Apnea is a temporary cessation of breathing during sleep. Obstructive sleep apnea: causes, symptoms, diagnosis, treatment, prevention. Symptoms and signs of sleep apnea

Sleep apnea occurs when breathing stops temporarily and repeatedly, which gradually reduces the efficiency of the lungs. How to treat sleep apnea, what complications arise from the disease, as well as other pressing questions and answers to them - below.

Apnea can contribute to poor sleep, daytime sleepiness and poor memory. What is sleep apnea? This is a condition characterized by stopping breathing for 10 seconds or more. In front of him, a person takes several deep breaths, sometimes accompanied by pronounced snoring. Afterwards, there is a sudden stop of snoring and breathing along with it, and only after that the patient snores heavily and begins to breathe. There are more than 3 hundred such stops per night, and this seriously affects the quality of sleep.

Moreover, patients usually do not remember whether they woke up at night. Drowsiness can occur spontaneously, and driving a car is dangerous for such patients, because acute drowsiness also occurs while driving. Statistics indicate that sleep apnea syndrome is often the cause of accidents.

Obstructive sleep apnea syndrome (or OSA) is one of the most common sleep disorders. Its development occurs when the soft tissues in the back of the larynx collapse and the airways are completely blocked. Then a similar syndrome occurs; it is characterized by blockage of the airways at night due to complete muscle relaxation.

If there is problematic breathing during sleep, a person awakens from a lack of oxygen. But there are also cases when the blockage of the airways is incomplete, due to which breathing is also continuous, but superficial. This condition is called obstructive hypopnea. It causes snoring, but snoring does not always indicate apnea or hypopnea.

Developed sleep apnea syndrome contributes to a decrease in the level of oxygen in the blood, resulting in severe hypoxia. At this stage, the patient is choking or snorting. It is worth noting that OSA, as a rule, is characterized as several episodes of hypopnea or apnea, and if this condition occurs in no more than 15 episodes per hour of sleep, we are talking about moderate apnea.

If such conditions occur, urgent treatment of apnea is necessary, because it is life-threatening!

Symptoms

Headache is a sign of obstructive apnea.

With a long-term illness, there is no quality sleep. A patient with sleep apnea develops symptoms similar to neurological diseases:

• severe fatigue;
• poor attention and memory;
• psychological depression and irritability;
• in some cases – problems with potency;
• decreased ability to work;

• severe drowsiness during the day;
• severe morning cephalgia;
• loud snoring, sometimes abruptly interrupted.

In children, the symptoms are somewhat different from the signs of OSA in adults:

• it takes more time to sleep, especially for those suffering from obesity or severe OSA;
• the child makes more effort with each breath;
• on the behavioral side, uncharacteristic changes are noted, expressed in increased aggressiveness and hyperactivity;
• inattention appears;
• Some children experience urinary incontinence;
• Your baby may have a headache in the morning;
• There may be a pronounced discrepancy in height and weight.

These signs are similar to some neurological diseases, so the child should definitely be shown only to a highly qualified specialist.

Complications

Sleep apnea is a condition that requires urgent treatment, because it provokes:

1. Sudden death. It has been proven that children under 2 years of age with this disease have a high risk of dying, like older people. People over 50 years of age are more likely to die in their sleep due to cardiac arrest. Moreover, the higher the pause index per hour, the higher the risk of dying in your sleep.
2. Severe increase in blood pressure. This occurs due to the body's compensatory reflex in an attempt to restore the lack of oxygen. As a result, blood circulation increases and blood pressure rises. And this is fraught with vascular and cardiac wear.
3. Heart failure. With hypoxia and lack of nutrients, the heart rate is disrupted, blood pressure rises and the heart becomes overworked faster. Heart failure occurs, which is also fatal.
4. Myocardial infarction. Occurs when irregular blood pressure destroys the vascular functioning of the heart.
5. Stroke . Blood pressure affects all blood vessels, including the brain. And with severe hypoxia, one of the vessels ruptures, which leads to hemorrhage and stroke.

Risk factors

To prevent these conditions, urgent treatment is required. During diagnosis, the attending physician determines possible risk factors. These include:

1. Age . Most often it occurs in patients over 40 years of age.
2. Floor . It has been proven that the disease is more common among the male population, and is often associated with a large neck and large weight. But women after menopause also rapidly gain weight, and, accordingly, are also at risk.
3. Genetic factor. Patients with a history of OSA are at risk for this disease.
4. Bad habits. It has been proven that smokers and drinkers have a ten times higher risk of developing sleep apnea than people who prefer a healthy lifestyle. It is also highly recommended that patients not drink alcohol before bedtime.
5. Obesity. In this case, the severity of obesity plays a big role. The more fat deposits on the tissues of the neck (especially the throat), the higher the risk of obstructive sleep apnea syndrome.

Classification of the severity of obstructive sleep apnea syndrome.

Reasons

For quality therapy, the doctor determines the causes of the disease: narrowing or blocking of the airways due to muscle relaxation. However, certain physiological characteristics also provoke this condition. These include:

1. Wide neck. But only if this reason is related to obesity. If the neck is initially physiologically wide, apnea does not develop.
2. Structural abnormalities of the skull and face. Micrognathia (a face with an underdeveloped lower jaw), retrognathia (with a protruding lower jaw), a narrowed upper jaw, a large tongue, enlarged tonsils, or a softened or enlarged palate all lead to obstructive apnea.
3. Muscle weakness. Abnormalities characterized by muscle weakness around the respiratory system can trigger OSA.

In children, OSA occurs due to craniofacial anomalies, including brachycephaly - an abnormality of the skull, expressed in a short or wide head, and not corresponding to the norm. Enlarged adenoids, tonsils, and neuromuscular disorders also lead to the disease.

Diseases that cause apnea include diabetes mellitus, polycystic ovary syndrome and gastroesophageal disease. With diabetes mellitus, obesity occurs, leading to apnea. With GERD, a symptom characteristic of sleep apnea occurs - a spasm of the larynx, blocking the flow of oxygen.

Diagnosis and types

For other sleep disorders, a prolonged diagnosis is required, during which an obligatory step is the study of the medical history. During diagnosis, the doctor determines all these symptoms and treatment tactics. But first, it differentiates this disease from others, defining:

• whether the patient works overtime or night shifts;
• is he taking any medications that can cause drowsiness?
• has bad habits;
• what are the medical indicators from tests and instrumental diagnostics;
• general psychological state.

• big neck;
• obesity in the head, neck and shoulders;
• large size of tonsils;
• aberrations from the soft palate.

Based on the clinical picture, the type of disease and further treatment tactics are determined. There is central, obstructive and mixed apnea. Central is much less common than obstructive, and patients quickly wake up from rustling sounds. Often, central apnea provokes the development of heart failure. Mixed apnea is a rare type that includes central and obstructive apnea at the same time

Afterwards, polysomonography is performed, recording body functions during sleep. Doctors strongly recommend this procedure to be performed by people at risk of obstructive complications (obese, heart disease, etc.). During polysomonography, brain waves are recorded. This usually occurs in the sleep centers.

The procedure is carried out using an electronic monitor. During diagnosis, all stages of sleep are studied. It is worth noting that this testing method is allowed for people of any age. This technique is labor-intensive and expensive. The day after testing, the patient is given a CPAP titration.

An alternative to night polysomonography is split-night polysomonography. This technique helps to diagnose OSA and perform CPAP in 1 night.

For home diagnostics, use the main portable diagnostic monitor. It is often necessary for moderate or severe OSA.

Treatment

Treatment tactics depend on the severity of the disease. Long-term complications always require classifying the disease as chronic. Many patients believe that they know how to treat this disease. This is fundamentally wrong; only a qualified doctor will prescribe the correct treatment tactics.

This treatment usually includes positional therapy (the patient should train himself to sleep on the other side), medications for weight loss and diet, medications to eliminate comorbidities that contribute to hypoxia, and anti-anxiety medications. In some cases, dental and orthodontic treatment is required, including the elimination of deficiencies in the dentition.

CPAP

For productive treatment, devices are used that keep the throat open at night using compressed air. CPAP (CPAP) provides artificial ventilation of the lungs to help treat obstructive sleep apnea. The use of CPAP is safe for people of all ages.

After resting under such a device, patients rarely experience drowsiness or weakness during the day. It is worth noting that CPAP reduces the risk of developing heart disease associated with OSA. The maximum effect is achieved with daily use of the device.

To ensure the safety of using CPAP, the attending physician shows the patient how to set up the mask for improved sleep. A physician should be notified of any allergic reactions or ulcers from the mask. At first, the patient gets used to the device, so therapy begins with low atmospheric pressure. To avoid dry mouth or nasal congestion, use CPAP with a humidifying function.

Medicines

The following drugs help as drug therapy:

1. Provigil or modafinil. They are prescribed for narcolepsy. Both drugs are approved for the treatment of obstructive sleep apnea. Modfanil is effective for drowsiness, but therapy should be comprehensive, including the main part of treatment - artificial ventilation.
2. Intranasal corticosteroids. Appointed only in individual cases.

