Evaluating Your Sleep, Denial and Awareness

For people exploring sleep apnea and for their healthcare professionals, peer coaching article #2, updated 21 November 2011

The symptoms of sleep apnea (stopped or reduced breathing during sleep) can be very subtle and easily attributed to other factors. How can you tell what you do while you’re sleeping? It’s not unusual to be unaware of having sleep apnea, a nighttime respiratory disorder. You may think you are sleeping well. You may be in denial of the condition and unaware of its serious health risks. Your bed partner or family may be more aware of a potential problem than you are. Fifty percent or more of people with sleep-disordered breathing (SBD) remain undiagnosed. (Carl E Hunt MD p. xi in Johnson’s Sleep Apnea – The Phantom of the Night).

The Boiled Frog Analogy. Maybe you’ve heard this story. If you put a healthy frog into a pot of hot water, it will quickly jump out. If you put a frog into a pot of lukewarm water, and very gradually increase the temperature, it will stay in the pot until boiled. In the hot water, the frog noticed instant discomfort and danger and took action. In the tepid water, it was lulled into complacency until unaware or unable to take action. How does this translate to sleep apnea? Have you unconsciously adapted to fatigue and eventually daytime sleepiness because its progression was so long and gradual? Have you found other reasons for fatigue, while making the best of circumstances? Are those reasons valid? You can find out by consulting a physician, taking informal sleep quizzes and, if indicated, getting a sleep study in a sleep lab. When you find the real reason for your fatigue, you can crawl out of the pot to change, improve, or reverse the condition.

Untreated sleep apnea can lead to high blood pressure, stroke, heart attack, congestive heart failure, cardiac arrhythmia, depression. Other risks are driver fatigue, poor judgment, poor memory, and sleepiness leading to car crashes, wrongful death and injury.

Possible Symptoms of Sleep Apnea

·        loud and frequent snoring (in most people, but not in everyone)

·        periods of not breathing (apnea) during sleep, snorting, gasping, or choking during sleep

·        need to urinate at night

·        awakening tired in the morning, morning headaches, daytime or evening fatigue or lethargy

·        daytime or evening sleepiness when sitting or inactive, drowsy driving or falling asleep while driving

·        performing actions automatically or by rote, limited attention, memory loss

·        poor judgment, personality changes

·        weight gain, early onset of high blood pressure, severe leg swelling

·        especially in children, hyperactive behavior.

Possible risk factors:

·        overweight with a body mass index (BMI) of 25 or more

·        neck size for a man of 17 inches or more or for a woman of 16 inches or more

·        male gender, being a menopausal or postmenopausal woman

·        family history of sleep apnea, large adenoids or large tongue, short lower jaw which causes the tongue to position itself further back in the throat

·        smoking and use of alcohol or sedatives.

Sources: adapted from the journal Sleep, National Institutes of Health, and James C. O’Brien MD.

More possible hints of sleep apnea:

·        COPD (chronic obstructive pulmonary disease), asthma

·        heart abnormalities, stroke

·        high blood pressure that doesn’t respond to medication

·        acid reflux or GERD

·        diabetes

·        deviated septum (cartilage separating the nostrils going off midline)

·        bruxism (teeth grinding)

·        adult bed wetting

·        irritability, mood changes, anxiety, depression

·        procrastination, difficulty acting on plans or finishing projects, diminished work performance

·        social withdrawal, neglected relationships

·        less interest in sex, sexual dysfunction

·        persistent recurring dreams of struggle and failure

·        the ability to fall asleep two or three hours after getting up in the morning, and/or very long naps in the afternoon, and/or sleeping nine or more hours a night

Assessment Quizzes

If you suspect a sleep problem, take some of these quizzes. They are designed to build awareness and create dialog with your doctor, not to diagnose. Discuss the quiz results and your symptoms with your primary care physician, or a sleep doctor, pulmonologist (breathing specialist), cardiologist, ENT (Ear/Nose/Throat) doctor, or other specialist. If indicated by symptoms, the doctor may suggest a sleep study to rule out sleep apnea or other diagnostic procedures.

