Goal: The goal of this program is to
familiarize nurses with the risks, symptoms and treatments of sleep
apnea.
A warm summer day, sweltering conference room
and the speaker's monotone voice soothed Sally MacBride into an
unplanned nap. Juggling a career and familial obligations left her so
tired she would awake from a full night's sleep feeling fatigued,
although her husband would say she had snored straight through. As Sally
jerked awake, desperate for a good night's sleep, she decided a trip to
her doctor was most definitely in order.
Sleep -- The Pathway to Health
Sleep is a natural, active and organized
periodic state of rest, during which a consciousness of the world is
suspended. Regulated by the brain, the timing of sleep by the biological
(Circadian) clock and its restorative properties are an important
component of the health/illness continuum. The biological clock is found
in a small part of the brain located just above the nerves that leave
the back of the eyes. Influenced by light, it times the sleep-wake
period and runs on a 24 hour cycle. In addition to regulating sleep
patterns, the Circadian clock regulates the day-night activities of
certain bodily functions by lowering blood pressure and kidney function
during sleep, secreting necessary hormones and consolidating memory.
Disruptions in the internal clock can be caused by jet lag, shift work
or a disrupted sleep cycle.
The act of sleep follows a predictable pattern
that repeats itself approximately every 90 minutes. This pattern
alternates between two stages: NREM (non-rapid eye movement) and REM
(rapid eye movement).1 In adults, NREM sleep occupies
80 percent of the sleep cycle, while REM sleep occurs during the other
20 percent of the night.2 Dreaming takes place during
REM sleep, during which time the day's information and events are
processed. NREM sleep is the period of time when many of the restorative
functions of sleep occur. Sleep that is repeatedly interrupted, or
people who do not cycle through the phases of sleep normally, are
fatigued when awake and can display decreased levels of concentration.
Long-term sleep deprivation can lead to cardiovascular disease, the
development of diabetes, stroke, hypertension and premature
death.3
Sleep disorders manifest in several different
ways and run a large gamut that includes insomnia, snoring, narcolepsy,
restless leg syndrome, nightmares and sleepwalking. Insomnia, a deficit
of sleep at night, can be caused by stress, anxiety, poor sleep habits,
disruptions of the body's internal clock such as jet lag and by some
medications. It manifests in daytime fatigue and attention deficits.
Narcolepsy is a nerve/brain disorder that causes excessive daytime
sleepiness. Nightmares arise during REM sleep and can be caused by
stress, anxiety and some drugs. Conversely, sleepwalking occurs during
NREM sleep, during which time the sleepwalker can perform an extensive
range of activities while remaining asleep. A common problem among
middle-aged and older adults, restless leg syndrome occurs when
discomfort in the legs and feet generates the urge to move the legs and
feet in order to obtain pain relief, causing a disruption in the sleep
cycle.
A wide range of factors can contribute to sleep
disruption and include coffee, cigarettes, alcohol, certain medications,
depression and anxiety. Additional risk factors include heredity,
vitamin deficiencies, some nerve disorders, kidney failure, pregnancy
and fever.
Snore and You Snore Alone
Snoring is not sexy. Just ask any person with a
spouse who snores. Neither is it healthy. It can occur for any number of
reasons, from the common cold to sleep apnea. Caused by the soft palate,
uvula, or both, vibrating against the back of the throat or the base of
the tongue during sleep, it is a sign that the breathing passage is
blocked. This results in abnormal breathing, which can either be
extremely loud or very soft, the intensity of which is dependent upon
the amount of air that is passing through the breathing passage and the
speed at which the throat is vibrating. More prevalent in those people
who are either obese or have a large neck circumference, it is a
phenomenon seen more frequently in those individuals who drink alcohol
and smoke cigarettes.
