When apnea occurs, the brain moves from stage 4 or REM to a lighter stage in order to regain breathing. This decreases the amount of hours in the two most important stages of sleep, which leads to several problems, such as difficulty remembering things, difficulties paying attention, sleepiness during the day, among others.
Types and causes of sleep apnea
There are three types of sleep apnea: obstructive, central and mixed, which is a mixture of the first two. To understand each of them, it is necessary to have a certain notion of their causes. Understand:
Obstructive sleep apnea (OSA)
When we sleep, the muscles in the throat and tongue relax, taking up more space inside the neck. In some people, this relaxation is so intense that it can end up blocking the airways totally or partially. This blockage usually gives rise to snoring.
This obstruction is not always caused by the relaxation of the muscles. Often, anatomical differences such as airway size, large tongue, changes in the shape of the head and neck (which can be very wide), sunken chin, deviated nasal septum, large tonsils and adenoids, and even obesity, can be the cause. cause of apnea.
In some cases of infections such as colds and flu, when there is more mucus production and nasal congestion, obstructive apnea can occur temporarily and usually resolves when the individual improves the infection. The same occurs with allergic reactions such as rhinitis and sinusitis .
It is the most frequent type of apnea, accounting for about 80% of cases.
Central sleep apnea (CHA)
This type of apnea occurs due to a failure in communication between the brain and the airways. In these cases, the muscles responsible for breathing do not receive the signal that they must work and, therefore, remain static. What happens, then, is not an interruption of breathing, but the airways that do not even try to breathe , because they do not receive the command to do so.
It is usually caused by neurological diseases, such as Alzheimer’s disease, Parkinson’s, amyotrophic lateral sclerosis, in addition to brain damage such as caused by encephalitis , stroke, injuries, among others. This type is also linked to cardiovascular problems, hypothyroidism and kidney failure.
In some cases, doctors are not able to discover the source of the condition. In these situations, it is called Central Idiopathic Apnea .
Mixed sleep apnea
It is a mixture of the two types of apnea mentioned above. Sometimes, when treating obstructive apnea, the central is discovered, often without clearly knowing the reasons.
We know the causes associated with apnea, but there are also risk factors that contribute to it being more frequent, although in some cases it is not known exactly why.
Some risk factors apply to any type of sleep apnea. Understand:
- Being a man: Sleep apnea is 2 times more frequent in men;
- Age: Although the condition can manifest at any age, it is more common from the age of 40;
- High blood pressure : About half of people who have apnea also suffer from high blood pressure;
- Alcohol: Consuming alcoholic beverages before bedtime worsens apnea;
- Family history: Obstructive sleep apnea syndrome is more common in people who have a family history of the disease. This may be due to anatomical differences that are passed on by genes.
Sleep apnea is also related to cases of metabolic syndrome and diabetes .
- Obesity: Due to the higher concentration of soft tissue in the neck, which weighs during sleep, obstructing the passage of air;
- Small children: Due to the larger size of the palatine and pharyngeal tonsils (better known as tonsils and adenoids), which can cause airway obstruction;
- Having a wide neck: People with a wide neck (greater than 42.5 cm in men and 37.5 cm in women) are more likely to develop sleep apnea;
- Differences in the anatomical structure of the neck: Some people may have thinner airways, for example, which makes the air flow smaller than normal, making breathing worse during sleep;
- Cigarette: Smoking increases the chances of having any type of airway obstruction;
- Menopause: Changes in hormones during menopause can cause the throat muscles to relax more than normal;
- Nasal congestion: Congestion of the upper airways can stop breathing during sleep;
- Use of sedatives and sleeping medications: These medications help to relax the muscles, causing a blockage in the throat.