With the help of sedatives, sleep can be normalized. However, such drugs can cause sagging of soft tissues and worsen the body's respiratory functions.

Surgery

For severe OSA, surgical treatment is prescribed:

1. Uvulopalatopharyngoplasty (UPPP). This is a procedure designed to remove excess tissue in the throat to widen the airways. Severe sleep apnea syndrome is eliminated immediately after UPFP if the cause of OSA is adenoids, enlarged tonsils or a uvula hanging over the larynx. Also, after the procedure, a number of patients experience complications: infections, impaired swallowing, mucus in the throat, impaired sense of smell, relapse of OSA. The outcome of the operation is greatly influenced by the state of health. Therapy does not consist of UPFP, it must be comprehensive.
2. Laser UPFP. Used to reduce snoring. During the operation, a piece of tissue is removed from the back of the throat. The prognosis of such treatment is positive, but the long-term normal state may be lower than after standard UPFP. Complications of laser UPFP include even more pronounced snoring and dry throat.
3. A silent implantation column will help cure mild to moderate apnea. The implant reduces the amount of vibration during sleep, which eliminates snoring. The operation does not require general anesthesia, and the recovery period is an order of magnitude shorter than with UPFP.
4. Tracheostomy. During the operation, a hole is made through the neck to insert a tube. But since 100% of patients experience psychological or medical complications after surgery, it is started only in cases of severe apnea that is life-threatening.

Other operations are also possible:

• radiofrequency ablation;
• genioplasty;
• adenotonsillectomy;
• surgery of the nasal septum in case of their deviation.

Complications occur in ¼ of pediatric patients. Operations do not provide a 100% guarantee of complete recovery; then the patient requires treatment with continuous positive airway pressure.

In conclusion, it is worth noting that this disease should never be left without treatment. If no dynamics are observed during therapy, this should be reported to the attending physician.

Does your loved one's snoring regularly keep you awake at night? But the problem is not limited to the inconvenience caused to others. Sleep apnea can be truly dangerous, leading to many quite serious health problems. The term “apnea” is translated from Greek as “stopping breathing.” Of course, we all voluntarily encounter forced stops in breathing movements, for example, during immersion in water. However, unconsciousness, lasting from 20 seconds to 3 minutes, over time can lead to disorders that complicate both the physical and psychological state of a person.

Symptoms of the disease

Sleep apnea, the symptoms of which everyone should know, threatens to stop breathing. However, a person may not feel what is happening during sleep and may not be aware of his illness. It is worth paying attention to other obvious signs that characterize sleep apnea. This:

• Regular snoring.
• A feeling of suffocation that occurs during sleep.
• Fatigue and drowsiness throughout the day.
• Morning headache.
• Decreased concentration and irritability.
• Sensation in the mouth after waking up.

Types of apnea: central absence of breathing

Such a phenomenon as central absence of breathing is quite rare in medical practice. This type of apnea is characterized by the fact that at a certain point the brain temporarily stops sending signals to the respiratory muscles that control breathing. Because of this, breathing stops. Moreover, patients sleep so restlessly that they are able to remember their night awakenings. Central sleep apnea can lead to complications such as hypoxia or disturbances in the functioning of the cardiovascular system.

Types of apnea: obstructive absence of breathing

More often, doctors are faced with obstructive lack of breathing. In this case, the lumen of the respiratory tract critically narrows, the muscles of the pharynx relax, and the air flow is interrupted. Oxygen levels drop and the person is forced to wake up to regain breathing. However, these awakenings are so short-lived that they are not remembered the next morning. On average, a person suffering from this type of apnea experiences such attacks of respiratory arrest 5-30 times per hour. Naturally, we are not talking about any full-fledged sleep or rest. Obstructive sleep apnea, the treatment of which must begin when the first symptoms of the disease are detected, can lead to a number of problems with health and well-being.

Types of apnea: complex breathing

This type of apnea has all the characteristic signs of both central and obstructive rhythm. Periodic pauses in breathing combined with obstruction of the upper respiratory tract accompany a person throughout sleep. This sleep apnea syndrome requires immediate diagnosis and treatment, as it can have quite serious consequences, such as the development of coronary heart disease.

Apnea in children

Despite the fact that we are accustomed to consider this problem more likely to be age-related, it can also occur in children. Children with enlarged tonsils and adenoids, drooping palate and chin, and an underdeveloped nervous system are at risk. Premature babies, newborns with Down syndrome and cerebral palsy are also more likely to suffer from sleep apnea. The cause may also be medications taken by a nursing mother. Parents should be alert to loud breathing during sleep, wheezing or coughing at night, and long gaps between breaths. The child does not get enough sleep, sweats and looks restless while awake.

The most dangerous form of the disease is the obstructive form. The child's face turns pale, fingers and lips become bluish, the heartbeat slows down, and muscle tone decreases. Sleep apnea in children requires immediate medical attention, as it is believed that the disease can lead to sudden infant death syndrome.

Causes of apnea

Obstructed or impaired patency of the upper respiratory tract leads to a condition called apnea by doctors. Most often, people with excess body weight or any inflammation of the respiratory tract suffer from the disease. The causes of sleep apnea can be different:

• Obesity, especially cases where significant deposits of fat are located in the neck.
• Neurological disorders that cause the brain to “forget” how to breathe during sleep.
• Deviated nasal septum, as well as other anomalies in the structure of the respiratory tract.
• Bad habits such as smoking, drinking alcohol or taking drugs.
• Uncomfortable position while sleeping.
• Age-related changes associated with deterioration of muscle tone.

How dangerous is apnea?

Hypoxia is the main danger facing sleep apnea. A decrease in oxygen levels to a minimum level causes a person to become quiet, the skin turns blue, and a signal is sent to the brain that it is necessary to wake up. Upon awakening, a person inhales oxygen, thereby restoring impaired breathing. This state of affairs cannot be called normal. A person chronically does not get enough sleep, unable to get into much-needed deep sleep. This leads to constant stress and disruption of the nervous and cardiovascular systems. In this regard, the level of injuries at work and at home is increasing.

Often, in patients with sleep apnea syndrome, the level of morning pressure increases, the heart rhythm is disturbed, which leads to the development of ischemia, stroke, and atherosclerosis. Against the background of apnea, the condition of patients suffering from chronic diseases, for example, lung pathologies, worsens. As a significant side effect, one can also note the suffering of loved ones who are forced to not get enough sleep next to a person who regularly snores.

Diagnosis of apnea

To determine the severity of the problem, the most important role is played by the patient’s relatives, who, using the method of V.I. Rovinsky, use a stopwatch to measure the duration of respiratory pauses and their number. During the examination, the doctor determines the patient's body mass index. It is dangerous if the UTI is above 35. In this case, a diagnosis is made. The neck volume normally should not exceed 40 cm in women and 43 cm in men. A blood pressure reading above 140/90 may also indicate a problem.

When diagnosing, consultation with an otolaryngologist is mandatory. At this stage, health problems such as a deviated nasal septum, polyps, chronic tonsillitis, sinusitis and rhinitis are identified. A polysomnographic study allows you to record all electrical potentials, the level of respiratory activity, the number, and duration of attacks during sleep. In some cases, choking during sleep is not apnea. Breathing when screaming with certain disturbances may indicate the onset of asthma or other health problems.

Disease severity

In order to determine the severity of sleep apnea, it is necessary to calculate the average number of episodes of apnea per hour. Up to five episodes - no problem, up to 15 - mild syndrome, up to 30 - moderate. More than 30 attacks are considered a severe form of the disease, requiring immediate medical attention. The method of treatment is determined by the doctor based on the patient’s health condition, and traditional medicine becomes a tool that helps to quickly get rid of the problem.

Treatment

Treatment of apnea always involves eliminating the cause that caused the problem. Adenoids and tonsils are surgically removed, and a deviated nasal septum is also normalized, allowing the person to breathe fully. People who are obese are prescribed treatment to normalize their weight. Losing weight by just 5 kilograms in many cases helps get rid of the problem. For diseases of a neurological nature, drug intervention is required. Drugs that stimulate breathing are also prescribed, for example, Theophylline or Acetazolamide.

If the cause of sleep apnea is a flabby palate, then the radio wave method helps to strengthen it and also change its configuration. Local anesthesia, the absence of a long rehabilitation period and high efficiency have made the method the most popular today. The operation lasts only 20 minutes, after an hour the patient goes home, and spends the next night without the painful attacks of apnea that have become familiar. Treatments such as liquid nitrogen or laser are also popular and effective. But the healing of the palate after manipulation occurs more slowly, causing slight discomfort in the person.

In severe cases, CPAP therapy is used. A special device, which is a mask connected to a pressure-creating apparatus, is placed on the patient’s nose before going to bed. The pressure is selected so that the person can breathe easily and comfortably. Less popular are methods of treating apnea such as jaw retainers and adhesive strips that increase the clearance of the nasal passages, and pillows that force a person to sleep exclusively in the “side” position.

Traditional methods of treatment

Alternative medicine offers many options for getting rid of apnea. Simple and affordable recipes can be an excellent aid to the traditional treatment of the disease.

