Apnea attacks. Obstructive sleep apnea: causes, symptoms, diagnosis, treatment, prevention. Main causes of sleep apnea
Apnea is a pathological process caused by one or another etiological factor, which leads to a short-term cessation of breathing during sleep. Sleep apnea in newborns is quite common - up to 60% of cases. In premature babies, this figure reaches 90%. In this case, both a violation of the breathing process and its stop are possible, but not more than for 10 seconds. In most cases, sleep apnea goes away after 3-5 weeks.
In adults, sleep apnea syndrome is quite common, but older people are at risk. It is also noted that in men this disease is diagnosed twice as often as in women.
Due to the specific clinical sign (sleep apnea), the diagnosis is usually not difficult. However, only a doctor can accurately diagnose apnea attacks, as well as establish their etiology, by carrying out the necessary diagnostic procedures. Self-treatment or ignoring this problem is fraught with negative consequences.
According to the International Classification of Diseases of the tenth revision, sleep apnea refers to diseases of the nervous system and has its own separate meaning. ICD-10 code - G47.3.
The treatment of such a disorder can be both conservative and radical, depending on the current clinical picture, the collected history and examination data.
Etiology
Sleep apnea can be caused by such etiological factors:
- excess weight - excessive deposition of adipose tissue in the neck leads to the fact that the muscles of the throat are overloaded;
- nasal congestion, ;
- otolaryngological diseases;
- neoplasm in the upper respiratory tract;
- congenital pathologies of the respiratory tract, namely the narrowing of their lumen;
- a decrease in the tone of the muscles of the pharynx, which may be due to the intake of certain medications, excessive alcohol consumption;
- dysfunction of the thyroid gland;
- damage to peripheral nerves;
- brain diseases, including the formation of tumors;
- violation of blood supply and gas exchange.
In addition, sleep apnea may be due to a psychosomatic factor, which in this case will have the character of a syndrome, and not a separate pathology.
Only a doctor can determine the cause of such a violation of breathing during sleep, after carrying out all the necessary diagnostic measures.
Classification
The following forms of development of such a pathological process are distinguished:
- apnea - the soft tissues of the throat and muscles relax so much that a person is out of breath;
- hypopnea - the pathogenesis is similar to the above form, however, in this case, soft tissues partially cover the upper respiratory tract;
- central apnea - in this case, the pathology is caused by disorders in the brain, during which the brain simply “forgets” to send signals to contract the muscles involved in the respiratory system;
- obstructive sleep apnea - most often diagnosed in children, due to congenital pathologies;
- mixed form.
The clinical picture does not depend on the form of the disease. Only a doctor can determine what type of sleep apnea a child or adult has.
Symptoms
Sleep apnea usually presents with the following symptoms:
- headache in the morning;
- frequent waking up at night;
- superficial and restless sleep;
- irritability, mood swings;
- drowsiness during the day, even if the person goes to bed on time;
- increased blood pressure in the morning, which in most cases disappears without taking medication;
- increased sweating at night;
- rapid heart rate;
- increased urge to urinate at night;
- weight gain for no apparent reason;
- deterioration of memory and concentration;
- decrease in working capacity;
- may be present in men.
It should be noted that it is precisely the attacks of respiratory arrest that the patient himself may not remember. Only people who live with it can tell about such a specific symptom. Therefore, in many cases, such a problem remains unattended for a long time, since the symptoms of the clinical picture are nonspecific and can simply be attributed to fatigue.
If you have symptoms of sleep apnea, you should immediately seek medical help, as the cause of such a violation can be extremely dangerous to health.
Diagnostics
If such a violation occurs during sleep, you should first of all contact a general practitioner. Additionally, you will need to consult such specialists:
- neuropathologist;
- neurosurgeon;
- endocrinologist;
- gastroenterologist or nutritionist.
First of all, a physical examination of the patient is carried out with the collection of a personal anamnesis, the establishment of a complete clinical picture. To accurately determine the diagnosis and its etiology, the following diagnostic measures can be carried out:
- polysomnography - with the help of special electrodes during sleep, all the necessary parameters for determining the diagnosis are recorded;
- CT and MRI of the brain;
- pulse oximetry;
- electromyography;
- electroencephalography;
- UAC and BAC;
- analysis for thyroid hormones;
- lipid spectrum of blood;
- general urinalysis and urine analysis for albumin;
- Rehberg's test.
If a benign or malignant tumor in the brain or in the upper respiratory tract is suspected, additional diagnostic measures are prescribed.
Treatment
Effective treatment of sleep apnea is possible only with an integrated approach, namely:
- lifestyle changes;
- drug treatment;
- physiotherapy procedures.
In addition, you need to understand that quite often conservative methods for eliminating such a violation during sleep are not enough or they are not at all appropriate, therefore, an operable intervention is performed.
Treatment of sleep apnea with medications involves the use of such drugs:
- topical corticosteroids;
- sedatives.
In general, drug treatment will be aimed at eliminating the factor that led to the development of such a pathological process. Based on this, we can say that medications can only be prescribed on an individual basis.
Surgical treatment of sleep apnea can be carried out through the following methods:
- adenoidectomy;
- tracheostomy;
- tonsillectomy;
- bariatric surgery - if the cause of sleep apnea is obesity;
- installation of the Pillar system.
