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Sleep apnea syndrome

THE NIGHT APNEA SYNDROME 

Sleep apnea is an emerging disease that spreads more and more among the population and represents a challenging challenge for the otorine doctor, both on a diagnostic and therapeutic level.

The NIGHTNESS APNEA SYNDROME consists of repeated stops of breathing during sleep , more or less protracted, which may be several hundred during the night.
Basically there are 2 types of sleep apnea:

CENTRAL NIGHT APNEE

They are due to a disturbance of the nerve centers that control the automatism of the breath: in such cases the nervous impulse that causes the respiratory muscles to move is stopped. The most famous form of central apnea is the so-called “Ondina Syndrome”which owes its name to a Nordic legend according to which a curse would have obliged the man who had betrayed the nymph Ondine to stay awake forever because she would not breathe during sleep and it would be dead.
These are relatively rare forms, which appear in some neurological diseases.
A separate case is represented by the “syndrome of death in the cradle”  called in English SIDS (see link).
APNEE NIGHTLY OBSTRUCTIVE

In these forms the apnoic episode is due to a  sudden MECHANICAL BLOCK  of the respiratory tract during sleep.
They represent the most common form of the disease, with   an incidence of 2% of the female population and 4% of the male.
For convenience from now we will define these forms of sleep apnea with the term   OSAS ( O bstructive S leep A pnoea S yndrome)

Let us now try to understand the mechanisms that underlie OSAS and the possible repercussions of this pathology on health.

 

In obstructive sleep apnea during sleep, some of the throat structures collapse inside the respiratory canal and go to mechanically close the airway   causing a suffocation crisis .

Let’s see concretely what happens during the apnoic crisis:

the crisis begins during deep sleep; in general the transition from the NON REM 4 sleep phase to the REM phase ( see link ).
At the beginning of the crisis the patient, who is usually a snorer (in fact, obstructive sleep apnea is very correlated with the phenomenon of snoring) suddenly becomes “silent”, that is, stops snoring.
The cessation of snoring is actually due to the onset of breath blocking.

At this point the partner, who is often a spectator of the apnoic event, presents an impressive scene :
the patient makes enormous respiratory efforts to try and unblock the breath.
The lungs push and the chest contracts and expands strongly; at the same time, there is a rapid increase in blood pressure, which can reach 200 mmHg and an increase in heart rate.
The patient is agitated, sweaty, he squirms in the bed.
At this moment the effort for the body, and in particular for the heart, is considerable
 .

The lack of oxygenation of the blood due to the blockage of breathing makes (fortunately) trigger the mechanism that protects us from the danger of death during the apnoic crisis : the rapid collapse of the oxygen content of the blood, called pO2, triggers a protective reaction from the sensors placed inside the carotid arteries that constantly monitor this value.

The sensors send an alarm signal to the brain that activates an IMMEDIATE AWAKENING mechanism .

The awakening causes an immediate resumption of tonicity by the throat muscle structures that bring the collapsed structures into the airway in the correct position, restoring their patency.

At this point the patient makes a loud noise, resumes breathing, and goes back to sleep.

Unfortunately, in many subjects, as soon as the sleep is resumed, a new cycle of apnea begins again .

In this way, in the most severe forms, in some cases we arrive at several hundred crises per night .

A very important fact is that  the patient has no memory of his sleep apnea crisis. This is due to the fact that the brain does not record the micro-awakenings  that occur at the end of the apnoic crises since they last too little.

For this reason, sometimes family members are forced to film their loved ones during the sleep apnea crisis, to convince them of the existence of the problem and cause them to go to the doctor.

In other cases it happens instead that the victims of sleep apnea wake up in a more clear, totally, agitated, sweaty, in the grip of considerable tachycardia and a terrible anxiety related to the sense of suffocation.

 

WHAT ARE THE CLINICAL CONSEQUENCES OF THE NIGHT APNEA?

As we saw in the description of the crisis, the most stressed apparatus from the apnoic event is the cardio-vascular system .

The disease can lead to ARTERIAL HYPERTENSION and, in predisposed patients, to CARDIAC ISCHEMIC DISORDERS (angina, infarction); for this reason, especially in cardiac patients, it is essential to eliminate sleep apnea.