- Spinal problems: Arthritis, surgeries or radiation treatments in the spinal region can increase the risk of central apnea, due to the fact that it is close to the spinal cord (mass of nerves that descends from the brain to the lumbar region, responsible for communication between the brain and the rest of the body);
- Use of narcotics: Opioid analgesics such as codeine, morphine and methadone increase the risk of central apnea;
- Heart problems: People with heart failure are more likely to suffer from apnea;
- Stroke: People who have suffered a stroke (stroke) may have damaged the parts of the brain responsible for the respiratory reflex, which causes respiratory arrest at night;
- Premature birth: In premature newborns, the cerebral respiratory center is not fully formed, which can cause loss of the respiratory reflex. This condition usually passes as the baby develops, but there are cases where the baby simply does not resume breathing.
Severity of sleep apnea
The respiratory disturbance index is the name for the number of episodes of apnea or hypopnea per hour during sleep, which determines its severity. In order to be diagnosed with sleep apnea, this index must be greater than or equal to 5. However, most patients with index 20 have no symptoms.
The severity of sleep apnea can be classified as follows:
- Less than 5 breaks per hour: Normal;
- From 6 to 15 breaks per hour: Take;
- From 16 to 30 breaks per hour: Moderate;
- More than 30 breaks per hour: Severa.
Symptoms of sleep apnea
Often, the individual himself does not know that he suffers from apnea, because the awakening of the brain is very subtle, without regaining total consciousness. In these cases, it is the bed partner who perceives the disease, as the person usually snores very loudly and makes sounds as if he were choking or suffocating while sleeping, symptoms that are more common in obstructive apnea.
Sometimes, when these symptoms are not present (which is more recurrent in central apnea), the individual will only know that something is wrong when analyzing some symptoms that are reflected in daily life, such as the feeling of not having rested during the night. .
Some symptoms that can be felt by the patient himself are:
- Excessive sleep during the day (hypersomnia);
- Headache upon awakening;
- Waking up with a dry mouth or a sore throat;
- Difficulty remembering some information (loss of recent memory);
- Difficulty concentrating;
- Waking up abruptly at night with shortness of breath (more common in cases of central apnea);
- Loss of sexual interest;
- Waking up many times during the night to urinate (nocturia).
In children and infants
Often, children do not know how to express their feelings very well. Therefore, parents should pay attention to the following signs:
- Pause in breathing while sleeping, with snoring and choking noises;
- Sleep in weird positions, different from normal;
- Peeing in bed frequently, in the case of children who have already learned to control their bladder during the night;
- Sweating too much at night;
- Waking up in the middle of the night with feelings of fear, fast heart rate, confusion, with the possibility of screaming or not – a condition called night terror;
- Demonstrate drowsiness during the day;
- Develop behavior problems and lower grades;
- Nasal voice (fanha).
When you notice these symptoms, it is important to take your child to a pediatrician who specializes in sleep disorders. This is because such a condition affects the quality of sleep, which reflects on the child’s learning ability, mood, growth and general development.
In babies, the signs are more subtle, since several of these behaviors are normal for their age (peeing in the diaper, for example) and others are difficult to perceive (such as the nasal voice). The mother must be attentive to the baby’s breathing while he sleeps, looking for signs of respiratory arrest, such as suffocation noises.
Read more: What are the causes and symptoms of sleep paralysis?
Is it snoring or apnea?
Not everyone who snores has apnea, nor does everyone who suffers from apnea produce snoring. To find out what it is about, you can:
Observe your symptoms during the day
Normal snoring does not usually interfere with sleep quality as much as apnea, as it does not usually wake the individual. If you do not suffer from extreme fatigue and drowsiness during the day, it is probably not apnea.
Ask someone to watch your snoring
When you have sleep apnea, snoring is extremely loud and usually comes with pauses, in addition to sounds like suffocation or trying to catch your breath. Asking someone to observe and note the abnormalities in your snoring can help you get a sense of whether it is just normal snoring or if it is something more serious.
An alternative is to record yourself while sleeping. This recording can be taken to the doctor if apnea is suspected.
When to visit a doctor?
