About Sleep Apnea ABOUT SLEEP APNEA

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1 ABOUT SLEEP APNEA About Sleep Apnea What is Sleep Apnea? Sleep Apnea (from Greek, meaning "without breath") is one of the most common sleep disorders in which breathing stops and then restarts again recurrently during slumber. Obstructive Sleep Apnea (OSA), occurs when the airway temporarily collapses during sleep, preventing or restricting breathing for up to ten seconds or more. OSA patients will commonly suffer from low oxygen levels in the blood, high blood pressure and an overall decrease in the quality of life due to daytime drowsiness and headaches. Breathing pauses can last from a few seconds to minutes. Such events can occur several hundred times a night severely disrupting sleep. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound. The term "sleep-disordered breathing" (SDB) includes a spectrum of respiratory disorders ranging in severity from snoring to OSA. Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep 3 or more nights each week. You often move out of deep sleep and into light sleep when your breathing pauses or becomes shallow. This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness. Prevalence-Over 40 million Americans suffer from a sleep disorder, and 20 million suffer from OSA. Despite the high prevalence, 93% of women and 82% of men with moderate to severe OSA remain undiagnosed. In a community-based study, men were found to be 2 times more likely than women to have OSA. However, men are 8 times more likely to be treated for OSA than women. This suggests that the symptoms of OSA in women are often attributed to other conditions, such as chronic fatigue syndrome, depression, and fibromyalgia. Untreated OSA can severely affect quality of life, health and mortality. Clinical research shows that it is linked strongly to a range of serious, even life-threatening, chronic diseases such as stroke, heart failure, hypertension, diabetes, obesity and coronary heart disease. 70 million suffer sleep deprivation of which 40 million have a chronic disorder; 20 million OSA patients, only 5% of which have been diagnosed and treated The US OSA market is estimated at $2.5 Billion with an AGR of over 20% Currently, there is a greater than one month patient wait time for sleep lab evaluations. SDB affects around 20% of the adult population¹, making it as widespread as diabetes or asthma. However, awareness is low and we believe that about 90% of people who have OSA remain undiagnosed and

2 untreated. Along with an increasing understanding of the morbidity and mortality caused by SDB, this discrepancy has created one of the fastest growing segments of the respiratory industry. What Causes Sleep Apnea? Obstructive Sleep Apnea(OSA) occurs in individuals whose upper airway is narrower or more collapsible than normal. The most common cause of this airway abnormality is obesity. Having a large neck (men: greater than 16.5 inches around, women: greater than 15 inches around) increases your risk for OSA, because it narrows the airway. In small children, large tonsils are the most common cause of OSA. For some people with smaller jaws, OSA can also be more common. The drawing below shows the airway of a healthy individual (left) and an OSA patient (right). During sleep, the healthy patient is breathing normally without blockage, but the OSA patient's upper airway is obstructed, with the arrows showing the blockage. When your brain is given the choice between sleeping and breathing, it always picks breathing. So with obstructed breathing, your brain's response is to wake up. These awakenings are very brief and often are not remembered unless you wake up choking. Your throat muscles respond to your brain's message to wake up, you begin breathing again, your blood oxygen levels return to normal, and then you fall back asleep. If your airway partially closes and then you wake up, it is called a hypopnea. If your airway fully closes, it is called an apnea. Summary of causes of Sleep Apnea- If you have obstructive sleep apnea, your airway can be blocked or narrowed during sleep because: Your throat muscles and tongue relax more than normal. Your tongue and tonsils (tissue masses in the back of your mouth) are large compared to the opening into your windpipe. You are overweight. The extra soft fat tissue can thicken the wall of the windpipe. This causes the inside opening to narrow and makes it harder to keep open. The shape of your head and neck (bony structure) may cause a smaller airway size in the mouth and throat area. The aging process limits the ability of brain signals to keep your throat muscles stiff during sleep. This makes it more likely that the airway will narrow or collapse.