Another important consequence we find in the nervous system: the continuous micro-awakenings cause a phenomenon called SLEEP FRAGMENTATION . Fragmentation causes a marked reduction in the amount of deep sleep , the so-called REM sleep, which represents the RESTING SLEEP. For this reason, as we will see later, SUNDAY DENTISTRY is one of the main symptoms of the disease.

So let’s see the SYMPTOMS OF THE NIGHT APNEA

Patients experience severe  daytime sleepiness and fall asleep easily even while seated; I am often a victim of SLEEPING BLADES while driving and therefore accidents; they are very tired and tend to reduce their physical activity more and more with consequent weight gain, and further aggravation of the disease.

Other typical symptoms are changes in character , nervousness and a generalized drop in psychophysical performance . In the otorine field, there are frequent problems with the throat, a sense of dryness, neck pains upon awakening and alterations of the voice. To download the sleep apnea self-assessment test

click here .

WHY THE OSAS COMES IN SLEEP?

During deep sleep, when the transition between NON-REM sleep and REM sleep occurs, deep muscle relaxation occurs .
(For more information on sleep click here ) .
In people with particular anatomical predispositions in the regions of interest otorino, ie with hypertrophy of the tonsils, the uvula, the soft palate and the base of the tongue, it may happen that such structures, if not adequately supported by muscle tension, fall towards the center of the throat going to CLOSE the airway and causing the suffocation crisis.

WHO IS AFFECTED BY THE NIGHT APNEA: RISK FACTORS

Obstructive sleep apnea is present in all ages.

It is common experience in the otorine field that young children, up to 6 years, may present some crises during the night.
A picture of this kind is considered normal and is linked in part to the immaturity of the nerve centers that control the breath.

In adults, apnea, if not sporadic, always assumes a pathological character .

RISK FACTORS

  • PEDIATRIC AGE

the most common risk factor is the ‘ Hypertrophy adeno-.TONSILLARE

  • ADULTS :

Sex male
aged over 40.
Overweight
smoke
nasally anomalies and / or pharyngeal
disease gastro-oesophageal reflux

 

WE ANALYZE RISK FACTORS

SEX : as we have seen, the male sex has a double incidence of OSAS compared to the female

AGE : normally apnea affects people over 40 years due to a progressive relaxation of the muscular tissues that support the structures involved in the collapse (tongue, tonsils, palate).

DRUGS: any product with muscle relaxant action, which reduces muscle tone, tends to worsen the apnoic tendency.
This means that ALL SEDATIVES and SUSPENDERS are extremely dangerous for those who already suffer from sleep apnea.
Even ALCOHOLIC  are very dangerous   for the powerful muscle-relaxing effect of alcohol.

OVERWEIGHT : there is a linear relationship between weight gain and apnea.
Studies by Prof. Pirsig, dean of the study of obstructive sleep apnea, showed a 1: 5 ratio between apnea and weight .
This means that an increase in body weight of 10% increases the likelihood and frequency of apnea by as much as 50%; on the other hand, an overweight apnoic patient, reducing his weight by 10%, can achieve a clinical improvement of 50%, without the need for special interventions or treatments

NASAL BREATHING: In obstructive sleep apnea also nasal breathing plays a very important role: a good nasal breathing allows to keep the mouth closed during sleep with a consequent forward movement of the tongue and a marked reduction in the probability of obstruction.
In patients with diseases such as septal deviations, hypertrophic rhinopathies, chronic polypose sinusopathies , the correction of these pathologies, restoring proper nasal breathing, always leads to a marked improvement in apnea and snoring.

 

DIAGNOSIS

The diagnosis is based on the history and results of a test called POLYSONNOGRAPHY .

It is a computerized monitoring that is performed for one night, in hospitalization queues or at home, and allows to control different cardiovascular parameters as well as snoring, chest movements and patient movements.
The examination shows the so-called APNEA / HYPOPNEA INDEX , (AHI) that is the number of apneas and hypopneas / hour.
In this case, apnea means an airflow abolition of at least 4 seconds.

  • An AHI of less than 5 corresponds to a SIMPLE RUSSIAN situation
  • For AHI between 5 and 15 we speak of  mild OSAS 
  • Between 16 and 30 there are cases of moderate OSAS
  • above 30 there are cases of OSAS GRAVE situation that represents a serious problem for the health of the patient.

