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Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome is defined as repetitive episodes of upper airway obstruction and the cessation of airflow that occurs during sleep and is usually associated with a reduction in blood oxygen saturation. Snoring is one of the cardinal signs of obstructive sleep apnea syndrome.  Produced by the vibration of soft tissues in the upper airway, snoring varies in intensity and quality, depending on the time of night, the stage of sleep, body position, airflow rate, and the anatomical structure of the individual’s nose and throat. Once thought to be a benign occurrence, snoring alone may lead to hypertension due to partial airway obstruction and nocturnal hypoventilation.  

Patients with obstructive sleep apnea syndrome are typically described as restless sleepers, and their movements during sleep may be violent. Characteristic snoring, consisting of loud snorts alternating with periods of silence, is almost always present. Movements, moans, or gasps typically occur at the end of an episode of apnea. The numerous arousals caused by repetitive apneas result in fragmented sleep, which can lead in turn to excessive daytime sleepiness, a common symptom of sleep apnea.  

Few patients are aware of their nighttime respiratory difficulties. Frequently, the presenting complaints are of nonrefreshing sleep, frequent urination during the night, daytime sleepiness, daytime napping, and morning headaches. Morning headaches lasting up to 1–2 hours and sleepiness during quiet activities are common, although sometimes the sleepiness is not recognized or admitted. Severe sleepiness may occur, even during activities such as talking, eating, or driving. Daytime naps are typically not refreshing, regardless of length. Depression, irritability, and impotence may also be present.   

 

All of these symptoms are suggestive of sleep apnea. Cessation of breathing, as well as cyanosis with prolonged apnea, may be observed by the bed partner. Some patients, however, are aware of their sleep disruption (but not the cause) and complain of insomnia and nonrestorative sleep. The severity of symptoms typically increases with weight gain or the consumption of alcohol or sedative medication.  

An obstructive apneic event occurs when airflow ceases due to a total obstruction of the airway during sleep. Typically the jaw and tongue fall back and the muscles relax at the back of the throat. There may be progressive narrowing of the air passage with each breath, until a complete blockage occurs. Respiratory effort usually persists or increases until an arousal occurs to reestablish airway patency. Typically, repetitive dips in oxygen saturation levels occur in conjunction with the apneas, particularly in people who have underlying lung disease.  

Obstructive sleep apnea syndrome is associated with higher risk of irregular heartbeat, high blood pressure, stroke, and heart attack. Hypertension and cardiac arrhythmias during sleep are also common in these patients. Arrhythmias range from sinus arrhythmia to premature ventricular contractions (PVCs) and sinus arrest. Bradycardia (a decreased heart rate) and tachycardia (an increased heart rate) are most commonly seen in association with apnea accompanied by blood oxygen desaturation. Bradycardia occurs during the apneic episode, while tachycardia occurs when breathing resumes. Prolonged hypoxemia (a decreased blood oxygen level) in patients with underlying chronic obstructive pulmonary disease (COPD) or alveolar hypoventilation may lead to pulmonary hypertension and right-sided heart failure.  

Obstructive sleep apnea syndrome occurs more often in patients who are male, obese, and elderly, but it may occur in patients who have none of those risk factors. Morbid obesity (a body weight of 100 pounds or more over ideal body weight) is not the rule in these patients. An individual whose weight is as little as 20–25 pounds above ideal body weight may experience obstructive sleep apnea.

Some patients are not overweight but may have nasopharyngeal abnormalities, craniofacial abnormalities, or neurological abnormalities resulting in obstructive sleep apnea. Anatomic factors, such as a small jaw (micrognathia), a large tongue (macroglossia), and a large neck circumference, also increase the risk of obstructive sleep apnea. Obstructive sleep apnea syndrome can also be associated with medical disorders such as acromegaly (a disease characterized by marked elongation and enlargement of the bones of the extremities and the head), hypothyroidism, or enlarged tonsils. Apnea may occur or worsen with age or weight gain. Obstructive sleep apnea patients are usually advised to reduce their weight, and also to avoid sedatives or hypnotic drugs and alcohol, especially at bedtime.  

Symptoms of obstructive sleep apnea syndrome in children include hyperactivity, learning difficulties, restless sleep, and unusual sleeping positions. These symptoms are much more common in children than excessive daytime sleepiness. Snoring is usually loud and continuous. Nocturnal enuresis, daytime mouth breathing, difficulty swallowing, and speech difficulty are also common. In children, enlarged tonsils and adenoids are the most common cause of obstruction.