• To moisturize the mucous membranes of the throat and nose before going to bed, rinse your nose with salt water, pour it into your palm, suck it in with your nose and immediately blow your nose. To prepare the mixture, dissolve a teaspoon of sea salt in a glass of warm water.
• Cabbage juice has also long been used in the treatment of sleep apnea. Add a teaspoon of honey to a glass of freshly squeezed juice. The drink should be consumed within a month before bedtime.
• Healing sea buckthorn oil will help improve nasal breathing. It is enough to instill 5 drops of oil into each nostril for several weeks before going to bed. This method helps relieve inflammation from the tissues of the nasopharynx, has a healing effect, and restores blood circulation.
• Carrots have proven to be effective in treating snoring. You should eat one baked root vegetable three times a day before meals.

• Yoga can also be used as a treatment for sleep apnea. Simple exercises performed 30 times in the morning and before bed will help you forget about attacks of the disease. Move your tongue forward while lowering it towards your chin. Hold your tongue in this position for two seconds. Press your chin with your hand and move your jaw back and forth, applying some force.
• The easiest and most enjoyable way to treat mild or moderate apnea is singing. Simply chant daily for half an hour to strengthen your throat muscles. This method is really effective.

This treatment of sleep apnea with folk remedies will help to cope with the problem, provided that all the doctor’s recommendations and subsequent preventive measures are followed.

Prevention of the syndrome

People with excess body weight need to reconsider their diet and lose weight. Smoking and alcohol are also some of the main reasons leading to apnea. Giving up these bad habits in many cases helps to get rid of the problem forever. Tonic drinks, including your favorite cup of coffee in the afternoon, can also lead to the development of sleep apnea. It is enough to limit the intake of such drinks to a reasonable minimum.

A firm mattress and low pillow will make breathing easier while you sleep. Train yourself to sleep on your stomach. This will help prevent a recurrence of sleep apnea. Walking before bed, soothing baths, and massage are good preventative measures for problems that prevent you from getting enough sleep and lead to many health problems.

Update: December 2018

During sleep, the body adapts to a completely different operating pattern than during wakefulness. Contrary to popular belief, he does not rest at all at this time - the brain controls a person’s well-being and creates dreams, and the internal organs support all vital functions: heartbeat, hormone production, breathing and others.

However, for some people, the normal functioning of the body may be disrupted during sleep. Due to a number of reasons, less air enters the lungs, and the body begins to experience “oxygen starvation.” Doctors call this condition sleep apnea syndrome. How dangerous the disease is, how to detect it and successfully treat it - you will find a competent and reasoned answer to all these questions in this article.

What is “night apnea”

This term means partial or complete cessation of breathing during sleep. These periods last no longer than a few minutes, so they are practically not capable of leading to sudden death. The brain manages to notice the lack of oxygen, after which it forces the person to wake up and restore normal breathing. The disease is hidden and some people may not notice it for several years or even decades.

However, breathing problems occur every night and cause chronic oxygen deficiency that continues even during the day. The patient experiences metabolic disorders, decreased functions of various organs, and hormonal changes. The result is the development of complications and the appearance of other diseases.

The following are the most common complications that occur with sleep apnea:

• Obesity;
• Arterial hypertension - an increase in blood pressure more than 140/90 mmHg;
• Diabetes and prediabetes (synonym – “impaired glucose tolerance”);
• Atherosclerosis is the deposition of plaques on the wall of the arteries that supply blood to various organs;
• Coronary heart disease, including rhythm disturbances, angina pectoris (attacks of chest pain), heart attack;
• Cerebrovascular disease (abbreviated as CVD). This is a group of pathologies in which the nutrition of the brain and part of its functions are disrupted: memory, attention, control over emotions, etc.;
• Chronic heart failure is an irreversible damage to the heart muscle, in which blood begins to “stagnate” in various organs/tissues.

It should be noted that each of the above diseases shortens life expectancy and reduces its quality. About 500 thousand people die from these diseases every year. Of these, 40-70 thousand people suffered from apnea syndrome, which caused or aggravated the underlying disease. Getting rid of it and reducing the risk of developing the listed pathologies is the main task of a patient who wants to prolong his life.

Causes and variants of the disease

There are two groups of reasons why a person experiences this disease.

• The first is partial blockage of the airways. As a rule, obstruction occurs at the level of the nose or pharynx. It is associated with various anatomical defects or chronic diseases. Temporary apnea is often observed in patients with obesity, chronic rhinitis, deviated nasal septum, polypous rhinosinusitis, etc.
• The second group of reasons is disruption of the respiratory center of the brain. Since in a dream a person cannot consciously control the breathing process, this function falls entirely on the reflexes of the nervous system. With sleep apnea, the brain partially loses control over this process, which causes “interruptions” in the supply of oxygen to the blood.

Obstructive apnea

Depending on the cause of apnea, there are three variants of the disease:

1. Obstructive – this form is associated with impaired air conduction;
2. Central - oxygen deficiency occurs due to improper functioning of the respiratory center;
3. Mixed - one person has two pathological factors simultaneously.

Determining the type of disease is important for selecting the right therapy that will eliminate the very cause of the disease and influence the mechanisms of its development. The table below summarizes all the necessary information that will help you understand this issue.

Pathology variant	Obstructive	Central
Conditions that can lead to apnea (risk factors)	Obesity, as it is accompanied by the formation of “fat pads” around the pharynx; Enlargement of the pharyngeal tonsils (synonym - adenoid growths); Deviation of the nasal septum; Abnormal structure of the upper jaw; The presence of polyps (benign tumors) in the nasal cavity - polypous rhinosinusitis; The presence of chronic rhinitis (usually allergic or vasomotor); Acromegaly; Some neurological diseases: amyotrophic lateral sclerosis, diabetic polyneuropathy, Guillain-Barré syndrome, various myodystrophies.	Use of sleeping pills, tranquilizers (Haloperidol, Chlopromazine) or potent sedatives (Diazepam, Phenazepam, Clonazepam, etc.); Alcohol or drug intoxication; Hypothyroidism; Some neurological pathologies: stroke and post-stroke conditions, Parkinson's disease/syndrome, Alzheimer's disease and others.
“Trigger” factor for respiratory disorders	Sleep - at this time, muscles throughout the body relax and are practically not controlled by the brain. The muscles of the pharynx, which ensure patency of the respiratory tract, are no exception. If one of the above factors is present, they relax too much and close the lumen of the larynx, where air should flow. This leads to partial or complete cessation of breathing.
Body response	When the brain detects a lack of oxygen in the blood, it “gives orders” to release stress hormones: adrenaline and cortisol. This leads to increased blood pressure, increased blood glucose levels and awakening of the body. The awakened body restores muscle tone and normal breathing. Then he falls asleep again, and the cycle repeats again.

The mixed version is the most difficult in terms of treatment, as it combines two mechanisms of breathing problems. Therefore, to eliminate the symptoms, it is necessary to eliminate two causes simultaneously. Otherwise, the therapy will be ineffective.

Symptoms

Since this syndrome occurs only in a dream, it is quite difficult to detect the disease yourself. However, 100% of people suffering from apnea have characteristic breathing during sleep - periods of loud snoring alternate with interruptions in breathing. Others cannot help but notice this. If a person sleeps alone and does not know that he snores, then you should pay attention to other signs of the disease, which include:

• Frequent nightmares or restless sleep. A lack of oxygen flow to the brain leads to changes in its functioning and disruption of information processing. This process is manifested by a change in the nature of dreams. They become frightening, chaotic, tense. The process of sleep does not refresh the patient and does not allow him to rest, but on the contrary, it oppresses him and causes anxiety;
• Regular night awakenings. The production of stress hormones and the restoration of breathing are invariably accompanied by interruption of sleep. There can be a varying number of such attacks of apnea - from single episodes to several dozen times. If they occur continuously (over weeks or months), it is necessary to suspect the presence of hidden pathology;
• Daytime sleepiness. For normal performance, people need to sleep 6-9 hours daily. Otherwise, the natural biorhythm is disrupted and a feeling of constant lack of sleep appears;
• Decreased attention and performance. Over time, air deficiency begins to occur in patients not only at night - it continues to persist during wakefulness. Excess carbon dioxide in the blood has a negative effect on the brain, which causes disruption of its functioning;
• Decreased mental abilities;
• Emotional lability: unreasonable mood swings, constant irritability, anger, tendency to depression;
• Decreased libido in men and women.

We should also not forget about the objective signs of the disease. Constant pauses in breathing during apnea inevitably lead to the development of complications. They can be suspected based on the following criteria:

Pathological sign		Complication of the disease
Increased blood pressure more than 140/90 mmHg.		Formation of persistent arterial hypertension and chronic heart failure; Increased risk of vascular accidents: strokes, heart attacks, transient ischemic attacks; Development of cerebrovascular disease.
Increase in body mass index (BMI) more than 30 BMI =		Development of obesity; Increased likelihood of diabetes and prediabetes; Formation of atherosclerosis and coronary heart disease; It is possible to develop fatty liver disease.
Changes in laboratory parameters	Increased fasting glucose levels: Whole blood– more than 6.1 mmol/l; Venous blood(plasma) – more than 7.0 mmol/l.
	Changes in blood lipid concentrations: Total cholesterol– more than 6.1 mmol/l; LDL– more than 3.0 mmol/l; HDL– less than 1.2 mmol/l; Triglycerides– more than 1.7 mmol/l
	C-reactive protein level – more than 4 mg/l	Increased risk of heart and vascular diseases: angina pectoris, arrhythmias, heart attacks, chronic failure of the heart muscle.

