Sleep Apnea: Keeping Up the Positive Pressure

Harvard Health

Harvard Health Letters

Many people have trouble sticking with the main treatment for sleep apnea -- the continuous positive airway pressure machines that keep airways open.

If you snore, it can be hard on those within earshot, especially bed partners. But if you snore and have sleep apnea, it's hard on you, too. Without realizing it, people with sleep apnea briefly stop breathing -- apnea means cessation of breathing -- or breathe very shallowly many times during the night.

The consequences include bad sleep and all that can come from that: grogginess when you're awake, an inability to concentrate, depression, accidents. Numerous studies have linked sleep apnea to various cardiovascular problems, including high blood pressure, stroke, and heart arrhythmias. Uneven breathing lowers oxygen levels in the blood, which can trigger aspects of the flight-or-fight response that boosts blood pressure. The herky-jerky breathing of sleep apnea may overtax the heart.

Central or obstructive

In one type of sleep apnea, breathing stops because the part of the brain that controls respiration "forgets" to send signals to the diaphragm and chest muscles. This form of the condition is called central sleep apnea because the brain, along with the spinal cord, form the central nervous system. Central sleep apnea doesn't cause snoring, but it can interfere with sleep. It's an unusual condition, although it does become more common with age.

Far more often, sleep apnea is caused by the fleshy tissues in the back of the mouth -- the tongue, tonsils, soft palate -- getting in the way of air flow in and out of the throat. Obstructive sleep apnea, as it is called, is sometimes a consequence of being overweight: extra fat tissue in the neck area can narrow the airway. But some people have obstructive sleep apnea because they have naturally lax tissues or a narrow airway to begin with.

Contrary to the suspicions of many frustrated bed partners, not everyone who snores has obstructive sleep apnea. Yet people with the obstructive version of the disorder frequently do "saw logs" -- and in a loud, halting fashion. So snoring is a good clue, but proper diagnosis of sleep apnea often requires an overnight stay in a sleep clinic and being hooked up to machines that measure brain, breathing, and heart activity.

Extra air for the airways

If excess weight and extra fat tissue in the neck are the cause of obstructive sleep apnea, then losing weight can ease sleep apnea, even make it go away. For some people, just a change in sleeping position (usually from the back to the side) can make a difference. And dental devices -- they resemble athletic mouth guards -- can open up the back of the throat by moving the lower jaw and tongue forward. There are also some surgical procedures that will get rid of excess tissue, but they're usually offered as a distant second or third choice.

The main treatment for problematic cases of obstructive sleep apnea is continuous positive airway pressure, a term almost always shortened to its acronym, CPAP (pronounced see-pap). It usually involves wearing a small plastic mask over the nose. A hose connects the mask to a small air pump. Extra air from the pump opens the airway by applying pressure to the floppy tissue, and, essentially, pushing it out of the way.

Sticking with it

CPAP has been a common treatment for obstructive sleep apnea since the early 1990s. The air pumps have gotten increasingly sophisticated, so now some of the machines sense when the person is inhaling and exhaling and change the air pressure accordingly. Many have built-in humidifiers that warm and moisten the air. The masks are lightweight and can be worn fairly loosely so they don't press against the face. Some versions aren't masks but smaller "nasal pillows" that fit just over the nostrils.

If people stick with it, CPAP does an impressive job of improving the quality of their sleep. Some studies show that CPAP also reduces high blood pressure, but the benefit might be limited to people who didn't respond to blood pressure-lowering medication.

But adherence to CPAP therapy is a serious problem. A large proportion -- half, by some reckonings -- of people who start CPAP quit within a year, and most of those gave up during the first four weeks. It's understandable that people would want to abandon a treatment that involves wearing a mask and being tethered to a machine while in bed. Moreover, all that air blowing through your nose can cause nasal congestion, which, at the very least, is uncomfortable and can defeat the entire purpose of CPAP, if the air necessary to open the airway is blocked by a clogged-up, congested nose.

Humidifying the air that comes out of the CPAP machine can help with the nasal side effects of the treatment. Sometimes patients are prescribed a nasal decongestant or a topical nasal steroid, although a study published in 2009 found that nasal steroids did not reduce nasal symptoms.

Usually sleeping pills and obstructive sleep apnea don't mix, because sleeping pills tend to relax airway tissue, so they're even more likely to block the airway. But the results of a study reported in 2009 suggest that giving people a sleeping pill -- in this case eszopiclone (Lunesta) -- for the first two weeks of CPAP therapy might help them get used to it and improve compliance later on. A single, industry-sponsored study shouldn't change clinical practice, but this approach deserves more research.

To view a video about sleep apnea, its diagnosis, and treatment, you'll find a link to it at www.health.harvard.edu/healthextra. -- Harvard Health Letter

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