What is sleep apnea?
Expansion and contraction of the chest during respiration in the cage of our our our right we took the heart to the lungs diaphragm vacuum effect by making a withdrawal in the air and creates inflammation throughout the respiratory tract depending on the impact, the airway is narrow in areas where mucous surfaces in mutual contact with each other can loose the case of the soft tissue. During sleep relaxation of the muscles around the airway of the respiratory canal lining the walls of the narrow areas as a result of vibration of the sound of snoring mutual collision occurs. The vacuum airway during respiration due to the effect of the air passage in the wall, causing respiratory wane as a result of the narrowing the channel even completely closed, breathing can stop.
Breathing nose and mouth so that it takes 10 seconds to stop, ”apnea“ sleep apneas observed during the number of “obstructive sleep apnea” is called. The air flow 30-50% reduction lasts more than 10 seconds, if the decrease in the blood oxygen saturation or respiratory movement (O2 saturation) is therefore expressed as cost decrease or hypopnea.
The severity of the sleep apnea disease, which is the value most commonly used in the detection of RDI (RespiratoryDisturbance Index) or apnea-hypopnea index (ahi) is the sum of the number of apneas and hypopneas that occur per hour. However, in recent years, especially due to the severity of the disease condition in the definition of hypopnea different approaches in determining the apnea-hypopnea index than the duration of the reduction occurring in the reduction of blood oxygen saturation during sleep and began to be considered more and more.
Most insurance related sleep disorders from simple snoring, upper airway resistance syndrome and obstructive sleep apnea syndrome.
Simple Snoring
- Ahis is under five,
- During sleep, Blood Oxygen Saturation (Saturation) is always 90% watching
- The measured pressure during breathing do not fall below -10 CM water level in the esophagus in patients with simple snoring is mentioned.
Upper Airway Resistance (Resistance) Syndrome
- AHI less than five per hour,
- Oxygen saturation 90% watching
If the measured pressure falls below the value of -10 CM of water in the esophagus upper airway resistance syndrome is referred to. In these patients, as well as snoring and waking periods there is increase in the electrical activity in the diaphragm.
Obstructive sleep apnea syndrome (OSAS)
- On five of ahis
- Of oxygen saturation below 90% are identified with watches.
It is well known that in these patients the number of apnea classification which is the sum of apneas and hypopneas to be important in the apnea-hypopnea index (AHI) makes the use of more meaningful. The classifications in this topic in the application is updated periodically and Helen, “the American Academy of Sleep Medicine” the classification of patients according to the apnea-hypopnea index between 5 and 15, then between 15-30 light, medium, and severe sleep apnea is recognized as higher than 30.
The measurements of blood oxygen saturation during the night according to other criteria: 85% falls below if moderate, 60% falls below if it comes to severe sleep apnea is.
What is the incidence of snoring and sleep apnea?
Patients often defined by the complaints of snoring, in addition to additional complaints even if they have not, in fact, may have mild sleep apnea. Simple snoring in men under the age of thirty, the rate is 10%, while in men over the age of 60, the rate reaches 60%. When was snoring and we investigated the relationship of weight, your ideal weight has been shown to increase the incidence of snoring and apnea in people who have more. Moderate and severe sleep apnea in adults, apnea, sudden death also you could have. To moderate obstructive sleep apnea of adult men and 2% in males in the age group 35-60 severe sleep apnea were found in 0.3%, is monitored.
Sleep Apnea Is Associated With Disease.
Besides providing important clues in the diagnosis of sleep apnea, the patient's complaints, findings, it is important that patients occur during sleep, and especially most of the time the actual application of the most common reasons they could not be aware of the patient, and the trailing sleeping bed partner or his relatives, while the observations are very valuable. Complaints of the patients identified the most significant daytime sleepiness is a state of the varying depending on the severity of the disease. Patients slept long hours of the night and during the day they tend to be tired in the morning even if you suffer from sleep problems. Patients with mild sleep apnea while in a quiet environment in the day showed inclination to moderate, severe and may even fall asleep during apnea speech during driving. Patients with sleep apnea the possibility of traffic accidents is 2 to 7 times more than normal people.