Asleep Or Not Asleep -- That Is The Question
"Apnea" is a Greek word meaning
"without breath".4 Sleep apnea is a
dysfunction of the sleep process that is characterized by brief
interruptions of breathing during sleep. The soft tissue at the rear of
the throat collapses and closes the airway, causing breathing to cease
for a short period of time. This can occur as frequently as 400 times
per night, for at least 10 to 30 seconds at a time.5
It is characterized by periods of complete breathing cessation (apnea)
and periods of reduced breathing (hypopnea). Consequently, sleep is
extremely fragmented and of poor quality. The American Academy of Sleep
Medicine (AASM) rates the number of apneic events per hour as the
respiratory distress index (RDI), also known as the apnea/hypopnea index
(AHI).6 Whereas a level of 0 to 5 is considered within
a normal range, any number over 40 is considered severe. In order for
one of these events to be considered a period of apnea, it must occur
for a period of time that is at least 10 seconds in duration.
During an apneic event, normal breathing
processes are impaired, and the person is unable to breathe in oxygen or
to exhale carbon dioxide. The reduction in oxygen and increase in carbon
dioxide alerts the brain to a dangerous situation, and an emergency
alert is sent from the brain to the upper airway to resume breathing,
often accomplished with a loud snort or gasp. Frequent arousals,
although necessary to sustain life, are prohibitive factors for sleep
that is adequate enough in length and depth to provide restorative
benefits.
The three types of sleep apnea are obstructive,
central and mixed, which is a combination of the two. Obstructive sleep
apnea, its most common manifestation, is characterized by repetitive
pauses in breathing during sleep. This is caused by a blockage of the
trachea from either the tongue, tonsils, uvula, a large amount of fatty
tissue in the neck, or by relaxed throat muscles, which causes a
blockage of the airway and thus a cessation of breathing. Central sleep
apnea, a rare form of sleep apnea, occurs not because the airway is
blocked, but because the brain does not signal the muscles to breathe.
It is a neurological condition that causes cessation of all respiratory
function during the period of sleep. Arousal from sleep is triggered by
an automatic breathing reflex, thereby allowing little rest and leading
to daytime fatigue and drowsiness. Mixed apnea is a combination of both
obstructive sleep apnea, which is a physical blockage, and central sleep
apnea, a neurological disorder.
Sleep -- As Perverse As Human Nature
Sleep apnea affects more than 12 million
Americans per year according to the National Institute of
Health.7 Unfortunately, almost 10 million of the
people who are affected remain undiagnosed, which means that
approximately 90 percent of all those who are affected remain
untreated.8 Although sleep apnea can affect both sexes
and people of ideal weight, the most typical person is an overweight
male who is over the age of 40. Affecting approximately 4 percent of all
adult men and 2 percent of all adult women, it is characterized by loud
snoring at night and excessive sleepiness during the
daytime.9 If untreated it can have implications that
range from the simply irritating to the life-threatening. The
consequences of sleep apnea include hypertension, stroke, learning and
memory disorders, weight gain, depression, irritability, impotence,
headaches and cardiovascular disorders.10
Untreated, sleep apnea can also be responsible
for poor job performance and motor vehicle accidents due to impaired
cognitive ability and high levels of fatigue. The sleep deprivation
caused by sleep apnea leads to decreased productivity, increased
healthcare costs and an overall increased risk of both accidents and
injuries. Consequences increase over time, in pace with the severity of
the symptoms. Untreated, sleep apnea will progressively worsen,
ultimately causing either complete disability or death.
Obesity, a family history of sleep apnea,
smoking, alcohol use and structural abnormalities of the upper airway
can also contribute to the emergence of sleep apnea. Most commonly, it
is seen among the African-American, Pacific Islander and Mexican
populations.11
The 12 Hours of the Day and the 24 Hours of
the Night
Sleep disorders are difficult to diagnose, since
they can be caused by many different factors, and the affected person is
usually unaware that a problem exists. Often, family members or friends
are the first people to suspect that something is wrong. A spouse may
notice heavy snoring and difficulty breathing. Coworkers might notice a
lack of attentiveness and extreme states of fatigue. At this point, it
is important for a physician to evaluate the sleep patterns and
disturbances that are manifesting.
Several tests are available to evaluate and
confirm a diagnosis of sleep apnea. They can be conducted either at home
or at a sleep center. Wherever the sleep analysis is performed, however,
a full night's study must be monitored and evaluated.
