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Primary Snoring

Snoring is a condition characterized by noisy breathing during sleep. Usually, any medical condition where the normal airway is blocked during sleeping, like obstructive sleep apnea, gives rise to snoring. Snoring, when not associated with any such Obstructive phenomenon is known as Primary Snoring. Apart from the specific condition of Obstructive Sleep Apnoea, other causes of snoring include alcohol intake prior to sleeping, stuffy nose, sinusitis, obesity, long toungue or uvula, large tonsil or adenoid, smaller lower jaw, deviated nasal septum, asthma, smoking and sleeping on one's back. Primary Snoring is also known as Simple Snoring or Benign Snoring, and is not associated with sleep apnea, ie, temporary ceassation of breathing.


Upper Airway Resistance Syndrome

Upper Airway Resistance Syndrome or UARS is a sleep disorder characterized by airway resistance to breathing during sleep. The primary symptoms include daytime sleepiness and excessive fatigue.

There is question in the medical community as to not only the existence of this syndrome, but whether it should be classified as a separate syndrome or part of the larger group Sleep-disordered Breathing (SDB). This unfortunately has led to a poor understanding of the illness by the medical community at large as well as a consequential lack of acceptance by medical facilities and health insurers.

It is difficult to confirm diagnosis, as few sleep testing centers have the proper test equipment to recognize the illness. Polysomnography (sleep study) with the use of a probe to measure Pes (esophageal pressure) is the gold standard diagnostic test for UARS. Apneas and hypopneas are absent or present in low numbers. Multiple snore arousals may be seen, and if an esophageal probe (Pes) is used, progressive elevation of esophageal pressure fluctuations terminating in arousals is noted. UARS can also be diagnosed using a nasal cannula/pressure transducer to measure the inspiratory airflow vs time signal.

During sleep the muscles of the airway become relaxed. The relaxation of these muscles in turn reduces the diameter of the airway. Typically, the airway of a UARS patient is already restricted or reduced in size, and this natural relaxation reduces the airway further. Therefore, breathing becomes labored. It can be likened to breathing through a coffee straw.

Pathophysiology of UARS is similar to obstructive sleep apnea / hypopnea syndrome in that abnormal airway resistance in the upper airway during sleep leads to unwanted physiologic consequences. Increased upper airway resistance in this disorder does not lead to cessation of airflow (apnea) or decrease in airflow (hypopnea), but instead leads to an arousal secondary to increased work of breathing to overcome the resistance. Repeated and multiple arousals (which the patient is usually unaware of) result in an abnormal sleep architecture and daytime somnolence (sleepiness). Arousals result in sympathetic activation, and UARS is therefore likely to cause hypertension similar to obstructive sleep apnea syndrome (This has not been verified in large clinical populations because of the relatively small number of patients with UARS in the larger epidemiologic studies so far. However, repeated arousals in individuals have clearly been shown to be related to sympathetic activation and elevation in blood pressure.)

Patients present with snoring and excessive daytime somnolence. Hypotension is likely to be present. Also, fatigue, cognitive impairment, unrefreshing sleep, frequent awakenings, and chronic pain may be present. UARS is often misdiagnosed as Fibromyalgia or similar disorders. Guilleminault et al. write that up to 75% of adult patients with sleepwalking have UARS.


Sleep Apnea

Sleep apnea (or sleep apnoea in British English) is a sleep disorder characterised by having one or more pauses in breathing or shallow breaths during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram, or a "sleep study".

There are three distinct forms of sleep apnea: central, obstructive, and complex (i.e., a combination of central and obstructive) constituting 0.4%, 84% and 15% of cases respectively. Breathing is interrupted by the lack of respiratory effort in central sleep apnea; in obstructive sleep apnea, breathing is interrupted by a physical block to airflow despite respiratory effort. In complex (or "mixed") sleep apnea, there is a transition from central to obstructive features during the events themselves.

Regardless of type, the individual with sleep apnea is rarely aware of having difficulty breathing, even upon awakening. Sleep apnea is recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body (sequelae). Symptoms may be present for years (or even decades) without identification, during which time the sufferer may become conditioned to the daytime sleepiness and fatigue associated with significant levels of sleep disturbance.


Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep apnea caused by obstruction of the airway. It is characterized by pauses in breathing during sleep. These episodes, called apneas (literally, "without breath"), each last long enough that one or more breaths are missed, and occur repeatedly throughout sleep. In obstructive sleep apnea, breathing is interrupted by a physical block to airflow, despite the effort to breathe.

The individual with sleep apnea is rarely aware of having difficulty breathing, even upon awakening. Sleep apnea is recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body (sequelae).

Symptoms may be present for years, even decades without identification, during which time the sufferer may become conditioned to the daytime sleepiness and fatigue associated with significant levels of sleep disturbance. Persons who sleep alone without a long-term human partner may not be told about their sleep disorder symptoms.

Since the muscle tone of the body ordinarily relaxes during sleep, and since, at the level of the throat, the human airway is composed of walls of soft tissue, which can collapse, it is easy to understand how breathing can be obstructed during sleep. Although a very low level of obstructive sleep apnea is considered to be within the bounds of normal sleep, and many individuals experience episodes of obstructive sleep apnea at some point in life, a much smaller percentage of people are afflicted with chronic, severe obstructive sleep apnea.

Many people experience episodes of obstructive sleep apnea for only a short period of time. This can be the result of an upper respiratory infection that causes nasal congestion, along with swelling of the throat, or tonsillitis that temporarily produces very enlarged tonsils. The Epstein-Barr virus, for example, is known to be able to dramatically increase the size of lymphoid tissue during acute infection, and obstructive sleep apnea is fairly common in acute cases of severe infectious mononucleosis. Temporary spells of obstructive sleep apnea syndrome may also occur in individuals who are under the influence of a drug (such as alcohol) that may relax their body tone excessively and interfere with normal arousal from sleep mechanisms.


Treatment

There are a variety of treatments for obstructive sleep apnea, depending on an individual's medical history, the severity of the disorder and, most importantly, the specific cause of the obstruction.

In acute infectious mononucleosis, for example, although the airway may be severely obstructed in the first 2 weeks of the illness, the presence of lymphoid tissue (suddenly enlarged tonsils and adenoids) blocking the throat is usually only temporary. A course of anti-inflammatory steroids such as prednisone (or another kind of glucocorticoid drug) is often given to reduce this lymphoid tissue. Although the effects of the steroids are short term, in most affected individuals, the tonsillar and adenoidal enlargement are also short term, and will be reduced on its own by the time a brief course of steroids is completed. In unusual cases where the enlarged lymphoid tissue persists after resolution of the acute stage of the Epstein-Barr infection, or in which medical treatment with anti-inflammatory steroids does not adequately relieve breathing, tonsillectomy and adenoidectomy may be urgently required.

Obstructive sleep apnea in children is sometimes due to chronically enlarged tonsils and adenoids. Tonsillectomy and adenoidectomy is curative. The operation may be far from trivial, especially in the worst apnea cases, in which growth is retarded and abnormalities of the right heart may have developed. Even in these extreme cases, the surgery tends to cure not only the apnea and upper airway obstruction, but allows normal subsequent growth and development. Once the high end-expiratory pressures are relieved, the cardiovascular complications reverse themselves. The postoperative period in these children requires special precautions (see surgery and obstructive sleep apnea syndrome below).

The treatment for obstructive sleep apnea in adults with poor oropharyngeal airways secondary to heavy upper body type is varied. Unfortunately, in this most common type of obstructive sleep apnea, unlike some of the cases discussed above, reliable cures are not the rule.

Some treatments involve lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep. For those cases where these conservative methods are inadequate, doctors can recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures intended to remove and tighten tissue and widen the airway, but none are reproducibly successful.[citation needed] Some individuals may need a combination of therapies to successfully treat their sleep apnea.

Physical intervention

The most widely used current therapeutic intervention is positive airway pressure whereby a breathing machine pumps a controlled stream of air through a mask worn over the nose, mouth, or both. The additional pressure splints or holds open the relaxed muscles, just as air in a balloon inflates it. There are several variants:

