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Ailmemts & Remedies

Breathing Disorders During Sleep

You Can Snore Your Life Away.
This sounds more like a joke than a warning. But, in fact, habitual loud snoring is the most common symptom of breathing disorders that occur during sleep. The person who snores not only sleeps restlessly, but also is at risk for serious disorders of the heart and lungs. Snoring can therefore be lifethreatening because it can lead to high blood pressure, irregular heart beats, heart attacks, and sudden death.

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Normal breathing must continue at all times whether awake or asleep. The act of breathing is an automatic, highly regulated mechanical function of the body. In healthy sleeping individuals, most muscular and neural activities will slow or even shut down but respiration goes on under a neuromuscular “auto pilot.” However, if something goes wrong with the auto pilot during sleep, breathing may become erratic and inefficient.

Understanding Sleep
Sleep is a complex neurological state. Its primary function is rest and restoring the body’s energy levels. Repeated interruption of sleep by breathing abnormalities such as cessation of breathing (apnea) or heavy snoring, leads to fragmented sleep and abnormal oxygen and carbon dioxide levels in the blood. Excessive daytime sleepiness and various disorders of the heart, lungs, and the nervous system result.

In the 1950’s scientists realized that sleep is not just a quiet state of rest. In fact, two stages of sleep occur with distinct physiological patterns-rapid-eye-movement sleep (REM), and non rapid-eye-movement sleep (NREM) or deep sleep. In normal sleep, REM occurs about 90 minutes after a person falls asleep. The two sleep stages recur in cycles of about 90 minutes each, with three non-REM stages (light to deep slumber) at the beginning and REM towards the end. The amount of sleep needed by each person is usually constant although there is a wide variation among individuals.

How sleep occurs and how it restores the body are not well understood. Scientists originally believed that sleep occurs because the brain lapses into a passive resting state from lack of stimulation. Another theory proposed that sleep occurs when the body generates and accumulates sufficient amounts of a “sleep-inducing substance.” However, research now suggests that sleep results when specific changes in brain function occur. By studying brain waves, scientists can define and measure various degrees, levels, and stages of sleep.

Sleep consists of a rhythmic combination of changes in physiological, biochemical, neurophysiological and psychological processes. When the rhythm is disturbed or the individual processes are abnormal during sleep, a variety of sleep-related disorders may result.

Sleep-Related Disorders
Sleep-related complaints appeared regularly in medical literature in the beginning of the 19th century. However, from 1900 to the mid-1960s little was published in scientific journals about the “sleepy patient” except for an occasional report on the normal or abnormal aspects of sleep physiology. Recent developments of research techniques in neurobiology, molecular biology, molecular genetics, physiology, neuropsychiatry, internal medicine, pulmonary medicine, and cardiology have allowed scientists to study the details of sleep. As a result, there has been an explosion in interest in understanding sleep and “sleep disorders.”

Some sleep-related disturbances are simply temporary inconveniences while others are potentially more serious. Sleep apnea is the major respiratory disorder of sleep. Other serious sleep-related disorders are narcolepsy and clinical insomnia. “Jet lag syndrome,” caused by rapid shifts in the biological sleep-wake cycle, is also an example of a temporary sleep-related disorder. So are the sleep problems experienced by shift workers. Sleep apnea is the condition of interrupted breathing while asleep. “Apnea” is a Greek word meaning “want of breath.” Clinically, sleep apnea, first described in 1965, means cessation of breathing during sleep.

Narcolepsy is a neurological disorder whose main symptoms in uncontrollable, excessive sleep, regardless of the time of day or whether the person has had enough sleep during the previous night. The other features of this disorder can include brief episodes of muscle weakness or paralysis caused by laughter and anger (cataplexy), paralysis for brief periods upon awakening from sleep (sleep paralysis), and dreamlike images at sleep onset (hypnagogic hallucination). Narcolepsy, which may affect several members of the same family, is a life-long condition. Medications help to reduce the symptoms but do not cure the disease.

Insomnia is the commonly experienced difficulty in falling asleep, remaining asleep throughout the night, and the inability to return to sleep once awakened. Its causes may be physical or psychological and it may occur regularly or only occasionally.

Even a partial list of all the disorders caused by or associated with disturbed sleep adds up to some 70 items. The costs to society due to loss of productivity, industrial accidents and medical bills are estimated to be over $60 billion. These staggering statistics led to the creation by the U.S. Congress in 1988 of a National Commission of Sleep Disorders Research. This group is charged with task of developing a blueprint for a national effort to reduce the medical and economic consequences of sleep disorders.

Likely Candidates for Sleep-Related Disorders

Some of the people most likely to have or to develop a sleep-related disorder include:

* adults who fall asleep at inappropriate times and places (e.g., during conversation, lecturing, driving) and who exhibit nighttime snoring
* elderly men and women
* postmenopausal women
* people who are overweight, or have some physical abnormality in the nose, throat, or other parts of the upper airway
* night-shift workers
* people who habitually drink too much alcohol
* blind individuals who tend to develop impaired perception of light and darkness and have disturbed circadian rhythms, the cycles of biologic activities that occur at the same time during each 24 hours
* people with depression and other psychotic disorders.