Diagnosis of the disease

There are two simple methods that can confirm the presence of the disease. The first is a survey - scientists have developed a series of questions that can be used to determine the degree of sleep deprivation of a person and indirectly assess the presence of “oxygen starvation.” This questionnaire is called the Epworth Sleepiness Scale (abbreviated ESS). If you wish, you can assess the likelihood of you having the disease yourself.

To do this, you need to answer several questions below that will assess your susceptibility to daytime sleepiness. For each of them there are three answer options:

• I don’t fall asleep in this situation – 1 point;
• There is a low probability of dozing off – 2 points;
• I can easily fall asleep – 3 points.

Epworth scale questions:

With a score of more than 14 points and the presence of risk factors, there is a high probability of apnea in an adult. In this case, you need to consult a doctor who will choose the most appropriate treatment tactics.

The second method is called pulse oximetry. A pulse oximeter is a small device that fits on your finger and detects the presence of oxygen deficiency. This study can be carried out in any hospital, it does not require preparation and takes no more than a minute. However, it has one drawback. Pulse oximetry can only detect long-term obstructive apnea. In other cases, the study will not show deviations from the norm.

"Gold standard" of diagnostics

According to European recommendations, the best method for diagnosing the disease is a polysomnographic study. However, in Russia this method is used extremely rarely, only in large research centers or private clinics.

The principle of performing polysomnography is quite simple:

1. The patient falls asleep or is put to sleep using hardware or medication methods;
2. During sleep, the patient undergoes the following studies: electroencephalography, electrocardiography, assessment of the blood coagulation system, chin electromyogram, pulse oximetry, assessment of air flow, counting respiratory movements of the chest and abdomen, electromyography of leg muscles;
3. The doctor evaluates the results obtained and compares them with the norms.

It is almost impossible to carry out such a comprehensive examination in the Russian Federation. Therefore, the diagnosis of this pathology is carried out on the basis of patient complaints, the presence of risk factors, questionnaire data and pulse oximetry.

Modern principles of treatment

To successfully get rid of the disease, you need to know its variant (obstructive, central or mixed) and the immediate cause of the pathology (deviated nasal septum, presence of adenoids, etc.). Only after this can you begin treatment for sleep apnea, the goal of which is to restore the patency of the respiratory tract.

Eliminating the cause of the pathology

In 85-90% of cases, the main factor in the occurrence of obstructive apnea syndrome is obesity. If your body mass index increases above 30, it is necessary to take weight loss measures. In most cases, after the BMI is reduced to 20-25, the symptoms of the disease disappear on their own.

At the moment, the pharmaceutical market is overflowing with “diet pills,” private clinics offer various options for operations, and strict diet plans bordering on starvation are ubiquitous on the Internet. For the vast majority of people, all these methods will not bring any benefit, but will only further harm their health.

Rational weight loss can be achieved by regularly observing the following conditions:

• Avoiding the use of alcohol and nicotine (including cigarettes, smoking mixtures, vapes, etc.). One-time consumption of strong alcoholic drinks of no more than 50 g is acceptable, no more than 2 times a week;
• The right diet. You should not give up all types of food and go hungry - these measures are only effective for a short period of time. To lose weight, just change your diet as follows:
  • Refuse any confectionery products, including chocolate, cookies, cakes, pastries and others. These products are sources of quickly digestible carbohydrates that the body does not have time to use for its needs. As a result, they are stored in fatty tissue throughout the body, including in internal organs (liver, pancreas, heart, blood vessels, etc.);
  • Avoid fatty foods: various foods cooked in butter/margarine; fatty meats (veal, lamb, pork, beef); sausages and others;
  • Give preference to protein foods - poultry and grain porridges;
  • Be sure to include fruits and vegetables in your diet as a source of plant fiber and activators of intestinal function.
• Adequate daily physical activity is a prerequisite for losing weight. This point does not mean that a person should go to the gym every day and exercise for several hours. Light jogging, brisk walking, visiting the pool or doing exercises at home is enough. The main thing is regularity physical exercise.

For most patients, these recommendations are sufficient to gradually reduce BMI to acceptable values ​​over several years. The main thing is not to deviate from the listed principles and adhere to the described scheme. It is quite difficult to rebuild your lifestyle, so people often neglect simple methods, searching for a “magic pill” or other means. Unfortunately, at the moment there is no safe and effective means that would allow you to reduce weight without human effort.

Principles for eliminating other causes

If apnea is not associated with the development of obesity, it is necessary to discover the cause of the disease and try to eliminate it. In most cases, this can be done with special therapy or minor surgery.

Different diseases have their own treatment characteristics. For each patient, the doctor individually determines the most optimal approach, depending on the condition of his body and the type of respiratory disorders. Below are general principles for eliminating pathologies that can cause apnea, and the specifics of a doctor’s tactics for various diseases.

Medical tactics	Diseases that cause apnea	Recommended treatment method
Surgical – elimination of pathology is carried out mainly by surgical intervention.	Adenoid growths of the pharyngeal tonsils (Adenoids)	Adenoidectomy is the removal of excess tissue from the nasopharyngeal tonsil. Currently, it is performed without additional incisions - the surgeon performs all manipulations through the nasal passage, using special (endoscopic) instruments. In addition to surgical treatment, otolaryngologists recommend a course of therapy that eliminates the cause of the disease and prevents relapses of the disease. The classic scheme includes: Antimicrobial medications in the form of sprays and nasal drops; Saline solutions (Aqua Maris, Physiomer, Sea water, etc.) for rinsing the nasal passages; Physiotherapy; Spa treatment in a warm maritime climate.
	Presence of polyps in the nasal cavity	Endoscopic polypectomy – removal of tumor formations through the nasal passage. Prevention of relapses is carried out with topical glucocorticosteroids (in the form of a spray). Drugs – Nasobek, Tafen nasal, Budesonide and others.
	Deviated nasal septum	Rhinoseptoplasty is an operation to restore the correct shape of the nasal septum and the patency of the nasal passages.
Conservative – improvement of the patient’s well-being can be achieved with the help of pharmaceuticals.	Chronic rhinitis (vasomotor, allergic, occupational, etc.)	Treatment of this group of diseases should be comprehensive. The classic treatment regimen, regardless of the type of pathology, necessarily includes the following points: Eliminating contact with a factor that provokes an increase in runny nose (allergen, industrial dust, stress, etc.); Rinsing the nose with sea water solutions; Local anti-inflammatory therapy (glucocorticosteroid sprays).
	Hypothyroidism	Replacement therapy with thyroid hormone analogues (L-thyroxine).
	Diabetes as a risk factor for obesity and impaired innervation of the pharyngeal muscles	Blood sugar control can be achieved in three main ways: Diet; Antiglycemic drugs (the best option for most patients is Metformin); Insulin preparations.
	Overdose of medications, alcohol/drug intoxication	The principles for eliminating body poisoning are as follows: Stopping the use of a toxic substance; Waiting for the toxin to be eliminated from the body; In severe cases, hospitalization of a person in a hospital is indicated for intravenous infusions and administration of an antidote (if available).

Treatment of "oxygen starvation"

With a long course of the pathology, a lack of air can persist in the blood even after adequate therapy. Since the body “gets used” to a certain concentration of gas in cells and tissues, it continues to maintain its deficiency. As a result, the person continues to have symptoms despite excellent airway patency.

To saturate the body with oxygen, American scientists have developed a new technique called “non-invasive ventilation”. Its principle is extremely simple - a mask is put on a person’s face or breathing tubes are put on the nose, after which a special device begins to supply gas under a certain pressure. This procedure is performed during sleep, and all apnea treatment occurs at home.

The only drawback of this method is the price. Therapy requires special equipment necessary for daily use: a CPAP machine or a ViPAP machine. Their cost in Russia ranges from 40 thousand to 200 thousand, when ordering from American sites - half the price. Not every patient can afford such expensive equipment, which limits its use.

"The Curse of Ondine"

The article described many reasons that can cause sleep apnea. However, in some people the disease may occur without any reason. How does this happen? Against the background of complete health, a small child or adult develops snoring with episodes of respiratory arrest. These episodes can last significantly longer than in the classic course of the disease. In some cases, they end in death from strangulation.

This option is called Ondine's Curse syndrome or idiopathic hypoventilation. The exact cause of its occurrence is not known to this day. Scientists suggest that the syndrome is associated with congenital underdevelopment of the respiratory center or damage to the nerves that control the functioning of the respiratory muscles. Most often, it manifests itself in newborns or young children, but there are cases of late onset of the disease (at 30-40 years of age).