Regardless of which apnea treatment regimen is chosen, the patient needs to make adjustments to his lifestyle, namely:
- reduce weight if there is a factor;
- start eating right. In this case, it means eating in a timely manner, slowly, the diet should be balanced;
- moderate consumption of alcoholic beverages. In addition, you need to remember that you can not drink alcohol 4-6 hours before bedtime;
- sleeping pills or tranquilizers should be used only under the strict prescription of a doctor;
- The best sleeping position is on your side, not on your stomach. This makes it possible to breathe correctly during complete relaxation;
- if a person has problems falling asleep, then before going to bed you should stop reading books, watching TV. You can replace sleeping pills through massage, meditation and other relaxation methods.
With the right approach to treatment, central sleep apnea and other forms of this disease can be treated quite well.
Treatment at home is possible, but only with an easy stage of development of such a pathological process. The use of traditional medicine, in this case, is inappropriate, as it does not give the desired result.
In general, with the right approach, sleep apnea in children and adults responds well to therapy and does not cause complications.
Possible Complications
In the event that treatment is not started in a timely manner, then there is a high risk of developing the following complications:
- significantly increased risk of sudden death.
Prevention
Prevention of such a pathological process consists in the following activities:
- maintaining a healthy lifestyle;
- blood pressure control;
- compliance with the optimal mode of work and rest;
- complete healthy sleep.
At the first signs of such a disease, you should seek the advice of a doctor, and not engage in therapeutic measures at your discretion.
Is everything correct in the article from a medical point of view?
Answer only if you have proven medical knowledge
Diseases with similar symptoms:
Intoxication of the body - occurs due to prolonged exposure to the human body of various toxic substances. This can be industrial poisoning with poisons or chemical elements, prolonged use of medicines, for example, in the treatment of oncology or tuberculosis. The influence of toxins can be both external and internal, produced by the body itself.
»» N 3 2008
Volov N.A., Shaydyuk O.Yu., Taratukhin E.O.
Russian State Medical University, Department of Hospital Therapy No. 1, Moscow
Sleep is a special process that serves to restore the body, accompanied by a decrease in the level of metabolism, a decrease in blood pressure, heart rate, and a change in the functioning of most functional systems.
Paroxysmal sleep apnea syndrome is a recurring episode of respiratory arrest or a significant decrease in airflow during sleep. This is a fairly common condition that affects up to 9% of women and up to 24% of middle-aged men. The criteria for this syndrome can be called periodic cessation (apnea) or a decrease of less than 50% (hypopnea) of the respiratory flow detected during cardiorespiratory monitoring, lasting more than 10 seconds, accompanied by a drop in the content of oxyhemoglobin by 4% or more according to pulse oximetry. The average number of such episodes per hour is indicated by the apnea-hypopnea index (AHI - apnea-hypopnea index) and the desaturation index (ODI - oxygen desaturation index). The values of these indices less than 5 are considered acceptable in a healthy person, although they are not the norm in the full sense.
The development of sleep apnea syndrome is possible for any person. The main risk factors for this condition are hereditary predisposition, male gender, overweight (especially the deposition of adipose tissue in the upper half of the body), alcohol consumption and smoking. Obesity is believed to be the most important factor, as evidenced by a large population-based study showing that the proportion of individuals with a BMI >30 kg/m² is increasing in parallel with the AHI. True, a large proportion of patients with an increased apnea index were normal or moderately overweight.
During normal sleep, the tone of the parasympathetic nervous system predominates. If a person has too many episodes of apnea and desaturation, the restorative function of sleep decreases, sudden awakenings occur, the tone of the sympathetic nervous system, blood pressure increases, the risk of arrhythmias increases, etc. With the constant repetition of such episodes every night, many pathological processes develop, which will be discussed in this article.
There are two forms of sleep apnea-hypopnea syndrome: obstructive and central. The cause of obstructive sleep apnea is the closure of the lumen of the upper respiratory tract as a result of a decrease in the tone of the muscles of the larynx. Normally, their slight relaxation and “sagging” does not lead to a significant narrowing of the lumen, however, in the presence of predisposing factors, it overlaps at the level of the oropharynx and laryngopharynx in the region of the palatine curtain, the base of the tongue, the epiglottis, etc. conditions such as micro- and retrognathia, hypertrophy of the tonsils, macroglossia and acromegaly, as well as the supine position, leading to retraction of the root of the tongue.
Modern studies using high-tech imaging methods (CT, MRI, endoscopy) have shown that the localization of such areas is dynamic, and for each person they are as individual as fingerprints.
In the pathogenesis of the second type of sleep apnea - central - the main role is assigned to the disruption of the respiratory center. Periods of apnea give way to periods of hyperventilation, creating a pattern of Cheyne-Stokes respiration. This begins with chronic hyperreflexia from the vagus nerve receptors. They are activated by blood flow to the pulmonary circulation in a horizontal position of the body. As a result of the period of hyperventilation, pCO 2 falls below the threshold of irritation of the respiratory center, which is manifested by a period of apnea. Next comes a new episode of hyperventilation. The termination of the apnea episode is accompanied by spontaneous awakening recorded on the EEG (decrease in the depth of sleep, which does not always reach the level of true awakening). It has been shown that the artificial creation of hypercapnia by CO 2 inhalation in the experiment prevents hyperventilation and the subsequent episode of lack of breathing. It is possible to switch from one type of apnea to another during the night.