Click to see:->Sleep related breathing disorders in adults with Down syndrome
Sleep and Breathing Disorders
In 1944, the important observation was made that ventilation (exchange of air between the lung and environment) normally decreases during sleep. Even in “normal” people, breathing patterns during sleep may show a few irregularities. For example, a person might experience an average of seven breathing pauses of up to 10 seconds per night without any associated symptoms or problems. However if the breathing irregularities are accompanied by reduced oxygen supply to tissue (hypoxia) and repeated loss of sleep, these people are at risk of developing more serious problems.

Sleep Apnea...
Sleep apnea is the most common sleep disorder in terms of mortality and morbidity, especially in middle-age men. Perhaps the best known sleep apnea “patient” is Charles Dickens’ Fat Joe in The Posthumous Papers of the Pickwick Club, the overweight, red-faced boy in a permanent state of sleepiness, who snored and breathed heavily. The term “Pickwickian” syndrome is now used to describe patients with the most severe form of sleep apnea that is associated with reduced levels of breathing even during the day. Click to see:->Sleep apnea patients have altered cardiovascular responses during exercise recovery

Sleep apnea occurs in all age groups and both sexes, but seems to predominate in males (it may be underdiagnosed in females) and in African Americans. The Association of Professional Sleep Societies estimates that as many as 20 million Americans have this condition. The conditions associated with sleep apnea are a cascade: apnea, arousal, sleep deprivation, and excessive daytime sleepiness. Each is related to the frequency of the prior condition.

Like obesity with which it is often associated, the clustering of sleep apnea in some families suggests a genetic abnormality. Ingestion of alcohol and sleeping pills increases the frequency and duration of breathing pauses during sleep in people with or without sleep apnea.

Because of serious disturbances in their normal sleep patterns, patients with sleep apnea feel sleepy during the day and their concentration and daytime performance suffer. The common consequences of sleep apnea range from annoying to life-threatening. They include personality changes, sexual dysfunction and falling asleep at work, on the phone, or driving.

Symptoms of Sleep Apnea
Patients with sleep apnea have many repeated involuntary breathing pauses during sleep. The length of the breathing pause can vary within a patient, and among patients, and can last for 10 seconds to 60 seconds. Fewer than 30 such breathing pauses during a 7-hour sleep, or shorter breathing pauses, are not considered indicative of sleep apnea. Most sleep apnea patients experience 20 to 30 “apneic events” per hour, more than 200 per night. These pauses may occur in clusters.

The breathing pauses are often accompanied by choking sensations which may wake up the patient, intermittent snoring, nighttime insomnia, early morning headaches, and excessive daytime sleepiness, although not all patients, for some reason, complain of daytime sleepiness. During the apneic events, a person may turn blue from low blood oxygen levels.

Other features of sleep apnea include slowing down of heart beat below 60 beats per minute (bradycardia), irregular heart beat (cardiac arrhythmias), high blood pressure (both systemic and pulmonary arterial), increase in red cells in the blood (polycythemia), and obesity. The absence of restful sleep may cause deterioration of performance, depression, irritability, sexual dysfunction, and defects in attention and concentration.

Types of Sleep Apnea
Scientists have distinguished three types of sleep apnea: obstructive, central, and mixed. However, since all three types can have the same symptoms and signs, a sleep evaluation is needed to tell the difference among them.

Obstructive Sleep Apnea (OSA) is the most common type. During OSA efforts to breath continue but air cannot flow out of the patient’s nose or mouth. The patient snores heavily and has frequent arousals (abrupt changes from deep sleep to light sleep) without being aware of them.

OSA occurs when the throat muscles and tongue relax during breathing and partially block the opening of the airway. When the muscles of the soft palate at the base of the tongue and the uvula (the small conical fleshy tissue hanging from the center of the soft palate) relax and say, the airway becomes obstructed marking breathing labored and noisy. Airway narrowing may also occur due to overweigh, possibly because of the associated increases in the amount of tissue in the airway.

The reduction in oxygen and increase in carbon dioxide which occur during apnea cause arousals. With each arousal, a signal is sent to the upper airway muscles to open the airway; breathing is resumed with a loud snort or gasp. Although arousals serve as a rescue mechanism and are necessary for a patient with apnea, they interrupt sleep, and the patient ends up with less restorative and sleep than normal individuals.

Central Apnea occurs less frequently than obstructive apnea. There is no airflow in or out of the airways because efforts to breathe have stopped for short periods of time. In central apnea, the brain temporarily fails to send the signals to the diaphragm and the chest muscles that maintain the breathing cycle. It is present more often in the elderly than in younger people but often goes unrecognized.

In central apnea, there is periodic loss of rhythmic breathing movements. The airways remain open but air dose not pass through the nose or mouth because activity of the diaphragm and the chest muscles stops. Patients with central apnea may not snore and they tend to be more aware of their frequent awakenings than those with obstructive apnea.

In Mixed Apnea, a period of central apnea is followed by a period of obstructive apnea before regular breathing resumes. People with mixed apnea frequently snore.

Snoring and Sleep Apnea
Snoring is a sign of abnormal breathing. It occurs when physical obstruction causes fluttering of the soft palate and the adjacent soft tissues between the mouth, external orifices of the nose (nares), the upper part of the windpipe (trachea), and the passage extending from the pharynx to the stomach (esophagus).

Snoring always occurs with obstructive sleep apnea. When diagnosing sleep disorders, obstructive sleep apnea is excluded if snoring is not a symptom. All snorers do not necessarily have sleep apnea; however, because they almost certainly have some physical obstruction in their airways, they may develop sleep apnea.