The Legend of Ondine.In German mythology, there is a story about the beautiful mermaid Ondine, who lived on the shore of a raging sea. A knight passing by her hut was amazed by the beauty and singing of the girl. Swearing to her with his morning breath, he won the heart of Ondine and married her. Over time, the knight forgot about his love and found a new object of desire. Seeing this, Ondine cursed her husband, depriving him of the ability to breathe during sleep, saving him only his “morning breath.”

The "Curse of Ondine" is a diagnosis of exclusion. It can only be determined after all other possible causes have been excluded. A distinctive feature of this pathology is the absence of any symptoms other than respiratory arrest and snoring. No diagnostic method can confirm its presence, so laboratory and hardware techniques are needed only to exclude other causes.

It is impossible to completely get rid of this disease. In severe cases, the patient has to fight for every breath all his life, since all respiratory movements are performed through an effort of will. Existing treatment methods do not affect the cause of hypoventilation syndrome and do not allow getting rid of it. The only way to maintain a decent quality of life for such patients is CPAP machines for BiPAP therapy.

Sleep apnea in children

The principles of treatment and diagnosis of this disease in a child are practically no different from those procedures in an adult. However, the causes and manifestations of the pathological process have certain characteristics at a young age that need to be known. This will allow you to suspect the disease earlier and begin to confirm the diagnosis in a timely manner.

Apnea in children rarely develops due to tumor processes, damage to the nervous system and obesity. In terms of frequency of occurrence, the following conditions come first in young patients:

• Entry of foreign bodies into the respiratory tract. Various options are possible - the object can pass from the larynx to the bronchial tree. In this case, a diagnosis can only be made using an x-ray examination;
• Adenoid growths (enlarged nasopharyngeal tonsils);
• Anomalies in the structure of the airways (deformation of the septum, choanal atresia, hypertelorism, etc.) or the upper jaw;
• Chronic rhinitis, often of an allergic nature;
• Acromegaly is the rarest option.

In addition to the classic symptoms, apnea in newborns and young children (up to 14 years old) is manifested by a number of additional disorders. All of them are associated with a deficiency of tissue nutrition and a constant lack of air. These include:

1. Delayed growth and physical development. Apnea in newborns may be manifested by slower weight gain compared to normal values. With a long course of the pathology, characteristic signs for young patients are short stature, muscle weakness and fatigue;
2. Decreased thinking and cognitive functions. In preschool age, it manifests itself as absent-mindedness and difficulties with learning the skills of reading, counting, time orientation, etc. In schoolchildren, this disease can cause poor performance and discipline in the classroom;
3. Daytime lethargy/hyperactivity.

A separate group of patients consists of children born ahead of schedule. With a slight deviation from the norm (for 1-2 weeks), the child may not have respiratory problems. However, premature birth at an earlier stage often causes apnea in premature babies.

Making a diagnosis in this situation rarely causes difficulties. Since the child is not discharged from the perinatal center until his condition normalizes, airway obstruction is promptly detected by a neonatologist and successfully treated in a medical facility. With a late “debut” of the pathology, it is also not difficult to detect it - the mother quickly detects periods of lack of breathing that occur during sleep and turns to the pediatrician for medical help.

TOP 5 misconceptions about sleep apnea

There are many articles on the Internet describing this problem. It must be remembered that when reading any information, you need to treat it critically and, first of all, consult your doctor. When analyzing various resources and medical portals, the most common misconceptions of the authors were identified.

Here are our TOP 5 misconceptions about sleep apnea:

1. Menopause is a risk factor for sleep apnea. Until now, scientists have not discovered a connection between the amount of female sex hormones and the tone of the pharyngeal muscles. There are no studies or clinical recommendations that would confirm this risk factor. Otherwise, the main contingent of patients with this disease would be women over 50 years of age. However, almost 90% of patients are men 30-40 years old;
2. ARVI can cause illness. No acute illness causes sleep apnea in children. Of course, they can lead to difficulty in nasal breathing, but this disorder persists in daytime. This pathology is a consequence of chronic respiratory failure lasting more than 2 months;
3. Mandibular splints are an effective treatment method. At the moment, European and domestic doctors recommend treating sleep apnea without using the above methods. Since splints do not affect the tone of the pharynx, cannot improve nasal breathing or the functioning of the respiratory center, their use is not justified;
4. Tracheostomy and bariatric surgery are good methods of eliminating the disease. Tracheostomy (making an incision in the larynx and inserting a tube into it) has only one indication - a threat to life due to complete blockage of the upper respiratory tract. This method is never used to treat sleep apnea.
   Bariatric surgery (for weight loss) is also a last resort in the treatment of obesity and should not be widely used. Patients with apnea, for the most part, are people who have practically no worries. In this case, the risk/benefit ratio of surgical intervention is incomparable - the consequences of such operations can be hospital infection, adhesive disease, laryngeal stenosis, etc. Preference should be given to conservative therapy;
5. Bronchodilators and sedatives can be used to treat sleep apnea. These groups of drugs are not used in therapy. Bronchodilators are substances that dilate the bronchi and improve air circulation. lower parts of the respiratory tract. They do not affect the condition of the nasal cavity and pharynx. The main indications for their use: bronchial asthma, COPD, bronchospasm attack. With these diseases, breathing may be impaired not only at night, but also during the day.

Sedative medications also do not have a positive effect on the course of the disease. On the contrary, some of them increase the symptoms of central apnea and increase the risk of complications. This fact can be found in the “contraindications” section if you carefully read the instructions.

Frequently asked questions

Question:
How to determine the severity of apnea?

Question:
What is hypopnea?

Decreased depth or frequency of breathing movements, leading to the accumulation of carbon dioxide in the blood. It is quite difficult to detect hypopnea during a routine examination, so this sign is rarely used in making a diagnosis.

Question:
Can breathing problems occur while falling asleep rather than during sleep?

Yes, since relaxation of the pharyngeal muscles begins to occur already at the stage of falling asleep. In this case, further examination is necessary to identify pathology.

Question:
Can the disease develop due to allergies, vaccinations, ARVI, etc.?

This pathology occurs with prolonged respiratory failure, only during sleep. Therefore, acute conditions, such as acute respiratory viral infections or the body’s reaction to a vaccine, cannot cause sleep apnea.

Question:
How to treat apnea in young children?

The principles of therapy do not differ from those in the adult population. The main thing is to determine the cause of the violations, after which you can begin to eliminate it and combat air deficiency.

Question:
Which doctor should you consult with this pathology?

Making this diagnosis is the responsibility of a therapist/pediatrician. Any competent specialist will be able to suspect a violation, prescribe further examination and, if necessary, consultation with other specialists.

»» N 3 2008

Volov N.A., Shaidyuk O.Yu., Taratukhin E.O.
Russian State Medical University, Department of Hospital Therapy No. 1, Moscow

Sleep is a special process that serves to restore the body, accompanied by a decrease in the level of metabolism, a decrease in blood pressure, heart rate, and a change in the functioning of most functional systems.

Paroxysmal sleep apnea syndrome is characterized by repeated episodes of cessation of breathing or significant reduction in airflow during sleep. This is a fairly common condition, affecting up to 9% of middle-aged women and up to 24% of middle-aged men. The criteria for this syndrome include periodic cessation (apnea) or a decrease of less than 50% (hypopnea) of the respiratory flow, lasting more than 10 seconds, detected during cardiorespiratory monitoring, accompanied by a drop in oxyhemoglobin content by 4% or more according to pulse oximetry. The average number of such episodes per hour is indicated by the apnea-hypopnea index (AHI - apnea-hypopnea index) and the oxygen desaturation index (ODI). Values ​​of these indices less than 5 are considered acceptable in a healthy person, although they are not normal in the full sense.

The development of sleep apnea syndrome is possible in any person. The main risk factors for this condition are hereditary predisposition, male gender, excess weight (especially the deposition of adipose tissue in the upper half of the body), alcohol consumption and smoking. Obesity is considered the most important factor, this is also proven by a large population study that showed that the proportion of people with a BMI>30 kg/m² is growing in parallel with AHI. True, a considerable part of patients with an increased apnea index were normal or moderately overweight.

During normal sleep, the tone of the parasympathetic nervous system predominates. If a person has too many episodes of apnea and desaturation, the restorative function of sleep decreases, sudden awakenings occur, the tone of the sympathetic nervous system, blood pressure increases, the risk of arrhythmias increases, etc. With the constant repetition of such episodes every night, many pathological processes develop, which will be discussed in this article.

There are two forms of sleep apnea-hypopnea syndrome: obstructive and central. The cause of obstructive sleep apnea is the closure of the lumen of the upper respiratory tract as a result of decreased tone of the laryngeal muscles. Normally, their slight relaxation and “sagging” does not lead to a significant narrowing of the lumen, however, in the presence of predisposing factors, it overlaps at the level of the oropharynx and laryngopharynx in the area of ​​the velum, base of the tongue, epiglottis, etc. The tendency to obstruction of the upper respiratory tract is aggravated by such conditions such as micro- and retrognathia, hypertrophy of the tonsils, macroglossia and acromegaly, as well as a supine position, leading to retraction of the root of the tongue.