Although snoring may be normal in some people, it is necessary to visit the doctor when any sleep disturbance is suspected, especially when the snoring is loud and pauses – a time when the person is probably not breathing.
You should also go to the doctor when you notice other symptoms related to lack of sleep, such as excessive daytime sleepiness, irritability and difficulty concentrating, which can be caused by a variety of sleep disorders.
Some symptoms can be caused by other conditions, so it is important that you make it clear that you suspect problems while sleeping, don’t be ashamed and talk about all the symptoms – including snoring, if applicable.
How is sleep apnea diagnosed?
To have a diagnosis of sleep apnea, the patient must visit a sleep doctor , who will recommend a sleep study or polysomnography . However, the patient is not always able to perform this test and, therefore, there are other, simpler tests that help the diagnosis. Understand:
This exam consists of measuring several variables during the patient’s sleep and, therefore, he must spend the night in the hospital.
It is performed with electrodes (sensors):
- In the chest, to assess cardiac activity;
- Near the eyelids, to identify REM sleep;
- In the head, in order to measure brain waves;
- In the legs, to assess muscle tone (check if the muscles are relaxed).
Other devices used are:
- Strips around the trunk, in order to assess the movement of the chest and abdomen (respiratory effort);
- A nasal cannula, to monitor breathing;
- An oximeter on your finger, to measure blood oxygen levels.
All of this is recorded and analyzed in order to check for the presence of sleep apnea or any other disorder that may be causing the symptoms. Other doctors who can do the analysis of the results are neurologist , cardiologist and pulmonologist .
Mini sleep study
A similar way of making the diagnosis is the mini sleep study, which can be done at home, using a device that measures the patient’s breathing, oxygen levels in the blood and pulse.
An expert shows the patient how to apply the sensors and monitors, explaining how to use the recording device. On the day of the study, the individual must follow his normal routine, put on the device and go to sleep normally. Upon waking up, you must take the device back to the laboratory, clinic or hospital.
If central apnea is suspected, an MRI scan may be ordered. This test uses radio waves to create detailed images of internal structures and can detect anomalies in the spinal cord.
These anomalies may be responsible for respiratory arrest, since it is from the spinal cord that the signal for the airways to perform their function comes.
Especially in children, a physical examination may be enough to diagnose sleep apnea, due to the possibility of large tonsils. In adults, the doctor can analyze the size of the uvula (the “bell”, “bell” or “throat” of the bottom of the mouth) and the soft palate (deeper portion of the roof of the mouth), which may be responsible for obstruction.
Medical and family history
In consultation with the doctor, it is likely that the doctor wants to know details such as the time when the patient goes to sleep, when he wakes up, how he feels when he wakes up, etc. He may also ask if the patient snores and how often. The patient is hardly aware of this alone and needs someone else (someone in the family, bed partner, among others) to say so.
If there is a family history of sleep apnea in the family, the doctor will give more importance to the possibility of sleep apnea, before trying to find another diagnosis.
Is sleep apnea curable? What is the treatment?
The possibility of curing sleep apnea will depend on its cause , since it is not uncommonly caused by some other condition. However, there are several treatment alternatives that can be of great help during the treatment of the other disease, depending on the severity of the syndrome.
To treat apnea, the patient can do a lot for himself. Some clinical measures are:
- Losing weight: If the patient suffers from apnea due to obesity, losing weight is one of the best treatment options;
- Regular exercise: In addition to assisting with weight loss, exercising regularly helps to strengthen the muscles, including the throat muscles (which causes obstructive apnea). For that, aerobic exercises and even yoga are recommended;
- Sleeping on your side: Sleeping with your belly up is the position that most eases airway obstruction. So sleeping on your side is a good alternative, although it is difficult to maintain your position all night;
- Quitting smoking: Patients who smoke should quit, not only because of apnea, but to ensure a better quality of life in general, since smoking is responsible for the development of several chronic diseases;
- Keep your nose decongested: Talk to your doctor about using nasal decongestants and other options to keep your air passages open, as some medications can be harmful in the long run;
- Raising the head of the bed: Leaving the head of the bed between 10 and 15 cm higher causes gravity to pull the relaxed muscles of the throat down at an angle that does not obstruct the passage of air;
- Singing or playing wind instruments: These two conditions help to strengthen the muscles of the throat and the soft palate, preventing excessive relaxation during sleep.
