WHEN a friend, JG, was having atrial fibrillation, his cardiologist told him “You need to get checked for sleep apnea.”
“I told him I sleep like a champ,” JG recalled—but the cardiologist insisted.
When he did get tested and got the results, “I was shocked,” he said. “I was having episodes of not breathing for up to eight seconds about 42 times per hour”—which qualified him as “severe” obstructive sleep apnea.
OSA occurs when the airway becomes obstructed during sleep—but the respiratory effort persists, and builds, until the person gasps or jerks, and starts breathing again. Often people with OSA snore loudly, or their bed partner observes them not breathing.
Such a pattern leads to non-restorative sleep and the subject often is hyper-somnolent in the day time—falling asleep whenever they sit down, which can be dangerous when driving. It also predisposes them to diabetes, and multiple adverse effects on the cardiovascular system, like high blood pressure, strokes and atrial fibrillation—like JG was having.
For the sake of being thorough, I should mention there is a far less common “central” sleep apnea caused by a lack of respiratory drive from the brain.
The prevalence of OSA shows up in a formidable 26% of adults between the ages of 30 and 70, according to The National Healthy Sleep Awareness Project. And it seems to be on the increase.
To explain why, I tracked down Dr. Neal Maru with the Mary Washington Sleep Medicine group—a neurologist whose interest was piqued when doing an assignment with an attending in Sleep Medicine during his residency. He found sleep medicine “fascinating.”
The in creasing prevalence, he told me, is partly due to greater awareness and testing. But also because the population is getting older and more overweight. But nasal obstruction, large neck (greater than 17 inches for men) a floppy soft palate, large tonsils and adenoids, or a small jaw with an overbite can also all cause OSA.
People are often unaware and have no symptoms, notes Maru—like JG, appeared to—though when I pressed him, he did admit to falling asleep on the bus on the way to work every day (he said it was the best part of his day), or if he ever flew on a plane.
Another indicator I learned about from Kojo Nyarko and Carrie Ludwig, who run the sleep lab where I dropped by to see how the actual testing is done, is the “elbow sign”—the bed partner repeatedly jabbing the subject with their elbow to get them to start breathing again.
Diagnosis and Treatment
Passing an exotic display of different types of masks on glass mannequin heads in the front lobby in the lab, I was shown the comfortable rooms where patients get to sleep (hopefully) after being fitted with skin sensors to monitor brain waves, eye movements, respiratory effort, oxygen saturation and more.
Monitoring the activity are two technicians that are in a central control room where multiple jiggly lines on a monitor indicate sleep stage, snoring, respiratory or other movements, and if oxygen saturation is dropping.
They do a lot of testing for the Department of Transportation, I was told, which is reassuring—a nice idea that your bus, truck or train driver will be diagnosed before they fall asleep on the job.
As for treatment, I am from the era where the solution was to sew a tennis ball into the back of the pajamas, so the person doesn’t sleep on their back—where obstruction is worse.
Things have advanced since then, however, and the most common treatment of OSA is now with CPAP, continuous or bilevel positive airway pressure, generated from a pump that is connected to a mask over the nose and/or mouth—the positive pressure holding the airway open.
Other approaches to opening the airway involve dental devices to reposition the jaw and tongue, or sometimes surgery to clear soft tissue obstruction. There is also a cutting-edge treatment with an implanted device called Inspire, that stimulates the hypoglossal nerve causing the tongue to push forwarded and open the airway.
Underdiagnosed
JG’s OSA was discovered because of his heart issues—not so unexpected perhaps, judging by a paper in the Texas Heart Institute Journal that says “OSA is 2–3 times more common in cardiac disease.” But also, worryingly, “the degree of under-diagnosis of OSA—hence of under treatment—remains high even in cardiac patients.”
He is a member of the Coffee Klatch I wrote about last month (how several have had atrial fibrillation) and of them, several were apparently precipitated by sleep apnea. Incidentally, I’m grateful to my chums for letting me capitalize on their maladies, and glad JG got diagnosed in time.
It just makes me wonder how many others are out there with OSA, but who have not been diagnosed.
