HEALTHNET

An Invisible Killer - Sleep Apnea Syndrome

(Posted on 2 June 2008)

Sleep Apnea Syndrome is very common in Hong Kong. It is estimated that over 100,000 people are suffering from this illness.

What is Sleep Apnea?

Sleep apnea is periods when you stop breathing while you are sleeping. These interruptions in your breathing, which can last 10 seconds or longer, occur when the muscles in your soft palate, uvula, tongue and tonsils relax during sleep. This is the same process involved with normal snoring, but with sleep apnea, the airway narrows so much that it closes. Your breathing stops, cutting off the flow of oxygen into your body and reducing the elimination of carbon dioxide (CO2) from the blood. Your brain detects this rise in CO2 and briefly wakes you up, re-opening your airways and re-starting your breathing. This process can be repeated several times during the night, more than five times per hour is counted as abnormal.

What are the health risks due to untreated sleep apnea?

Long-term brain oxygen deficit caused by untreated sleep apneas may bring other serious illnesses such as hypertension, cardiopulmonary function failure and stroke.

Sleep Apnea can be further classified into three main categories:

1. Obstructive Sleep Apnea (OSA): It is the most common category of sleep-disordered breathing, mainly caused by excessive soft tissue blocking the throat or an overly narrow upper respiratory tract resulting in breathing difficulty which can leads to periodic obsyrcution eventually.
2. Central Sleep Apnea (CSA): It occurs when the brain fails to send the signal to muscles to breathe. This usually occurs in infants or in adults with heart disease, cerebrovascular disease, or congenital diseases.
3. Mixed Sleep Apnea: Patients will have obstructive and central sleep apnea at the same time, such as the central nervous coordination problems together with airway obstruction.

The cardinal symptom of sleep apnea is loud snoring and periodic apnea during sleep. The other common symptoms are headaches, sore and/or dry throat after waking up in the morning, excessive daytime sleepiness.

 

Source: Quality HealthCare Medical Services

 

• Is there a direct relationship between sleep apnea, genes and daily living habits?
• My kids are skinny, should they have less chance of suffering from Sleep Apnea?
• What are the treatments of sleep apnea? What extra attention should the patients be aware in their daily lives?
• Why are we still snoring even without suffering from sleep apnea? Would it affect our health in general?
• What are the ways to improve loud snoring especially when it is affecting your partner's chance for a good night rest and the relationship?
• Assess your day time sleepiness - Epworth Sleepiness Scale
• What is fluid and electrolyte balance? (1)
• What is fluid and electrolyte balance? (2)
• Common diseases in young children - otitis media (1)
• Common diseases in young children - otitis media (2)

Is there a direct relationship between sleep apnea, genes and daily living habits?

Men may not pay attention to their snoring habit. In fact, it is estimated that about four percent of Hong Kong male population are suffering from this illness. Obesity in middle-aged men constitutes among the high-risk population, due to lack of exercises. Lack of exercise leads to increase in body fat and loose muscle tissues will lead to upper respiratory tract congestion.

Sleep apnea can be divided into the causes of congenital and acquired causes. Congenital factors such as Down's syndrome, brain development, and other development anomaly are affecting children mainly. Sleep Apnea is not a hereditary illness; it is mainly caused by the acquired factors including too much fat in the throat and hypoplastic jaw.

In Hong Kong, people tend to believe that taking sleeping pills can ease the sleeping problem. Sleeping pills in fact will suppress central nervous system, thus triggering Sleep Apnea. Smoking can causes pharyngitis. While taking too much alcohol can narrow the airway and loosen breathing muscle, increasing the potential of tongue throat obstruction and suffocation.

In addition, hypertrophic tonsils and adenoid can compromise the upper airway of children. In fact, unlike adult counterparts, children with obstructive sleep apnea syndrome are caused by hypertrophic tonsils and adenoid. Tonsillectomy and adenoidectomy are effective treatment in children with OSA.

Back to top

 

My kids are skinny, should they have less chance of suffering from Sleep Apnea?