3 What are the symptoms of Obstructive Sleep Apnea? The most common symptom of OSA is loud snoring, dry mouth, sore throat, or headaches in the morning-snorers may not realize that they have difficulty breathing at night unless there is someone listening to them who can tell them that they snore, or sound like they are holding their breath. Having someone to watch and listen to you sleep can be very helpful. If a bed partner witnesses that you stop breathing, it is a warning that you may have Obstructive Sleep Apnea. Loud snoring can affect the bed partner's ability to get a good night sleep as well! The next most common symptom is sleepiness during the day. Each time the OSA patient fails to breathe they must awaken sufficiently to get a breath and their sleep is interrupted. Patients may develop sleepiness so slowly over the years that they "forget" what normal alertness is like. Many patients with severe sleep apnea are unable to reach a sleep state that allows them to dream. Other people can be affected by severe sleepiness, as well: Patients with severe OSA are 2-7 times more likely to have a motor vehicle accident creating additional OSA victims!-other symptoms of OSA include dry mouth, sore throat, or headaches in the morning. Some patients suffer from impotence or having to use the restroom several times during the night. Others have restless sleep or night sweats. Depression, irritability, morning confusion, and inability to think clearly have all been linked to OSA. Most Common Symptoms of Sleep Apnea (OSA) Loud snoring, which is usually more prominent in obstructive sleep apnea Morning headache Observed episodes of breathing cessation during sleep Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea Excessive daytime sleepiness (hypersomnia) Awakening with a dry mouth or sore throat Difficulty staying asleep (insomnia) Frequent trips to the bathroom (Nocturia) Sleep Apnea Risk Factors The most common cause of OSA is obesity. Having a large neck (men: greater than 16.5 inches around, women: greater than 15 inches around) increases your risk for OSA, as it collapses the airway. In small children, large tonsils are the most common cause of OSA. High blood pressure is also commonly linked to OSA. It is important to check your family history and ask a spouse or loved one if they sense your snoring or you stop breathing during the night.

4 Most common risks of Sleep Apnea Neck Circumference-The size of your neck may indicate whether or not you have an increased risk of sleep apnea. That is because a thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 16.5 inches is associated with an increased risk of obstructive sleep apnea. High blood pressure (hypertension) Sleep apnea is not uncommon in people with hypertension. Obesity or Excess weight Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people develop the disorder, too. A narrowed airway: You may inherit a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway. Male vs. Female: Men are twice as likely to have sleep apnea as women are. However, women increase their risk if they are overweight, and the risk also appears to rise after menopause. Age Sleep apnea occurs two to three times more often in adults older than 65. Family history If you have family members with sleep apnea, you may be at increased risk. Alcohol, sedatives or tranquilizers These substances relax the muscles in your throat. Smoking Smokers are three times as likely to have obstructive sleep apnea than are people who've never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after you quit smoking. Sleep Apnea (OSA) & Heart Disease

5 The circulatory system (heart and blood) is responsible for delivering oxygen to all the cells in your body. Every time an OSA patient stops breathing during the night, the amount of oxygen in the blood decreases, which means the cells in the body are not getting the oxygen they need. Heart rate increases in an effort to raise oxygen levels in the blood and deliver oxygen to cells. When this happens repeatedly throughout the night, it increases the stress on your circulatory system and creates a serious medical condition. Some studies suggest that OSA causes hypertension (high blood pressure). OSA is also strongly correlated with the following cardiovascular conditions: Congestive heart failure Stroke Coronary artery disease Myocardial infarction Cardiac arrhythmias Other Complications correlated to Sleep Apnea Daytime Fatigue-Severe daytime drowsiness, fatigue, and irritability are common complications related to Sleep Apnea. Normal, restorative sleep is virtually impossible due to the repeated awakenings associated with sleep apnea. People complain and have difficulty concentrating or find they fall asleep at work, while watching TV or even while driving. Another strong indicator is irritability, moodiness, or depression. Sleep apnea is also linked to children and adolescents who may do poorly in school or have behavioral problems. Headaches Sleep apnea can cause morning headaches, memory problems, mood swings, and feelings of depression. You are irritable and have to deal with headaches associated with a lack of sleep. Impotence For snorers and those who suffer from sleep apnea, erectile dysfunction is more common. During sleep, the cessation of breathing (apneas) causes blood pressure to rise, which puts a strain on the vascular system. High blood pressure can suppress an interest in sex. Hormone levels and blood vessels are affected by the reduction in oxygen in the blood caused by sleep apnea. Medications A complication with medications and obstructive sleep apnea is also a concern with general anesthesia and certain medications. Prior to any surgery, it is important that you get tested for sleep apnea and you doctor is aware of you condition. People are prone to breathing issues when sedated and lying on their backs.

6 *It is important that you get tested for sleep apnea and your doctor is aware of your condition *. Your Partner-Many partners of people who have sleep apnea and/or snore are sleep deprived. There are studies that link weight gain to the partners of those who have sleep apnea. It is common for a partner to have to sleep in another room in order to get a good night's sleep. Ask your partner if you keep them up at night! Other Issues Another issue is nocturia, or the need to urinate frequently at night. Gastroesophageal reflux disease (GERD) may be more prevalent in people with sleep apnea. Children with untreated sleep apnea may be hyperactive and may be diagnosed with attention-deficit/hyperactivity disorder (ADHD). Sleep Apnea Test and Diagnosis The greatest technology advances in sleep have been made in the diagnostic technology for the home solution, focusing on size, comfort, ease to use and accuracy of sleep test results. Sleep facilities' technology for conducting diagnostic testing procedures has been relatively stagnant for several years. Therapeutic device technology (i.e. CPAP) has been improved over time to facilitate ease of use and patient comfort. The greatest technology advances in sleep have been made in the diagnostic technology for the home solution. Home solutions technology focused on size, comfort and ease of use. There are two major sleep study tests that are widely accepted: Home Sleep Test This test is conducted at the home of the patient. This test is specifically designed to assist in the diagnosis of sleep disordered breathing, specifically Sleep Apnea. The test is convenient for the patient and many experts agree that testing the patients sleep in their normal home environment offers many advantages to the laboratory setting that is admittedly uncomfortable for the patient. The process for this test is to have your dentist screen patients for sleep abnormalities during their routine visits. When abnormalities are found, the physician will dispense a take home device that they have available in their office. The patient will take the device home, wear it that evening while they sleep, and return it to the physician's office the next day. Results will be available

