SLEEP APNEA. Multimedia Health Education. Disclaimer

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Virgil Alexander
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1 Disclaimer This movie is an educational resource only and should not be used to manage your health. All decisions about the management of Sleep Apnea must be made in conjunction with your Physician or a licensed healthcare provider.

2 MULTIMEDIA HEALTH EDUCATION MANUAL TABLE OF CONTENTS SECTION CONTENT

3 INTRODUCTION Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep. Breathing pauses can last from a few seconds to minutes. They often occur 5 to 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound. Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep 3 or more nights each week. You often move out of deep sleep and into light sleep when your breathing pauses or becomes shallow. This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness. In order to learn more about sleep apnea, it helps to understand the normal anatomy of the upper respiratory system.

4 The Gastrointestinal System The upper respiratory system consists of the nose and sinuses, oral cavity (mouth), and pharynx (throat). Please click on the links to learn more about the anatomical parts that can be involved with sleep apnea. (Refer fig. 1) Tonsils Tonsils are lymph nodes located at the back of the throat next to the tongue. There are two tonsils, one on each side of the throat. Tonsils are comprised of soft lymphatic tissue and are part of the lymphatic system, our body s defense system against infection. Unit 1: Normal Anatomy (Fig. 1) (Fig. 2) Their purpose is to assist in fighting infection by acting as a filter for bacteria and viruses entering the body through the nose and mouth. (Refer fig. 2) Uvula This is the small piece of soft tissue that hangs down from the roof of the mouth at the back of the throat. (Refer fig. 3) (Fig. 3)

5 Soft Palate This is the soft roof of the mouth at the back of the throat (Refer fig. 4) Unit 1: Normal Anatomy (Fig. 4)

during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night.

6 What is Sleep Apnea? Unit 2: Overview of Sleep Apnea Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night. People with sleep apnea will partially awaken as they struggle to breathe, but in the morning they will not be aware of the disturbances in their sleep. The most common type of sleep apnea is obstructive sleep apnea (OSA), caused by relaxation of soft tissue in the back of the throat that blocks the passage of air. Central sleep apnea (CSA) is less common and is caused by irregularities in the brain s normal signals to breathe. (Fig. 5) (Refer fig. 5 to 7) (Fig. 6) (Fig. 7)

8) The snoring usually is loudest when you sleep on your back and may be less noisy when you turn on your side. Snoring may not happen every night.

7 Symptoms of Sleep Apnea Snoring: One of the most common signs of obstructive sleep apnea is loud and chronic (ongoing) snoring. Pauses may occur in the snoring and choking or gasping may follow the pauses. (Refer fig. 8) Unit 2: Overview of Sleep Apnea (Fig. 8) The snoring usually is loudest when you sleep on your back and may be less noisy when you turn on your side. Snoring may not happen every night. Over time, the snoring may happen more often and get louder. It is important to understand that not everyone who snores has sleep apnea. Daytime Fatigue: Another common sign of sleep apnea is fighting sleepiness during the day, at work, or while driving. You may find yourself rapidly falling asleep during the quiet moments of the day when you're not active. (Fig. 9) (Refer fig. 9) Other Signs and Symptoms Others signs and symptoms of sleep apnea may include: Restless sleep Falling asleep during the day Morning headaches Urination at night (Fig. 10)

Unit 2: Overview of Sleep Apnea Memory or learning problems and not being able to concentrate Feeling irritable, depressed, or having mood swings or A dry throat when you wake up (Fig.

Children who have sleep apnea also may have unusual sleeping positions, bedwetting, and may breathe through their mouths instead of their noses during the day.

8 Unit 2: Overview of Sleep Apnea Memory or learning problems and not being able to concentrate Feeling irritable, depressed, or having mood swings or A dry throat when you wake up (Fig. 10) In children, sleep apnea can cause hyperactivity, poor school performance, and aggressiveness. Children who have sleep apnea also may have unusual sleeping positions, bedwetting, and may breathe through their mouths instead of their noses during the day. Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation. Risk Factors A risk factor is something that is likely to increase a person s chance of developing a disease or condition. Risk factors for developing obstructive sleep apnea include the following: Being overweight. Over half of people diagnosed with sleep apnea are overweight or obese (Refer fig. 11) (Fig. 11)

Unit 2: Overview of Sleep Apnea Sleep apnea is more common in men.

Women are much more likely to develop sleep apnea after menopause.

