Sleep Apnea
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Sleep Apnea is a breathing problem in which the soft tissues in the throat close down for about 20-30 seconds at a time during sleep.  With each pause in breathing, the brain “wakes up” just enough to start breathing properly, although the person may or may not be aware that these obstructions are occurring.  Many people have some pauses in breathing when they sleep.  We diagnose Obstructive Sleep Apnea (OSA) when we count at least 5 pauses in breathing per hour of sleep.  The more pauses there are, the more severe is the case of Sleep Apnea.  Patients who have an overnight sleep study (PSG) are given a number or index of how many pauses occurred per hour of sleep.  It is important to ask your doctor how to interpret  this number (the "AHI").

Click here for sleep apnea FAQs. 


Treatments for Sleep Apnea

There are many different options available to treat sleep apnea.  Although wearing a mask at night remains the gold standard, not everyone can adapt to this strategy.  The treatments fall into several categories: positive airway pressure (PAP), surgery, dental appliance, and conservative measures.


Positive airway pressure
Because sleep apnea is mainly a problem of airway closure, the standard treatment involves using air pressure to hold the airway open during sleep.  Your doctor sets the pressure settings, typically based on what is observed during a night in the lab when several pressures are tried.  The main determinant of mask choice is patient preference.  However, some patients open their mouths when they sleep, and if this happens, they may try adding a chin strap, or try what is called a “full face” mask, meaning it covers the nose and mouth.  

  • CPAP stands for continuous positive airway pressure.  The CPAP machine takes regular air from the room, purifies and humidifies it, and blows it at a constant pressure through a hose and into the mask.   Although oxygen can be added to the machine, most patients do not need any extra oxygen, they just need the air pressure to keep their airway open – and then they breathe naturally  
  • BiPAP stands for bi-level positive airway pressure, which means there is one amount of pressure when you inhale, and a lower pressure when you exhale.   BiPAP can be useful in patients who have low oxygen even though their apnea is treated (such as obesity or certain pulmonary diseases).  It may also be useful in patients who need such a high pressure that they have trouble exhaling against the airflow.  Although the BiPAP machines are capable of breathing for you (called a back-up rate), most patients do not need this feature.
  • AutoPAP is a type of machine that monitors your breathing and can adjust the amount of pressure depending on how frequently apneas are occurring.  The doctor sets the range of pressures the machine can choose from. These devices may not be appropriate for all patients - your doctor should review the data card to confirm that the AutoPAP is controlling the sleep apnea.  
  • Adaptive PAP is a special kind of machine that is used for patients with central or “complex” apnea.  In these patients, the standard CPAP and BiPAP machines do not improve the breathing problem, and breathing pauses can get worse as the pressure increases.   It is different from the AutoPAP (which can worsen complex/central apnea), but it does use a range of settings to adjust to your breathing as the night progresses.
Surgery
For some patients, surgery is an option – mainly those individuals who cannot tolerate wearing a mask at night, but their apnea is significant enough to warrant treatment.  There are two main kinds of surgery for sleep apnea.  Both are designed to increase the amount of space in the airway to reduce the amount of apnea that occurs in sleep. 
  • Palate Surgery is performed by otolaryngologists, also known as Ear Nose and Throat surgeons (ENT).  This typically involves removing the uvula and portions of the soft palate at the back of the throat.  Although sometimes having surgery for deviated septum can relieve congestion and improve breathing, this is often insufficient as a sole treatment for sleep apnea. 
  • Maxillomandibular Advancement surgery is performed by Oral and Maxillofacial Surgeons (OMFS).  This procedure involves moving the bones of the upper and lower jaw forward and using screws and plates to anchor them in place.  This is considered a major surgery, and involves extensive planning, so it is usually reserved for those with severe sleep apnea.


Dental appliance
These devices use the top jaw as an anchor and move the bottom jaw forward.  The device is placed in the mouth at bedtime and remains in place overnight.  Dental appliances are custom-fitted by dental specialists for use in sleep apnea patients.  The best evidence for these devices is for use in patients with mild to moderate sleep apnea.  Note that these devices are different than the mouth guards used for teeth grinding, which do not treat OSA.

