Obstructive sleep apnea (OSA) is a very common problem. Patients with this disorder experience repeated episodes of obstructing their airway when they sleep that culminates in transiently waking up from sleep. In simple terms this means that they repeatedly choke themselves and wake up for a very short period of time. Patients don’t remember waking-up, as the process is very brief. OSA is associated with many health problems such as increased risk for high blood pressure, heart problems and stroke. Additionally patients with severe OSA are at higher risk for traffic accidents. Patients feel tired and fall asleep at times when they should not be asleep (such as work or in the doctor’s waiting room). OSA is more common as we age. Weight gain (obesity) is an important risk factor. However, you can be thin and still have severe OSA. Having a relative with OSA is a powerful risk factor as well.
Why is OSA important in PAH?
In patients with very severe OSA, it may be a cause of PAH. More commonly we think of sleep apnea as a disease amplifier. This means that although by itself mild to moderate OSA may not cause PAH, it may make it worse. For this reason, we look carefully for the possibility of sleep apnea and treat it when we find it.
Common symptoms of OSA include fatigue and more specifically sleepiness. Loud snoring or witnessed choking or apnea episodes are common. Other important risk factors include large neck circumference, obesity, crowded mouth, and family history of OSA. Patients with symptoms or risk factors should undergo a sleep study (the official name for this test is polysomnograph). This test may be done at home or in a supervised sleep center. The advantages of a home study are that it is cheaper and you get to sleep in your bed. The advantages of a supervised sleep study are that the quality of the data is higher and treatment may be tried mid-way through the night.
How is OSA treated?
There are several approaches. Some patients only have OSA when they sleep on their back. In this case, avoiding sleeping on your back works well. With more severe disease, patients require other interventions. Continuous Positive Airway Pressure (CPAP) is the most commonly used treatment. This involves using a mask (nose mask, face mask, nasal pillows) to deliver air under pressure to help keep your airway open. BIPAP is similar to CPAP but involves higher pressure when you breathe in and lower pressures when you breathe out. Patients that don’t tolerate CPAP or BIPAP may try a dental device. This is a fancy mouth-piece that is made by a specially trained dentist. While CPAP/BIPAP is covered by most insurance plans, dental devices are rarely covered. They are generally effective for mild to moderately severe OSA. They are generally not adequate treatment for severe OSA. A new device that implants an electrode under the neck to stimulate the tongue muscle was recently approved. I would generally avoid this invasive procedure for patients with PAH. I would also avoid airway surgeries that can treat OSA. These invasive procedures are high risk for PAH patients.
Important basic measures to help your OSA include:
1. Weight loss
2. Avoid sleeping pills
3. Avoid narcotic pain medications
4. Avoid alcohol
5. Avoid sleeping on your back
6. CPAP takes time to get used to, be patient and persevere!