The prevalence of snoring is greater in the older population and apparently peaks in 60-year-old men and women, declining in older individuals. Men seem to snore more than women. Men also are more likely to develop sleep-disordered breathing. It is estimated that nearly half of all males over 40 snore habitually. Snoring is also more common in overweight people.

A visit to the doctor is not necessary when a person snores unless some of the other symptoms of sleep disordered breathing also occur. However, since snoring is an annoying or irritating symptom with some negative social aspects, many people have sought a “cure” for it. More than 300 devices have been patented in the U.S. which claim to control snoring. Many of these devices were developed even before medical scientists found out that heavy snoring is a potential marker of sleep apnea.

Sleep Apnea and the Heart
Sleep apnea and snoring seems to increase the likelihood of having a variety of cardiovascular diseases. These include high blood pressure, ischemic heart disease (a condition caused by reduced blood supply to the heart muscle), cardiac arrhythmias (abnormal heartbeat rhythm), and cerebral infarction (blood clot in the brain). It is not unusual for patients with sleep apnea to be mistakenly treated for primary heart disease because cardiac arrhythmias may be more prominent than the breathing disturbances.

Nearly 50 percent of sleep apnea patients have high blood pressure. Patients with the most severe sleep apnea seem to have the highest blood pressure levels and are also more likely to have trouble controlling their blood pressure than patients who do not have sleep apnea. No one knows whether a cause and effect relationship exists between high blood pressure and sleep apnea. If it does exist, the ways these conditions interact is unknown.

Snoring alone does not appear to be a risk factor for heart disease. Only when snoring occurs with sleep apnea or obesity does it seem to be associated with these conditions.

Sleep Apnea in Infants
Before a baby is born, the mother’s breathing takes care of its respiratory needs. Although the unborn baby’s lings are filled with fluid and are not ready to take in air, its respiratory muscles make breathing motions, as if “training” to take on the responsibilities of breathing after birth.

As soon as birth occurs, the normal newborn baby begins a continuous pattern of periodic breathing characterized by a succession of apneas followed by regular breathing. Apneas occasionally lasting longer than 10 to 15 seconds are common during the newborn period. Apneas are more frequent and longer in premature newborns than in full-term infants. The frequency of apnea decreases with age during the first 6 months of life.

Babies turn blue during sleep and appear limp may be undergoing episodes of insufficient breathing. They should be checked for a sleep-related disorder.

Sleep Apnea and Sudden Infant Death Syndrome
Sleep apnea is sometimes implicated in sudden infant death syndrome (SIDS), also called crib death. About 10,000 infants die every year in this country for SIDS. Scientists do not know the reasons for these deaths but sleep apnea may play a role because these babies die when they are asleep and show no evidence of trauma. On autopsy, pinpoint hemorrhages are sometimes noted in the thoracic cavity which may be caused by lack of oxygen prior to cardiac arrest and vigorous respiratory movements.

Diagnosis of Sleep Apnea
The general physician may sometimes recognize sleep apnea, but specialists in neurology, psychiatry, pulmonary medicine and cardiology may be needed for accurate diagnosis and management. Diagnosis of sleep apnea is difficult because disturbed sleep can cause various other diseases or make them worse. Several major medical centers now have pulmonologists, neurologists, and psychiatrists with specialty training in sleep disorders on their staff. Although an evaluation for sleep apnea can sometimes be done at home, it is more reliable if it is done in a sleep laboratory.

A variety of tests can be used to diagnose sleep apnea. These include pulmonary function tests, polysomnography, and the multiple sleep latency test. Physicians continue to try to develop other simple and economic procedures for the early diagnosis of sleep apnea.

Pulmonary function tests taken by sleep apnea patients may show normal results unless the patient has a coexisting lung disease. To make a definitive diagnosis of sleep apnea, the physician may order an all-night evaluation of the patient’s sleep stages, and of the status of breathing and gas exchange during sleep.

Polysomnography is a group of tests that monitors a variety of functions during sleep. These include sleep state, electrical activity of the brain (EEG), eye movement (EOG), muscle activity (EMG), heart rate, respiratory effort, airflow, blood oxygen and carbon dioxide levels. Other tests may be ordered depending on a particular patient’s needs. Polysomnography sometimes helps to distinguish between different sleep disorders. These test are used both to diagnose sleep apnea and to determine it severity.

The Multiple Sleep Latency Test is done during normal working hours. It consists of observations, repeated every 2 hours, of the time taken to reach various stages of sleep. In this test, people without sleep apnea take more than 10 minutes to fall asleep. On the other hand, patients with sleep apnea or narcolepsy fall asleep fairly rapidly. When it takes the patient an average of less than 5 minutes to fall asleep, it is considered pathological sleepiness. There is thus some uncertainty in the diagnosis if the sleep latency period (speed of falling asleep) is between 5 and 10 minutes. This test is important because it measures the degree of excessive daytime sleepiness and also helps to rule out narcolepsy, which is associated with onset of REM sleep (dream sleep) in many of the naps.

Treatment of Sleep Apnea…...
More than 50,000 patients are treated each year for breathing disorders of sleep. Physicians tailor therapy to the individual patient based on medical history, physical examination, and the results of laboratory tests and polysomnography.

Patients with sleep apnea can help themselves by trying avoid doing anything that can worsen the disease. Sleeping in improper positions can increase the frequency of apnea. Use of alcohol suppresses the activity of the upper airway muscles so that the airway is more likely to collapse. Sleeping pills and sedativehypnotic drugs suppress arousal mechanisms and prolong apneas. Moving to high altitudes may aggravate the condition because of low oxygen levels. Overweight sleep apnea patients should lose weight.