Violations of ventilation, episodes of awakenings, a cyclical drop in blood oxygen saturation in a chronic course affect the general condition and well-being of people. The first complaint of patients is usually the lack of satisfaction from a night's sleep, no matter how long it may be. Possible daytime sleepiness, sleep inversion, nightmares, headaches in the morning. Such symptoms serve as an indication for examination of nocturnal breathing. Snoring is also a very important indicator.
Sleep apnea causes many disorders in the body. Let us consider various variants of pathological processes, which are caused by episodes of sleep apnea that repeat day after day.
Increasing the intensity of free radical oxidation. Repeated episodes of a decrease in the concentration of oxygen in the blood can be likened to episodes of ischemia-reperfusion, accompanied by damage to tissues subjected to hypoxia. It is known that this damage is due to the formation of reactive oxygen species that interact with nucleic acids, lipids and proteins and form free radicals. Some studies have shown that repeated episodes of sleep apnea lead to an increase in the concentration of reactive oxygen species, lipid peroxidation products and fatty acids, including malonic dialdehyde and 8-isoprostane. It has been established that in patients with high AHI, the total antioxidant capacity of serum is reduced. In addition, the work of Yamauchi M et al. (2005), who studied the concentrations of 8-isoprostane and 8-hydroxy-2-deoxyguanosine, showed that the severity of sleep apnea syndrome directly and independently of other risk factors (including body weight and age) highly significantly correlates with the severity of free- radical cell damage.
Saito H et al. (2002) used the difference in the morning and evening uric acid/creatinine ratios (UA/Cr) and the concentration of adenosine in blood serum as a sign of tissue hypoxia. It has been shown that in patients with severe apnea (AHI>15/hour, minimal SaO 2<80%) разность UA/Cr >1, and the concentration of adenosine is increased, which was evidence of a more pronounced catabolism of nucleic acids and nitrogenous bases during periods of tissue hypoxia. Finally, the data obtained by Sahebjami H (1998) show that in patients with severe sleep apnea, uric acid excretion is significantly (p<0.0003) выше, чем у пациентов без такового, и нормализуется на фоне немедикаментозной терапии (CPAP 1). Таким образом, повторяющиеся эпизоды тканевой гипоксии во время периодов ночного апноэ повреждающее действуют на клетки и ткани, вызывая повышение уровня катаболизма и экскреции метаболитов белков, липидов и нуклеиновых кислот.
1 CPAP - continious positive airway pressure. A method of treating obstructive sleep apnea by creating positive air pressure in the airways during periods of respiratory arrest. The magnitude of the generated pressure ranges from 4 to 30 mm of water. Art.
Increased levels of inflammatory markers. In a number of studies, the concentrations of C-reactive protein and interleukin-6 were measured in patients with sleep apnea syndrome, and a significant increase in their level was shown, which returned to normal after non-drug treatment. According to other data, in patients with an elevated AHI index in the blood, excessive levels of serum amyloid A (SAA), TNF-, adhesion molecules (VCAM, ICAM), E-selectin, and type 1 monocyte protein chemoattractant are determined. Changes were found in the daily rhythm of TNF-secretion in comparison with the control group. It has been shown that CPAP therapy does not reduce the level of C-reactive protein in patients with coronary artery disease and sleep apnea syndrome.
The study of nasopharyngeal flushing in patients with sleep apnea revealed an increase in the number of polymorphonuclear leukocytes, as well as the concentrations of bradykinin and vasoactive intestinal peptide (VIP), which may be associated with damage to the soft tissues of this area during snoring. Similar changes were found in children suffering from snoring and sleep apnea (including those associated with hypertrophy of the tonsils). In the condensate of exhaled air, they revealed a significant (p<0.01) повышение концентрации лейкотриенов и простагландинов по сравнению с группой контроля, коррелировавшее с индексом AHI.
In general, the presence of elevated levels of inflammatory mediators, especially TNF-α and IL-6, may contribute to the poor health of people suffering from sleep apnea syndrome, be an additional risk factor for atherosclerosis, and progression of arterial hypertension, and heart failure.
Metabolic disorders, proatherogenesis. The role of sleep apnea episodes in the development of metabolic syndrome, insulin resistance and type 2 diabetes mellitus is shown. The levels of leptin and insulin were increased in patients with sleep apnea, regardless of body weight and age, and internal (visceral) obesity had a similar dependence, while the level of adiponectin (a hormone with antidiabetic and antiatherogenic effects) was reduced. Ip M et al. (2000) showed an increase in leptin levels corrected by non-drug treatment.
In a study by Can et al. (2006) found an increase in the concentration of proatherogenic factors in patients with sleep apnea. So, reliably (p<0.05) был повышен уровень гомоцистеина, аполипопротеина В, липопротеина (а), холестерина липопротеидов низкой плотности, общего холестерина. Повышение гомоцистеина при сочетании ИБС и ночного апноэ выявлено и в другой работе. Предполагается, что это связано со свободно-радикальным повреждением клеток, в том числе, эндотелия. Tuma R et al. (2007) установлено, что риск развития сахарного диабета при синдроме апноэ сна выше в 2,7 раз, чем без такового .
The development of daytime hypercapnia in people suffering from nocturnal apnea has been shown, both in the presence of obesity and the associated hypoventilation syndrome, and in its absence.
A significant increase in fatal and non-fatal events was found in patients with coronary artery disease and arterial hypertension with severe sleep apnea compared with a similar group of patients using non-drug treatment (CPAP), as well as with the control group. In Theodore L et al. (2004) reported an increase in the level of blood aldosterone in patients with obesity and arterial hypertension with severe sleep apnea compared with a similar group without it. It is suggested that this may be one of the factors of resistance to therapy in such patients. An increase in aldosterone levels during sleep apnea has also been found in other studies.