The lighter is marked and then in the morning, headaches, forgetfulness, lack of attention, lack of concentration, accompanied by the main findings. Have damaged the quality of sleep in patients with anxiety disorders, a decline in mental abilities, aggression and can lead to depression.
Snoring and sleep apnea syndrome patients often have fatigue, lack of motivation, psychological disorders and sexual function disorders due to hormonal changes that occur with insomnia consists of. The amount of carbon dioxide in the blood during sleep in patients with sleep apnea, the increase in bladder contraction disorders in children and frequent urinary incontinence in adults causes frequent night to get up to urinate.
Sleep apnea disease, depending on changes in the metabolism of fat as a result, patients tend to gain weight. Weight problems increases metabolic changes and the patient became increasingly evident and makes it difficult to lose weight. Emerged as significant at the chest and nape, and other findings in patients with this type of night sweats. Expands the rib cage during respiration, while the negative thoracic pressure that occur with obstruction of the upper airway as a result of the increase in the acid contents of the stomach come up through the esophagus (gastroesophageal reflux).
Treating acid reflux in obstructive sleep apnea symptoms in 30% improvements have been identified. As a result of inadequate breathing asleep in the blood vessels to reduce the amount of oxygen in the blood are detected by sensitive sensors in order to meet the need of the circulation of blood and oxygen to the brain to increase reflexes are activated. For this reason, high blood pressure, pulmonary hypertension, heart rhythm disorders, such as cardiovascular diseases and stroke in patients with sleep apnea sleep apnea syndrome are not uncommon. Apnea also increases the risk of death is much higher than normal over 20 index patients, therefore, should be used for the treatment of patients in the group.
Overall assessment and physical examination
Because sleep apnea syndrome can occur due to many different reasons, patients should only examination of the upper respiratory tract, are not sufficient in diagnosis and treatment planning.
The patient's alcohol use in recent months, he got significant weight and metabolic status (diabetes, thyroid problems) should be questioned in biochemical tests should be performed. Where the patient complaints of depressed mood can increase that by considering whether it should be questioned whether he is using drugs and sedative. Reduced blood flow regulation in the brain during sleep, as due to the increase in the secretion of hormones that increase blood pressure, not able to watch during the day or only at night, high blood pressure, the blood pressure of the patient necessarily should be checked. The patient's overall body structure (obesity-obesity), the condition of the bones of the jaw (the position and size of the lower jaw, upper jaw development disorders) treatment approach in determining the success of selection and the structure of the neck is important.
The measurement of the circumference of the neck of patients admitted with suspicion of sleep apnea is important. Adult erkeklerdeboy of the environment is recognized as a risk factor to be greater than 43.18 CM. Men in this group and in 30% of sleep apnea syndrome is implicated in. The critical value is 38.10 CM for women.
Body mass index (body mass index – BMI) to calculate that is useful in the diagnosis and treatment of snoring and sleep apnea is an important parameter. In practice, the body weight in kilograms divided by the square of height in meters is calculated by adults over the age of 20, this value is normally an average of 25.5 kg/m2 is close to. 27.3 BMI of 27.8 for men and women as it is considered to be on obesity.
Ear, Nose And Throat Examination
In patients with suspicion of sleep apnea, nose and lips and throat (larynx), which ends requires a thorough examination of the upper respiratory tract.
Standard ENT examination with inspection is not performed because the diagnosis of sleep apnea syndrome sleep in the airways collapse during sleep that occurs in the area of blockage and so put to the determination of probable aimed.
Facial skeletal structure: the patient's first examination of the relationship between the closing of the teeth of the upper jaw and the lower jaw in the back of the placement of the lack of development (retrognatizm) should be evaluated. The back of the lower jaw in patients with soft tissue surrounding the root of language and place the root at the level of the throat and tongue that I would change back the risk of clogging is high.