Because the exact mechanism responsible for obstructive sleep apnea is not known, there is still no treatment that directly addresses the underlying problem. In most cases, medications have not proved successful. Surgical procedures are effective only 50 percent of the time because the exact location of the airway obstruction is usually unclear.

Since patients with sleep apnea usually have significant family and work problems, the treatment should include strategies that will help them cope with these problems. Education of the patient, family, and employers is sometimes needed to help the patient return to an active normal life.

Position Therapy
In mild cases of sleep apnea, breathing pauses occur only when the individual sleeps on the back. Thus using methods that will ensure that patients sleep on their side is often helpful.

Nasal Continuous Positive Airway Pressure (CPAP)
CPAP is the most common effective treatment for sleep apnea. In this procedure, the patient wears a mask or a pillow over the nose during sleep and pressure from an air compressor forces air through the nasal passages. The air pressure is adjusted so that it is just enough to hold the throat open when it relaxes the most. The pressure is constant and continuous. Nasal CPAP prevents obstruction while in use but apneas return when CPAP is stopped.

The major disadvantage of CPAP is that about 40 percent of patients have difficulty using it for long periods of time. Irritation and drying in the nose occur in some patients. Facial skin irritation, abdominal bloating, mask leaks, sore eyes, and headaches are some of the other problems. Because many patients stop using nasal CPAP due to the discomfort arising form exhaling against positive pressure, the search goes on for more comfortable devices. Modifications of CPAP in the treatment of sleep apnea are currently being defined.

One device, which some patients find more comfortable, is the bilevel positive airway pressure (BiPAP). Unlike CPAP where the pressure is equal during inhalation and exhalation, BiPAP is designed to follow the patient’s breathing pattern. It lowers the pressure during expiration and maintains a constant inspiratory pressure.

The ramp system, a modification of CPAP, allows the pressure to be applied only when the patient goes to sleep, increasing pressure slowly over a 30-minute period. The purpose of the ramp system is to make CPAP more comfortable.

Nocturnal Ventilation
Patients can be ventilated non-invasively during sleep with positive pressure ventilation through a CPAP mask. This technique is now used in patients whose breathing is impaired to the point that their blood carbon dioxide level is elevated, as happens in patients with obesity-hypoventilation syndrome and certain neuromuscular disease.

Pharmacologic Therapies
No medications are effective in the treatment of sleep apnea. However some physicians believe that mild cases of sleep apnea respond to drugs that either stimulate breathing or suppress deep sleep. Acetazolamide has been used to treat central apnea. Tricyclic antidepressants inhibit deep sleep (REM) and are useful only in patients who have apneas in the REM state.

Oxygen administration sometimes benefits patients without andy side effects. However, the role of oxygen in the treatment of sleep apnea is controversial and it is difficult to predict which patients will respond to oxygen therapy.

Dental Appliances
Dental appliances which reposition the lower jaw and the tongue have been helpful to some patients with obstructive sleep apnea. Possible side effects include damage to teeth, soft tissues, and the jaw joint.

Surgery
Some patients with sleep apnea may require surgical treatment. Useful procedures include removal of adenoids and tonsils, nasal polyps or other growths, or other tissue in the airway, or correction of structural deformities. Younger patients seem to benefit from surgery better than older patients.

Tracheostomy
Tracheostomy is used only in patients with severe, life-threatening obstructive sleep apnea. In this procedure a small hole is make in the windpipe (trachea) below the Adam’s apple. A T-shape tube is inserted into the opening. This tub stays closed during waking hours and the person breathes normally. It is opened for sleep so that air flows directly into the lungs, bypassing any upper airway obstruction. Its major drawbacks are that it is a disfiguring procedure and the tracheostomy tube requires proper care to keep it clean.

Uvulopalatopharyngoplasty (UPPP)
UPPP is a procedure used to remove excess tissue at the back of the throat (tonsils, adenoids, uvula, and part of the soft palate). This technique probably helps only half of the patients who choose it. Its negative effects include nasal speech and backflow (regurgitation) of liquids into the nose during swallowing. UPPP is not considered as universally effective as tracheostomy but does seem to be a cure for snoring. It does not appear to prevent mortality form cardiovascular complications of severe sleep apnea.

Some patients whose sleep apnea is due to deformities of the lower jaw (mandible) benefit from reconstruction of surgical advancement of the mandible. Gastric stapling procedures to treat obesity are sometimes recommended for sleep apnea patients who are morbidly obese.

Treatment of Patients with Coexisting Lung Diseases
Asthma, chronic bronchitis, emphysema, or other lung diseases can cause breathing problems during sleep. Patients with these diseases may be frequently awakened by cough, aspiration of secretions, choking sensations, and apnea-like sleep disturbances. The treatment in these cases depends on whether the sleep disturbances are due to lung disease or sleep apnea.

Pathophysiology of Sleep and Breathing:

Highlights of the National, Heart, Lung, and Blood Institute Programs

Sleep
The modern era of sleep research started in the mid-1950’s with the discovery that sleep is not a homogeneous phenomenon. Rather it fluctuates cyclically between two distinct sequential stages of sleep.