Conservative measures
Patients with sleep apnea may benefit from weight loss or sleeping on their side instead of their back.  However, these conservative measures may or may not be sufficient to treat sleep apnea.  Positional therapy consists of pillows or shirts/vests that are designed to help prevent you from rolling onto your back.  These may be helpful for people in whom the OSA is much worse while lying on the back (supine) compared to lying on the side.  About half of OSA patients show this pattern.  In terms of obesity, while it is true that being overweight is a risk factor for sleep apnea, there are many other factors involved.  For patients who lose substantial weight, it is important to re-test for OSA, even if you feel better and snoring has improved.  Treating nasal congestion or allergies may help improve breathing, and possibly reduce snoring, but these are not considered sole treatments for sleep apnea.  Breathe right strips, chin straps, teeth-grinding guards, or other advertised options are largely considered "gimmicks" and are not considered treatments for sleep apnea.  
Insomnia
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People with insomnia may report difficulty falling asleep or staying asleep.  Many factors can lead to insomnia symptoms, ranging from stress or caffeine to pain or medical problems that interrupt sleep.  For some people, simple tips known as sleep hygiene are enough to improve sleep.  But for others, the situation can be more complicated.  Some patients have such negative experiences with sleep that they actually get caught in a cycle: each night, the idea of trying to sleep itself causes stress which then makes it harder to sleep. 

Insomnia is divided into many subtypes, in part because the suggested treatments may differ depending on the individual case.  It is important to note that beliefs about what is “normal” sleep can impact whether a person seeks treatment.  For example, some people think that it is abnormal to awaken during the night, or that they need 8 hours of sleep per night to be healthy.  Although sleep is certainly important, individual needs vary greatly . Thus, failing to meet general expectations can cause anxiety (which can impact sleep!), and make a person feel like they have a problem or that they need to take medication.  To make things even more challenging, people with insomnia may be sleeping more than they think.  Read more about sleep misperception.

Click here for insomnia FAQs.
Restless Legs Syndrome (RLS)
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Some people experience uncomfortable sensations in their legs, especially at night or if they sit for long periods, where they feel like they need to move or stretch.  RLS is different from the brief muscle twitches that occur as we fall asleep (which are called “hypnic jerks”).  The symptoms of RLS can range from being barely noticeable and not requiring any treatment, to being so bothersome that it makes it hard to fall asleep.  RLS may not be limited to night-time- it can also happen any time a person is sitting still, like in a car or movie theater.   You don’t need to have an overnight sleep study to diagnose RLS, your doctor makes the diagnosis based purely on the symptoms you feel while you are awake.  For some patients, treatment can simply involve keeping hydrated and stretching before bed.  Low iron levels can play a role, which can be treated with oral iron tablets (taken with Vitamin C, between meals, to aid absorption).  Prescription treatments are also available. 

For patients who undergo sleep testing in the lab, we sometimes also observe leg movements during sleep, known as Periodic Limb Movements of Sleep.  Many patients with RLS symptoms also have leg movements during sleep, which they usually don’t even realize (but the bed partner may notice them).  Some patients with RLS also have sleep apnea, and treating the sleep apnea may indirectly benefit the RLS symptoms. 
Narcolepsy
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For a small portion of patients who are sleepy during the day, the problem is a neurological disorder called narcolepsy.  In addition to feeling sleepy, patients with narcolepsy often have other symptoms, like feeling paralyzed for a minute or so when they wake up, or having dream sensations as they are about to fall asleep but are still awake.  In about half of patients with narcolepsy, cataplexy may occur: weakness of part of the body (or the whole body) that is triggered by laughter or strong emotion.  Patients experiencing cataplexy spells are awake – these “attacks” are different than fainting or a seizure, where the person loses consciousness.
Parasomnia
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Some people engage in activities such as talking or walking in their sleep.  Sleep walking and sleep talking mainly occur during NREM sleep (sometimes called slow wave sleep parasomnias).  Dream enactment can also occur in some patients who lose the natural paralysis that occurs during REM sleep (also called REM sleep behavior disorder). 
Circadian Rhythm Disorders
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Our internal “clock” is located in a small part of the brain called the suprachiasmatic nucleus (SCN).  For most people, the clock runs on a cycle that is just slightly longer than 24 hours, and is synchronized with the light-dark cycle.  In fact, light detected by the eyes entrains the clock by sending signals to the SCN.  However, for some people the clock does not synchronize properly, causing the person to feel sleepy before or after “normal” bed times.  In teenagers and young adults, the most common circadian rhythm disorder is called delayed phase (staying up late and then sleeping late the next morning), while in older adults the advanced phase pattern is more likely (early to bed, early to rise).  These patterns can cause difficulty when the person’s social or work schedule is not compatible with the timing of the internal clock.  Fortunately, the clock can be entrained to change – this happens when we cross time zones: the clock reacts to light as well as other clues (food, social activity, exercise).