In general, most authors agree that sleep apnea syndrome is an independent and significant risk factor for atherosclerosis, metabolic syndrome, endocrine system dysfunction, in particular, adrenal glands and pancreas.
Worsening of myocardial damage, progression of heart failure. Stiles S et al. (2006), as well as Corra U et al. (2006) showed a significant deterioration in the prognosis of survival in individuals with circulatory failure and sleep apnea syndrome. A slowdown in the recovery of myocardial function, its scarring after a heart attack was established. On the other hand, the edematous syndrome itself in CHF, which leads to a redistribution of fluid at night, exacerbates the obstruction of the upper respiratory tract. A positive effect of diuretics on the severity of sleep apnea was found. There are some differences in the course of sleep apnea in heart failure. It has been shown that the syndrome of the central type itself can be caused by fluid stagnation in the pulmonary circulation, which stimulates the n.vagus receptors, causing hyperventilation and hypocapnia, and leading to an episode of respiratory arrest. This, in turn, stimulates the activity of the sympathetic nervous system, causing spontaneous awakenings, increasing the level of adrenaline in the blood, causing tachycardia and increasing myocardial oxygen demand. Cheyne-Stokes respiration episodes, low-frequency heart rate oscillations, and high sensitivity of peripheral chemoreceptors are indicators of an increased risk of death in patients with chronic heart failure.
The main pathogenetic factor in the adverse effects of obstructive sleep apnea is considered to be a sharp increase in negative intrathoracic pressure, reaching 65 mm Hg. Art. during inhalation, causing an increase in preload on the heart. Repeated dozens and hundreds of times every night, these episodes lead to chronic overload of the myocardium. During periods of obstructive sleep apnea, there is no drop in heart rate that is normal for sleep. As a result of an increase in pre- and afterload, activation of neurohumoral systems, a drop in blood oxygen concentration, myocardial remodeling occurs, which ultimately leads to and contributes to the progression of heart failure.
Laaban J.P. et al. (2002) revealed a relationship between systolic dysfunction of the left ventricle and the presence of sleep apnea syndrome, corrected by the treatment of this syndrome.
Kraiczi H et al. (2001) point to thickening of the interventricular septum, prolongation of the isometric relaxation time, a decrease in the difference between the peak early and late mitral blood flow rates, as well as a decrease in the endothelium-dependent ability to relax the brachial artery. All parameters were associated with the duration and severity of desaturations according to the results of pulse oximetry (SpO 2<90%), имели достаточную достоверность (p<0.05) и учитывали поправку на возраст и индекс массы тела .
In a study by Lentini S et al. (2006) showed a moderate increase in blood CPK activity, corrected by non-drug treatment (CPAP). Gami AS et al. (2004) acknowledges that it has not been possible to detect elevated troponin T levels indicative of myocardial injury in patients with severe sleep apnea and CAD. The same author points to a significant (p=0.046) and independent relationship between mortality from cardiovascular causes in history and the severity of sleep apnea syndrome. In a study by Multu GM et al. (2000) revealed episodes of ischemic ST segment depression during ECG monitoring. They were expressed in patients with two- or multi-vessel coronary artery disease against the background of recurring episodes of apnea and the appearance of tachycardia.
Koehler U et al. (1999) analyzed the circadian rhythm of myocardial infarction in 89 patients. Among patients who developed a heart attack during sleep, in the early morning hours, the AHI index was higher compared with patients who developed a heart attack after waking up (20.3/hour versus 7.3/hour at p<0.05) .
Rhythm and conduction disorders. Back in 1979, Deedwania PC et al. the development of AV blockade in individuals with sleep apnea has been shown. And modern research reveals rhythm disturbances in such patients. For example, Gami AS et al. (2004) compared groups of patients with paroxysmal atrial fibrillation and patients with coronary artery disease, differing in the presence of stenosing atherosclerosis of the coronary arteries, the presence of arterial hypertension and diabetes mellitus, but similar in sex composition, age and body weight. Significant (p<0.0004) превалирование синдрома ночного апноэ в группе мерцательной аритмии (49%) по сравнению с общей группой больных ИБС (32%) . В исследовании Porthan KM et al. (2004) также показано, что больные пароксизмальной формой мерцательной аритмии без диагностированной ИБС чаще предъявляют жалобы, свойственные для синдрома ночного апноэ (сонливость, головные боли, остановки дыхания ночью). В наблюдениях Singh J et al. (2004) демонстрируется развитие фибрилляции предсердий во время сна , а Kanagala R et al. (2003) установлено, что пароксизмы мерцательной аритмии после электрокардиоверсии рецидивировали в течение года у 82% больных синдромом ночного апноэ, тогда как в группе контроля – только в 53% (p=0.013). В группе же, получавшей СРАР-терапию, новые пароксизмы развивались у 42% больных – реже, чем в контрольной .
The effect of sleep apnea on heart rate variability has been shown. The relationship was significant when arterial hypertension, CHF, and other conditions that could affect the severity of this syndrome were excluded. In the group with severe apnea (AHI>30/hour), RR intervals were shorter on average (793±27 ms) than in the control group (947±42 ms). Overall RR variability in the apnea group was reduced (p=0.01). Similar changes, with less significance (p=0.02), were also found in patients with moderate sleep apnea. The work of JoJA et al. (2004) shows that in patients with sleep apnea, according to the results of a polysomnographic study, a decrease in the quality of autoregulation of the heart-lung system was established: an increase in the sensitivity threshold of baroreflexes and a decrease in respiratory oscillations in the heart rate variability curve.