13) African Americans, Hispanics, and Pacific Islanders are more likely to

9 Unit 2: Overview of Sleep Apnea Sleep apnea is more common in men. (Refer fig. 12) (Fig. 12) Sleep apnea becomes more common as you get older. Women are much more likely to develop sleep apnea after menopause. (Refer fig. 13) (Fig. 13) African Americans, Hispanics, and Pacific Islanders are more likely to develop sleep apnea than Caucasians. If someone in your family has sleep apnea, you're more likely to develop it. (Refer fig. 14) (Fig. 14)

Unit 2: Overview of Sleep Apnea Small children often have enlarged tonsil tissues in the throat. This can make them prone to developing sleep apnea. (Refer fig. 15) (Fig.

10 Unit 2: Overview of Sleep Apnea Small children often have enlarged tonsil tissues in the throat. This can make them prone to developing sleep apnea. (Refer fig. 15) (Fig. 15) People who have small airways in their noses, throats, or mouths also are more likely to have sleep apnea. Smaller airways may be due to the shape of these structures or allergies or other medical conditions that cause congestion in these areas. Other risk factors for sleep apnea include smoking, high blood pressure, and risk factors for stroke or heart failure. Complications If sleep apnea is left untreated, serious complications can develop. Untreated sleep apnea can increase the risk for: High Blood Pressure Heart Attack Obesity Diabetes Stroke and transient inshemic attacks ( mini-strokes or TIA's)v Other complications that can result from not treating sleep apnea include: Increasing the risk for or worsen heart failure Make irregular heartbeats more likely Increase the chance of having work-related or driving accidents

11 Diagnosis Unit 2: Overview of Sleep Apnea Sleep apnea often goes undiagnosed. Doctors usually can't detect the condition during routine office visits and most patients are unaware they even have the condition. Also, there are no blood tests for the condition.doctors diagnose sleep apnea based on your medical and family histories, a physical exam, and results from sleep studies. Usually, your primary care doctor evaluates your symptoms first. He or she then decides whether you need to see a sleep specialist. These specialists are doctors who diagnose and treat people with sleep problems. Such doctors include lung, nerve, or ear, nose, and throat specialists. Other types of doctors also can be sleep specialists. Medical and Family Histories Your doctor will ask you and your family questions about how you sleep and how you function during the day. Your doctor also will want to know how loudly and often you snore or make gasping or choking sounds during sleep. Often you're not aware of such symptoms and must ask a family member or bed partner to report them. Let your doctor know if anyone in your family has been diagnosed with sleep apnea or has had symptoms of the disorder. Physical Exam Your doctor will check your mouth, nose, and throat for extra or large tissues. The tonsils often are enlarged in children with sleep apnea. A physical exam and medical history may be all that's needed to diagnose sleep apnea in children. (Fig. 16) Adults with the condition may have an enlarged uvula or soft palate. The uvula is the tissue that hangs from the middle of the back of your mouth. The soft palate is the roof of your mouth in the back of your throat. (Refer fig. 16) Sleep Studies A sleep study is the most accurate test for diagnosing sleep apnea. It captures what happens with your breathing while you sleep. A sleep study is often done in a sleep center or sleep lab, which may be part of a hospital. You may stay overnight in the sleep center.

Unit 2: Overview of Sleep Apnea Sleep Studies A sleep study is the most accurate test for diagnosing sleep apnea. It captures what happens with your breathing while you sleep.

12 Unit 2: Overview of Sleep Apnea Sleep Studies A sleep study is the most accurate test for diagnosing sleep apnea. It captures what happens with your breathing while you sleep. A sleep study is often done in a sleep center or sleep lab, which may be part of a hospital. You may stay overnight in the sleep center. A polysomnogram (poly-som-nogram), or PSG, is the most common study for diagnosing sleep apnea. This test records: Brain activity Eye movement and other muscle Breathing and heart rate How much air moves in and out of your lungs while you're sleeping The amount of oxygen in your blood (Fig. 17) A PSG is painless. You will go to sleep as usual, except you will have sensors on your scalp, face, chest, limbs, and finger. The staff at the sleep center will use the sensors to check on you throughout the night. A sleep specialist reviews the results of your PSG to see whether you have sleep apnea and how severe it is. He or she will use the results to plan your treatment. (Refer fig. 17)