The first sleep stage is variously called synchronized sleep, slow sleep, slow-wave sleep, quite sleep, or nonrapid-eye-movement (NREM) sleep. In this state the EEG is dominated by large-amplitude slow waves; body functioning generally slows: there are slow, rolling eye movements; the pupils constrict; the respiratory and heart rates decline; blood pressure decreases; and total body oxygen consumption is reduced. It is believed that NREM sleep is a recuperative state.

The second state of sleep is called synchronized sleep, fast sleep, fast-wave sleep, dream sleep, or rapid-eye-movement (REM sleep. The EEG is synchronized, with low-voltage fast waves and there are intermittent eye movements. It is also called paradoxical sleep because of the paradox that the EEG in this sleep stage is similar to that in wakefulness or light sleep, although this is deep sleep in terms of arousability. During REM sleep, central-nervous-system (CNS) activity generally increases, and body system are variously activated and inactivated in a complex physiological pattern. The normal adult spends some 15 to 20 percent of the sleeping hours in REM sleep; this percentage decreases with aging. In contrast, the human fetus of 30 weeks spends 80 percent of its sleep in REM sleep. This declines to 50 percent at term. The amount of quiet sleep (NREM) increases for 50 to 60 percent by 3 months and to 70 percent between 6 and 23 months.

At the biochemical level, hormone-like prostaglandins and cytokines, which are intercellular messengers found in the brain, are implicated in the mechanisms that control sleep. Some speculate that a balance between prostaglandin D2 which increases sleep, and prostaglandin E2 which increases wakefulness, may be involved in the controlling mechanism. The prostaglandins produce their effects when injected into the preoptic area of the hypothalamus, an area responsible for temperature regulation. This may explain the link between sleep and fall in temperature, and also may unify the neurophysiological and biochemical mechanisms of sleep.

Interleukin-1 is localized in the brain in areas associated with control of sleep, and is believed to play a sleep regulatory role. The amount of interleukin-1 in cerebrospinal fluid fluctuates in parallel with the normal sleep/wake cycle.

There is no clear biological answer to the fundamental question of why we sleep. A wide variety of medical and psychiatric illnesses and factors related to age and gender can pathophysiological sequelae. A major goal of sleep research is the characterization of the etiology and pathophysiology of the causes and effects of disturbed sleep.

Breathing
The two major components of breathing are inspiration and expiration. Inspiration is an active process involving contraction of the diaphragm, external intercostal, and in certain circumstances, accessory muscles. It serves to increase intrathoracic volume, decrease intrapleural pressure and allow exchange of air and carbon dioxide within the alveoli of the lungs. Oxygen is transported from the alveoli to the pulmonary bloodstream by passive diffusion and is made available to tissues. Expiration, on the other hand, is a relatively passive process, requiring little or no contraction of the muscles during quiet breathing. A main function of the breathing process is to bring about the exchange of oxygen and carbon dioxide and other gaseous products from biological system.

At birth, the baby switches from dependence on placental gas exchange to air breathing. At the moment of birth there is also a switch from intermittent breathing efforts of the fetal stage to sustained breathing efforts. Since the infants’ respiratory muscles are not well-equipped to sustain high workloads, respiratory muscle fatigue is a problem for premature infants, and apneic episodes requiring intervention occur in at least 50 percent of surviving infants weighing less than 1,500 grams.

Breathing disorders during sleep occur either when there are deficiencies in neurally generated rhythmic respiratory efforts or when there is normal generation of rhythmic efforts but mechanically impeded airflow in upper airways. Metabolic and behavioral control systems in the brain are believed to be the control mechanisms for sleep and breathing. The metabolic system that responds to changes in carbon dioxide and oxygen seems to exert its major influence over NREM sleep. On the other hand, the behavioral control system is involved in voluntary respiratory activities and appears to influence REM sleep; many of the ventilatory changes that occur in REM sleep are similar to the behavioral ventilatory activities such as swallowing, voluntary breath holding, and hyperventilation.

Subjects without any clinical problems may exhibit obstructive or central apnea during periods of REM sleep. Although severe changes in respiratory behavior often occur during the REM sleep, sleep apnea can occur in both NREM and REM sleep. However, sleep staging in patients with severe sleep apnea syndrome is difficult because of severe sleep fragmentation. Thus it is difficult to define the relative importance of abnormal respiration detected during REM or NREM sleeps.

Research Highlights
A recent basic research advance of potential clinical implication relates to the application of modern three dimensional medical imaging techniques to the study of pathogenesis of sleep apnea. Magnetic resonance imaging (MRI) and ultrafast X-ray computed tomography (CT) of the upper airways, combined with computer graphics and reconstructions, have begun to provide exquisite details of the geometry of the upper airway. These approaches now permit identification of the precise anatomical sites of collapse or areas of abnormal compliance to determine if the problem is in a specific area or is a more generalized multifocal abnormality. This information will impact on the treatment options, particularly if there is more diffuse involvement since this wold predict failure of localized surgical procedures.

Only 50 percent of patients with sleep apnea undergoing uvulopalatopharyngoplasty benefit from this procedure. Investigators are exploring ways to identify those patients most likely to benefit from this procedure. A small scale clinical trial conducted to determine predictors of success for UPPP revealed that 86 percent of patients who had documented (by fiberoptic endoscopy) preoperative nasopharyngeal obstruction at the level of the soft palate, showed significant improvement in the number of apneas, arousals and in the cumulative time in apnea-hypopnea following surgery. In contrast, only 18 percent of the patients who had a collapsing segment in regions of the pharynx other than the soft palate showed any improvement following UPPP. This is the first prospective clinical study to demonstrate that closure of the passive pharynx at the level of the soft palate predicts a favorable surgical outcome.