Sleep Apnea is not limited to obese persons. Children tend to have symptoms slightly different from adults. Apart from cardinal symptoms of snoring, children with OSA were observed to have labored breathing and gasping during sleep while in the daytime, they exhibit excessive daytime sleepiness, inability to concentrate and hyperactivity. In addition, children suffering from sleep apnea are not always related to obesity, they are more likely to be thin because the brain hypoxia has affected their growth.

Children suffering from obstructive sleep apnea are three times higher at risk to hypertension than the normal children.

Children having high blood pressure will have higher chance of getting deformed blood vessels, thus increasing the risk of stroke when they grow up. Parents should not take it lightly. If your children present heavy snoring and breathing or short-term pause, mouth breathing, waking up with dry throat and bedwetting, immediate medical diagnosis is strongly recommended.

Back to top

 

What are the treatments of sleep apnea? What extra attention should the patients be aware in their daily lives?

Different treatment methods can be employed for various degrees of sleep apnea.

Improving living habits

The first thing patients must do, is improving their living habits. Patients must be aware of their weight problem, take effective measures to lose or control their weight and exercise regularly. Stop smoking, avoid excessive alcohol and sleeping pills. Take a lateral approach to sleep and use special pillows, can both help to improve the condition.

Continuous Positive Airway Pressure Machine(CPAP)

Positive airway pressure, the most widely recommended treatment for moderate to severe obstructive sleep apnea, entails wearing a mask-like device while you are sleeping. The device supplies pressurized air, which helps prevent the airway from collapsing. The most common of these devices is called CPAP (Continuous Positive Airway Pressure), which provides constant positive air pressure to the oral airway when it is collapsed.

Dental appliance

This device opens up the narrow oral airway by drawing lower jaw or tongue forward during sleep.

Surgery

Surgery can be performed to reconstruct the jaw and enlarge the upper airway if the above treatments are proven to be ineffective, or patients do not prefer wearing a sleeping-mask. The operation process can be divided into stages to counteract the different levels of obstruction in the airway. They include correction of the nasal septum, resection of nasal turbinates, laser assisted uvulpalatal surgery, advancement of mandible and maxilla, tonsillectomy and adenoidectomy etc.

Back to top

 

Why are we still snoring even without suffering from sleep apnea? Would it affect our health in general?

Snoring is caused by a narrowing of your airway, either from poor sleep posture or abnormalities of the soft tissues in your throat. A narrow airway interferes smooth breathing and creates the "snore" sound caused by vibration of uvula. Although Sleep Apnea patients will snore, it does not necessarily means one is suffering from sleep apnea. Snoring itself will not pose a health threat, but if it is caused by sleep apnea, immediate doctor diagnosis is suggested.

Back to top

 

What are the ways to improve loud snoring especially when it is affecting your partner's chance for a good night rest and the relationship?

Finding a cure for your snoring problem can improve the quality of life for you and your loved ones. Losing weight will reduce the fatty tissue in your airway. Eating light and improving your fitness level can significantly improve your ability to breathe freely when you sleep.

For less severe cases, you can use nose paste, mouth guard, and other support to help. While for those acute cases, you may consider increasing the size of your airway by surgically removing the tissues or correcting the abnormalities. In addition, two other approaches could also be considered:

1. Using a laser, radiofrequency energy, or a surgery to remove tonsils, adenoids and excess tissue at the back of the throat or inside the nose, or to reconstruct the jaw.
2. Palatal implantation with Teflon pillars a new surgery, which has shown promising results for snorers recently. Small Teflon implants, less than an inch-long in size, are inserted into the soft palate stiffening the uvula and reduce the snoring sound.

Back to top

Assess your day time sleepiness - Epworth Sleepiness Scale

Most snoring people are unaware of the potential threat of sleep apnea. Before seeking doctor's diagnosis, you can try the following sleepiness scale test (Epworth Sleepiness Scale), which will help you assess the level of daytime sleepiness.

Have your ever dozed in the following situations (not just feeling tired, but really fell asleep)? Please try to circle the closest answer.