13 Unit 3: Conservative Treatment The goals of treating obstructive sleep apnea are to: Treatment Options Restore regular breathing during sleep Relieve symptoms such as loud snoring and daytime sleepiness Treatment may help other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk for heart disease, stroke, and diabetes. Lifestyle changes and/or mouthpieces may be enough to relieve mild sleep apnea. People who have moderate or severe sleep apnea may need breathing devices or surgery. Currently, there are no medicines to treat sleep apnea. Lifestyle Changes If you have mild sleep apnea, some changes in daily activities or habits may be all that you need. Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep. Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms. Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows that prevent you from sleeping on your back. Keep your nasal passages open at night with nose sprays or allergy medicines, if needed. Talk to your doctor about whether these treatments might help you. Stop smoking. Mouthpiece A mouthpiece, sometimes called an oral appliance, may help some people who have mild sleep apnea. Your doctor also may recommend a mouthpiece if you snore loudly but don't have sleep apnea. A dentist or orthodontist can make a custom-fit plastic mouthpiece for treating sleep apnea. An orthodontist specializes in correcting teeth or jaw problems. The mouthpiece will adjust your lower jaw and your tongue to help keep your airways open while you sleep. Breathing Devices. Continuous positive airway pressure (CPAP) is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your mouth and nose, or just over your nose. The machine gently blows air into your throat. The air presses on the wall of your airway.

14 Unit 3: Treatment Options The air pressure is adjusted so that it's just enough to stop the airways from becoming narrowed or blocked during sleep. Usually, a technician will come to your home to bring the CPAP equipment. The technician will set up the CPAP machine and adjust it based on your doctor's orders. After the initial setup, you may need to have the CPAP adjusted on occasion for the best results. CPAP treatment may cause side effects in some people. These side effects include a dry or stuffy nose, irritated skin on your face, sore eyes, and headaches. If your CPAP isn't properly adjusted, you may get stomach bloating and discomfort while wearing the mask. If you're having trouble with CPAP side effects, work with your sleep specialist, his or her nursing staff, and the CPAP technician. Together, you can take steps to reduce these side effects. These steps include adjusting the CPAP settings or the size/fit of the mask, or adding moisture to the air as it flows through the mask. A nasal spray may relieve a dry, stuffy, or runny nose. Surgical Overview If conservative treatment options fail to resolve your sleep apnea, your doctor will refer you to an Otolaryngologist, an ENT surgeon, to be evaluated for surgery. The type of surgery and how well it works depend on the cause of the sleep apnea. Surgery is done to widen breathing passages. It usually involves removing, shrinking, or stiffening excess tissue in the mouth and throat or resetting the lower jaw. Surgery to shrink or stiffen excess tissue in the mouth or throat is done in a doctor's office or a hospital. Shrinking tissue may involve a series of small shots or other treatments to the tissue. To stiffen excess tissue, the doctor makes a small cut in the tissue and inserts a small piece of stiff plastic. Surgery to remove excess tissue is only done in a hospital. Uvulopalatopharyngoplasty (UPPP) surgery is the most common surgical procedure to treat obstructive sleep apnea. It involves removing the uvula, and excess soft tissue at the back of the throat. A tonsillectomy (removal of the tonsils) will usually be performed at the same time if the tissues are enlarged and blocking the airway.

Unit 3: Treatment Options There are various surgical techniques that may be used including conventional scalpel or newer methods using lasers.

Genioglossus and hyoid advancement are also surgical options to treat sleep apnea.

The goal of sleep apnea surgery is to improve airway obstruction.

15 Unit 3: Treatment Options There are various surgical techniques that may be used including conventional scalpel or newer methods using lasers. UPPP is indicated for patients with upper pharyngeal obstruction at the palatal level. Genioglossus and hyoid advancement are also surgical options to treat sleep apnea. They open the obstructed airway by preventing the collapse of the lower throat and pulling the tongue muscles forward. The goal of sleep apnea surgery is to improve airway obstruction. Surgical Treatment Uvulopalatopharyngoplasty (UPPP) is performed in a hospital operating room with the patient under general anesthesia. The patient will be asleep and unaware of the surgery. The patient is positioned on the operating table on their back with the shoulders elevated on a small pillow to hyperextend the neck. (Fig. 18) (Fig. 19) A mouth gag is used to keep the mouth open for the surgeon to have a clear view and room to work. (Refer fig. 18 to 23) (Fig. 20)

Unit 3: Treatment Options Your surgeon will trim the lower part of the soft palate

21) If indicated, your surgeon will perform the tonsillectomy to remove the tonsils. (Fig.

The instruments and mouth gag are then removed. (Refer fig. 18 to 23) (Fig.

16 Unit 3: Treatment Options Your surgeon will trim the lower part of the soft palate including the uvula. (Fig. 21) If indicated, your surgeon will perform the tonsillectomy to remove the tonsils. (Fig. 22) Sutures are then placed to bring the raw tissue edges together. The instruments and mouth gag are then removed. (Refer fig. 18 to 23) (Fig. 23) Post Operative Guidelines Your surgeon will give you guidelines to follow depending on the type of surgery performed and the surgeon s preference. Common post-operative guidelines include:

Unit 3: Treatment Options You will usually be monitored overnight for

24) You will be given pain medications to manage your pain.