An important opportunity for research on the pathophysiology and treatment of sleep apnea has open up with the finding that the English bulldog seems to be a suitable animal model of sleep apnea. This model is permitting the study of the regularly occurring periodicities in neural activity of the upper airways and the inspiratory muscles, and the role of neural mechanisms in the genesis of sleep apnea. Studies with this model revealed that the consequences of intermittent apnea (sleepiness or hypox emia) serve to increase the magnitude and frequency of neural inhibitory activity, thereby worsening the apnea.

Other studies exploring new treatments for obstructive sleep apnea in animals and humans have identified buspirone, a hypnotic agent as a potentially effective drug for sleep apnea. Buspirone seems to increase ventilation in both anesthetized and awake rats and cats without producing the traditional respiratory depressive effect. In a small scale, controlled clinical trial, this drug decreased sleep apnea and improved respiratory status in the patients receiving the drug.

Associations between snoring, hypertension, heart disease, and stroke raise the possibility of common factors and/or causal relationships between sleep apnea and cardiovascular disorders. Such links may be related to biochemical factors such as insulin, catecholamine, or cortisol that are increased in stress. Sleep apnea may itself be a stress that produces hormonal imbalances that lead to the hypertensive state. Alternately obesity, sleep apnea, and other cardiovascular risk factors may share common metabolic pathways and therefore may be genetically determined. These relationships are being explored by studying families with a history of sleep apnea and/or sudden infant death syndrome as well as by studying racial and genetic differences in the prevalence of sleep apnea-related illnesses.

THE MOST EFFECTIVE  TREATMENT IS REGULAR YOGA EXERCISE  WITH MEDITATION (BREATHING EXERCISE)

Research Opportunities
Since 1986, the Division of Lung Diseases, National Heart, Lung, and Blood Institute, has been engaged in a concerted national program in cardiopulmonary disorders in sleep designed to fill critical gaps in the understanding of the pathogenesis, diagnosis, treatment, and prevention of sleep-disordered breathing. Some research areas of current emphasis include the following.

1. Natural history of sleep apnea with the goal of determining the magnitude of the problem and designing the most effective therapy.
2. Scientific basic for the influence of age, gender, ethnicity, smoking obesity, and snoring on the development of sleep apnea.
3. Assessment of the severity of sleep apnea and defining the relationships of disease severity, response to treatment and prognosis.
4. Cellular and molecular basis of the role of hypoxia in excessive daytime sleepiness and sleep apnea.
5.Cardiovascular consequences of sleep apnea and the underlying neural cellular and respiratory mechanisms.
6.Improved therapeutic modalities for sleep apnea when associated with blood pressure, asthma, chronic heart failure, angina pectoris, chronic pulmonary disease and stroke.
For More Information
Additional information about breathing-related sleep disorders and other disorders of sleep can be obtained form your local sleep disorders center and the following sources:

Unites States
American Sleep Apnea Association
P.O. Box 3893
Charlottesville, VA 22903

The American Sleep Disorders Association 604 Second Street Southwest
Rochester, MN 55902

Association of Sleep Disorders Centers

P.O. Box 2604
Del Mar, CA 92014

AWAKE NETWORK
P.O. Box 534
Bethel Part, PA 15102

American Narcolepsy Association
P.O. Box 1187
San Carlos, CA 94070

Narcolepsy Network
155 Van Brackle Rd.
Aberdeen, NJ 07747

National Heart, Lung, and Blood Institute (NHLBI) Communications and Public Information Branch 9000 Rockville Pike
Bethesda, MD 20892

(Other institutes at NIH that have information about sleep disorders include the National Institute of Neurological Disorders and Stroke, National Institute od Child Health and Human Development, National Institute of Mental Health, National Institute on Aging. The address for each is 9000 Rockville Pike, Bethesda, MD 20892.)

Centers for Disease Control and Prevention 1600 Clifton Road, NE
Atlanta, GA 30333

International
Sleep Apnea Research Association, Inc.
65 Kitchener Avenue
Earlwood NSW 2206
Australia

Sleep Apnea Society of Alberta
Faculty of Nursing
University of Calgary
2500 University Drive NW
Calgary, Alberta T2N 1N4

Nederlandse Vereniging Van Slaap Apnoe Patienten De Nye Oanliz 25
9084 AN GOUTOM
The Netherlands

British Sleep Society
Sleep Disorder Clinic
Leicestershire General Hospital
Leicester, LE5 4PW
United Kingdom

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Sources:http://www.medhelp.org/lib/breadiso.htm

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Better Sleep From A to Zzzzz

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Stop counting sheep! Check out these tips for getting a good night’s sleep.

Adenosine
Cats nap soundly and often, possibly thanks to this natural substance. Harvard Medical School researchers found in 1997 that levels of adenosine rise before sleep and drop during it, indicating that adenosine may help us slip into slumber. Now the rush is on to determine whether a new sleeping pill could be made of synthetic adenosine. In the meantime we’re left with the current crop of prescription pills .

Babies
New moms often sleep poorly, regardless of whether their offspring sleep well. But even among nonparents, the mere threat of being awakened can disrupt sleep. It triggers what experts have dubbed on-call syndrome, named after the fitful sleep that afflicts emergency workers, medical students, and doctors. These people lose about 1½ hours of sleep when on call, even if their services are never needed, reports Thomas Roth, Ph.D., director of the sleep disorders and research center at Henry Ford Hospital, in Detroit. If you’re in an on-call situation, make up for a little lost sleep by napping for 30 minutes the next day.

