How to Know When Obstructive Sleep Apnea Is Severe

June 14, 2022

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Lack of sleep can be a problem. Just how big of a problem, however, depends on the cause.

Maybe your patient and their spouse have developed a habit of watching a favorite TV show after finally getting the kids to bed. Maybe well-intentioned plans to simply get in one episode of your current binge-watch get derailed by a clever cliffhanger, and you’re pulled into an additional one or two installments. Your patients know they are going to pay for it the next day, but, darn it, they just can’t hit the off button on the remote seeing how the latest twist in Good Girls turns out.

Your patients can compensate and take corrective action, of course, by taking a nap or getting to bed earlier the next night. But if there is a health-related issue behind the current sleep deprivation—like obstructive sleep apnea, for example—then there are more important considerations in play, and addressing the root cause of the problem becomes imperative.

If you have a feeling that a patient’s lack of sleep may be more related to sleep apnea than to being hooked on Season Two of Love is Blind, then it’s time to discuss the types, complications, diagnosis, and treatment of sleep apnea with your patient.

Different Types of Sleep Apnea

Before getting too far into the discussion, it’s best to point out that there are three types of sleep apnea, a serious disorder where your breathing suffers a series of stops and starts during the night. The first, obstructive sleep apnea (OSA), occurs when throat muscles relax during sleep and block your airway. The second, central sleep apnea, happens when your brain doesn’t send the proper signals to the muscles that control your breathing. The third, complex sleep apnea, occurs when a person has both obstructive and central sleep apnea.2

OSA is the most common type of sleep apnea. Symptoms of OSA include the following:

  • Loud snoring
  • Episodes of stopped breathing
  • Waking up gasping for air
  • Morning headache
  • Awakening with a dry mouth
  • Difficulty staying asleep
  • Excessive daytime drowsiness
  • Difficulty focusing or paying attention
  • Irritability2

The severity of OSA is determined by the apnea-hypopnea index (AHI), which measures the number of apneas (breathing cessation) and hypopneas (shallow breathing) per hour of sleep during a sleep study.4 OSA is considered severe when a patient has 30 or more apnea or hypopnea events in an hour.4 A diagnosis of severe OSA indicates your patient is more likely to experience numerous health complications.

Complications of OSA

There are myriad complications of OSA. Some of the most common include these:

  • Daytime fatigue and drowsiness
  • Cardiovascular problems
  • Complications with medicine and surgery
  • Eye problems
  • Sleep-deprived partners2

Daytime fatigue and general sluggishness can severely affect OSA sufferers in many ways. First, they often have trouble staying awake or focusing on the task at hand. While this certainly affects overall work performance and increases the risk of at-work accidents, it also presents a clear danger when traveling to and from employment as it hinders alertness behind the wheel.2

OSA takes an additional toll as sudden drops in blood oxygen levels increase blood pressure and put extra strain on the cardiovascular system. This can lead to a litany of health issues such as high blood pressure and an increased risk of heart disease, coronary artery disease, heart attacks, heart failure, strokes, and arrhythmias (abnormal heart rhythms).4 Some research even indicates a connection between OSA and glaucoma, or additional eye issues. These, however, can usually be treated.6

OSA also bears extra scrutiny when it comes to medications and surgery. General anesthetics as well as certain medications (like sedatives and narcotic analgesics) relax a person’s upper airway. OSA sufferers are prone to further potential complications following surgery due to breathing problems that are exacerbated by being sedated and lying on your back.4 Patients with OSA symptoms should consult with their physicians before surgery.

Memory problems, type 2 diabetes, morning headaches, mood swings, and depression have also been linked to OSA.2

Treatment for Severe OSA

Managing patients with severe OSA is best accomplished by an interprofessional team of sleep specialists, including a primary provider, cardiologist, otolaryngologist, dietitian, pulmonologist, neurologist, and dentist.2 While continuous positive airway pressure (CPAP) therapy is considered the gold-standard treatment for severe OSA, oral appliances (OA) can also help alleviate symptoms of severe OSA.3

OA and CPAP are commonly viewed as alternative treatment pathways. For patients with severe OSA, however, the use of both an OA and CPAP could be a superior treatment option.3 Patients may also benefit from alternating between the two therapies in situations such as travel when CPAP is inconvenient.1,3 The American Academy of Sleep Medicine (AASM) recommends OAs as first-line therapy in patients with mild-to-moderate OSA and for severe OSA patients who fail treatment attempts with CPAP therapy.

The most common mechanism of action of OAs is to hold the lower jaw in a more anterior position. These types of OAs are referred to as mandibular advancement devices (MAD), mandibular advancement splints (MAS), or mandibular repositioning appliances (MRA).3 For patients suffering from severe OSA, one study found that OA therapy was more successful when the mandible was advanced 75 percent compared to 50 percent, which indicates maximizing advancement is more important for severe disease.3  A recent study found mandibular advancement devices have a similar impact to CPAP on patient-centered outcomes, such as sleepiness and quality of life, in severe OSA patients. CPAP was more effective in reducing AHI, but treatment compliance was in favor of mandibular advancement appliances.5 

Untreated sleep apnea can cause long-term consequences for your patients’ health. If you suspect a patient has OSA, discuss how OSA can affect their quality of life, how they can receive a formal diagnosis, and what treatment options they have to consider. When discussing treatment options with a patient and their sleep medicine team, it is important to personalize treatment for each patient to ensure the resolution of symptoms. Your patient and their significant other will thank you.

To learn more about how OSA can affect your patients, visit The Vivos Institute blog.

References

1. Ramar, K., Dort, L. C., Katz, S. G., Lettieri, C. J., Harrod, C. G., Thomas, S. M., & Chervin, R. D. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015: An American academy of sleep medicine and American academy of dental sleep medicine clinical practice guideline. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 11(7), 773–827. doi:10.5664/jcsm.4858

2. Slowik, J. M., & Collen, J. F. (2022). Obstructive Sleep Apnea. StatPearls Publishing

3. Sutherland, K., Vanderveken, O. M., Tsuda, H., Marklund, M., Gagnadoux, F., Kushida, C. A., & Cistulli, P. A. (2014). Oral appliance treatment for obstructive sleep apnea: an update. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 10(2), 215–227. doi:10.5664/jcsm.346

4. Tietjens, J. R., Claman, D., Kezirian, E. J., De Marco, T., Mirzayan, A., Sadroonri, B., & Yeghiazarians, Y. (2019). Obstructive sleep apnea in cardiovascular disease: A review of the literature and proposed multidisciplinary clinical management strategy. Journal of the American Heart Association, 8(1), e010440. doi:10.1161/JAHA.118.010440

5. Trzepizur, W., Cistulli, P. A., Glos, M., Vielle, B., Sutherland, K., Wijkstra, P. J.,&Gagnadoux, F. (2021). Health outcomes of continuous positive airway pressure versus mandibular advancement device for the treatment of severe obstructive sleep apnea: an individual participant data meta-analysis. Sleep, 44(7). doi:10.1093/sleep/zsab01

6. Wong, B., & Fraser, C. L. (2019). Obstructive sleep apnea in neuro-ophthalmology. Journal of Neuro-Ophthalmology: The Official Journal of the North American Neuro-Ophthalmology Society, 39(3), 370–379. doi:10.1097/WNO.0000000000000728