Some means of treating apnea are not related to the phenomenon itself, but to conditions that also need medical attention. Understand:
- Suspend the use of medications: Under medical guidance, suspend the use of medications that can cause apnea, such as tranquilizers, sleeping pills, opioids, among others;
- Speech therapy : In speech therapy, exercises can be done to strengthen the throat muscles, which prevents excessive relaxation from occurring;
- Treating otorhinolaryngological problems: Problems such as deviated nasal septum, nasal turbinate hypertrophy, allergies, polyps, tumors, adenotonsillar hypertrophy, among others, must be treated, as they can cause respiratory pauses during sleep.
Intraoral devices position the mandible further forward, avoiding obstructions, which allows air to pass through the throat. They are mainly used in cases of mild apnea and snoring, but they have limitations.
It is not recommended for people who have few teeth, wear large dental prostheses, suffer from severe periodontal problems or who have great difficulty keeping the device in their mouths.
People with TMJ disorder (temporomandibular joint, which articulates the mandible with the rest of the skull) should not use intraoral devices, as they can worsen the condition.
In very obese people, with severe apnea or with any degree of central apnea, the use of intraoral devices is not effective.
Continuous Airway Pressure Apparatus (CPAP)
CPAP ( Continuous Positive Airway Pressure ) is one of the most effective alternatives in cases of severe obstructive apnea. It consists of a high-tech air compressor device, which connects to a mask that covers the patient’s nose and mouth, and releases a continuous flow of air into the patient’s airways.
It is able to prevent airway obstruction during sleep, in addition to preserving the air intake in patients who are not doing the respiratory effort (central apnea). Therefore, CPAPs are indicated for all types of sleep apnea.
The device must be used with medical advice. It is necessary that the patient is evaluated to find out what the ideal pressure is, in order to adjust the equipment in an appropriate way, avoiding its incorrect use.
Although it looks uncomfortable, most patients adapt well to the device.
Another alternative is BiPAPs, which are similar to CPAP, but have two levels of pressure: one of inhalation and another of exhalation, so that there is more comfort when breathing out.
In some patients whose apnea has been attributed to anatomical differences, surgery may be indicated. Such procedures focus on correcting disorders that can cause breathing difficulties.
Some of these surgeries are:
- Septoplasty: Corrects the alignment of the septum in cases of deviation;
- Uvulopalatopharyngoplasty: It consists of the removal of the tonsils and the soft palate (the part where the “little bell” of the throat, also known as the “throat”), opening more space so that the air can pass;
- Maxillomandibular advancement: This procedure consists of moving the maxilla (upper) and mandible (lower) bones forward, freeing more space in the palate region (bottom of the mouth).
Sleep Apnea Medicines
There are no specific medications for sleep apnea and the treatment is mostly mechanical, that is, without the use of any type of chemistry.
However, in some cases of central apnea, the doctor may prescribe acetazolamide to stimulate the respiratory system.
Due to poor sleep quality, nighttime apnea complications go beyond tiredness . In the long run, sleepless nights increase the risk of developing a variety of illnesses. Know more:
Due to the drop in blood oxygen levels at night, it is common for the body to try to compensate in some way. Thus, many sleep apnea patients develop high blood pressure .
Moreover, when left untreated, sleep apnea increases the chance of recurrent heart attacks, cardiac arrhythmia , atrial fibrillation, sinus bradycardia, atrioventricular block, ventricular extrasystoles isolated and bigeminal, and myocardial acute infarction and cerebrovascular accident (CVA).