Chronotherapy
Sleep problems often arise when the body’s internal clock gets out of kilter. As a result of travel across time zones or a series of late nights in their own hometown, people who once dozed off at 11 p.m. suddenly find that they can’t fall asleep until 3 a.m. and don’t want to awaken before noon. When this occurs, doctors recommend chronotherapy to gradually reset the body’s clock. In this process, sleep is delayed in three-hour increments. For example, someone who’s having trouble falling asleep at 11 p.m. might be told to stay up until 2 a.m. The next night, she stays up until 5 a.m., the next until 8 a.m. and so on, until she has circled the clock and readjusted her natural bedtime to 11 p.m.

Depression
Depression is just one of the health problems reported by people with chronic insomnia. The list also includes cardiovascular, gastrointestinal, and musculoskeletal ills. Insomniacs are four times as likely as the general population to be depressed, and daytime sleepiness can be a warning sign of a blue mood. Researchers aren’t sure which comes first — the depression or the sleep problem. Caution: The typical treatment for depression, antidepressant drugs, can often have a sedative effect as well.

Estrogen
Hormonal changes take a toll on sleep. “It’s not uncommon for women to feel fatigued and need more sleep than usual in the few days before menstruation,” says Margaret Moline, Ph.D., director of the sleep-wake disorders center at New York Hospital-Cornell Medical Center, in White Plains, N.Y.

Another hormone-linked sleep shortage begins just before menopause, at around age 49. “Women with hot flashes are aroused out of restful sleep every eight minutes, while those without hot flashes find their sleep disrupted an average of every 18 minutes,” says Suzanne Woodward, Ph.D., an assistant professor of psychiatry at Wayne State University, in Detroit.

Postmenopausal hormone replacement therapy can help relieve hot flashes, as can lowering the thermostat in your bedroom (for details, see “Temperature,” below).

Exxon Valdez
In perhaps the most famous of a long list of sleep-related disasters, this grounded oil tanker dumped 11 million gallons of crude oil into Alaska’s Prince William Sound. The third mate, who was at the helm, was sleep deprived. Need more incentive to get your nightly eight hours? Lack of sleep also contributed to the space shuttle Challenger explosion and the Chernobyl disaster, according to Stanley Coren, Ph.D., a professor of psychology at the University of British Columbia, in Vancouver, and the author of Sleep Thieves.

Falling Asleep
If you lie awake for an hour or more before dozing off, you have insomnia. About 20% of people have it occasionally; for 10% the condition is chronic. Most insomniacs turn to over-the-counter products such as sedating antihistamines for help. Only 4% take prescription sleeping pills, most often benzodiazepines, which should not be used for more than a month because they can cause dependence and rebound insomnia.

The latest research suggests that the best sleep inducer in people with chronic insomnia is behavioral therapy. A study done in 1998 at the Mayo Clinic, in Rochester, Minn., found that changes in habits can help eliminate persistent insomnia, and that the benefits last longer than those of sleeping pills. Techniques used included having patients attempt to deduce the causes of their insomnia and experiment with lifestyle changes, such as avoiding napping or evening exercise, to see what worked best for them.

Gallup Poll
One-third of American adults are hazardously sleepy, according to a 1997 Gallup Poll sponsored by the National Sleep Foundation (NSF) in Washington. Almost half of Americans — 41% — report getting less sleep than they need, while a third say daytime sleepiness has interfered with routine activities.

Hilton Hotels
Is there such a thing as a caffeine-free hotel room? Actually, there are 35 of them in Hilton hotels across the country. Though these “Sleep Tight” rooms have no coffeepot, they’re outfitted with everything you need for sound sleep, and at no extra charge. The rooms boast features that fitful sleepers might benefit from having in their own bedrooms: blackout drapes; double-paned windows; extra-insulated walls; and an alarm lamp that wakes sleepers with gradually increasing levels of light.

Insomniaphobia
People who miss a night or two of solid sleep often begin to lie awake fretting that they won’t be able to doze off. This fear is self-perpetuating. “We tell people with insomnia to take away their bedside clock,” says Dr. Moline. This tactic works particularly well with insomniaphobes, who tend to be clock watchers.

Jet Lag
It’s a bane of modern living that’s not confined to international travelers: Changing time zones, even within the U.S., can be enough to upset the sleep schedule. In fact, Harvard Medical School researchers reported in 1997 that even the end of daylight savings time in October may be enough to throw off the body’s internal clock and increase the risk of on-the-job accidents. Cautious use of melatonin can help reset the body clock, as can exposure to bright sunlight. Talk to your doctor or a sleep specialist about how to time the use of either therapy for maximum benefit.

Kids

As sleep-deprived as many adults are, kids often fare worse. Mary Carskadon, Ph.D., a professor of psychiatry and human behavior at Brown University, found more depressed moods, lower grades, and more severe behavioral problems among ninth and tenth graders who got fewer than seven hours of sleep a night than among teens who slept more.

Furthermore, as adolescents mature, their body clocks may shift so that their ideal wake-up time is about an hour later than it was in their early teens. The natural bedtime changes from 9:30 in young teens to 10:30 in those over age 14. This means that for a teenager, getting up at 6 a.m. is as difficult as awakening at 3 a.m. would be for an adult. As a result, schools in Minnesota, California, Florida, and Washington have already begun to delay school start times to synchronize them with teens’ ideal sleep schedule. Early reports are that grades and behavioral problems are improving.