Criteria:

Total Score:

 

Breaking it down further, you are having excessive daytime sleepiness if you scored higher than 10. If you are having a snoring problem at the same time, you may be suffering from Sleep Apnea already, immediate medical diagnosis is suggested.

Back to top

What is fluid and electrolyte balance? (1)

Total body water contributes to 40% to 60% of total body weight, playing an important role in physiological function. This percentage of water varies with age and sex, with infants having 75% to 85% of body weight being water. This percentage in man is greater than that in woman. Two-third of the body fluid contributes the intracellular fluid, while the other one-third the extracellular fluid, which constitutes the plasma, lymph, connective tissue. Electrolytes are present in the body fluid. Sodium (Na+), chloride (Cl-) and bicarbonate (HCO3-) are predominant in the extracellular space; while potassium (K+), magnesium (Mg2+) and phosphate (PO32-) are the major intracellular ions. Solute concentration of electrolytes and the volume of intracellular or extracellular fluid are inter-related.

The kidneys control the volume of body fluid by excretion of more concentrated urine or of relatively diluted urine. Body fluid is also loss through feces, skin and the lung. Volume depletion or dehydration is a kind of fluid and electrolyte imbalances and can be due to vomiting, diarrhea, excessive sweating, burns or fever. Normally every electrolyte is present at a fixed range of concentration, regulated by the kidney and other systems of the body. Deviation from the normal electrolyte concentration will cause problems in body function and required treatment specifically.

Disturbance of serum sodium presents in the form of hyponatremia (abnormally low sodium concentration) or hypernatremia (abnormally high sodium concentration). Serum sodium measurement is not an absolute amount of sodium in the body, but the concentration of sodium in the extracellular fluid and is a reflection of water balance. Hyponatremia can be due to increase in total body water or can be due to true low sodium level (due to decrease in absorption or increase in excretion). Treatment for hyponatremia varies with underlying etiologies. Either fluid and sodium restriction or replacement of fluid and electrolyte may be required. Hypernatremia can accompany dehydration or arise from problem in the kidney. The water deficit in hypernatremia should be replaced with hypotonic solution such as 0.45% or 0.3% sodium chloride solution or dextrose 5% solution.

 

Source: Hong Kong and Drug Education Resources Centre, The Society of Hospital Pharmacists of Hong Kong

Back to top

What is fluid and electrolyte balance? (2)

Hypokalemia (abnormally low potassium concentration) and hyperkalemia (abnormally high potassium concentration) are disturbance in serum potassium level. Medications such as diuretics, penicillins, and angiotensin-converting enzyme inhibitors (a type of cardiovascular medication), etc., can lead to disturbance in potassium concentration. Oral or intravenous absorption of potassium and function of the kidney also affect serum potassium level. Around 98% of potassium ion is stored inside cells, a shift of potassium from intracellular to extracellular fluid can cause high potassium level and vice versa. Symptoms of potassium imbalance included weakness, in severe case included arrhythmia and even arrest. Treatment for hypokalemia included oral or intravenous potassium supplementation; hyperkalemia require different treatment strategies according to patients' status.

Calcium is mainly found inside bone, the rest found in intracellular and extracellular fluid as an electrolyte are responsible for physiological functioning. Vitamin D help absorption of calcium, therefore deficiency in vitamin D may lead to hypocalcemia; decrease in parathyroid hormone level also cause hypocalcemia. Hypocalcemia can be treated with oral calcium supplement. Parathyroid hormone or thyroid hormone increase can cause hypercalemia, as can the breaking down of bone in some disease states leading to release of calcium from bone to the bloodstream. Treatment method included giving normal saline with diuretics to aid excretion of calcium, or giving medications such as calcitonin or biphosphonates, etc.

Sodium, potassium and calcium talked above are the electrolytes commonly causing problems, while balance of magnesium, phosphate and bicarbonate ions in serum is also important. The above is just a brief introduction on the water and electrolytes system; in fact the balance of electrolytes and water in the body is a very complicated issue, regulated by different hormones and organs and may also be affected by food and drugs. Symptoms of electrolyte disturbances are non-specific and may be present only when deviation in serum level is great, so blood test is usually required for diagnosis. Underlying disorders causing electrolyte disturbances should be treated apart from correcting the serum levels.

