INDEX

S.no TOPIC

1. ABSTRCT

INTRODUCTION
2.

CATEGORIES OF SLEEP APNEA

3.  ANALYSIS OF SLEEP APNEA
 SIGNS AND SYMPTOMS
 FACTORS

DIAGNOSIS
4.

CASE ANALYSIS
5.
CPAP MACHINE

6.

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 ABSTRACT

A potentially serious sleep disorder in which breathing repeatedly stops and starts.Risk
factors include age and obesity. It's more common in men.Symptoms include snoring
loudly and feeling tired even after a full night's sleep.Treatment often includes lifestyle
changes, such as weight loss and the use of a breathing assistance device at night, such
as a continuous positive airway pressure (CPAP) machine. Proper diagnosis and
treatment are essential to manage the condition and improve overall health.

INTRODUCTION

Sleep apnea is a common and serious sleep disorder where breathing repeatedly stops
and starts during sleep. This interruption in breathing can lead to fragmented sleep and
low blood oxygen levels, causing daytime fatigue and increasing the risk of
cardiovascular issues. There are three main types: obstructive sleep apnea (OSA), central
sleep apnea (CSA), and complex sleep apnea syndrome, also known as treatment-
emergent central sleep apnea. OSA, the most prevalent form, occurs due to airway
blockage, while CSA involves a failure of the brain to signal muscles to breathe. Proper
diagnosis and treatment are essential to manage the condition and improve overall
health.

SLEEP APNEA

Sleep apnea is a sleep-related breathing disorder in which repetitive pauses in

breathing, periods of shallow breathing, or collapse of the upper airway
during sleep results in poor ventilation and sleep disruption. Each pause in breathing
can last for a few seconds to a few minutes and occurs many times a night. A choking or
snorting sound may occur as breathing resumes. Common symptoms include daytime
sleepiness, snoring, and non restorative sleep despite adequate sleep time. Because the
disorder disrupts normal sleep, those affected may experience sleepiness or feel tired
during the day. It is often a chronic condition.

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 CATEGORIES OF SLEEP APNEA

Sleep apnea may be categorized as obstructive sleep apnea (OSA), in which breathing is
interrupted by a blockage of air flow, central sleep apnea (CSA), in which regular
unconscious breath simply stops, or a combination of the two. OSA is the most common
form. OSA has four key contributors; these include a narrow, crowded, or collapsible
upper airway, an ineffective pharyngeal dilator muscle function during sleep, airway
narrowing during sleep, and unstable control of breathing (high loop gain). In CSA, the
basic neurological controls for breathing rate malfunction and fail to give the signal to
inhale, causing the individual to miss one or more cycles of breathing. If the pause in
breathing is long enough, the percentage of oxygen in the circulation can drop to a lower
than normal level (hypoxaemia) and the concentration of carbon dioxide can build to a
higher than normal level (hypercapnia). In turn, these conditions
of hypoxia and hypercapnia will trigger additional effects on the body such as Cheyne-
Stokes Respiration.

Some people with sleep apnea are unaware they have the condition. In many cases it is
first observed by a family member. An in-lab sleep study overnight is the preferred
method for diagnosing sleep apnea. In the case of OSA, the outcome that determines
disease severity and guides the treatment plan is the apnea-hypopnea index (AHI). This
measurement is calculated from totaling all pauses in breathing and periods of shallow
breathing lasting greater than 10 seconds and dividing the sum by total hours of
recorded sleep. In contrast, for CSA the degree of respiratory effort, measured by
esophageal pressure or displacement of the thoracic or abdominal cavity, is an
important distinguishing factor between OSA and CSA.

ANALYSIS OF SLEEP APNEA

Analysis took in 2019 says that OSA affects 936 million to 1 billion people between the
age of 30-69 around the world. and up to 30% of the elderly.]Sleep apnea is somewhat
more common in men than women, roughly a 2:1 ratio of men to women, and in general
more people are likely to have it with older age and obesity. Other risk factors include
being overweight, a family history of the condition, allergies, and enlarged tonsils.

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SIGNS AND SYMPTOMS

The typical screening process for sleep apnea involves asking patients about common
symptoms such as snoring, witnessed pauses in breathing during sleep and excessive
daytime sleepiness. There is a wide range in presenting symptoms in patients with sleep
apnea, from being asymptomatic to falling asleep while driving. Due to this wide range in
clinical presentation, some people are not aware that they have sleep apnea and are
either misdiagnosed or ignore the symptoms altogether. A current area requiring further
study involves identifying different subtypes of sleep apnea based on patients who tend
to present with different clusters or groupings of particular symptoms.