Polysomnography records a variety of bodily
functions during the body's time of sleep. Most sleep centers monitor 16
different parameters, which include the electrical activity of the
brain, eye movements, muscle activity, heart rate, respiratory effort,
air flow and blood oxygen levels. An analysis of these test results can
confirm a diagnosis of sleep apnea and determine its severity. Once a
diagnosis of sleep apnea has been ascertained via polysomnography, a
titration study will be performed in order to tailor the treatment to
each patient's individual requirements.
Another test that is performed is the multiple
sleep latency test (MSLT), which measures the speed at which a person
falls asleep. This test is primarily utilized to analyze the sleep
patterns of those people who fall asleep during the middle of the day.
Each time a person falls asleep when he should normally be awake, the
time period is measured and recorded. People who fall asleep in under
five minutes require medical intervention to stay awake. It is a useful
test with which to evaluate extremes of daytime sleepiness.
Bed -- Heaven On Earth to the Weary Head
Treatment for sleep apnea is individualized for
each patient and is based upon medical history, a physical exam and the
results of a polysomnography and titration study. Medications as well as
oxygen supplementation devices are not an effective tool in the
treatment of sleep apnea. Positive results can be achieved by lifestyle
changes, the use of oral appliances and nasal devices and, for some,
surgical intervention. Although lifestyle changes and medical
interventions can alleviate and sometimes eliminate the symptoms of
sleep apnea, there is no cure at this time, and no quick or easy
solution to either the treatment or elimination of sleep apnea in any of
its forms.
The most effective treatment for obstructive
sleep apnea is to deliver air under pressure to the airway, via a mask
that is placed over the nose during sleep. Although not a cure for sleep
apnea, continuous positive air pressure (CPAP) is a non-invasive method
for improving the quality of sleep that dramatically improves daytime
functioning and overall health and well-being. There are several
different devices that can be employed to deliver the positive airway
pressure required, all programmed to perform the same function in
slightly varied ways.
Nasal CPAP is the sleep apnea treatment method
that is the most effective and most commonly in use. CPAP flow
generators deliver a constant and controlled pressure to the upper
airway, so that normal breathing is maintained. The units are reliable,
quiet, efficient, come in a variety of shapes and sizes and are
effective in 95 percent of patients with sleep apnea who use
them.12 A small and comfortable mask is fit over the
nose, leaving the mouth uncovered. A chin strap is snapped into place,
since the mouth must be closed for the machine to function adequately,
while air under pressure is forced through the nasal passages. The
constant and continuous air pressure delivered is individually adjusted
so that it is at just the right pressure to prevent the patient's throat
from closing off during the period of sleep and is set at a slightly
higher pressure than the surrounding air. The pressure acts in the same
way as a splint, holding the airway open and maintaining a patent airway
during sleep.
Although periods of sleep apnea are prevented
while this device is in use, if it is stopped or not used, or if used
improperly, the sleep apnea will return. There is a quick dramatic
increase in daytime alertness and energy for people who have used a CPAP
for even a short period of time.
Variations of the CPAP, such as the bi-level
positive airway pressure devices, and the "smart" airway
pressure devices, attempt to minimize some of the side effects that
sometimes occur, and thus cause lack of use and non-compliance with the
treatment regimes. These effects include such side effects as nasal
irritation and drying, facial skin irritation, abdominal bloating, mask
leaks, sore eyes and headaches. Utilizing the basic belief that a
reduction of total airflow would provide greater patient comfort and
thereby increase compliance with its use, these newer devices vary the
pressure delivered, providing less when it is not required, raising the
pressure when an apneic episode appears.
Many people are intolerant of the CPAP in any
variation. Careful teaching is an important step toward compliance in
this regard. Many find the mask uncomfortable because it hasn't been
adjusted properly. Air leaks can be closed without adjusting the straps
to prohibitively painful levels. The hose can be loosely positioned on a
pillow to prevent excessive pulling during sleep. "Nasal
pillows" are noseplugs that can be used with the CPAP in place of a
mask. This is a less bulky option for patients who are totally
intolerant of wearing a mask to sleep. Air leaks do not occur as often
when nasal pillows are used. In addition to the nasal masks and pillows,
air flow can also be introduced into the airway via a nasal seal. Seals
fit against the opening of the nostrils and are held in place by a frame
attached to the headgear. Experimentation, patience and persistence are
the best teachers in this regard.