Make sure to finish all your pills and do not drink alcohol as this

17 Unit 3: Treatment Options You will usually be monitored overnight for swelling and breathing problems. (Refer fig. 24) (Fig. 24) You will be given pain medications to manage your pain. It is normal to have a sore throat after surgery for 1-2 weeks. (Refer fig. 25) (Fig. 25) You will probably be given antibiotics to prevent infection. Make sure to finish all your pills and do not drink alcohol as this interferes with their effect. (Refer fig. 26) (Fig. 26) Avoid dairy products such as milk and ice cream as they can coat the throat and interfere with healing. (Refer fig. 27) (Fig. 27)

Unit 3: Treatment Options Do not use aspirin or ibuprofen

Children under 12 should never be given aspirin due to the

28) Get plenty of rest (Refer fig. 29) (Fig.

and lifting for 1-2 weeks after surgery as this may cause

18 Unit 3: Treatment Options Do not use aspirin or ibuprofen products as these can cause bleeding to occur. Children under 12 should never be given aspirin due to the potential for Reyes Syndrome. (Refer fig. 28) (Fig. 28) Get plenty of rest (Refer fig. 29) (Fig. 29) You should avoid strenuous activity as well as bending and lifting for 1-2 weeks after surgery as this may cause bleeding. (Refer fig. 30) (Fig. 30) Sleep with your head elevated on extra pillows (Refer fig. 31) (Fig. 31)

Unit 3: Treatment Options Do not smoke as smoking delays healing and increases your risk of developing complications. (Refer fig.

The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

Complications can be medical (general) or specific to Uvulopalatopharyngoplasty (UPPP) surgery.

Almost any medical condition can occur so this list is not complete.

19 Unit 3: Treatment Options Do not smoke as smoking delays healing and increases your risk of developing complications. (Refer fig. 32) (Fig. 32) Risks and Complications As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to Uvulopalatopharyngoplasty (UPPP) surgery. Medical complications include those of the anesthetic and your general well being. Complications can be medical (general) or specific to Uvulopalatopharyngoplasty (UPPP) surgery. Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include: Allergic reaction to medications Blood loss requiring transfusion with its low risk of disease transmission Heart attack, strokes, kidney failure, pneumonia, bladder infections (Fig. 33)

Complications are rare after UPPP surgery, but unexpected events can follow any operation.

20 Unit 3: Treatment Options (Fig. 33) Complications from nerve blocks such as infection or nerve damage Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death. Complications are rare after UPPP surgery, but unexpected events can follow any operation. Your surgeon feels that you should be aware of complications that may take place so that your decision to proceed with this operation is Possible complications following UPPP surgery can include the following: Bleeding Bleeding Infection Scar Tissue Difficulty Swallowing Altered Speaking Tones Significant bleeding is uncommon. Frequent swallowing may be a sign of bleeding from the surgery site in children. Check the mouth frequently for the first few days after surgery for any signs of bleeding. Report any abnormal bleeding to your surgeon. Infection Report fever of 38.5 C or F or higher. Report foul smelling, greenish yellow drainage as well as increasing pain or unresolved vomiting to your surgeon. Antibiotics will be prescribed to treat the infection.

21 Unit 3: Treatment Options Scar Tissue Excess scar tissue may develop causing a narrowing of the airway with possible worsening of sleep apnea. Difficulty Swallowing This can be due to tissue swelling in the throat or due to pain with swallowing. Altered Speaking Tones Removal of the uvula causes inability to correctly pronounce some french language sounds. Occasionally speech may have nasal qualities.

22 Unit 3: Disclaimer Summary A good knowledge of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery. Disclaimer Although every effort is made to educate you on sleep apnea and take control, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any concerns you have about sleep apnea.

23 YOUR SURGERY DATE READ YOUR BOOK AND MATERIAL VIEW YOUR VIDEO/CD/DVD/ WEBSITE PRE - HABILITATION ARRANGE FOR BLOOD MEDICAL CHECK UP ADVANCE MEDICAL DIRECTIVE PRE - ADMISSION TESTING FAMILY SUPPORT REVIEW Physician's Name : Physician's Signature: Date : Patient s Name : Patient s Signature: Date :

Obstructive Sleep Apnea

Obstructive Sleep Apnea Introduction Obstructive sleep apnea is an interruption in breathing during sleep. It is caused by throat and tongue muscles collapsing and relaxing. This blocks, or obstructs,