Examination of the nose: nasal pathologies creations nose clogging, as well as the resistance against the flow of air by raising negative pressure within the nose by increasing the degree of clogging in the throat and can lead to precipitation in this region. Mouth breathing due to nasal congestion in patients who in the walls of the respiratory tract consists of muscle relaxation.
On the other hand, sleep apnea treatment sleep in devices that provide continuous positive airway pressure (CPAP=Continuous Positive Airway Pressure) devices that provides us with a path to the use of the nose of the patients to be able to use correction of the problems that lead to nasal congestion is required.
Examination of the mouth and throat: the throat, where it is a frequently occurring problem in patients with sleep apnea examination of the area of the soft palate and the uvula (the uvula), the structure of language, structure and language of the roots, the palate, and the back of the back of the tongue the size of the area should be carefully considered. Many surgical techniques are applied for the treatment of sleep apnea syndrome skeletal and soft tissue structure of the region where the occurrence of the disease and evaluation of each structure is necessary to determine the possible role of examination of the oral cavity, the tongue and soft palate begins with the determination of the natural position. The placement of the language to the plane of the closure of the teeth (occlusal plan) should be evaluated according to. The language than the normal size and position in the occlusal plan is set forth below. Settled on the plane of the outer closure if he would be able to speak a great language a language is available. According to the position of the language survey, “the Mallampati classification” is used.
The soft palate, tonsils, uvula, and the area enclosed by the rear wall of the throat should be examined. May have very different views as to the structure of the soft palate. Roughly low, thick, two-piece or can be classified as located close to the rear wall. Small language (uvula) is considered to be the size of if it exceeds 1 cm long. The tonsils (tonsils) size is also of importance. He cleared his throat, narrowing of your airway, causing snoring and sleep apnea and hence are responsible for large tonsils or less. Especially toward the lower section of the tonsils must assess the degree of bulge of his throat.
Examination of the tongue base: direct vision in the field of non-nose with the side effects of the evaluation of this region the best flexible (bendable-can be done with flexible fiberoptic endoscopy.
Flexible (Bendable) Fiberoptic Endoscopic Examination
In this examination, the nose and the mouth slightly open position when the natural language that can be bent and inserted the endoscope with a soft nasal cavity, palate, tongue root, it is possible to evaluate the area of the larynx and behind the tongue.
During the examination the patient was closed and the mouth and nose breathing challenging execution (Mueller Maneuver) helps in the identification of Regions collapsed under negative pressure. Flexible fiberoptic endoscopic examination, the condition of the patient awake while giving valuable information for diagnosis and treatment in respiratory tense the muscles that surround the canal is being done due to the fact that while the diagnostic value of the examination is relatively decreased. In order to overcome this problem the technique of sleep endoscopy has been developed.
Radiological Imaging Methods
Radiological imaging is used for diagnosis and treatment planning in patients with obstructive sleep apnea. Computed tomography (CT) and magnetic resonance imaging (MRI) of the soft tissues that make up the airway wall in the path of the air volume and provides information about the extent and location of the obstruction.
Today, with dynamic imaging techniques with CT and MRI during sleep which can be made in the diagnosis of these assessments has to be done extremely useful information, but this method has not yet become standard practice, which is quite costly.
Facial and jaw bones and structure of the position used for the purpose of the analysis of cephalometric X-rays, especially in the upper and lower jaw bones of the patients to a surgical operation are used for the planning of surgery.
Tests, Analysis Of Sleep (Polysomnography)
The blockage of the previously mentioned examination and evaluation methods with the aim to identify the degree and location of the disease when it is used for the definitive diagnosis of a sleep study is performed. To review the likelihood of the diagnosis of sleep apnea without having to put it is not possible.