OSA may increase risk for driving accidents and work-related accidents due to sleep
fragmentation from repeated arousals during sleep.If OSA is not treated it results in
excessive daytime sleepiness and oxidative stress from the repeated drops in oxygen
saturation, people are at increased risk of other systemic health problems, such as
diabetes, hypertension or cardiovascular disease. Subtle manifestations of sleep apnea
may include treatment refractory hypertension and cardiac arrhythmias and over time
as the disease progresses, more obvious symptoms may become apparent.Due to the
disruption in daytime cognitive state, behavioral effects may be present. These can
include moodiness, belligerence, as well as a decrease in attentiveness and
energy. These effects may become intractable, leading to depression.

FACTORS OF SLEEP APNEA

Effects of OSA are regardless of sex , race or age .But it factors

 male gender
 obesity
 age over 40
 large neck circumference
 enlarged tonsils or tongue
 narrow upper jaw

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  small lower jaw
 tongue fat/tongue scalloping
 a family history of sleep apnea
 endocrine disorders such as hypothyroidism
 lifestyle habits such as smoking or drinking alcohol

Factors of CSA is more often realted with

 ransition period from wakefulness to non-REM sleep

 male gender
 older age
 heart failure
 atrial fibrillation
 stroke
 spinal cord injury

OBSTRUCTIVE SLEEP APNEA (OSA)

When anatomical risk factors are combined with non-anatomical contributors such as
an ineffective pharyngeal dilator muscle function during sleep, unstable control of
breathing (high loop gain), and premature awakening to mild airway narrowing, the
severity of the OSA rapidly increases as more factors are present.When breathing is
paused due to upper airway obstruction, carbon dioxide builds up in the
bloodstream. Chemoreceptors in the bloodstream note the high carbon dioxide levels.
The brain is signaled to awaken the person, which clears the airway and allows
breathing to resume. Breathing normally will restore oxygen levels and the person will
fall asleep again.This carbon dioxide build-up may be due to the decrease of output of
the brainstem regulating the chest wall or pharyngeal muscles, which causes the
pharynx to collapse. People with sleep apnea experience reduced or no slow-wave
sleep and spend less time in REM sleep.

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CENTRAL SLEEP APNEA (CSA)

There are two main mechanism that drive the disease process of CSA, sleep-related
hypoventilation and post-hyperventilation hypocapnia. The most common cause of CSA
is post-hyperventilation hypocapnia secondary to heart failure. This occurs because of
brief failures of the ventilatory control system but normal alveolar ventilation.]In
contrast, sleep-related hypoventilation occurs when there is a malfunction of the brain's
drive to breathe. The underlying cause of the loss of the wakefulness drive to breathe
encompasses a broad set of diseases from strokes to severe kyphoscoliosis.

DIAGNOSIS

There are three types of sleep apnea. OSA accounts for 84%, CSA for 0.9%, and 15% of
cases are mixed.

OBSTRUCTIVE SLEEP APNEA

The diagnosis of OSA syndrome is made when the patient shows recurrent episodes of
partial or complete collapse of the upper airway during sleep resulting in apneas or
hypopneas, respectively. Criteria defining an apnea or a hypopnea vary. The American
Academy of Sleep Medicine (AASM) defines an apnea as a reduction in airflow of ≥ 90%
lasting at least 10 seconds. A hypopnea is defined as a reduction in airflow of ≥ 30%
lasting at least 10 seconds and associated with a ≥ 4% decrease in pulse oxygenation, or
as a ≥ 30% reduction in airflow lasting at least 10 seconds and associated either with a ≥
3% decrease in pulse oxygenation or with an arousal.

POLYSOMNOGRAPHY

Nighttime in-laboratory Level 1 polysomnography (PSG) is the gold standard test for
diagnosis. Patients are monitored with EEG leads, pulse oximetry, temperature and
pressure sensors to detect nasal and oral airflow, respiratory impedance
plethysmography or similar resistance belts around the chest and abdomen to detect

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motion, an ECG lead, and EMG sensors to detect muscle contraction in the chin , chest,
and legs.

A hypopnea can be based on one of two criteria. It can either be a reduction in airflow of
at least 30% for more than 10 seconds associated with at least 4% oxygen desaturation
or a reduction in airflow of at least 30% for more than 10 seconds associated with at
least 3% oxygen desaturation or an arousal from sleep on EEG.

An "event" can be either an apnea, characterized by complete cessation of airflow for at

least 10 seconds, or a hypopnea in which airflow decreases by 50 percent for 10 seconds
or decreases by 30 percent if there is an associated decrease in the oxygen saturation or
an arousal from sleep. To grade the severity of sleep apnea, the number of events per
hour is reported as the apnea-hypopnea index (AHI). An AHI of less than 5 is considered
normal. An AHI of 5–15 is mild; 15–30 is moderate, and more than 30 events per hour
characterizes severe sleep apnea.

