, so it’s like checking into a hotel but you’ll have a trained technologist watching you when you sleep.”
The overnight sleep study is more extensive than the home test. It measures electrical activity of the brain, eye movements, muscle activity, heart rate, breathing patterns, air flow and blood oxygen levels.
Conservative treatments are the first line of treatment for mild cases of sleep apnea. If the patient is overweight, losing weight will decrease the symptoms. Some patients can get relief from changing their sleeping position – from sleeping on their back to their side. People with sinus or nasal congestion should use nasal sprays or breathing strips to increase airflow for more comfortable nighttime breathing.
Positive Airway Pressure therapy is the preferred initial treatment for most people with obstructive sleep apnea. With this therapy, patients wear a mask over their nose and mouth and the air pressure is adjusted to prevent the upper airway tissues from collapsing during sleep. There are several styles of the devices specialized for the specific needs of the patient.
Mandibular advancement devices are dental appliances for patients with mild to moderate obstructive sleep apnea. These devices prevent the tongue from blocking the throat and advances the lower jaw forward keeping the airway open.
There is also a simulator that can be implanted under the skin with electrodes tunneled under the skin to the hypoglossal nerve in the neck and to intercostal muscles (between two ribs) in the chest. The device is turned on at bedtime with a remote control, and with each breath the hypoglossal nerve is stimulated, moving the tongue forward out of the airway to keep it open.
“The FDA has just approved a new device that you can use for 20 minutes during the daytime that trains the muscle to keep the tissue away,” Dr. Endara-Bravo said. “The technology is ever-changing, and we can discuss the right device or surgery for you, based on your level of sleep apnea.”
Dr. Andres Santiago Endara-Bravo earned his medical degree from the Pontifical Catholic University of Ecuador and completed additional training in pulmonary and critical care medicine at Tulane University Hospital in New Orleans and sleep medicine at the University of Miami. He is accepting new patients at Cleveland Clinic Indian River Hospital’s Health and Wellness Center, 3450 11th Court, Vero Beach. To schedule an appointment call 772-794-5800.