Type 2 diabetes
Compared to people without sleep disorders, individuals who suffer from apnea are more likely to develop insulin resistance, which is characteristic of type 2 diabetes.
This syndrome is, in fact, a combination of several risk factors linked to heart problems. These factors are mainly arterial hypertension, abnormal cholesterol, hyperglycemia and a larger waist circumference, usually caused by obesity.
People with sleep apnea tend to have more abnormalities in liver function tests, in addition to a greater propensity to have cirrhosis , even without excessive alcohol consumption.
Traffic accidents and work
With the drowsiness caused by sleepless nights, the chances of traffic and work accidents increase. Studies show that the chances of traffic accidents in patients with OSAHS are 2 to 3 times higher in relation to the world population.
Due to poor nights and little time in stages 4 and REM sleep, it is common for patients with sleep apnea to have cognitive disorders. Loss of recent memory, learning difficulties and attention deficit are common manifestations.
Can sleep apnea kill?
Unfortunately yes, sleep apnea can kill . This is due to the frequent episodes of hypoxemia (lack of oxygen in the blood), which takes little oxygen to the cells of the body. These episodes cause the heart to try to get around the situation, resulting in sudden death from irregular heartbeat.
Other problems during sleep
Some patients with sleep apnea are harassed during the night, too, by terrifying situations, such as nightmares, nocturnal paralysis and hallucinations. Understand:
They are dreams that evoke bad feelings like fear, despair, anxiety and sadness. Apnea patients may experience nightmares in which they are drowning, being suffocated, among others related to difficulty in breathing.
It occurs when the brain moves from REM sleep to the awake state very quickly, making the individual conscious, but unable to move due to the relaxed muscles, characteristic of deep sleep stages, which take a while to return to normal activity. .
During the episode, the person may feel pressure in the chest area, in addition to shortness of breath. Paralysis can occur without apnea, but frequent awakenings caused by the disorder can increase the chances of an episode.
They may present as a result of nocturnal paralysis. Due to an electrochemical exacerbation of the brain, it is common for people with nocturnal paralysis to see, hear or feel things during the episode. It is common for patients to describe some presence, which they are usually afraid of, that can be felt, seen and sometimes heard.
It differs from nocturnal paralysis in that it occurs during stage 4 of sleep, that is, the person does not actually wake up, and when he wakes up, he often does not remember what he saw or felt.
The person “wakes up” suddenly, screaming or moaning, with a fast heartbeat, and may experience restlessness, but does all of this while the brain is still asleep in stage 4.
Living with sleep apnea
After the start of treatment, living with sleep apnea is easier, since the quality of sleep improves and the patient has greater energy for the day to day. However, adapting to the continuous or intraoral pressure device can be a little difficult at first.
In such cases, the tip is to evaluate the options available and choose the one that best suits your needs. Look for a quiet device, preferably with the technology of adjusting the flow for a more natural exhalation, and a comfortable mask. In the case of intraoral appliances, the ideal is to talk to the dentist and discuss the options available.
It is extremely important that the patient tries to maintain the weight (or lose, if it is the case of obesity), having an adequate diet and practicing physical exercises. Smokers and people who usually consume alcoholic beverages should avoid these two activities, which worsen or prevent the improvement of the apnea picture.
Operated patients should follow medical recommendations regarding rest and diet.
Keeping doctor visits (check-ups) up to date is one of the best ways to prevent sleep apnea complications. Talking to a doctor about episodes that disturb sleep, such as night terrors and nightmares, can help find a solution for them – although it is expected that they will not occur during the treatment of apnea.
How to prevent sleep apnea?
There is no specific way to prevent sleep apnea beyond what has already been mentioned here: adequate food, maintaining a normal weight, avoiding smoking and consuming alcohol in excess, among others.
However, sleeping in the lateral decubitus position (on the side) greatly reduces the chances of having an obstruction apnea, since the weight of the throat tissue falls to the side and does not pressure the airways. Although it is not the ideal solution for everyone, it is a way to try to avoid an episode at night.