In a study by Garrigue S et al. (2007), who randomly included patients with permanent pacemakers who did not have diagnosed sleep apnea, showed that 59% of them have sleep apnea syndrome. It was detected in 58% of patients with SSSU, in 68% with complete AV block, in 50% with dilated cardiomyopathy.
An association between sleep apnea and sudden death has been established. Gami AS et al. (2005) retrospectively reviewed data from 112 patients who died suddenly between 1987 and 2003 and underwent polysomnography some time before death. It was found that 46% of patients with sleep apnea died in the period from 00 to 06 hours, while in the general population this interval accounts for 16% of deaths (p<0.001), индекс AHI у них был выше, чем у умерших в другое время суток. Он прямо коррелировал с относительным риском внезапной смерти, который для больных ночным апноэ составил 2,57 к общей популяции .
Resistant arterial hypertension. The identification of hyperaldosteronism in sleep apnea syndrome was mentioned above. This is confirmed by the work of Pratt-Ubunama MN et al. (2007). Plasma aldosterone concentration correlated with AHI>5/hour (p<0.0002). Выраженное апноэ сна было более свойственно мужчинам, чем женщинам с резистентной гипертонией (90% против 77%), у них же концентрация альдостерона была выше (12 нг/дл против 8.8 нг/дл) .
Haas DC et al. (2005), based on the results of a study of 6120 patients, reports an association between sleep dyspnea and the degree of systolic-diastolic hypertension in persons under 60 years of age, as well as the absence of this association in persons over 60 years of age and in the case of isolated systolic hypertension in persons of any age. Data on the relationship between sleep apnea and arterial hypertension are also shown in other sources.
Narkiewicz K et al. (1998) indicates the effect of hyperactivity of the sympathetic nervous system on the state of muscle-type arteries, expressed in an increase in blood pressure, in particular, during sleep (the so-called 'non-dipper' or 'night peaker'), and in addition, it is reported that there is no effect of obesity on hyperactivity of the sympathetic nervous system, if it is not combined with sleep apnea syndrome. The same author points to a positive significant correlation (r=0.40, p=0.02) between the increase in AHI and the severity of nocturnal hypertension. The Wisconsin Sleep Cohort Study (2000) showed an association between sleep apnea and hypertension, independent of other risk factors such as body weight, sex, age, alcohol, and smoking. Pankow W et al. (1997), according to the results of daily monitoring of blood pressure, a significant (p<0.001) связь тяжести ночного апноэ с гипертензией как таковой и с отсутствием снижения АД ночью .
Sleep apnea syndrome should be excluded in patients with arterial hypertension, especially essential, with severe refractory hypertension, with no decrease in blood pressure at night, as well as in the detection of ischemic changes or heart rhythm disturbances during sleep.
Mental disorders. In a large study by Pillar G et al. (1998), using the SCL-90 anxiety and depression scale, 2271 patients with sleep apnea syndrome of one or another severity were included. It was found that in men the level of anxiety and depression, although it exceeded the reference values, still did not depend on the AHI index, or on the body mass index and age. Among women, on the contrary, there were on average higher levels of depression and anxiety compared to men, and the degree of their severity directly correlated with the degree of respiratory disorders.
Attention deficit hyperactivity disorder, which affects 3–16% of children, has been identified in adults with sleep apnea. It is characterized by impulsivity, hyperactivity, difficulty in social adaptation and difficulty in learning. A significant improvement in the condition after non-drug therapy of apnea was revealed. A study by Chervin RD (2000) showed that in addition to drowsiness, people suffering from night breathing disorders may complain of general chronic fatigue and lack of energy, while not feeling a lack of sleep. Moreover, in women, these complaints are much more pronounced than in men.
In an experiment on rats, a connection was established between the serotonergic system and sleep apnea syndrome: the introduction of serotonin into the blood and its binding to 5-HT 3 receptors led to episodes of apnea during sleep. Farney RJ et al. (2004) reported on the identification of a relationship between the appointment of combination therapy with antihypertensive drugs and antidepressants and the detection of sleep apnea syndrome. This indirectly indicates the role of night breathing disorders in the development of both arterial hypertension and depression. A relationship was found between the daytime sleepiness of people suffering from sleep apnea and the absence or reduction in the duration of the slow-wave activity phase on the EEG during episodes of respiratory distress. Non-drug treatment of apnea had a significant positive effect on this situation. Attention acuity tests on car driving simulators have found a decrease in the quality of mental function in people suffering from sleep apnea.
Hemostasis disorders. Hemostasis is a complex system based on a delicate balance between pro- and anticoagulant factors. It is logical to assume that sleep apnea syndrome, which affects many parameters of the body, will also affect this system. There have been a number of studies of hemostasis in patients with sleep apnea syndrome. Their results are somewhat conflicting. Thus, when studying platelet aggregation, three out of five studies found its increase, and in the other two, no difference was found.