CENTRAL SLEEP APNEA

The diagnosis of CSA syndrome is made when the presence of at least 5 central apnea
events occur per hour. There are multiple mechanisms that drive the apnea events. In
individuals with heart failure with Cheyne-Stokes respiration, the brain's respiratory
control centers are imbalanced during sleep. This results in ventilatory instability,
caused by chemoreceptors that are hyperresponsive to CO2 fluctuations in the blood,
resulting in high respiratory drive that leads to apnea.Another common mechanism that
causes CSA is the loss of the brain's wakefulness drive to breathe.

PSG system showing a central apnea

CSA is organized into 6 individual syndromes:

Cheyne-Stokes respiration, Complex sleep apnea, Primary CSA, High altitude periodic
breathing, CSA from medication, CSA from comorbidity. Like in OSA, nocturnal
polysomnography is the mainstay of diagnosis for CSA. The degree of respiratory effort,

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measured by esophageal pressure or displacement of the thoracic or abdominal cavity, is
an important distinguishing factor between OSA and CSA.

Mixed apnea

Some people with sleep apnea have a combination of both types; its prevalence ranges
from 0.56% to 18%. The condition, also called treatment-emergent central apnea, is
generally detected when obstructive sleep apnea is treated with CPAP and central sleep
apnea emerges.The exact mechanism of the loss of central respiratory drive during sleep
in OSA is unknown but is most likely related to incorrect settings of the CPAP treatment
and other medical conditions the person has.

Management

The treatment of obstructive sleep apnea is different than that of central sleep apnea.
Treatment often starts with behavioral therapy and some people may be suggested to try
a continuous positive airway pressure device. Many people are told to avoid alcohol,
sleeping pills, and other sedatives, which can relax throat muscles, contributing to the
collapse of the airway at night.The evidence supporting one treatment option compared
to another for a particular person is not clear.

CHANGE IN SLEEP POSITION

More than half of people with obstructive sleep apnea have some degree of positional
obstructive sleep apnea, meaning that it gets worse when they sleep on their
backs. Sleeping on their sides is an effective and cost-effective treatment for positional
obstructive sleep apnea.

For moderate to severe sleep apnea, the most common treatment is the use of
a continuous positive airway pressure (CPAP) or automatic positive airway pressure
(APAP) device. These splint the person's airway open during sleep by means of
pressurized air. The person typically wears a plastic facial mask, which is connected by
a flexible tube to a small bedside CPAP machine.

Although CPAP therapy is effective in reducing apneas and less expensive than other
treatments, some people find it uncomfortable. Some complain of feeling trapped, having
chest discomfort, and skin or nose irritation. Other side effects may include dry mouth,
dry nose, nosebleeds, sore lips and gums.

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Whether or not it decreases the risk of death or heart disease is controversial with some
reviews finding benefit and others not.This variation across studies might be driven by
low rates of compliance—analyses of those who use CPAP for at least four hours a night
suggests a decrease in cardiovascular events.

WEIGHT LOSS

Excess body weight is thought to be an important cause of sleep apnea. People who are
overweight have more tissues in the back of their throat which can restrict the airway,
especially when sleeping. In weight loss studies of overweight individuals, those who lose
weight show reduced apnea frequencies and improved apnoea–hypopnoea index
(AHI). Weight loss effective enough to relieve obesity hypoventilation syndrome (OHS)
must be 25–30% of body weight. For some obese people, it can be difficult to achieve and
maintain this result without bariatric surgery.

RAPID PALATAL EXPANSION

In children, orthodontic treatment to expand the volume of the nasal airway, such as
nonsurgical rapid palatal expansion is common. The procedure has been found to
significantly decrease the AHI and lead to long-term resolution of clinical symptoms.

Since the palatal suture is fused in adults, regular RPE using tooth-borne expanders
cannot be performed. Mini-implant assisted rapid palatal expansion (MARPE) has been
recently developed as a non-surgical option for the transverse expansion of the maxilla
in adults. This method increases the volume of the nasal cavity and nasopharynx,
leading to increased airflow and reduced respiratory arousals during sleep. Changes are
permanent with minimal complications.

SURGERY

Several surgical procedures (sleep surgery) are used to treat

sleep apnea,

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although they are normally a third line of treatment for those who reject or

are not helped by CPAP treatment or dental appliances.Surgical treatment

for obstructive sleep apnea needs to be individualized to address all

anatomical areas of obstruction.

