ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Tuesday, May 7, 1996 TAG: 9605070091
SECTION: EXTRA PAGE: 1 EDITION: METRO
COLUMN: Personal Health
SOURCE: JANE BRODY
For some 20 million Americans with obstructive sleep apnea, sleep is a nightly struggle with a function that is fully automatic for most people: breathing.
While asleep, their ability to inhale becomes blocked for a brief time - for 10 seconds to a minute or more - until they arouse enough to gulp in air with a snort that can rattle the windows. Then they immediately fall back into a sound sleep and the cycle starts over, often repeating itself hundreds of times a night.
The condition robs people of vitality, good humor, energy, concentration, memory and the ability to stay awake and alert during the day, especially during sedentary activities like reading and driving. Most importantly, sleep apnea can rob people of their physical and mental health and even their lives.
Yet, an estimated 80 percent of those affected by sleep apnea do not know it. Many are unaware of how loudly they snore, or they think that their snoring is a normal condition others must learn to live with.
Many spouses simply endure the nightly serenades, not realizing that the sleep-shattering snores are symptoms of a serious and potentially fatal disorder that can and should be treated. Even among those who now know they have sleep apnea, many waited a decade or more to find out why they repeatedly fell asleep at the wheel, dozed off at stoplights and never felt rested.
Obstructive sleep apnea results from a sleep-induced relaxation of the muscles in the back of the mouth and throat that causes the main airway to collapse, totally blocking the ability to inhale. As blood levels of carbon dioxide rise and oxygen levels fall, the hapless sleeper struggles to take a breath.
Finally, a partial arousal restores enough muscle tone to open the airway briefly and allow a breath, which becomes a loud snore. After sleep resumes, breathing stops again and again and again. The dazed sleeper is usually unaware of these awakenings and the scores or hundreds of times a night that sleep is disrupted.
Sleep apnea afflicts two to three times as many men as women, and the condition becomes more common with age, although children are sometimes affected.
The condition seems to run in families, according to a study by Dr. Susan Redline, a pulmonary specialist at Case Western Reserve University in Cleveland. A tendency toward sleep apnea could be due to an underlying genetic susceptibility or could result from a familial weight problem.
About two-thirds of those with the condition are obese, and excessive fatty tissue in the neck is believed to help cause airway obstruction. When such people lose a significant amount of weight, their problems with sleep apnea often disappear or become greatly reduced.
As with ordinary snoring, which results from a partial airway obstruction during sleep, various abnormalities in the mouth and throat can also cause a total obstruction and sleep apnea. But unlike the ordinary snoring that accompanies rhythmic breathing, sleep apnea, with its breathing disruptions, is a dangerous condition that can cause high blood pressure, abnormal heart rhythms, heart attacks, strokes and sudden death.
Because oxygen levels in the blood fall below normal, brain function is likely to be adversely affected, impairing memory, concentration, reaction time, job efficiency and judgment.
One study of 64 people in Virginia showed that patients with sleep apnea had seven times more automobile accidents than other people; one-quarter of the patients said they fell asleep at the wheel at least once a week.
As if such physical problems were not enough, pulmonary specialists at the Mount Sinai Medical Center in New York report that the symptoms of sleep apnea can also mimic those of depression: fatigue, cognitive impairment, decreased libido and sleep disruption.
An accurate diagnosis of sleep apnea usually requires spending a night in a sleep laboratory, which can be costly or difficult to arrange.
Although the likely presence of the problem can be detected through nap studies or various screening devices, such as snore meters or gadgets worn at home overnight on the wrist or ear, a complete monitoring of sleep stages, breathing patterns, limb movements, heart function and blood levels of oxygen and carbon dioxide during sleep is usually needed to determine an appropriate treatment and assess its effectiveness. The results should be interpreted by an expert.
When sleep apnea is mild, an expert committee of the National Heart, Lung and Blood Institute recently concluded, adequate therapy may consist of behavioral treatments, like losing weight and exercising regularly, refraining from alcohol and sedatives before bedtime, and avoiding sleeping on one's back.
For more serious cases, the use of a nighttime breathing device is often necessary in addition to behavioral treatments. The device consists of a mask that is placed over the nose and mouth during sleep; the mask is connected to a blower that forces air through the nasal passages and keeps the airway open.
This therapy, called continuous positive airway pressure, or CPAP, has been shown to eliminate daytime sleepiness and cardiopulmonary problems.
Used properly, after about a week the therapy ``produces rhythmic breathing and helps the patient feel dramatically better and function more efficiently,'' the expert committee reported in the January issue of the American Family Physician.
Unfortunately, not all patients can tolerate CPAP. Even among those who can, its use is often not consistent. Common side effects include nasal stuffiness, a runny nose and facial discomfort resulting from the pressure.
However, this therapy represents a vast improvement over the original ``cure'' for sleep apnea: tracheostomy, the surgical creation of a breathing hole in the throat to bypass the sleep-related obstruction.
Those who cannot use CPAP may benefit from the use of an individually molded oral appliance that repositions mouth structures during sleep. However, surgery to reduce the size of soft tissues in the mouth and throat may only relieve the snoring and not the apnea.
Whatever the remedy chosen, the single most important step is a repeat of the original sleep study to determine the effectiveness of the remedy, not just in reducing snoring but in restoring normal breathing patterns, heart function and levels of blood gases.
The committee also recommends periodic assessments because patients commonly relapse into old habits or stop using the breathing device.
HELP FOR PROBLEM SLEEPERS
A free patient information publication, ``Facts About Sleep Apnea,'' (publication No. 95-3798), is available from the National Heart, Lung and Blood Institute Information Center, P.O. Box 30105, Bethesda, Md. 20824-0105, or by calling (301) 251-1222 or faxing a request to (301) 251-1223.
The American Sleep Apnea Association at 2025 Pennsylvania Ave. N.W., Suite 905, Washington, D.C. 20006, (202) 293-3650), publishes a bimonthly newsletter, Wake-Up Call, the Wellness Letter for Snoring and Apnea, produces patient education videos and maintains a list of patient self-help groups that meet in communities throughout the country. Individuals who join the association for $25 a year will receive the newsletter and a MedicAlert bracelet or necklace.
There is also a useful paperback book, ``Snoring and Sleep Apnea'' by Dr. Ralph A. Pascualy and Sally Warren Soest (Raven Press, 1994, $19). Check your library since the book is out of print. Although the publication was partly underwritten by a manufacturer of the CPAP device, it discusses all remedies fairly.
``Snoring from A to Zzzz: Proven Cures for the Night's Worst Nuisance,'' by Dr. Derek S. Lipman, an otolaryngologist in Portland, Ore. (Spencer Press, $24.95); it is being distributed by Book World Services.
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