Modern studies using high-tech imaging methods (CT, MRI, endoscopy) have shown that the localization of such areas is dynamic, and for each person they are as individual as fingerprints.

In the pathogenesis of the second type of sleep apnea - central - the main role is played by disruption of the respiratory center. Periods of apnea are followed by periods of hyperventilation, creating a pattern of Cheyne-Stokes breathing. This begins with chronic hyperreflexia from the receptors of the vagus nerve. They are activated by blood flow to the pulmonary circulation when the body is in a horizontal position. As a result of a period of hyperventilation, pCO 2 drops below the threshold of irritation of the respiratory center, which is manifested by a period of apnea. Next comes a new episode of hyperventilation. The cessation of an episode of apnea is accompanied by spontaneous awakening, recorded on the EEG (a decrease in the depth of sleep, which does not always reach the level of true awakening). It has been shown that the artificial creation of hypercapnia by inhalation of CO 2 in the experiment prevents hyperventilation and the subsequent episode of lack of breathing. It is possible to transition from one type of apnea to another during the night.

Ventilation disturbances, episodes of awakenings, and a cyclical drop in blood oxygen saturation in a chronic course affect the general condition and well-being of people. The first complaint of patients is usually a lack of satisfaction from a night's sleep, no matter how long it may be. Daytime drowsiness, sleep inversion, nightmares, and headaches in the morning are possible. Such symptoms are an indication for examination of night breathing. Snoring is also a very important indicator.

Sleep apnea syndrome causes many disorders in the body. Let's consider various variants of pathological processes that result from episodes of night apnea repeated day after day.

Increasing the intensity of free radical oxidation. Repeated episodes of decreased blood oxygen concentration can be likened to episodes of ischemia-reperfusion, accompanied by damage to tissues exposed to hypoxia. It is known that this damage is caused by the formation of reactive oxygen species, which interact with nucleic acids, lipids and proteins and form free radicals. Some studies have shown that repeated episodes of sleep apnea lead to increased concentrations of reactive oxygen species, lipid peroxidation products and fatty acids, including malondialdehyde and 8-isoprostane. It has been established that patients with high AHI have reduced total serum antioxidant capacity. In addition, the work of Yamauchi M et al. (2005), who studied the concentrations of 8-isoprostane and 8-hydroxy-2-deoxyguanosine, showed that the severity of sleep apnea syndrome directly and independently of other risk factors (including body weight and age) highly reliably correlates with the severity of sleep apnea. radical cell damage.

In Saito H et al. (2002) used the difference in morning and evening uric acid/creatinine ratios (UA/Cr) and serum adenosine concentration as a sign of tissue hypoxia. It has been shown that in patients with severe apnea (AHI >15/hour, minimum SaO 2<80%) разность UA/Cr >1, and the concentration of adenosine was increased, which was evidence of more pronounced catabolism of nucleic acids and nitrogenous bases during periods of tissue hypoxia. Finally, data obtained by Sahebjami H (1998) show that in patients with severe sleep apnea, uric acid excretion was significantly (p<0.0003) выше, чем у пациентов без такового, и нормализуется на фоне немедикаментозной терапии (CPAP 1). Таким образом, повторяющиеся эпизоды тканевой гипоксии во время периодов ночного апноэ повреждающее действуют на клетки и ткани, вызывая повышение уровня катаболизма и экскреции метаболитов белков, липидов и нуклеиновых кислот.

1 CPAP – continuous positive airway pressure. A method of treating obstructive sleep apnea by creating positive air pressure in the airways during periods of respiratory arrest. The amount of pressure created ranges from 4 to 30 mm of water. Art.

Increased levels of inflammatory markers. A number of studies have measured the concentrations of C-reactive protein and interleukin-6 in patients with sleep apnea syndrome, and showed a significant increase in their levels, which normalized after non-drug treatment. According to other data, in patients with an elevated AHI index, excess levels of serum amyloid A (SAA), TNF-, adhesion molecules (VCAM, ICAM), E-selectin and protein chemoattractant of monocytes type 1 are determined in the blood. Changes were found in the daily rhythm of TNF-α secretion compared to the control group. It has been shown that CPAP therapy does not reduce C-reactive protein levels in patients with coronary artery disease and sleep apnea syndrome.

A study of nasopharyngeal lavage in patients with sleep apnea found an increase in the number of polymorphonuclear leukocytes, as well as concentrations of bradykinin and vasoactive intestinal peptide (VIP), which may be associated with damage to the soft tissues of this area during snoring. Similar changes have been identified in children suffering from snoring and sleep apnea (including those associated with hypertrophy of the tonsils). In their exhaled air condensate, a significant (p<0.01) повышение концентрации лейкотриенов и простагландинов по сравнению с группой контроля, коррелировавшее с индексом AHI.

In general, the presence of increased levels of inflammatory mediators, especially TNF-α and IL-6, may contribute to the poor health of people suffering from sleep apnea syndrome and be an additional risk factor for atherosclerosis and the progression of arterial hypertension and heart failure.

Metabolic disorders, proatherogenesis. The role of episodes of sleep apnea in the development of metabolic syndrome, insulin resistance and type 2 diabetes mellitus has been shown. Levels of leptin and insulin were increased in patients with apnea, regardless of body weight and age; internal (visceral) obesity also had a similar relationship, while the level of adiponectin (a hormone with antidiabetic and antiatherogenic effects) was decreased. In the work of Ip M et al. (2000) showed an increase in leptin levels, correctable by non-drug treatment.

In a study by Can et al. (2006) found an increase in the concentration of proatherogenic factors in patients with sleep apnea. So, reliably (p<0.05) был повышен уровень гомоцистеина, аполипопротеина В, липопротеина (а), холестерина липопротеидов низкой плотности, общего холестерина. Повышение гомоцистеина при сочетании ИБС и ночного апноэ выявлено и в другой работе. Предполагается, что это связано со свободно-радикальным повреждением клеток, в том числе, эндотелия. Tuma R et al. (2007) установлено, что риск развития сахарного диабета при синдроме апноэ сна выше в 2,7 раз, чем без такового .

The development of daytime hypercapnia has been shown in people suffering from sleep apnea, both in the presence of obesity and the associated hypoventilation syndrome, and in its absence.

A significant increase in fatal and non-fatal events was revealed in patients with coronary artery disease and arterial hypertension with severe sleep apnea compared with a similar group of patients using non-drug treatment (CPAP), as well as with the control group. Theodore L et al. (2004) reported an increase in blood aldosterone levels in obese patients with arterial hypertension with severe sleep apnea compared with a similar group without it. It is assumed that this may be one of the factors of resistance to therapy in such patients. An increase in aldosterone levels during sleep apnea has also been found in other studies.

In general, most authors agree that sleep apnea syndrome is an independent and significant risk factor for atherosclerosis, metabolic syndrome, and dysfunction of the endocrine system, in particular, the adrenal glands and pancreas.

Worsening myocardial damage, progression of heart failure. The work of Stiles S et al. (2006) and Corra U et al. (2006) showed a significant deterioration in survival prognosis in individuals with circulatory failure and sleep apnea syndrome. A slowdown in the recovery of myocardial function and its scarring after a heart attack has been established. On the other hand, the edema syndrome itself in CHF, leading to fluid redistribution at night, aggravates the obstruction of the upper respiratory tract. Diuretics have been found to have a positive effect on the severity of sleep apnea. There are some differences in the course of sleep apnea syndrome in heart failure. It has been shown that the central type syndrome itself can be caused by stagnation of fluid in the pulmonary circulation, which stimulates n.vagus receptors, causing hyperventilation and hypocapnia, and leading to an episode of respiratory arrest. This, in turn, stimulates the activity of the sympathetic nervous system, causing spontaneous awakenings, increasing the level of adrenaline in the blood, causing tachycardia and increasing myocardial oxygen demand. Cheyne-Stokes breathing episodes, low-frequency oscillations of heart rate, and high sensitivity of peripheral chemoreceptors are indicators of an increased risk of death in patients with chronic heart failure.

The main pathogenetic factor in the adverse effects of obstructive sleep apnea is considered to be a sharp increase in negative intrathoracic pressure, reaching 65 mm Hg. Art. when inhaling, causing an increase in preload on the heart. Repeated tens or hundreds of times every night, these episodes lead to chronic overload of the myocardium. During periods of obstructive apnea, the usual drop in heart rate during sleep does not occur. As a result of increased pre- and afterload, activation of neurohumoral systems, and a decrease in blood oxygen concentration, myocardial remodeling occurs, which ultimately leads to and contributes to the progression of heart failure.

Laaban J.P. et al. (2002) revealed a connection between left ventricular systolic dysfunction and the presence of sleep apnea syndrome, which can be corrected by treatment of this syndrome.

Kraiczi H et al. (2001) indicate thickening of the interventricular septum, prolongation of isometric relaxation time, a decrease in the difference between peak early and late mitral blood flow velocities, and a decrease in the endothelium-dependent ability to relax the brachial artery. All parameters were associated with the duration and severity of desaturations according to the results of pulse oximetry (SpO 2<90%), имели достаточную достоверность (p<0.05) и учитывали поправку на возраст и индекс массы тела .