  1. (CPAP), or continuous positive airway pressure, in which a controlled air compressor generates an airstream at a constant pressure. This pressure is prescribed by the patient's physician, based on an overnight test or titration. Newer CPAP models are available which slightly reduce pressure upon exhalation to increase patient comfort and compliance. CPAP is the most common treatment for obstructive sleep apnea.
  2. (VPAP), or variable positive airway pressure, also known as bilevel or BiPAP, uses an electronic circuit to monitor the patient's breathing, and provides two different pressures, a higher one during inhalation and a lower pressure during exhalation. This system is more expensive, and is sometimes used with patients who have other coexisting respiratory problems and/or who find breathing out against an increased pressure to be uncomfortable or disruptive to their sleep.
  3. (APAP), or automatic positive airway pressure, is the newest form of such treatment. An APAP machine incorporates pressure sensors and a computer which continuously monitors the patient's breathing performance. It adjusts pressure continuously, increasing it when the user is attempting to breathe but cannot, and decreasing it when the pressure is higher than necessary. Although FDA approved, these devices are still considered experimental by many, and are not covered by most insurance plans.

A second type of physical intervention, a Mandibular advancement splint (MAS), is sometimes prescribed for mild or moderate sleep apnea sufferers. The device is a mouthguard similar to those used in sports to protect the teeth. For apnea patients, it is designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position holds the tongue farther away from the back of the airway, and may be enough to relieve apnea or improve breathing for some patients. The FDA accepts only 16 oral appliances for the treatment of sleep apnea. A listing is available at its website.

Oral appliance therapy is less effective than CPAP, but is more 'user friendly'. Side-effects are common, but rarely is the patient aware of them.

Pharmaceuticals

There are no effective drug-based treatments for obstructive sleep apnea that have FDA approval. However, a clinical trial of mirtazapine, has shown early promise at the University of Illinois at Chicago. This small, early study found a 50% decrease in occurrence of apnea episodes and 28% decrease in sleep disruptions in 100% of patients (twelve patients) taking them. Nonetheless, due to the risk of weight gain and sedation (two risk factors and consequences of sleep apnea) it is not recommended. An effort to improve the effects of mirtazapine by combining it with another existing medication was cancelled during Phase IIa trials in 2006. Dr. David Carley and Dr. Miodrag Radulovacki, the sleep researchers who were behind the initial clinical trial of mirtazapine are now working on a new treatment that consists of two other existing medications taken off-label together for treatment of sleep apnea.

Other serotonin effecting agents that have been explored unsuccessfully as a treatment for apnea include prozac, tryptophan and protriptyline.

Oral administration of the methylxanthine theophylline (chemically similar to caffeine) can reduce the number of episodes of apnea, but can also produce side effects such as heart palpitations and insomnia. Theophylline is generally ineffective in adults with OSA, but is sometimes used to treat central sleep apnea (see below), and infants and children with apnea.

When other treatments do not completely treat the OSA, drugs are sometimes prescribed to treat a patient's daytime sleepiness or somnolence. These range from stimulants such as amphetamines to modern anti-narcoleptic medicines. The anti-narcoleptic medicine modafinil is seeing increased use in this role as of 2004.

In most cases, weight loss will reduce the number and severity of apnea episodes. In the morbidly obese, a major loss of weight (such as what occurs after bariatric surgery) can sometimes cure the condition.

Neurostimulation

Some researchers believe that OSA is at root a neurological condition, in which nerves that control the tongue and soft palate fail to sufficiently stimulate those muscles, leading to over-relaxation and airway blockage. A few experiments and trial studies have explored the use of pacemakers and similar devices, programmed to detect breathing effort and deliver gentle electrical stimulation to the muscles of the tongue.

This is not a common mode of treatment for OSA patients as of 2004, but it is an active field of research.

Surgical intervention

A number of different surgeries are available to improve the size or tone of a patient's airway. For decades, tracheostomy was the only effective treatment for sleep apnea. It is used today only in rare, intractable cases that have withstood other attempts at treatment. Modern operations employ one or more of several options, tailored to each patient's needs. Long term success rates are low, resulting in most doctors favoring CPAP.

Nasal surgery, including turbinectomy (removal or reduction of a nasal turbinate), or straightening of the nasal septum, in patients with nasal obstruction or congestion which reduces airway pressure and complicates OSA.

Tonsillectomy and/or adenoidectomy in an attempt to increase the size of the airway.

Removal or reduction of parts of the soft palate and some or all of the uvula, such as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP). Modern variants of this procedure sometimes use radiofrequency waves to heat and remove tissue.

Reduction of the tongue base, either with laser excision or radiofrequency ablation.