7 usually within 24 hours. Based on the results, the physician can a) rule out OSA b) diagnose OSA and prescribe therapy or c) prescribe further testing or titration to be performed in a sleep laboratory using PSG. Prior to the home sleep test, only option 3 was available to primary care physicians at the expense and inconvenience of millions of patients. An overnight PSG (Polysomnogram) This test is conducted in a sleep lab or hospital setting. It requires the patient to stay in the sleep lab of hospital overnight which can be inconvenient. It is an expensive process (hospital setting, sleep technician, often manual scoring) and many sleep centers are operating at full capacity so there is often a 3-4 week wait. We have found a 40% drop off rate from patients that are referred to a sleep lab to those who actually show up and complete the test. In addition, the patient is traditionally burdened with extra deductibles and charges ($700-$2500) since this is occurring outside of the primary care setting. It is widely agreed that PSG is a thorough and reliable test when the patient completes the process. Sleep Apnea Treatments There are several treatment options for mild to moderate OSA, especially if the OSA occurs primarily in the supine position (i.e., when sleeping on the back). For severe sleep apnea and pregnancy-related OSA, continuous positive airway pressure (CPAP) is the primary treatment of choice. CPAP treatment is also recommended for drivers of commercial vehicles with severe OSA. A brief description of treatment options and issues are presented below. Treatments for Obstructive Sleep Apnea may include: Weight Loss-The most common cause of OSA is obesity, so losing weight is important for those who are overweight regardless of OSA severity. For mild sleep apnea, this might be enough.

8 Continuous Positive Airway Pressure (CPAP) Nasal Continuous Positive Airway Pressure, or CPAP treatment, requires the patient to wear a mask over the nose during sleep. The mask is connected by a hose to a small air pressure generator. When the mask is worn, the air pressure inside the throat is increased. The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. The CPAP eliminates a person's snoring, gasping, and choking during the night. The CPAP prevents airway closure while it is worn, but apnea episodes will return when CPAP is stopped or if it is used improperly. CPAP technology has improved considerably in the past five years. The devices are much quieter and there are numerous mask options that improve the fit and comfort. Treatment with CPAP requires adjustment (or titration) of the amount of pressure needed to keep the airway open. Patients who have an ARES study no longer need to have a CPAP pressure setting determined in the laboratory. Multiple studies have shown that auto-adjusting CPAPs, which automatically deliver the correct pressure, are as effective as in-laboratory determined pressure. Alternatively, the CPAP pressure can be predicted using a formula and the pressure adjusted until the snoring subsides. CPAP units are obtained from Durable Medical Equipment providers with a prescription provided by your physician. Oral Appliances An oral device is fitted by a dentist and worn much like a retainer or sport mouth-guard. They are designed to keep the mandible (jaw) and/or tongue in a forward position that allows the airway to remain open. Generally, oral devices work best for patients with mild to moderate OSA, patients who experience OSA mostly in the supine position (when sleeping on their backs), and for those who are not obese and do not have a large neck. In Advanced Brain Monitoring (ABM) clinical

9 study, the ARES showed a 96% efficacy rate across all patients, even in patients who suffered from severe OSA but had failed CPAP therapy. Surgery A variety of surgical techniques have been used to reconfigure the upper airway so that it remains open during sleep, but these procedures may not be helpful in every patient, and their long term effectiveness is unproven. The most common surgery to treat OSA, uvulopalatopharyngoplasty (UPPP), has a short-term success rate of about 50% in unselected cases. Removing the tonsils and/or adenoids may be effective in some patients. Sleep Position Restriction Gravity promotes sleep apnea when a person sleeps on his or her back (supine). The ARES measures OSA by position, so if it is shows difficulty only or mostly on the back, then simply avoiding sleeping on the back may be successful. Patients who have OSA primarily while on their back are also more likely to be helped by an oral appliance. Treatment Follow-up For all treatment options other than CPAP, it is recommended that a follow-up ARES study be performed approximately 1 to 3 months after initiation to ensure that the selected procedure was effective. After any significant weight loss or weight gain, your treatment may need to be reevaluated. This information has been provided by Watermark Medical.