REM sleep (rapid eye movement) and non-REM phases containing at least 3-4 hours a sleep study is sufficient for a diagnosis of sleep apnea syndrome. During REM sleep relaxation of the muscles in the airway of the throat as a result of the region still remains, although it has decreased the tension in non REM sleep. Therefore, the collapse of the wall of the upper respiratory tract is more prominent in REM sleep. Without REM sleep, the tests should be repeated. Polysomnography is a test that is highly sensitive, on consecutive nights, the test does not change the diagnosis to be repeated, only it was determined that the volume of effect were ahis.
Polysomnography test duration and number of stop breathing on the capabilities of the device used during testing, as well as heart rate, body position, blood oxygen saturation, sleep apnea severity, the electrical activity of the brain, many parameters such as negative pressure in the airway during sleep are monitored and the data obtained for analysis at the end of the sleep period are recorded. Usually performed in a sleep center sleep testing, although patients in the home environment which allows them to portable devices and test systems.
Sleep Endoscopy
Lately, increasingly more preferred in patients diagnosed with sleep apnea assessment method. Sleep endoscopy in patients during IV anesthesia given operating conditions while impersonating night's sleep with flexible endoscopy of the nose by way of the obstruction made by entering the level and shape is evaluated. To be able to decide on which surgical treatment the technique is extremely useful for this evaluation, especially during the root of language-induced airway problems in patients with oral opener, the effect of the apparatus can be controlled too. Sleep endoscopy is the technique of detailed information about the “sleep endoscopy” can be accessed via the link.
What Is The Treatment For Sleep Apnea?
In the treatment of patients with snoring or sleep apnea, airway obstruction and the severity of the disease according to the level of the region of different treatment approaches are preferred. Surgical procedures outside of treatment methods;
- General precautions
- Special treatments
- Drugs
- Compressed air face masks (CPAP, BPAP devices)
- Oral appliances are
General Precautions
The majority of patients with snoring and sleep apnea are on a lot of patients who are normal weight. By slowing down your metabolism and decrease your intake of calories, especially with sleep apnea to reduce your consumption of oxygen and decrease in the activity due to the fatigue of the day, both as a result of the weight causes it to increase. The root of the tongue with the weight gain in the region of the neck and soft tissues by increasing the volume leads to an increase in the severity of the disease. Therefore, it is one of the most important elements of weight loss treatment. All patients who are above the normal weight that lead to weight gain metabolic and / or hormonal problems investigated whether there is. An additional treatment in patients without pathology for permanent weight loss only diet don'ts, and the daily activity needs to be brought into this to increase the standard of lifestyle. At this stage, particularly in the regulation of the diet of patients who have serious weight problems should take the help of a professional.
Sedative drugs or alcohol use in patients who have complaints of snoring and sleep apnea syndrome is a more severe disease. Patients and soothing not use alcohol as much as possible, should be advised to stay away from drugs that have a soporific effect.
The patient in the supine position, increased sleep complaints such as position determination made identified in tests, typically has been expressed by the relatives of the patient. The side position is recommended in patients with snoring and sleep apnea in a cool way. Although the supine position produced by means of special apparatus to get rid of back and put the pillow pillows exist, sew a tennis ball into the back of methods such as pajamas are also used.
Nasal congestion is an important problem that increases snoring and apnea. Allergies that can heal with medical therapy in patients with nasal congestion, sinusitis, vasomotor rhinitis diseases such as should be investigated. Structurally linked to lower swelling or obstruction of the nose for different reasons while lying in supine position of the head to the heart to be elevated in patients it is useful to be supported with a pillow.
Sleep apnea may cause or may be accompanied in the determination of internal problems that must be treated. Main apne diseases such as hypothyroidism and acromegaly treatment is important because there may be reasons.
Special Treatments
Drugs (medical agents): many medications that are used to treat patients with snoring and sleep apnea, although they are monitored during long-term use is not a preferred approach to treat the side effects of Medicine today. Surgical applicable for a variety of reasons, are unable to use CPAP in patients with mild sleep apnea and who is the obvious tension relaxation Nov Nov REM sleep by reducing time to prevent loss of medications may be used.