Based on the result of polysomnography and physical examination, the treatment strategy is then decided.

 

THERAPY

There are 4 possible curative approaches for sleep apnea: DRUGS There are some stimulating products under study that would have the task of reducing muscular hypotonia during sleep. However, at present there is no APARTHIC DRUG.

In pharmacies there are many sprays or other products that promise a reduction in snoring and nighttime sleep: ALL ARE ABSOLUTELY INEFFICACIOUS AND WITHOUT ANY SOLID SCIENTIFIC BASE.


LIFESTYLE
First of all it is necessary to act on predisposing factors, in particular reducing body weight, eliminating the use of alcohol and sedative drugs.
Weight reduction, obviously in overweight individuals, is absolutely a priority.
Often a weight loss of 8-10 kg radically changes the situation of the patient making corrective surgical interventions unnecessary.

You should have dinner early and eat light food, avoid sleeping in a supine position (which favors the fall towards the larynx of the base of the tongue), do not drink any type of alcohol at dinner and after dinner, eliminate sleeping pills and sedatives, reduce or eliminate the smoke.

SURGERY
In pediatric age, adeno-tonsillectomy surgery normallyeliminates the problem in all patients.

Surgical therapy of adult sleep apnea is very varied and in the last few decades various types of interventions have been proposed.
In general, in the surgical field, we are witnessing a so varied flourish of proposals for the solution of a clinical problem when the “perfect” intervention has not yet been identified to resolve with certainty in all patients the problem we are facing, and this is the case of sleep apnea.

Today a series of interventions are proposed, of increasing invasiveness, whose objective is to reduce the volume of structures involved in the genesis of nocturnal apnea or their “stiffening”.

In the surgical ladder it is always advisable to start with a correction of the nasal obstructive pathologies to guarantee the patient proper breathing.

The next step typically consists in the correction of the palate hypertrophy, the lingual base of the tonsils and the uvula.

The volumetric reduction can be obtained with “soft” techniques such as RADIOFREQUENCY SURGERY “, performed under local anesthesia with a slight sedation, or with a laser resection that generally requires general anesthesia.

In order to stiffen the palate, synthetic devices can be inserted into the musculature of the devices which constitute a sort of skeleton of the soft palate.

There is also a series of very invasive interventions, which entail for the patient several sufferings and post-operative disorders, the use of which does not agree all the otorino surgeons. The indication to this surgery must always be weighted, only after having corrected the risk factors mentioned above.
MECHANICAL TREATMENT
In people with sleep apnea who do not benefit from the correction of their LIFESTYLE and do not have any findings to recommend a surgical treatment, the solution of the problem comes from ventilatory treatment.

This is a method in which the patient is provided with an apparatus defined as  CPAPthat is applied during sleep: the CPAP is presented as a mask that is applied to the face at night, connected to a machine that, as soon as it perceives the blockage of the breathing, “pump” with air force in the upper airways by reopening them.


MASK FOR C-PAP MACHINE

Although it may appear “brutal”, patients with high-level OSAS unanimously report a marked improvement in their condition with the CPAP technique. Further information is available at http://it.wikipedia.org/wiki/CPAP .

Although it may appear surprising, patients using CPAP report sleeping beautifully and feeling much better.

FAQ 

Is OSAS a serious disease? 

A: Depends on gravity: an apnea index above 20 is related to an increase in mortality. It is also shown that OSAS causes an increase in cardiovascular disease with hypertension, arrhythmias and cardiocirculatory failure.

Can OSAS cause sleepiness and traffic accidents?
A: Yes. Some studies claim that patients with apnoic syndrome have a frequency of traffic accidents up to 7 times higher than average .

My child has respiratory arrest at night. Could you die? 

A: The danger exists only in the earliest childhood in which the nerve pathways are not perfectly mature. In such cases, we speak of the sudden death of the infant (Sudden Infant Death Syndrome). For more information click here . Sleep apnea can not cause death in otherwise healthy children.

Is there a correlation between OSAS and RONCOPATIA?

A: Yes. Virtually all apnoic patients snore strongly. Only a part of the snorers has clinically relevant apneas. Surgeries to treat the two diseases are common and their effect is better on snoring than it is on apnea.

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