An increase in the plasma concentration of fibrinogen was found in sleep apnea syndrome, a twofold increase in the inhibitor of plasminogen activator type 1 (PAI-1). Patients who had episodes of apnea during the night showed an increase in blood viscosity in the morning. In other studies, no difference was found in the concentrations of the thrombin-antithrombin complex, D-dimer and von Willebrand factor in patients with sleep apnea compared with controls, however, it was shown that CPAP treatment significantly reduces the procoagulant activity of the blood, reduces platelet aggregation at night. After one night of therapy with the CPAP machine, a decrease in the concentration of fibrinogen was found, which appeared by noon and lasted until the next morning.
The fact that sleep apnea syndrome has hyperactivation of the sympathetic nervous system as one of its pathogenetic mechanisms was confirmed in the study by Eisensehr I et al. (1998). A correlation was found between an increase in the morning level of blood adrenaline and an increase in platelet aggregation compared with the same parameters in the evening. It has also been shown that physical and psychological stresses, like the introduction of sympathomimetics into the body, accelerate the formation of thrombin and soluble fibrin-monomer complexes. Changes in the work of the adrenergic system affect various links of hemostasis.
In some experiments on the induction of hypobaric hypoxia in pilots with the achievement of SaO 2 61.5% by decompression in the pressure chamber, an acceleration of blood clotting time, increased platelet aggregation, and an increase in the concentration of factor VIII were found. In an experiment on mice that were in an atmosphere of 6% oxygen for six hours, the appearance of fibrin overlays in the vessels of the pulmonary circulation was found. Also, a decrease in the activity of messenger RNA of the t-PA gene (tissue plasminogen activator) and an increase in mRNA of PAI-1 (type 1 plasminogen activator inhibitor) were found in mouse lung cells, which within four hours led to a corresponding change in the levels of these components of the hemostasis system. Similar procoagulant effects of experimental hypoxia and the sleep apnea syndrome itself may explain the propensity to develop vascular complications in this category of patients.
The aspects of the effect of intermittent nocturnal breathing, episodes of respiratory arrest and hypoxia considered in the article demonstrate the complexity and polyvalence of the pathological effects of sleep apnea syndrome. Changes in homeostasis occur at the deep - cellular and molecular level, subsequently causing clinically pronounced diseases, primarily of the cardiovascular system.
Sleep apnea gradually leads to disadaptation of the circulatory system, contributing to the formation of severe arterial hypertension, provoking heart rhythm disturbances. Sleep apnea syndrome explains the high frequency of hypertensive crises, cerebrovascular accidents and myocardial infarction in the early morning hours, when the maximum number of adverse shifts in homeostasis accumulates when breathing is disturbed during sleep. Free-radical damage to vascular cells, changes in the lipid profile, a tendency to hypercoagulability, inflammatory changes in the blood contribute to the development of atherosclerosis and atherothrombosis, and heart rhythm disturbances are one of the main causes of sudden death during sleep.
Literature The rest of the sources (41-62) can be found in the edition of the RKZh.
A plump, red-faced fellow was sitting on the box, sunk in a slumber.
- Amazing little one! said Mr Pickwick. Does he always sleep like this?
- Asleep! said the old gentleman. - He always sleeps. In his sleep, he follows orders and snores while serving at the table.
Charles Dickens
The Posthumous Papers of the Pickwick Club
It is believed that snoring in a dream, although it can create significant inconvenience for others, is a kind of norm. In fact, in many cases this is far from the truth. Snoring is not just a sound phenomenon, it can indicate difficulty in passing air through the upper respiratory tract during sleep.
Here's how it goes. During sleep, all our muscles relax and the muscles responsible for keeping the pharynx open are no exception. As a result, the air passing through the upper respiratory tract at this time causes vibrations in their walls, similar to how a flag is rinsed with gusts of wind. This vibration of the soft tissues of the oropharynx leads to the sound of snoring. If such fluctuations are large enough, then the walls of the pharynx periodically completely close, for some time not allowing air to enter the lungs, while the chest continues to make respiratory movements, unsuccessfully trying to take another breath. Such respiratory arrests associated with periodic obstruction of the upper respiratory tract are called obstructive sleep apnea.
If breathing stops occur frequently, then, medically speaking, such a person suffers from obstructive sleep apnea syndrome.
Other possible causes of sleep apnea
Sometimes even in quite healthy people in certain phases of sleep, a short-term cessation of breathing may occur due to a failure in the mechanism of its regulation by the central nervous system - the so-called central apnea. A feature of central sleep apnea is the absence of respiratory movements of the chest with normal airway patency. Such rare respiratory pauses are a variant of the norm, are not accompanied by health problems and do not cause disturbances in the functioning of the cardiovascular system.
However, if the mechanisms of central regulation are unstable all the time and such respiratory disorders occur frequently, then a person develops a disease - central sleep apnea syndrome with the onset of symptoms that pose a serious threat to the patient's health or even his life. Most often, central sleep apnea occurs in patients with chronic heart failure or stroke.
In the case when both obstruction of the upper respiratory tract and a violation of the excitability of the respiratory control center in the brain become the cause of the development of sleep apnea syndrome, the prognosis of the disease worsens even more.
Why is obstructive sleep apnea dangerous?
The cessation of breathing leads to oxygen starvation. This in turn stimulates the brain, forcing it to wake up in order to avoid death by suffocation. In this case, not a complete awakening usually occurs, but a short-term transition to a state of drowsiness, which in most cases is not stored in the patient's memory. Nevertheless, this time is enough to increase muscle tone, restore the patency of the upper respiratory tract and normalize the breathing process. After the blood is sufficiently saturated with oxygen, the person falls asleep again, the muscle tone decreases again and the whole cycle of abnormal respiratory events repeats again and again.
