• Forty to fifty percent of those individuals diagnosed with congestive heart failure have a sleep disordered breathing problem. Effective treatment of this problem stopped 12,600 vascular events per year of men in the US.
  • Twelve million people have been diagnosed with the combination of sleep apnea, heart problems and sleep deprivation.

What is Sleep Apnea?

Sleep apnea refers to breathing that stops during sleep. Sleep apnea events can be followed by a de-saturation or lowering of oxygen levels or a respiratory micro-arousal (going to a lighter stage of sleep to become more alert especially if there is an oxygen problem). This is the human organism’s way of protecting itself it however results in sleep deprivation and poor sleep so characteristic of the presence of sleep apnea, to the degree that daytime sleepiness is just as significant as episodes of gasping or stopped breathing during sleep.

The definition of sleep apnea is stopped breathing for ten seconds followed by either a de-saturation and/or respiratory micro-arousal (with the potential to result in lighter stages of sleep and overall non-restorative sleep). The range is highly variable and individuals can have very long apneas lasting longer than 60 seconds or meet the criteria of ten seconds for adults. Hypopneas are baby apneas, with diagnostic criteria of ten seconds in duration followed by a de-saturation and/or respiratory arousal. The criteria to establish sleep apnea in children is one apnea event per hour.

Hallmark symptoms of possible Sleep Apnea:

  • Excessive daytime sleepiness
  • Hard to wake up in the morning
  • Finally awake several hours later and then tired again late morning
  • Loud snoring
  • Gasping or choking episodes during sleep
  • Drowsy when driving
  • Asleep the minute they sit down
  • Personality changes, increased anger, low frustration tolerance
  • Hyperactivity or overactivity in children
  • Thinking deficits related to memory and executive reasoning processes seen on neuropsychological evaluation

Alerting factors of possible UARS:

  • Mouth breathing
  • Bad breath
  • Unresolved respiratory conditions
  • Hyperactivity in children
  • A child or adult who has been sleeping on his side for a long time
  • A family history of snoring and diagnosed apnea that is not necessarily weight related
  • Respiratory events of apnea and hypopneas occur in the side or back position when measured on the overnight sleep study
  • There is evidence of jaw and facial changes
  • High palette, small mouth, history of mouth breathing, snoring
  • Learning difficulties, long term memory problems and deficits involving the executive reasoning processes measured on neuropsychological evaluation

For these individuals, removal of the tonsils and adenoids typically does not alleviate the problem. These are the children who, after having a honeymoon period following the surgery return to having similar problems as seen pre-surgery; when this situation occurs, treatment options narrow to a CPAP, dental re-positioning or examination of ways to open the airway.

Examination of Options:

An examination of the structure of the individual’s face, size of their tonsils, and a cursory examination of the airway is routinely suggested. Depending upon the outcome of this initial exam, referral to a sleep center would be in order. At the sleep center, a sleep medicine specialist will examine the airway more in depth and determine the need for a sleep study. A sleep interview completed by a behavioral sleep specialist rules out the presence of factors such as insufficient sleep or the presence of a sleep disorder that would not require an overnight sleep study. The behavioral specialist and sleep medicine specialist work together to determine the need for a sleep study and if a nap study is needed to rule out causal factors for excessive daytime sleepiness. If the problem is psychologically or emotionally related, then the treatment will ultimately involve use of behavioral therapies, requiring the services of a specialist in behavioral sleep medicine.

If a sleep problem is obviously linked to enlarged tonsils and/or adenoids, the next step may be a discussion with the primary care physician regarding a referral to an ear, nose, and throat (ENT) doctor. A sleep study provides important additional documentation to the clinical assessment and confirmation of surgical needs and/or benefit to the person. An overnight sleep study provides sufficient information to determine whether surgery is the best option by analyzing variables of:

  • Number of respiratory micro arousals (the index or number of times there was an arousal which tends to shift the person into a lighter stage of sleep that is usually non- restorative)
  • Amount of restorative sleep for the brain and the body the person is actually getting, especially the separation of stage III from stage IV
  • The apnea/hypopnea index (an hourly rate of documented breathing events)
  • The apnea/hypopnea index (for REM (more problematic) vs. non-REM sleep)
  • Number, degree and duration of de-saturations occurring during a respiratory event
  • The respiratory index based upon body position
  • End tidal CO2 and de-saturation highs and lows throughout the study as well as averages
  • Presence of tachycardia and/or bradycardia
  • Presence of snoring

If surgery is decided upon, there is a specific method of removing the tonsils that research reveals changes (or does not change) the presence of sleep apnea. The suggested course is for the child or adult to have a sleep study three to six months post-surgery. If six months post-surgery results in a positive sleep study once again for apneic events, the decision depending upon the severity would be to complete a CPAP sleep study and/or refer to the dentist for an airway evaluation.

If CPAP is pursued, the following issues are critical for future compliance:

  • Trial use and determination of an interface device that will work for that person. The best example is the mouth breather who becomes claustrophobic because they were fitted with a face mask as opposed to using alternative devices for their mouth or nose.
  • Consideration of a heated humidifier
  • Use of different interface devices that fit the person’s specific needs.
  • Pressure that the person can adequately tolerate.
  • Examination of the CPAP sleep study to see if there was restorative sleep; which means analysis of the micro-arousals. Good restorative sleep tends to be predictive of excellent CPAP compliance whereas the exact opposite will occur if sleep remains just as poor as the original sleep study.

An alternative that can be implemented with or without CPAP is the use of positioning devices to change the airway. Success will depend upon the knowledge and artistry of the dental specialist and their knowledge of airway problems and sleep. Additional surgical options are available; one of the most positive outcomes involves directly addressing the airway.
We begin with problems identified on neuropsychological evaluation and then attempt to find the reason for our test findings beginning with consideration of sleep as a causal factor.

Key points:

  1. Children and adults diagnosed with sleep apnea face the risk for brain or thinking processes becoming affected through time.
  2. Often the CPAP, a lifetime on a breathing machine, is the only alternative, although new devices are being developed, especially dental appliances for mild to moderate apnea. If an adult tolerates the CPAP receiving the benefit of vastly improved restorative sleep, they will remain compliant and happy. Children however tend to quickly grow tired of the machine that initially was quite interesting and novel to them. Facial redness, discomfort during the night results in inadvertently disconnecting themselves from the machine. It then becomes important to search for the best alternative to address the sleep apnea identified by the sleep study based upon the level of severity. It is critical given the importance of the sleep study that the quality of the sleep study is sufficiently accurate and provides the necessary data to accurately analyze the child’s breathing disorder.
  3. We have found successful intervention by referring to dentistry for re-positioning therapy.
  4. The issue for children suffering from sleep apnea is twofold as they face the results of sleep deprivation (that can have considerable affects upon their emotions and behavior as well as short term memory and attention) and the effects of oxygen losses upon their executive reasoning and visual perceptual processes affecting reading and language skill development.
  5. Working with the school and family is absolutely crucial to enlist their understanding and help them to cope with a child who is often out of control, displaying symptoms of impulsivity and hyperactivity which cannot be resolved by various attempts at classroom interventions.
  6. Sleep apnea and UARS are significant problems that impact the day to day functioning of the child, adolescent or adult.