In print, an excellent quiz to help detect sleep apnea is in the appendix of Sleep Apnea – The Phantom of the Night , a book by T. Scott Johnson MD, William A. Broughton MD, Jerry Halberstadt, a patient. An online version is at

http://www.healthyresources.com/sleep/apnea/phantom/orders/quiz.html

Epworth Sleepiness Scale and Scores widely used by sleep doctors

http://www.stanford.edu/~dement/epworth.html

American Academy of Family Physicians, Berlin Questionnaire, http://www.swclab.com/images/PDFS/Berlin-Questionnaire.pdf

Online sleep evaluation

http://yoursleep.aasmnet.org/SleepEval.aspx

Early Warning from an Overnight Recording Pulse Oximeter

When you have a routine visit to your physician, along with taking your temperature, the nurse may use a pulse oximeter on your finger tip to measure the oxygen in your blood. The device measures oxygen levels in your blood by noting the color. Oxygenated blood is bright red, blood with hemoglobin desaturation is darker red. It’s painless and noninvasive. Can you get access to not just an ordinary pulse ox, but one that records oxygen levels over time, from your doctor, a friend, rental, or purchase? It’s easy to wear a recording pulse ox overnight in the comfort of your own bed. If the reading in the morning shows a drop in oxygen level beyond a certain percentage, consult a physician, showing him/her the record. This may be an early warning that you have sleep apnea, since most people don’t notice any symptoms. A pulse oximeter alone may detect severe sleep apnea, but is not reliable in less severe cases.

Sleep Study Information

An overnight sleep study in a sleep lab is the gold standard of diagnosis. It’s a very sophisticated way of testing for sleep apnea – obstructive (the most common kind), central (more rare), or mixed – by checking airflow in your nose or mouth, snoring, and the effort your chest makes to breathe in various positions and in different stages of sleep. A lab study will also check for Restless Leg Syndrome, the amount of oxygen in your blood, and your heart rate and rhythm. If your doctor orders a sleep study, insurance or Medicare should pay for it. A split night sleep study may cost $4,000 or more.

1. In the most common, one-night “split study,” half the night is spent measuring your sleep, creating a polysomnogram (PSG) which is later interpreted by a physician. If you seem to have Obstructive Sleep Apnea (OSA), the second half of the night is spent using a CPAP (Continuous Positive Airway Pressure) machine to find the best airflow pressure setting for you.

2. A second option is a two-night study. It’s the same process as a split study, but a full night is used for each part. The first night is a baseline study of your sleep. The second night is a titration study to establish a CPAP pressure setting.

KNOW YOUR NUMBERS. Know your AHI, Apnea Hypopnea Index. This is a key number resulting from the sleep study, like knowing your height, weight, blood pressure, or cholesterol level. Sleep apnea treatment (a dental device, pillar technique, CPAP machine) may differ depending on the severity of the sleep apnea. Three simple definitions are useful:

Apnea. The Greek word “apnea” means “without breath.” You stop breathing during sleep for ten seconds or longer.

Hypopnea. There is airflow through your throat but at a much reduced level, which leads to not getting enough oxygen. It’s abnormally shallow breathing lasting at least ten seconds.

AHI, Apnea-Hypopnea Index for Sleep Apnea:
Less than 5 events (apnea or hypopnea) per hour is considered normal.

5 or more events per hour is considered Mild sleep apnea
15+ considered Moderate
30+ considered Severe
(from T. S. Johnson MD, Sleep Apnea - The Phantom of the Night, page 211)

The AHI doesn’t tell the whole story. A person may have a low AHI but severe sleep apnea. The duration of events and degree of oxygen desaturation are also important.

Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more? See the peer coaching articles at http://smart-sleep-apnea.blogspot.com , http://www.cpap.com FAQ Learning Center, or search http://www.cpaptalk.com or post a message there.

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.

© Mile High Sleeper, August 2006 - 2011. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you credit the author and include this copyright notice and the web address smart-sleep-apnea dot blogspot dot com