In patients with severe sleep apnea, respiratory arrest can occur almost every minute, due to which from a third to a half of the time spent in sleep, the person does not breathe at all and may develop severe respiratory failure.
Emergency micro-awakenings, which allow the patient with sleep apnea to breathe, are stressful for the body, accompanied by the release of adrenaline, which causes vasospasm and overload of the heart. Combined with oxygen starvation caused by sleep apnea episodes, this leads to accelerated wear and tear on the cardiovascular system.
In addition, micro-arousals caused by episodes of obstructive sleep apnea disrupt the normal structure of sleep, making it ragged and superficial. As a result, those deep stages of sleep almost completely disappear, during which there is a good rest and analysis of the information accumulated during the day. Instead of normal sleep, such a person spends most of the night in an unsuccessful struggle for his own breath.
Risk factors: when and who gets obstructive sleep apnea
Obstructive sleep apnea syndrome is not the only, but the most common breathing disorder directly related to sleep. It can occur at any age from childhood to old age, in men and women, but is usually most common in overweight middle-aged men.
External manifestations and consequences of obstructive sleep apnea syndrome
The main symptoms of this disease are night snoring and excessive daytime sleepiness, which is a natural consequence of sleep disorders associated with apnea.
The concept of drowsiness is quite subjective. Therefore, long-term ill people can partially get used to their condition and perceive it as a feeling of fatigue, weakness or fatigue during the day, finding an explanation for this in a tense rhythm of life and overload at work. However, drowsiness usually becomes apparent when the person is relaxed, and is manifested by falling asleep while resting, reading, watching television, and in severe cases even during vigorous activity and while driving.
But it's not just a bad quality of being awake. Oxygen starvation of the brain during sleep, combined with drowsiness during wakefulness, leads to a weakening of memory, attention, and reaction speed in a person. As a result, patients with severe sleep apnea not only find it difficult to cope with their work, but are much more likely than other people to experience car accidents, accidents at work and at home.
The following complaints are also common:
- increased mobility during sleep;
- nightmares;
- waking up, sometimes with a feeling of lack of air;
- nighttime heartburn;
- frequent urination at night;
- sweating during sleep;
- dryness and unpleasant taste in the mouth at night and in the morning after waking up;
- morning headaches;
- decreased sexual desire and potency.
As mentioned above, obstructive sleep apnea has an extremely negative effect on the state of the heart and blood vessels. Direct consequences of obstructive sleep apnea include:
- arterial hypertension, which is difficult to respond to traditional drug treatment, including with an increase in blood pressure during a night's sleep;
- dangerous cardiac arrhythmias;
- heart failure;
- high risk of myocardial infarction and stroke.
A significant proportion of deaths, including sudden deaths, formally related to cardiovascular problems, are in fact a direct or indirect result of undiagnosed and therefore untreated obstructive sleep apnea. The results of many scientific studies prove that with severe sleep apnea, the likelihood of death from cardiovascular disease increases by 4-5 times.
Impact of sleep apnea on life expectancy
Obstructive sleep apnea not only significantly worsens, but also shortens life. One third of untreated patients with severe obstructive sleep apnea die within the next ten years. At work, I see many patients with sleep apnea between the ages of 40 and 65. But among older people, not just snoring elderly people, but patients with a severe form of obstructive sleep apnea are practically not found. Over the long years of my medical practice, perhaps there will be a little more than a dozen patients with a newly diagnosed severe form of sleep apnea who would have crossed the 70-year mark. Where do you think all these people go?
On the other hand, timely effective treatment not only significantly improves the quality of life, but also radically reduces the likelihood of dangerous cardiovascular complications, creates all the prerequisites for living to a deep and happy old age.
Obstructive sleep apnea syndrome is a risk factor for the development of such life-threatening complications from the cardiovascular system as stroke, various arrhythmias, cardiac trophism disorders - heart attacks, and sudden death during sleep. Most of these conditions occur at night, between 3 and 4 in the morning, and more than 80% of them are directly related to respiratory failure.
Important! Do not ignore the problem, but contact a specialist in time for diagnosis and correct treatment.
Obstructive sleep apnea is a condition characterized by periodic It is interesting to know that normally a person can stop breathing for a while, but such pauses have absolutely no effect on the state of the body.
A condition is considered pathological when the apnea period lasts more than 10 seconds and occurs more than 30 times during a seven-hour sleep. The average duration of respiratory pauses is about 40 seconds, but in severe cases it can be up to 3 minutes and take up more than 60% of sleep.
During apnea, a person balances on the verge between sleep and wakefulness, he cannot fall into a deep sleep, but constantly seems to be dozing. As a result, the resources of the body are not restored, the nervous system does not rest.
As a result, in the morning the patient wakes up broken, not getting enough sleep, the productivity of his work is significantly reduced. Over time, this condition leads to an exacerbation of chronic and the development of new diseases of various organs and systems.
Why do pathological pauses in breathing occur during sleep
To prescribe the correct therapy to the doctor, first of all, it is necessary to determine the reason why respiratory arrests occur. There are a number of anatomical and physiological features that can provoke this pathological condition:
- Too wide neck due to obesity. In cases where the neck is wide from the moment of birth, this cannot cause apnea;
- Anomalies in the development of the skull
- Retrognathia - protruding lower jaw;
- Micrognathia is a pathology characterized by underdevelopment of the lower jaw;
- Narrowness of the upper or lower jaw;
- Too large tongue that does not fit properly in the mouth;
- Enlarged tonsils or swelling of the palate.
