Snoring and Sleep Apnea

snore

Snoring person/child may sound funny; but sometimes it’s a sign of a serious medical problem that should be treated. It is important to know if snoring is just normal or it is obstructive sleep apnea.

Obstructive Sleep Apnea

  • The snoring may be a symptom of obstructive sleep apnea.

  • Sleep Apnea is cessation of breathing (For 10 seconds or longer) while asleep

  • Breathing stops because airway collapse, air does not go inside the lungs, blood oxygen level drops, which causes the brain to wake up.

  • This cycle may repeat hundreds of times during the night while you have no idea it is happening.

Snoring and Sleep Apnea in Childeren

Sleep problems and sleep apnea in children usually go unnoticed by parents.

Persistent open mouth, open mouth while sleeping, hypo nasal speech, nocturnal snoring, and abnormal sleep positions may be considered habitual or may escape the parents notice as patients may not be aware of significance of these symptoms.

It may be the cause of poor school performance, learning disabilities, bed wetting, hyperactivity and even heart failure.

Causes/ Risk Factors of Obstructive Sleep Apnea

Nose

  • Nasal congestion

  • Blocked nose

  • Allergic rhinitis

Larynx

  • Tumors

  • Oedema

Pharynx

  • Enlarged adenoid

  • Enlarged tonsils

  • Large tongue

  • Elongated Uvula

  • Thick neck as in obese

Other

  • Down syndrome

  • Children with abnormal face

  • GERD

  • Smoking (active and passive)

  • Family history of Sleep apnea

What are the Common Symptoms?

  • Fatigue and tiredness during the day.

  • Loud snoring.

  • Waking up with choking or gasping.

  • Not feeling rested in the morning or satisfied with a night’s sleep.

  • A strong desire to take a daily afternoon nap.

  • Unexplained accidents or errors.

Other Common Features are

  • Obesity

  • Small jaw, thick neck

  • High blood pressure

  • Restless sleep; the repeated struggle to breathe can be associated with a great deal of movement.

  • Depressed mood and/or irritability

  • Reduced sex drive and impotence

  • Snorting, gasping, choking during sleep

How Serious is Snoring?

  • Sleep apnea is a potentially life-threatening condition.

  • Undiagnosed severe sleep apnea can cause irregular heartbeats, unstable high blood pressure,
    leg swelling, heart attack, stroke, cardiac arrest during sleep, or a harmful accident.

  • Increased daytime sleepiness poses a serious risk of automobile accidents, impaired functioning
    in the workplace and in personal relationships.

Complication of Obstructive Sleep Apnoea

  • High Blood pressure

  • Fatigue

  • Heart disease and heart attack

  • Stroke

  • Untreated sleep apnea tends to progressively worsen and can cause partial or complete disability and death.

How to Diagnose Obstructive Sleep Apnea( OSA)?

Obstructive sleep apnea (OSA) must be differentiated from simple snoring usually not accompanied by oxygen desaturation, hypercarbia, or sleep disruption

Other causes of excessive day time sleep are Chaotic sleep schedules, Sleep deprivation, fragmented sleep., restless leg syndrome, narcolepsy, hypothyroididm, drugs-sedatives, neurological-previous enchephelitis, previous head injury, stimulants-caffiene, amphetamines, b blockers

Thorough medical history, sleep history like total sleep time, bedtime routine & sleeping environment; and any behavioral problem to be asked.

Asking the parents to video record the snoring is often useful.

Clinical examination- Height and weight, Neck Circumference, Blood Pressure,

ENT (Ear, Nose and Throat) Examination: Careful Nose and Throat examination,

Video Flexible Nasal Endoscopy and Laryngoscopy day time or preferably during sleep – To identify and quantify the site of the obstruction accurately

Investigations:

X-Ray Nasopharynx –for adenoid and tonsil enlargement

X-Ray chest-to see heart size

Sleep observation, oxygen saturation and ECG in most children may be sufficient to document the need for adenoid and tonsil removal.

Overnight Sleep study (polysomnogram)

Overnight Sleep study (Polysomnography) at sleep lab or at home in natural regular sleep environment is required to make the diagnosis of OSA and to judge the severity

It is detailed examination during sleep to record the sleep stages, person is attached to machines that check heart rate, oxygen and carbon dioxide levels, eye movement, chest wall movement, and the flow of air through the nose.

EEG (Encephalogram –measure brain waves), EMG (Electromyogram-leg movement ) EOG (Electroocculogram) measure eye movement) ECG/EKG (electrocardiogram measure heart rate and rhythm); chest and abdominal movement (measure breathing movements); and monitoring of oxygen and carbon dioxide levels in the blood.

None of the devices is painful still it may be a little frightening for a young child.

A sleep technologist monitors the recordings during sleep and afterwards analyzed by sleep physician.

Other sleep disorders that cause unrestful sleep may be detected with a sleep study as well.

Snoring Management

General measures

  • Regular exercise

  • Weight loss

  • Avoid heavy diner

  • Healthy high fiber diet

  • Develop regular sleeping patterns

  • Tilting the top of a bed upward a few inches,

  • Sleeping on the side

  • Avoid alcohol/smoking

  • Avoid allergy triggers (stuffed animals, pets, and feather/down pillows from the bedroom.

  • Avoid sleeping pills and antihistamines before bedtime

Nasal Continuous Positive Airway Pressure (NCPAP)

CPAP (Continuous positive airway pressure by a nasal mask throughout the night) is the most effective and frequently used treatment for OSA. Compliance is a major problem but family should be motivated as major surgeries can be avoided. Sleep study should be repeated every 6-12 months with upper airway growth with age.

Oral Appliances (OA)

Mouthpieces worn at night works by repositioning the tongue or mandible forward

Nasopharyngeal airway – It may be the only treatment required for some children. Like Adequate airway is developed by the age of about 3 months in Pierre Robin syndrome.

Surgery for Snoring/OSA

Major complication of OSAS are reversible before the end stage heart and lung disease therefore surgery should be done for obstructive lesions of upper airway as soon as possible.

  • Tonsillectomy and Adenoidectomy (TAR / T&A) cures most children and it should be the initial treatment in children with other factors also.

  • In patients with craniofacial anomalies specific surgery can be done.

Nasal Surgeries

Nasal obstruction makes CPAP difficult to tolerate. Surgery are done to open the nasal passages such as septoplasty to correct deviated nasal Septum, Turbinoplasty/turbinectomy to reduce enlarged turbinates or FESS for Nasal Polyps.

Open nasal passages markedly improves tolerance to CPAP.

UPPP is done in selected cases usually LASER assisted- the tonsils are removed, the uvula is removed, and the palate is trimmed higher.

Tongue reduction surgery

In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the tongue.

To Conclude

Sleep apnea can have serious significant complications yet vast majority remain undiagnosed and untreated because of lack of awareness by the parents and health care providers.

All children with ADHD, behavioral problems and poor academic performances should be assessed for sleep apnea by ENT specialist and pulmonologists and upper airway should be evaluated by ENT specialists for every sleep apnea child.

Tonsillectomy and adenoidectomy results in dramatic resolution of symptoms


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