Behavioral and lifestyle changes are an
imperative part of the treatment of sleep apnea. Certain mild cases may
not require any additional interventions. Lifestyle changes should
include eliminating alcohol, especially in the hours before sleep, since
it relaxes the muscles in the back of the throat, making breathing more
difficult. Sleeping on the side with a pillow also helps in alleviating
airway obstruction.
Abstinence from cigarettes, which is associated
with nasal congestion, can also alleviate apneic effects. Allergies and
respiratory infections also can cause enough nasal congestion to narrow
the airway and contribute to apnea. When treating this or any other
disorder, take medications that do not interfere with sleep. Weight loss
will also alleviate apneic events, as it will reduce the fat deposits
that are in the throat, thereby providing a more spacious airway. A 10
percent weight loss can be enough to decrease the number of apneic
events for many patients.13
Many medications will interfere with either the
breathing reflex, sleep, or both. The most common offenders are sleeping
pills, tranquilizers and short-acting beta blockers.14
Patients should be encouraged to consult their physicians for
alternative medications.
Tongue-restraining devices are helpful for those
people who become apneic only while sleeping on their back and whose
tongue is the main source of obstruction. It acts as a suction device
that sucks the tongue forward, thereby opening the airway behind the
tongue and is made for the patient by either his dentist or an
orthodontist.
Lifestyle and behavioral changes or the use of a
CPAP may not always be enough for some patients, who may need surgery to
increase the size of their airways. However, this is no easy fix.
Several procedures might have to be performed before the patient
receives any positive results from the surgery, and none of them are
totally without risk. Surgical costs and success rates may vary greatly
dependent upon the procedure chosen and the skill of the surgeon.
The most common surgeries include removal of the
tonsils and adenoids, nasal polyps or other growths in the area of the
airway and/or the surgical correction of structural deformities. The
younger the age of the patient, the more they seem to benefit from these
surgical interventions.
Uvulopalatopharyngoplasty (UPPP) is a procedure
that removes any excess tissue that might be at the back of the throat.
This tissue is inclusive of the tonsils, uvula and a portion of the soft
palate. A surgery that is very specifically cause-directed, if
unsuccessful, can impede the effects of alternative treatment options in
the future.15
Laser-assisted uvulopalatoplasty (LAUP) uses a
laser to remove the excess tissue at the back of the throat. A procedure
utilized to alleviate snoring, a primary symptom of sleep apnea, it does
not eliminate the sleep apnea itself. Somnoplasty uses radiowaves to
reduce the size of airway structures such as the uvula and the back of
the tongue.
An extreme measure that is rarely used except in
the most severe forms of life-threatening sleep apnea, and the only
treatment that was available until the early 1980s, is the creation of a
surgically produced tracheostomy that is utilized only at times of
sleep. A small hole, closed during the patient's waking hours, is made
in the patient's trachea. At night, to sleep, a tube is inserted into
the opening, so that air flows directly into the lungs, bypassing all of
the upper airway obstructions.
Other surgical interventions that might benefit
the patient with sleep apnea include correction of deformities of the
upper jaw, as well as surgical interventions for those patients who are
suffering from sleep apnea that is in combination with morbid obesity.
A Good Laugh and A Good Sleep -- The Best
Cures
Patients experiencing sleepiness during the day,
loud snoring at night, pauses in breathing during sleep, or any
disturbances in sleep type or patterns should seek the intervention of a
physician. Sleep disorders are real and easily diagnosed at a sleep
center. More importantly, sleep disorders are treatable, which can make
a big difference in the quality and quantity of the balance of a
person's life.
Cathy S. Birn, RN, MA, BSN, CGRN, CNOR, has
been an endoscopy nurse for 15 years.
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