- Hypotonia of muscles, that is, their weakness, which are located near the respiratory organs.
- Defects in the nasal septum.
- The presence of polyps or other formations in the respiratory tract.
- Obstructive pathology of the lungs.
In addition, the appearance of sleep apnea may be preceded by certain diseases, such as obesity or diabetes.
Attention! Another interesting condition that can occur when falling asleep is or old witch syndrome.
Risk factors
In addition to the direct causes of obstructive sleep apnea, there are risk factors that do not guarantee the development of pathology, but significantly increase the risk of its occurrence:
- Gender - Respiratory arrests are more common in the male half of the population. This is due to the fact that men generally weigh more than women and their necks are much thicker. However, everything changes with age, with the onset of menopause, women become more vulnerable.
- Age - the peak incidence falls on the period from 40 to 60 years, but this does not prevent apnea from appearing both in the early and later periods of a person's life.
- Genetics - if close relatives have a history of OSA, then the patient has a high risk of getting sick.
- Abuse of tobacco products and alcohol.
Important! Monitor body weight, as obesity is a major factor in the development of obstructive sleep apnea syndrome.
How to suspect apnea
The grounds for suspicion of the presence of OSAS may be complaints of restless sleep, lack of a feeling of cheerfulness after a normal rest, morning headaches, and constant fatigue.
In addition, the patient's working capacity is significantly reduced, attention and the ability to concentrate on something are reduced. Such patients are distracted, they constantly forget something. They also have an increased tendency to fall asleep, that is, falling asleep at the workplace, at a boring lecture, or even driving a car - a common thing for people with obstructive sleep apnea.
In addition to the above, patients may present the following complaints:
- Feeling of suffocation at night;
- Insomnia;
- Frequent nightmares that lead to awakening;
- Increased irritability, it becomes difficult for such people to control their emotions;
- Depression - some patients fall into a depressed state due to constant lack of sleep;
- Dyspnea;
- Nocturia - the need to frequent the toilet at night;
- Impotence in men and a significant decrease in libido in women;
- Strong night sweats;
- Bruxism - teeth grinding;
- Increased activity in a dream - a person constantly rolls over from side to side, shudders, moves his arms and legs;
- Dream conversations.
Relatives or just close people focus on, sometimes they also notice respiratory arrest in a dream. The patient himself is not able to see these changes.
OSAS symptoms in children
In children, sleep problems due to respiratory arrests manifest themselves somewhat differently than in adults. Most often there are such manifestations:
- Longer sleep - children, especially those with severe OSAS, need much more time to get enough sleep;
- Difficulty inhaling - it takes a lot of effort from the child to fill the lungs with oxygen;
- Changes in behavior - the baby becomes somewhat aggressive and, despite being tired, hyperactive;
- involuntary urination;
- Deviations from the norm in height and weight;
- Morning headaches.
Important! These signs are nonspecific, that is, they can occur not only in obstructive sleep apnea syndrome, but also in other diseases. Therefore, when such symptoms appear, the child should be shown to a specialist.
OSA diagnostics
The diagnosis is based on the patient's complaints and melon objective examination. But since the symptoms of apnea are not characteristic and often practically do not appear, doctors resort to such a diagnostic method as polysomnography.
Polysomnography is a lengthy procedure and takes approximately 8 hours. With the help of various devices, specialists examine the patient's sleep throughout the night. The diagnostic method consists in registering vital signs, brain waves, respiratory arrests, and their duration. According to polysomnography, the final diagnosis is made.
How to get rid of sleep apnea
In mild, not neglected cases, it is enough to follow simple recommendations in order for apnea to recede:
- To lose weight - you need to follow a special diet and lead an active lifestyle.
- Avoid eating before bed. More than 3 hours must have elapsed from the last meal.
- Stop smoking and drinking alcohol. If it is impossible to do this completely, then at least do not take cigarettes in your hands 2-3 hours before bedtime, and during the daytime reduce their number to a minimum.
- Take the correct position in bed while resting. Most often, respiratory arrest occurs in people who sleep on their backs, so you need to learn how to rest on your side. If a person constantly rolls over on his back in a dream, then a pocket should be sewn on the back of the nightgown and some object should be put into it. Thus, lying on your back will be uncomfortable. In the first few nights, the patient will wake up constantly, it will be uncomfortable, but within 2 weeks he will get used to sleeping on his side.
- Make sure that nasal breathing is free. For this purpose, you can use special plates or patches.
But for some patients, unfortunately, all of the above is not enough. For example, with septal defects and in the presence of polyps, it is imperative to perform surgery, since there are no other ways to help. Patients who have sleep apnea due to an abnormally developed jaw can use special devices that are inserted into the mouth and correct the position of the jaw during sleep.
Assisted ventilation is often used in OSAS. With the help of the apparatus, oxygen is injected into the respiratory tract and does not allow them to narrow. Unfortunately, this method does not lead to recovery, but only allows a person to sleep normally and avoid complications.
Important! In no case should sleeping pills be used with obstructive sleep apnea, as they relax the muscles, and a person can simply suffocate.
Sleep apnea can have serious consequences, so you should not ignore the symptoms, thinking that it's just snoring. With timely diagnosis, the pathology is easily treatable, in most cases even without surgical intervention.