In a study by Lentini S et al. (2006) showed a moderate increase in blood CPK activity, correctable by non-drug treatment (CPAP). Gami AS et al. (2004) admits that it was not possible to detect an increase in troponin T levels, indicating myocardial damage, in patients with severe sleep apnea and coronary artery disease. The same author points to a significant (p=0.046) and independent relationship between mortality from cardiovascular causes in history and the severity of sleep apnea syndrome. In a study by Multu GM et al. (2000) identified episodes of ischemic depression of the ST segment during ECG monitoring. They were expressed in patients with two- or multi-vessel coronary artery disease against the background of repeated episodes of apnea and the appearance of tachycardia.

Koehler U et al. (1999) analyzed the circadian rhythm of the development of myocardial infarction in 89 patients. Among patients whose infarction developed during sleep, in the pre-morning hours, the AHI index was higher compared with patients whose infarction developed after awakening (20.3/hour versus 7.3/hour at p<0.05) .

Rhythm and conduction disorders. Back in 1979, Deedwania PC et al. the development of AV block in individuals with sleep apnea has been shown. And modern studies reveal rhythm disturbances in such patients. Thus, Gami AS et al. (2004) compared groups of patients with a paroxysmal form of atrial fibrillation and patients with coronary artery disease, differing in the presence of stenosing atherosclerosis of the coronary arteries, the presence of arterial hypertension and diabetes mellitus, but similar in gender composition, age and body weight. Revealed significant (p<0.0004) превалирование синдрома ночного апноэ в группе мерцательной аритмии (49%) по сравнению с общей группой больных ИБС (32%) . В исследовании Porthan KM et al. (2004) также показано, что больные пароксизмальной формой мерцательной аритмии без диагностированной ИБС чаще предъявляют жалобы, свойственные для синдрома ночного апноэ (сонливость, головные боли, остановки дыхания ночью). В наблюдениях Singh J et al. (2004) демонстрируется развитие фибрилляции предсердий во время сна , а Kanagala R et al. (2003) установлено, что пароксизмы мерцательной аритмии после электрокардиоверсии рецидивировали в течение года у 82% больных синдромом ночного апноэ, тогда как в группе контроля – только в 53% (p=0.013). В группе же, получавшей СРАР-терапию, новые пароксизмы развивались у 42% больных – реже, чем в контрольной .

The effect of sleep apnea on heart rate variability has been shown. The relationship was significant when excluding arterial hypertension, CHF and other conditions that could affect the severity of this syndrome. In the group with severe apnea (AHI>30/hour), RR intervals were on average shorter (793±27 ms) than in the control group (947±42 ms). Overall RR variability was reduced in the apnea group (p=0.01). Similar changes, with less reliability (p=0.02), were also detected in patients with moderate sleep apnea. Work by Jo JA et al. (2004) shows that in patients with sleep apnea, according to the results of a polysomnographic study, a decrease in the quality of autoregulation of the heart-lung system was established: an increase in the sensitivity threshold of baroreflexes and a decrease in respiratory oscillations of the heart rate variability curve.

In a study by Garrigue S et al. (2007), who randomly included patients with permanent pacemaker who did not have diagnosed sleep apnea, showed that 59% of them had sleep apnea syndrome. It was detected in 58% of patients with SSSU, in 68% with complete AV block, and in 50% with dilated cardiomyopathy.

A connection between sleep apnea and sudden death has been established. Gami AS et al. (2005) retrospectively reviewed data from 112 patients between 1987 and 2003 who died suddenly and who underwent polysomnography some time before death. It was found that 46% of patients with sleep apnea died in the period from 00 to 06 hours, while in the general population this interval accounts for 16% of deaths (p<0.001), индекс AHI у них был выше, чем у умерших в другое время суток. Он прямо коррелировал с относительным риском внезапной смерти, который для больных ночным апноэ составил 2,57 к общей популяции .

Resistant arterial hypertension. The detection of hyperaldosteronism in sleep apnea syndrome was mentioned above. This is confirmed by the work of Pratt-Ubunama MN et al. (2007). Plasma aldosterone concentration correlated with AHI >5/h (p<0.0002). Выраженное апноэ сна было более свойственно мужчинам, чем женщинам с резистентной гипертонией (90% против 77%), у них же концентрация альдостерона была выше (12 нг/дл против 8.8 нг/дл) .

Haas DC et al. (2005), based on a study of 6120 patients, reports an association between sleep dyspnea and the degree of systolic-diastolic hypertension in persons under 60 years of age, as well as the absence of this association in persons over 60 years of age and in the case of isolated systolic hypertension in persons of any age. Data on the connection between sleep apnea and arterial hypertension are also demonstrated in other sources.

In the works of Narkiewicz K et al. (1998) indicate the influence of hyperactivity of the sympathetic nervous system on the state of muscular arteries, expressed in increased blood pressure, in particular during sleep (the so-called 'non-dipper' or 'night peaker'), and in addition, the absence of the influence of obesity is reported on hyperactivity of the sympathetic nervous system, if it is not combined with sleep apnea syndrome. The same author points to a positive significant correlation (r=0.40, p=0.02) between the increase in AHI and the severity of nocturnal hypertension. The Wisconsin Sleep Cohort Study (2000) showed an association between sleep apnea and hypertension, independent of other risk factors such as weight, gender, age, alcohol, and smoking. Pankow W et al. (1997) based on the results of 24-hour blood pressure monitoring also showed significant (p<0.001) связь тяжести ночного апноэ с гипертензией как таковой и с отсутствием снижения АД ночью .

It is imperative to exclude sleep apnea syndrome in patients with arterial hypertension, especially essential hypertension, with severe refractory hypertension, in the absence of a decrease in blood pressure at night, as well as when ischemic changes or cardiac arrhythmias are detected during sleep.

Mental disorders. In a large study, Pillar G et al. (1998), using the SCL-90 anxiety and depression scale, included 2271 patients with sleep apnea syndrome of varying severity. It was found that in men the level of anxiety and depression, although it exceeded the reference values, still did not depend on either the AHI index or the body mass index and age. Among women, on the contrary, there were, on average, higher levels of depression and anxiety compared to men, and the degree of their severity directly correlated with the degree of respiratory disorders.

Mental disorder with hyperactivity and attention deficit, characteristic of 3–16% of children, has been identified in adults suffering from sleep apnea syndrome. It is characterized by impulsiveness, hyperactivity, difficulty in social adaptation and learning difficulties. A significant improvement in the condition was revealed after non-drug therapy for apnea. A study by Chervin RD (2000) showed that in addition to drowsiness, people suffering from night breathing disorders may complain of general chronic fatigue and lack of energy, but do not feel a lack of sleep. Moreover, in women these complaints are much more pronounced than in men.

An experiment on rats established a connection between the serotonergic system and sleep apnea syndrome: the introduction of serotonin into the blood and its binding to 5-HT 3 receptors led to episodes of apnea during sleep. Farney RJ et al. (2004) reported a relationship between the prescription of combination therapy with antihypertensive drugs and antidepressants and the detection of sleep apnea syndrome. This indirectly indicates the role of night breathing disorders in the development of both arterial hypertension and depression. A relationship has been identified between daytime sleepiness of people suffering from sleep apnea and the absence or reduction in the duration of the phase of slow-wave activity on the EEG during episodes of respiratory distress. Non-pharmacological treatment of apnea had a significant positive effect on this situation. Tests to determine the acuity of attention on car driving simulators have found a decrease in the quality of mental function in people suffering from sleep apnea.

Hemostasis disorders. Hemostasis is a complex system, the basis of which is a precarious balance between pro- and anticoagulant factors. It is logical to assume that sleep apnea syndrome, which affects many body parameters, will also affect this system. A number of studies have been conducted on hemostasis in patients with sleep apnea syndrome. Their results are somewhat contradictory. Thus, when studying platelet aggregation, an increase was found in three of five studies, while in the other two, no difference was detected.

An increase in plasma fibrinogen concentration in sleep apnea syndrome and a twofold increase in plasminogen activator inhibitor type 1 (PAI-1) were found. In patients who have had episodes of apnea during the night, an increase in blood viscosity in the morning is shown. Other studies have not found a difference in the concentrations of thrombin-antithrombin complex, Ddimer and von Willebrand factor in patients with sleep apnea compared to controls, however, it has been shown that CPAP treatment significantly reduces the procoagulant activity of the blood and reduces platelet aggregation at night. After one night of CPAP therapy, a decrease in fibrinogen concentration was detected, which appeared by noon and lasted until the next morning.

The fact that sleep apnea syndrome has hyperactivation of the sympathetic nervous system as one of its pathogenetic mechanisms was confirmed in a study by Eisensehr I et al. (1998). A correlation was identified between an increase in the morning level of blood adrenaline and an increase in platelet aggregation compared with the same parameters in the evening. It has also been shown that physical and psychological stress, like the introduction of sympathomimetics into the body, accelerates the formation of thrombin and soluble fibrin-monomer complexes. Changes in the functioning of the adrenergic system affect various parts of hemostasis.

