Refer to the Exploring Sleep and Wellness post for a summary.

When to suspect Apnea or other Sleep Disorder

If you are not depriving yourself of sleep and notice the following:

1. Even though you are getting at least 7 hours of sleep, you do not feel well-rested.
2. Taking any substance to assist you to sleep. You are using alcohol or other medication at night and more than 4 cups of coffee in the day as a stimulant or drinking it throughout the day.
3. Taking longer naps during the day.
4. You feel irritable toward the evening or have a greater flight of emotions – anger and sadness.
5. You are waking up with headaches or you get migraines more frequently than 1-2 times a month.
6. Your body is in greater pain through the day – fibromyalgia has been linked to sleep deprivation.
7. You are waking up snoring or your bed partner is concerned that you take long pauses in between breaths. Maybe your partner has decided to sleep in a different bed, because of the snoring or leg movements.
8. You are having night terrors, nightmares or confusional arousals.
9. You are getting up more than once nightly to urinate.
10. You have noticed an increase in swelling in your legs.
11. You have been diagnosed with diabetes, high blood pressure, atrial fibrillation or other heart rhythm disorder, a heart attack, a stroke, low testosterone function or low thyroid function.
12. You are taking pain medications on a daily basis
13. You body mass index is greater than 27

Diagnosis of Apnea (Symptom checklist/Signs)

Questionnaires

Epsworth Sleepiness Scale and Stop-Bang are useful. You can fill these out before you see your doctor. There are three major types of apnea: central, obstructive and mixed. The above list is also beneficial to go through before the clinic visit.

Physical Examination

1. Neck circumference in men >17 inches and Women > 16 inches
2. Body Mass Index of >30
3. Elevated blood pressure >140 systolic (top) and >90 (bottom). Blood pressure elevation – usually both top and bottom numbers (systolic and diastolic). As many as 50% of those with hypertension have a sleep disorder.
4. Lower extremity swelling with pitting after applying pressure
5. Small testicles (from sleep apnea associated hypogonadism and low testosterone state)
6. Malampati Index >2 or a thick tongue (multiple conditions can cause this).

Laboratory evaluation

1. TSH (thyroid stimulating hormone): checks level of thyroid functioning – when the level is too high, the brain is signaling to an inactive thyroid gland = primary hypothyroidism
2. Iron studies: Iron deficiency may be associated with a parasomnia Restless legs disorder
3. Blood count: An elevated red blood count is a sign that the oxygen levels are getting too low at night from apnea (central or obstructive) or an associated lung condition. These low oxygen levels cause the kidney to produce erythropoeitin, a hormone that acts on the bone marrow to produce more red blood cells.
4. Testosterone, free and total: A low testosterone can be associate with sleep apnea.
5. Metabolic function panel: kidney and liver disorders can sometimes be associated with high blood pressure, fluid retention and fatigue.

Tests to Determine Apnea

If you have some of the above findings and the suspicion is high that you have significant apnea, a formal evaluation of your sleep is recommended. You have the choice between a home sleep study and a sleep center study. The advantage of a home sleep study are the convenience of home, the comforts of your own bed, the quick turn-around time, and the cost. The advantages of the in-center sleep study are the accuracy of diagnosis – your sleep is being assessed closely in real-time by a certified tech and then reviewed by the sleep doctor; it is also comprehensive and adaptive.

For instance, if someone is found to have significant sleep apnea at the study or has a high enough risk, a split study could be performed where a machine CPAP can be applied. The test uses several inputs, including brain waves, plethysmography (to detect movement of the chest wall), ECG (to detect heart arrhythmias, such as fast heart rate or sick sinus syndrome (fast and slow), pulse oximetry (to detect oxygen measurements and assist in determining apneas (no breaths) and hypopneas (shallow breaths) and a camera (to detect chest wall and leg movement).

1. Home Study
2. In-Center Study
3. Other Tools: Continuous Pulse Oximetry, Smart phone enabled applications

Treatments of Apnea

1. Implements: Jaw chinstrap or mouthpiece. The jaw chinstraps can be useful for mouth breathers (usually when using CPAP or BIPAP). The mouthpiece can prevent the tongue from blocking the airway at the level of the mouth and can be useful for those with mild sleep apnea in select candidates.
2. CPAP: This is continuous positive airway pressure machine, which blows air into the airway to serve as a pressure to allow better inspiration – making apnea risk less severe and improving hyponeas (smaller inspirations). Auto-titrating CPAP, or AutoPAP, is a newer iteration that uses programs to sense the inspiration and provides varied pressure depending on need. Various masks can be used, depending on the findings and preference: Mouth, nasal or face (mouth and nose) mask.
3. BIPAP: Bi-level positive airways pressure. This allows settings at two levels which helps particularly those with more severe cases
4. Oxygen: Occasionally this will be “bled-in”, or provided, in those with more severe cases of sleep apnea or lung diseases such as COPD.

However, the most important treatment for sleep apnea is also the most important prevention: maintain a healthy weight. A weight loss as little as 15 pounds can often produce a 25% improvement in the degree of apnea.