Genioglossus Advancement, in which a small portion of the lower jaw that attaches to the tongue is moved forward, to pull the tongue away from the back of the airway.

Hyoid Suspension, in which the hyoid bone in the neck, another attachment point for tongue muscles, is pulled forward in front of the larynx.

Maxillomandibular advancement (MMA). MMA is the most effective sleep apnea surgical procedure currently available. The success rate is usually between 75 and 100% with a long-term success approaching 90%. Although MMA is considered a fairly invasive procedure, the associated surgical risks are low, including bleeding, infection, malocclusion, and permanent numbness. In general, patient perceptions of surgical outcome have been very favorable.

The role of surgery in the treatment of sleep apnea has been questioned repeatedly as the long term success rate of the procedures has come into question. Surgery is generally only effective in obstructive sleep apnea where the obstruction can be effectively removed. The patient's age, weight and other factors may make them a bad candidate for surgery. Many sleep specialists still regard positive air pressure treatment as the gold standard.

Special situation: surgery and anesthesia in patients with sleep apnea

Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing.

Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.

Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction - swelling may negate some of the effects in the immediate postoperative period.

Individuals with sleep apnea generally require more intensive monitoring after surgery for these reasons.

Alternative treatments

One study showed that playing the didgeridoo may reduce snoring and daytime sleepiness due to obstructive sleep apnea. Since obstructive sleep apnea is sometimes caused by low tone (hypotonicity) in the muscles of the throat, playing the didgeridoo may improve symptoms of sleep apnea by exercising muscles of the throat and increasing tone.

A study published in 2009 tested the effect of a set of oropharyngeal exercises developed from exercises used by speech-language pathologists to improve swallowing function. Participants with moderate obstructive sleep apnea who performed the exercises every day showed a significant decrease in snoring frequency, snoring intensity, daytime sleepiness, sleep quality score, neck circumference, and apnea-hypopnea index (events per hour) when compared with a control group who performed sham exercises. The improvement in OSA shown by this group was comparable to the improvement shown in patients who use oral appliances to treat OSA.

Although this study was not designed to determine which specific exercises were beneficial, an editorial response to this study in the same journal argues that only 2 of the set of exercises were likely capable of effecting the improvements they reported. These 2 exercises included sucking the tongue upward against the palate for a total of 3 minutes throughout the day, and inflating a balloon by blowing forcefully and then breathing in deeply through the nose, repeated 5 times without removing the balloon from the mouth. The tongue exercise is intended to increase the strength of tongue protrusion, and the balloon exercise is intended to increase the strength of the pharyngeal wall. Although more research is needed to clarify the effects of oropharyngeal exercise on OSA, this recent study suggests a promising new approach to treating OSA.

Positional treatments

Many people benefit from sleeping at a 30 degree elevation of the upper body or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway. Lateral positions (sleeping on a side), as opposed to supine positions (sleeping on the back), are also recommended as a treatment for sleep apnea, largely because the gravitational component is smaller than in the lateral position. A 30 degree elevation of the upper body can be achieved by sleeping in a recliner, an adjustable bed, or a bed wedge placed under the mattress. This approach can easily be used in combination with other treatments and may be particularly effective in very obese people.


Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), refers to chronic bronchitis and emphysema, a pair of commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. In contrast to asthma, the limitation of airflow is poorly reversible and usually gets progressively worse over time.

COPD is caused by noxious particles or gas, most commonly from tobacco smoking, which triggers an abnormal inflammatory response in the lung. The inflammatory response in the larger airways is known as chronic bronchitis, which is diagnosed clinically when people regularly cough up sputum. In the alveoli, the inflammatory response causes destruction of the tissues of the lung, a process known as emphysema. The natural course of COPD is characterized by occasional sudden worsenings of symptoms called acute exacerbations, most of which are caused by infections or air pollution.

The diagnosis of COPD requires lung function tests. Important management strategies are smoking cessation, vaccinations, rehabilitation, and drug therapy (often using inhalers).

Some patients go on to require long-term oxygen therapy or lung transplantation. Worldwide, COPD ranked as the sixth leading cause of death in 1990. It is projected to be the fourth leading cause of death worldwide by 2030 due to an increase in smoking rates and demographic changes in many countries. COPD is the 4th leading cause of death in the U.S., and the economic burden of COPD in the U.S. in 2007 was $42.6 billion in health care costs and lost productivity.




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