Ask the Pharmacist

Q) How is sleep apnea diagnosed and are there any other types of treatment beyond those masks that most people seem to sleep with?

A) Before the Omicron variant deservedly ran away with our collective attention, we had been discussing symptoms that are not commonly associated with sleep apnea. A brief summary of that earlier column discussed the usual symptoms that we think of with apnea such as snoring and daytime somnolence and the less common ones like frequent urination, hot flashes/ night sweats among others.

The gold standard for the diagnosis of this condition is an overnight stay at a clinic where the subject is hooked up to a barrage of wires that monitor the number of times your breathing stops or slows during the night (which is essentially the definition of apnea), find high or low levels of activity in the muscles that control your breathing, examine your blood oxygen levels as well as your heart and brain activity. We call this whole procedure a “sleep study” which is one of the rare medical terms that accurately describes its purpose for those of us who have not spent a lifetime studying medical terminology. Based on the number of apnea type of events during the study, you may be diagnosed with mild (5-14 / hour), moderate (15-29/ hour) or severe sleep apnea. Blood tests may also be taken to rule out endocrine disorders which can lead to altered levels in your hormones and ultimately be contributing to your sleep issues.

There are three types of sleep apnea.

Obstructive sleep apnea is by far the most common form. It occurs when your airways are blocked (either partially or completely) during sleep due to the soft tissue in in the back of your throat collapsing. As a result of this, the other muscles involved in breathing, such as the ones in our diaphragm and chest, have to work harder in an effort to keep the airways open. This tends to lead to poor sleep quality and a lower flow of oxygen to your organs such as the heart.

Central sleep apnea is another type and instead of there being an blocked airway, there is a dysfunction of your central nervous system. This results in your brain failing to send the proper signals to the muscles that control your breathing. It occurs usually as a result of complications from other pre-existing medical conditions such as having had a stroke in the past, or being diagnosed with heart failure, ALS (Lou Gehrig’s disease), or either kidney or lung disease.

The last type of apnea is referred to as complex sleep apnea which is diagnosed when the individual’s sleep is affected by both obstructive and central factors.

The CPAP (continuous positive airway pressure) machine is almost always the first treatment tried for obstructive sleep apnea due to its terrific history of being safe, effective and reliable. The machine (about the size of an old clock radio) plugs into an outlet beside one’s bed and is connected to your face by a flexible plastic tube and mask/ prongs that cover either the mouth and nose or just the nostrils. The CPAP blows air into the airways causing them to remain open. Despite their track record of success, many individuals stop using them shortly after they have purchased it because they find it hard to tolerate for a variety of reasons. This is unfortunate but the silver lining is that this has caused a number of other treatment options to be devised to fill this gap.

There is another machine called a BPAP (bilevel positive airway pressure) device. In looks and action, this machine very closely resembles a CPAP device but differs in that it releases air at a higher pressure during a sleeper’s inhale and then changes to a lower pressure during the exhale. This makes the BPAP an excellent choice for those who found they had problems exhaling while using a CPAP (where the air pressure is constant). BPAP’s are also useful for those with apnea who are also extremely heavy or have been diagnosed with COPD.

Autonomic positive airway pressure (APAP) machines are another variation of the CPAP. These use pressure sensors to calculate the exact pressure of air a sleeper might need at that particular moment which depends on your sleeping position, sleep stage and how congested you may be and adjust the air flow delivered accordingly. This can make an APAP more comfortable for those who find the consistent flow of air from a CPAP bothersome.

EPAP (expiratory positive airway pressure) is very different from the other options in that it is not a machine but rather just a nasal mask that consists of two small valves that fit inside the nostrils. These valves serve to keep the airway expanded by creating resistance when a person exhales. While it is a newer therapy than the other options we have listed, it is becoming increasingly popular since it requires no electricity or tubing, is relatively inexpensive, is very portable due to its small size and creates little to no noise. It costs in the neighbourhood of $150 and should last about one year.

For those who cannot stand the thought of a mask or nasal prongs, perhaps an oral appliance might be a suitable option. These appliances are worn in the mouth like a sports mouth guard and work by holding the lower jaw forward just enough to keep the airway open. They are considered, along with the machines cited above, as first-line therapy for mild to moderate levels of apnea. They are sometimes used with a CPAP machine in severe apnea so as to allow the pressure generated by the machine to be dialled down somewhat making the CPAP more comfortable to use.

The two most common types of oral appliances are mandibular advanced splints (MAS) and tongue retaining devices. MAS are custom made by a dentist and fit over the top and bottom teeth and serve to keep the jaw and tongue forward. Tongue-retaining devices use suction to keep the tongue from rolling back and blocking the airway.

Lastly, there are a host of surgical solutions that can be tried if less invasive measures are not tolerated or fail to correct the apnea. The surgery can involve tissue removal, jaw repositioning, the nose and sinus cavity or the tongue itself. There are also newer nerve stimulation surgeries where an implant is inserted into the body and stimulates the appropriate nerves when apnea is detected.

With so many different treatment options, along with lifestyle modifications (lose weight, quit smoking, avoid alcohol and sedatives which relax airway muscles, practise throat exercises and learn to sleep on your side), there usually is a solution for even the most severe cases of sleep apnea.  For more information about this or any other health related questions, contact your pharmacist.