In some experiments on inducing hypobaric hypoxia in pilots with SaO 2 reaching 61.5% by decompression in a pressure chamber, an acceleration of blood clotting time, increased platelet aggregation, and an increase in the concentration of factor VIII were found. An experiment on mice exposed to an atmosphere of 6% oxygen for six hours revealed the appearance of fibrin deposits in the vessels of the pulmonary circulation. A decrease in the activity of messenger RNA of the t-PA gene (tissue plasminogen activator) and an increase in PAI-1 mRNA (plasminogen activator inhibitor type 1) were also detected in mouse lung cells, which within four hours led to a corresponding change in the levels of these components of the hemostatic system. Similar procoagulant effects of experimental hypoxia and sleep apnea syndrome itself may explain the tendency to develop vascular complications in this category of patients.

The aspects of the effect of intermittent night breathing, episodes of respiratory arrest and hypoxia discussed in the article demonstrate the complexity and polyvalence of the pathological effects of sleep apnea syndrome. Changes in homeostasis occur at a deep cellular and molecular level, subsequently causing clinically pronounced diseases, primarily of the cardiovascular system.

Night apnea gradually leads to maladaptation of the circulatory system, contributing to the formation of severe arterial hypertension, provoking heart rhythm disturbances. Sleep apnea syndrome explains the high frequency of hypertensive crises, cerebrovascular accidents and myocardial infarction in the early morning hours, when the maximum number of unfavorable shifts in homeostasis accumulates due to breathing disorders during sleep. Free radical damage to vascular cells, changes in the lipid profile, a tendency to hypercoagulation, inflammatory changes in the blood contribute to the development of atherosclerosis and atherothrombosis, and cardiac arrhythmias are one of the main causes of sudden death during sleep.

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Sleep apnea is a pathological condition that manifests itself as breathing disorders that suddenly occur during sleep. Episodes of apnea can last from a few seconds to several minutes, which negatively affects all internal organs, and especially the central nervous system.

Sleep apnea is a common pathology that occurs in at least 6% of the adult population. The incidence increases with age.

Blocked airway due to sleep apnea

Causes and risk factors

The most common cause of sleep apnea is obstruction of the airways, that is, mechanical blocking of their lumen (obstructive sleep apnea). During sleep, muscle tissue relaxes, and the walls of the pharynx begin to sag inward. At the same time, they not only interfere with breathing, but also vibrate under the influence of the air stream, which we perceive as snoring. However, if the walls of the pharynx sag sufficiently, they will block the lumen of the airways, resulting in respiratory arrest.

Against the background of apnea, the partial pressure of carbon dioxide in the blood increases sharply, irritating the respiratory center. As a result, the brain “wakes up” and gives the command to increase muscle tone. These processes are repeated many times during sleep.

In severe cases of obstructive sleep apnea, a person often experiences bouts of irresistible sleepiness during the day. At such moments, patients suddenly fall asleep and wake up after a short period of time.

Predisposing factors for obstructive sleep apnea syndrome include:

• old age;
• smoking;
• chronic inflammatory processes in the oropharynx;
• anomalies in the structure of the facial skeleton;
• obesity.

Another cause of sleep apnea is a violation of the regulation of respiratory movements by the central nervous system. Under the influence of certain reasons, during sleep the brain stops sending nerve impulses to the respiratory muscles, which causes breathing to stop. This pathology can lead to:

• stroke;
• hypoglycemia;
• epilepsy;
• water and electrolyte disturbances;
• prematurity in a child;
• some medications;
• cardiac arrhythmia;
• hyperbilirubinemia;
• septic conditions;
• severe anemia.

Forms of the disease

Based on the reason underlying the pathological mechanism, the following are distinguished:

• obstructive sleep apnea;
• central sleep apnea.

Depending on the number of episodes of breathing stops in 1 hour (apnea index), obstructive sleep apnea is:

• mild (5–15 apneas);
• moderate (16–30 apneas);
• severe (over 30 apneas).

Sleep apnea is a common pathology that occurs in at least 6% of the adult population. The incidence increases with age.

Symptoms

The main symptom of any form of sleep apnea is repeated episodes of sudden stops in breathing during sleep. However, each form of the disease has its own characteristics.

Obstructive sleep apnea is characterized by:

• heavy snoring;
• episodes of sudden cessation of snoring and breathing lasting from 10 seconds to 3 minutes;
• restoration of breathing, which is accompanied by a characteristic noise or snoring.

With prolonged apnea, hypoxia develops. Then cyanosis of the nasolabial triangle becomes noticeable. During episodes of apnea, the patient tries to inhale by tensing the abdominal and chest muscles.

With obstructive sleep apnea syndrome, patients often wake up in the morning unrested, feel exhausted during the day, experience drowsiness, apathy, and lethargy. Working capacity decreases.

In severe cases of obstructive sleep apnea, a person often experiences bouts of irresistible sleepiness during the day. At such moments, patients suddenly fall asleep and wake up after a short period of time (from a few seconds to a few minutes). These sudden falls asleep are very dangerous, especially if they occur while driving or performing other activities that require concentration and quick reaction. Moreover, the patients themselves do not notice their “blackouts.”

Sleep apnea of ​​central origin is manifested by the occurrence of Cheyne-Stokes breathing during sleep. This type of breathing is characterized by periodicity: breathing movements from slow and very superficial gradually intensify, become noisy, deep, frequent, and then the intensity of breathing fades again, until it stops for a short time. As a result, with central sleep apnea, the patient breathes intermittently and noisily. Snoring is not observed in all cases. The main distinguishing feature of central apnea compared to obstructive apnea is the absence of respiratory movements of the chest and anterior abdominal wall during episodes of respiratory arrest.

Diagnostics

Sleep apnea can be suspected if at least three of the following symptoms are present:

• episodes of respiratory arrest during sleep;
• loud snoring;
• frequent urination at night;
• unresting night's sleep;
• increased sweating during sleep;
• attacks of suffocation during sleep;
• headaches in the morning;
• constant feeling of fatigue, daytime sleepiness;
• increased blood pressure, especially in the morning and at night;
• decreased libido;
• excess body weight.

The gold standard for diagnosing sleep apnea syndrome is polysomnography. This is a non-invasive study, during which the physiological parameters of night sleep are recorded using special sensors:

• body position in sleep;
• the sound phenomenon of snoring;
• blood oxygen saturation (saturation);
• features of thoracic and abdominal breathing;
• features of nasal breathing.

During this study, the following is also carried out:

• electrocardiography;
• electromyography;
• electrooculography;
• electroencephalography.

The most common cause of sleep apnea is obstruction of the airways, that is, mechanical blocking of their lumen (obstructive sleep apnea).

Computer pulse oximetry can be used to screen for sleep apnea syndrome. To carry it out, a special attachment is put on the patient’s finger and a bracelet on the wrist. During night sleep, the device determines the pulse rate and oxygen content in the blood (saturation).

Treatment

Treatment for mild obstructive sleep apnea includes the following:

• normalization of body weight, if it is higher than normal;
• treatment, including surgery, of diseases of the ENT organs;
• the use of intraoral devices to maintain the lower jaw in the correct position and prevent tongue retraction;
• positional therapy for sleep apnea – the head end of the bed is raised by 15°;
• the use of devices that do not allow the patient to sleep on his back, that is, in a position that increases the intensity of snoring and the frequency of respiratory arrests;
• stopping taking tranquilizers, muscle relaxants and sleeping pills;
• performing breathing exercises;
• compliance with the daily routine.

For moderate and especially severe obstructive sleep apnea syndrome, the only effective treatment method is CPAP therapy. This is a hardware technique based on creating and maintaining constant positive pressure in the airways.

Treatment of central sleep apnea involves the use of medications that stimulate the respiratory center of the brain. If they are ineffective, a long course of CPAP therapy is carried out.

With CPAP therapy, sleep apnea stops; Most patients notice significant improvement already from the first night.

Possible complications and consequences

Sleep apnea syndrome can provoke the development of dangerous diseases:

• arterial hypertension;
• type 2 diabetes mellitus;
• cerebral stroke;
• coronary heart disease;
• myocardial infarction;
• cardiovascular failure;
• atrial fibrillation;
• immunodeficiency state;
• obesity.

Sleep apnea and snoring bring a lot of discomfort into life, leading to psycho-emotional problems, including in the family.

Sleep apnea is dangerous for pregnant women. Its consequences may be:

• arterial hypertension;
• fetal hypoxia;
• gestational diabetes mellitus;
• gestosis (late toxicosis of pregnancy);
• premature birth.

Forecast

With CPAP therapy, sleep apnea stops; Most patients notice significant improvement already from the first night. Patients need psychological support, since the treatment is long-term, sometimes lifelong, and sleeping with a CPAP machine is not always comfortable or aesthetically pleasing.

Prevention

Prevention of sleep apnea includes:

• maintaining normal body weight;
• quitting smoking and drinking alcoholic beverages;
• playing sports;
• timely treatment of diseases of the ENT organs;
• adherence to daily routine;
• refusal of long-term use of sleeping pills.

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