 

Source: Hong Kong and Drug Education Resources Centre, The Society of Hospital Pharmacists of Hong Kong

Back to top

Common diseases in young children - otitis media (1)

What is otitis media?

Generally speaking, otitis media is defined as the inflammation of the middle ear. It is the commonest illness in infants & young children. Three out of four children have experienced otitis media by the time they are 3 years old.

How many kinds of otitis media?

Clinically, otitis media is classified according to the clinical presentation: symptomatic (e.g. acute otitis media & unresponsive otitis media) and asymptomatic (e.g. persistent otitis media, chronic otitis media etc.) Other than that, inflammation with or without effusion is used to diagnose & treat otitis media.

What is the aetiology of otitis media:

Otitis media is the commonest in young children because of their eustachian tube are shorter, relatively wider and more horizontal than those of the adult. Moreover, the muscle responsible for the opening of the eustachian tube is less efficient. It may cause the reflux or accumulation of liquid in the middle ear and further develops inflammation. In addition, acute otitis media is a common accompaniment to upper respiratory tract infection in the cold seasons. Frequent exposure to smoking, attending long day care centers & allergic rhinitis, etc. are the risk factors.

Earache implies otitis media?

Not necessary true! Mumps, toothache, otitis externa, etc. may present with a major complaint of earache. For acute otitis media, the onset is rapid and the children may tug at the ears and cry. Fever, increased irritability and difficulty in feeding or sleeping are the usual symptoms. However, infants may not be able to tug ears. They demonstrate the discomfort by refusing to eat or crying bitterly. On the contrary, for persistent or chronic otitis media, the children may not complain about any earache or fever. Hearing loss and effusion may be the symptoms. Therefore, it is important to pay attention to their presentations. In any doubts, consultation of the pediatrician will be helpful.

 

Source: Hong Kong and Drug Education Resources Centre, The Society of Hospital Pharmacists of Hong Kong

Back to top

Common diseases in young children - otitis media (2)

While many cases of acute otitis media will spontaneously resolve, medicine may still be useful in the disease management. There are 5 main goals in treating otitis media:

1. Control of pain
2. Eradication of infection
3. Avoidance of unnecessary antibiotics
4. Prevention of complications
5. Minimization of adverse effects of therapy

Pharmacological therapy:

An analgesic & antipyretic drug like Paracetamol is beneficial in the comfort of the children. In case, there is a sight of bacterial infection, oral antibiotics e.g. Amoxicillin and Trimethoprim + Sulfamethoxazole, etc. will be prescribed. Particularly, in the management of chronic otitis media, low - dose antibiotics should be administered daily as a prophylaxis in order to reduce the risk of its recurrent & hearing loss.

Furthermore, topical antibiotic ear drop only be used in the children with considerable purulent drainage from the ear.

However, antihistamines or decongestants which are commonly prescribed in the upper respiratory tract infection are ineffective in the treatment of otitis media.

Non-pharmacological therapy:

Myringotomy or tympanocentesis (incision of the tympanic membrane), or insertion of ventilation tubes will usually be recommended in treating the unresolved pain which is due to the build-up of mucopurulent secretion in the middle ear or chronic otitis media.

Precautions:

1. It is important to adherent to the drug therapy especially antibiotic therapy.
2. Should consult a physician when the children do not respond to quiet sounds; do not keep balance; do tug their ears often, or fluid draining out from their ears. These might be the signs of ear infection.
3. Should pay attention while the children got a cold because otitis media is one of complications.
4. Avoid smoking around the children.

Since young children will get ear infection easily anatomically & may not be able to present the symptoms, it is highly recommended to consult a pediatrician if any doubts.

 

Source: Hong Kong and Drug Education Resources Centre, The Society of Hospital Pharmacists of Hong Kong

Back to top

 

2008 Issues: Jan . Feb . Mar . Apr . May . Jun . Jul . Aug . Sep . Oct        More stories