In his classic short story, “The Night the Bed Fell,” humorist James Thurber remembered “a nervous first cousin of mine,” who never went to sleep without a glass of “spirits of camphor, a powerful reviver,” by his bed. He instructed anyone nearby to guard him closely, and if he stopped breathing during his sleep, they were to dash that in his face to arouse him. (Spoiler alert: They did.)
In Thurber’s tale, this was just one of a series of misadventures his family endured on that memorable night. But for millions of people — up to 30 percent of males, and 15 percent of females, including children — not breathing during sleep is more than just a fear, but a very real condition called sleep apnea.
“Sleep apnea can occur in two forms,” says Dr. Rabin Shrestha, program director of sleep medicine at the University of Tennessee Health Science Center and section chief of pulmonary, critical care, and sleep medicine at the VA Medical Center. “Obstructive sleep apnea is caused by an obstruction in the airway — from your throat, down your trachea, and all the way down into your lungs. It’s the most common type, affecting some 95 percent of all patients. The other form, central sleep apnea, happens when the brain is not sending you the signal to breathe.”
Many times, the patient isn’t aware they have a problem. Instead, someone sleeping with them notices unusual snoring or periods when their bed partner stops breathing, from a few seconds to half a minute. When this happens all night long, it’s time to consult a sleep specialist. “Stopping less than five times an hour is normal,” says Shrestha. “Everybody does that. If you stop five to 15 times, we consider that mild apnea, and 15 to 30 times is moderate. But if you stop breathing more than 30 times an hour, all night long, that’s a serious problem.”
Sleep apnea is more than an inconvenience. “It affects your whole quality of life,” says Shrestha. “Medical, psychological, and social problems can all be consequences of inadequate sleep.”
If left untreated, long-term sleep apnea can increase blood pressure, provoke heart rhythm problems like atrial fibrillation, and in some cases can cause more serious heart problems — even cardiac arrest. It also can lead to cognitive impairment, lethargy, and fatigue. And those can induce other problems, such as motor vehicle accidents. “If you look at most industrial accidents,” says Shrestha, “in one way or another, they can be linked to inadequate or abnormal sleep.”
Sleep specialists screen for apnea with the “STOPBANG” series of questions. “That’s a mnemonic device,” says Shrestha. “S is for snoring — do you snore at night, or does someone else say you do? T is for tired — are you tired during the day? O is observed apnea — has anyone else observed that you stop breathing? P stands for pressure, or hypertension, since sleep apnea can cause (or be the result of) high blood pressure. B is BMI, or body mass index; if it’s more than 35, you’re at risk. A is age; more than 50 is a risk factor. N is neck circumference; a neck size over 16 inches is a risk factor. And G is gender; males are at higher risk than females.”
If a patient answers “yes” to three questions, they should be evaluated. More than five requires a sleep study.
In the past, this meant spending the night in the hospital, hooked up to electrodes and sensors that monitored breathing, heart rate, brain waves, and even uncontrolled leg movement. The study was expensive, and patients often had trouble falling asleep in a strange environment, with so many wires attached to their scalp, face, and chest.
These days, thanks to advances in diagnostic equipment, patients can conduct sleep studies at home. “We use simple gadgets like a watch, something that goes on your chest, and all of these readings go to your phone,” says Shrestha. “By morning, all this data has already been sent to your doctor.”
He cautions that home sleep study “has changed the way we diagnose sleep apnea, but it’s not for everyone. It’s not for patients who have heart conditions, or if we suspect it is central sleep apnea, which is a neurological condition.”
If a patient has sleep apnea, Shrestha says the “gold standard for treatment” is CPAP, or “continuous positive airway pressure.” This small bedside machine connects to an air mask. “They [CPAPs] give you a variable pressure that keeps your airway open, so the patient is able to breathe at night. There is no desaturation, or dropping of oxygen, and no waking up throughout the night because there is no collapse of the airway.”
Unfortunately, many patients say they cannot tolerate wearing the mask, the noise from the machine, or the pressure from the air pumped into their lungs. “Some patients have told me that, in their sleep, they have pulled off the mask because it was so uncomfortable. So CPAP is the gold standard for treatment, but we do realize it’s not for everyone.”
He urges patients to be, well, patient with their new device. “Noise is a common complaint, but it’s really not noisy. It’s like a fan blowing, and you get used to it. It’s certainly not as loud as snoring. And wearing the mask is like getting used to eyeglasses the first time you wear them. After a while, you don’t even notice them.”
The other complaint with CPAP machines is the regular cleaning they require. “But that is not a big deal,” says Shrestha. “When you wake up and brush your teeth, wash out the mask as well. Other parts, like the hose, only need to be cleaned once a week. It’s really not that hard.”
High-tech devices are available for sanitizing CPAP machines, some of them using sound waves or ultraviolet light. One product even adds a pleasant flavor to the air patients breathe. “The advertisement says, when you go to bed there’s a good flavor of vanilla and you can dream better,” says Shrestha. “Stay away from those; they offer no real benefit. Just use regular soap and water, hang it somewhere to dry, and it’s ready to use that evening.”
Even so, other treatments are available. If the problem is caused by the malformation of a patient’s throat or palate, they can wear a mouthpiece that moves the jaw forward just slightly — enough to open the airway. Other patients, especially children, can benefit from surgery, especially if they still have their tonsils or adenoids, which can become enlarged over time.
Medications can also help patients, especially if they are overweight. “A medicine has recently been approved for sleep apnea,” says Shrestha. “Believe it or not, it’s one of those weight-loss drugs, but it significantly reduces your sleep apnea numbers from severe to moderate, or moderate to mild.”
One device though, has caught the attention of sleep apnea patients, and physicians approve of it. For anyone suffering from obstructive sleep apnea, where the problem is caused by the position of their tongue, the Inspire Apnea Device may offer a solution.
“A small neurostimulator goes under the skin in the chest, with a wire leading to the hypoglossal nerve, which controls the tongue,” says Shrestha. “This works by sending a small electrical impulse to the tongue, which moves it forward and keeps the airway open. Some patients say it causes a tiny bit of discomfort, like a tingling sensation, but it works.”
For patients with central sleep apnea, where the problem is caused by the brain not telling the body to breathe, another device has been approved, but it’s more complicated. Called the Remede System, it’s a type of pacemaker, but for the diaphragm that controls the lungs.
“It is positionally activated only when you are asleep,” says Shrestha. “Let’s say you don’t move for a certain time, like 30 minutes. The machine will determine you are asleep, and it will activate and start moving your diaphragm to breathe for you.”
Sleep apnea is more than an inconvenience. “It affects your whole quality of life,” says Shrestha. “Medical, psychological, and social problems can all be consequences of inadequate sleep.” Fortunately, new procedures, medications, and devices can manage the problem — much better than keeping a glass of foul-smelling camphor by your bed every night.