The severity of the snoring sound in patients with snoring problems just with the aim of reducing the vibration occurs in the throat, soft palate and on the mucous membrane of the tongue base in the region to reduce the surface tension used in herbal medicine. These drugs are used before bedtime mouth by squeezing the throat that occurs in the mucosa of the area by yaglandirilm is intended to reduce the intensity of sound due to vibration. These drugs can be effective for simple snoring to obstructive sleep apnea, which is the lack of significant effects.
CPAP (Continuous Positive Airway Pressure continuous positive airway pressure) CPAP CPAP devices are the most important alternative to surgical treatment in patients with sleep apnea syndrome. In patients with sleep apnea, especially during REM sleep relaxation of the muscles in the walls of breathing that occur during the respiratory channels by the negative pressure in the airway collapse the upper respiratory tract and can cause obstructions. The CPAP device is supplied with air, which causes it to collapse during breathing with positive pressure negative pressure to allow air to equalize in the way of is to keep the passage open. When you do not agree to surgery, CPAP or surgery in the treatment of patients does not benefit enough from surgery should be tried. CPAP also prepared for surgery patients also can be used temporarily.
Patient compliance is the most important factor that restrict the use of CPAP. Preferably pressurized air by way of the nose, CPAP nose, which lead to serious problems because it is a device that gives the use of these devices in the presence of congestion is usually not possible. Despite regularly use the device every night moisturizer applied to the payment in the nose, and bleeding can lead to dry. The need to use the device every night for an active lifestyle, often complicates compliance of the patients in the younger age group and especially traveling. Depending on all these factors, patient compliance with CPAP devices between 60-80% remains.
The use of CPAP in patients who have trouble breathing during high-pressure compressed air to breathe in and exhale to improve compliance, which reduces the pressure on BPAP (Bilevel – bi-level CPAP) devices are manufactured, although the overall treatment of patients with these devices, there was a significant differences in the adherence to.
Oral appliances: in recent years many different types of oral appliances in the use of the language of suffering and one of those who forward the lower jaw there are two main types. To the front of the lower jaw the tongue, throat and tongue, while increasing the volume of the root of the front of the palate with the back of the tongue with the arrival in the region of the throat is expansion. Between 73-100 sees the benefit of such appliances have revealed that patients with simple snoring.
The increase in saliva, dry mouth, difficulties as early adaptation apart from the side effects, the most important problem that arise with long-time usage that result from the displacement of diseases of the joints of the jaw and teeth are the quality and quantity of the mouth. This applied to long-term problems due to be performed under the control of a dentist is recommended. The dome of the palate, which is curved a little long in very high language, and the use of oral appliances in patients with large tonsils is difficult.
Methods of surgical treatment of snoring and sleep apnea
Airway obstruction, which causes problems for snoring and sleep apnea disorders, mostly in a single area, but not at the same time to different degrees in different anatomical regions can be a problem. Depending on The Shape of the region where the blockage occurs airway obstruction and different treatment approaches for this disease has been the choice of surgical treatment methods, which were on the agenda and the main situations:
- AHI (Apnea hypopnea index) value over 30
- Blood oxygen saturation is below 90 %
- Sleepiness during the day affect the daily lives of
- Sleep apnea as a result, the creation of heart and circulatory problems
- Disease, determination of surgically significant anatomical problems intervened
- A mask positive airway pressure (CPAP) have seen benefit from other treatment methods, including
- The absence of surgery that will prevent medical problems
Location of the blockage in the respiratory tract in patients with snoring and sleep apnea and surgical interventions can be made and applied in different anatomical regions according to the content of the surgery are classified under the following headings.
- Rhinoplasty (nasal obstruction surgery)
- The soft palate surgery for
- Surgeries to the back of the tongue
- Upper and lower jaw bones advancing surgeries (advancing the maksillomandibu)
- Tongue muscles nerve stimulation (Hipoglossus nerve stimulation)
- Opening out the airway in the neck (Tracheotomy)