NASAL OBSTRUCTION

Often, correction of the nasal passages needs to be performed in addition to correction of

the oropharynx passage. Septoplasty and turbinate surgery may improve the nasal
airway, but has been found to be ineffective at reducing respiratory arousals during
sleep.

PHARYNGEAL OBSTRUCTION

Tonsillectomy and uvulopalatopharyngoplasty (UPPP or UP3) are available to address

pharyngeal obstruction.

Uvulopalatopharyngoplasty

A) pre-operative,

B) original UPPP,

C) modified UPPP,

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D) minimal UPPP.

The "Pillar" device is a treatment for snoring and obstructive sleep apnea; it is thin,
narrow strips of polyester. Three strips are inserted into the roof of the mouth (the soft
palate) using a modified syringe and local anesthetic, in order to stiffen the soft palate.
This procedure addresses one of the most common causes of snoring and sleep apnea —
vibration or collapse of the soft palate. It was approved by the FDA for snoring in 2002
and for obstructive sleep apnea in 2004. A 2013 meta-analysis found that "the Pillar
implant has a moderate effect on snoring and mild-to-moderate obstructive sleep apnea"
and that more studies with high level of evidence were needed to arrive at a definite
conclusion; it also found that the polyester strips work their way out of the soft palate in
about 10% of the people in whom they are implanted.

HYPOPHARYNGEAL OR BASE OF TONGUE OBSTRUCTION

Base-of-tongue advancement by means of advancing the genial tubercle of the mandible,

tongue suspension, or hyoid suspension (aka hyoid myotomy and suspension or hyoid
advancement) may help with the lower pharynx.

Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or
throat, procedures done at either a doctor's office or a hospital. Small shots or other
treatments, sometimes in a series, are used for shrinkage, while the insertion of a small
piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues.

MULTI-LEVEL SURGERY

Maxillomandibular advancement (MMA) is considered the most effective surgery for

people with sleep apnea, because it increases the posterior airway space (PAS). However,
health professionals are often unsure as to who should be referred for surgery and when
to do so: some factors in referral may include failed use of CPAP or device use; anatomy
which favors rather than impedes surgery; or significant craniofacial abnormalities
which hinder device use.

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POTENTIAL COMPLICATIONS

Several inpatient and outpatient procedures use sedation. Many drugs and agents used
during surgery to relieve pain and to depress consciousness remain in the body at low
amounts for hours or even days afterwards. In an individual with either central,
obstructive or mixed sleep apnea, these low doses may be enough to cause life-
threatening irregularities in breathing or collapses in a patient's airways. Use of
analgesics and sedatives in these patients postoperatively should therefore be minimized
or avoided.

Surgery on the mouth and throat, as well as dental surgery and procedures, can result
in postoperative swelling of the lining of the mouth and other areas that affect the
airway. Even when the surgical procedure is designed to improve the airway, such as
tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the
effects in the immediate postoperative period. Once the swelling resolves and the palate
becomes tightened by postoperative scarring, however, the full benefit of the surgery
may be noticed.

A person with sleep apnea undergoing any medical treatment must make sure their
doctor and anesthetist are informed about the sleep apnea. Alternative and emergency
procedures may be necessary to maintain the airway of sleep apnea patients.

CASE ANALYSIS

Patient : Kathijathul Ameena Sex : Female

Age : 72 .

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Symtoms like Excessive daytime sleepiness , Loud snoring , awaken with dry mouth and
morning headache are noticed .

SLEEP TEST RESULT

It was confirmed that the patient suffers from long term chronic Obstructive Sleep
Apnaea.

Doctor advised to use CPAP machine.

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 CONTINUOS POSITIVE AIRWAY PRESSURE (CPAP) MACHINE

CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to
keep breathing airways open while you sleep.

Your healthcare provider may prescribe CPAP to treat sleep-related breathing disorders
including sleep apnea. CPAP also may treat preterm infants who have underdeveloped
lungs.

A CPAP machine includes:

 A mask or other device that fits over your nose or your nose and mouth
 Straps to position the mask
 A tube that connects the mask to the machine’s motor
 A motor that blows air into the tube

How does CPAP work?

The patiend should use CPAP machine every time you sleep at home, while traveling,
and during naps.

Getting used to using your CPAP machine can take time and requires patience. Your
healthcare provider will work with you to find the most comfortable mask that works
best for you.

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You may also need help from your healthcare provider to use the humidifier chamber in
your machine or to adjust your pressure settings. You may also need to try a different
machine that has multiple or auto-adjusting pressure settings.

For the treatment to continue to work, it is important that you clean your mask and
tube every day and refill your medical device prescription at the right time to replace the
mask and tube.

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