Melatonin
Although nonprescription melatonin supplements have become popular as a sleep aid, the hormone isn’t a particularly powerful sleep inducer, according to Josephine Arendt, Ph.D., a professor of endocrinology at the University of Surrey, in England, who has studied melatonin since 1972. Indeed, its only known function in humans is as a “chronobiotic,” a regulator that helps the body adjust to seasonal time changes.

Many people have taken melatonin with no apparent harmful effects. Data showing that it may constrict the coronary arteries as well as create infertility, however, suggest that it is potent and should be used with caution, if at all.

According to the NSF, there are no valid scientific data to support the use of melatonin as a sleep promoter. If you take it as a remedy for jet lag, do so cautiously: At the very least, you could wind up on Japan time when you’re only going to London.

Narcolepsy

One in 1,000 people has this neurological disorder, with its hallmark symptoms: daytime sleepiness; sleep “attacks” in which a person is overwhelmed by the need to sleep; bad dreams; and cataplexy, a sudden loss of muscle control that might cause the knees to buckle.

Narcolepsy typically starts in one’s teens or early 20s, though it may go undiagnosed for years. Unfortunately, effective treatments are limited. Stimulants are prescribed for daytime sleepiness, and tricyclic antidepressants are often given for cataplexy. Two promising drugs, rohypnol and gamma hydroxy butyrate, or GHB, are available only to people in clinical trials and may remain largely inaccessible, because they can be fatal in high doses and have been used in date rapes. The good news is that another medication awaiting FDA approval, Provigil (modafinil), appears to keep patients awake without making them jittery, a side effect of other therapies.

Oversleeping
We all relish an extra hour of rest on an occasional Saturday morning, but researchers say oversleeping on weekends can be a clue to the extent of the sleep debt you’re building up during the workweek. If you sleep more than an hour late on weekends, try to increase the amount of sleep you get during the week.

Preparatory Napping
If you know you’re going to be shortchanging yourself on sleep, store up rest by napping ahead of time. William Anthony, Ph.D., a professor of psychiatric rehabilitation at Boston University and the author of The Art of Napping, coined the term “preparatory napping” and says good “naptitude” includes limiting naps to 15 minutes (a longer snooze may leave you groggy). Studies show napping improves skills and performance for hours afterward, and nappers report no greater sleep difficulties at night than non-nappers.

Restless Legs Syndrome
This annoying neurological condition triggers a pulling or crawling sensation in the legs that can be relieved only by movement. Because RLS disrupts sleep severely, it is often handled by sleep specialists. “It’s one of the toughest things we treat,” says Alex Clerk, M.D., director of the University of California at San Francisco/Stanford sleep disorders clinic.

According to the Restless Legs Syndrome Association in Rochester, Minn. (www.rls.org), the condition affects 3% to 8% of the population, though many people aren’t aware that the annoyance has a name, much less a treatment. Taking iron supplements, avoiding caffeine, and taking hot or cold baths helps many people, but dopaminergic or anticonvulsant drugs may eventually be needed.

Sleep Laboratories
Sleep science has surged in recent years, and there’s now a center specializing in treating sleep disorders within 150 miles of almost anyone in the U.S. Most sleep labs require an overnight stay while doctors, using wires and electrodes connected to a sleeping patient’s body, measure brain waves, eye and leg movement, and muscle tension. A microphone records snoring while airflow sensors track breathing. Technologists read each subject’s 1,000-page record to assess sleep quality and quantity.

If you decide to visit a sleep lab, check with your insurer to make sure you’ll be reimbursed for the test, which runs about $1,200. Because sleep science is a relatively new field, the treatment of sleep disorders is sometimes challenged by insurance companies. Avoid clinics that treat only sleep apnea, a breathing disorder; a good lab will diagnose and treat a variety of conditions.

Sleep Quotient
Generally speaking, adults require about eight hours of sleep a night; Americans average only six or seven hours. Sleep researchers agree, however, that it’s not how close we come to our sleep quotient that’s important, but how well we sleep. A common myth is that our need for sleep declines as we age. In fact, it’s sleep quality that may deteriorate. As both sexes age, says Dr. Moline, they find it harder to fall asleep; sleep may become more fragmented and nighttime awakenings occur more easily. If you’re awakening unrefreshed, talk to your doctor about screening for a possible sleep disorder.

Snoring
Not just a nighttime nuisance, snoring is also a symptom of sleep apnea, a condition in which the muscles in the nose and throat relax during sleep, causing breathing to stop for up to a minute at a time. The resulting strain can damage arteries, leading to high blood pressure.

Apnea’s most common symptoms are loud snoring and daytime sleepiness. The typical patient is an overweight, fortysomething man who snores, but women are at increased risk after menopause. It’s not yet clear whether this higher risk is hormone related or due to weight gain. “If a woman has very little space where the tongue and upper airway meet, is obese or has large tonsils,” she may be at greater risk, says Dr. Moline.

Premenopausal women with apnea may be particularly hard to diagnose, because their symptoms don’t show up on the standard sleep-lab workup. A special test that measures the pressure between lung surfaces inside the chest is often needed, according to Dr. Clerk.

Treatment for apnea has come a long way since the 1970s, when the only therapy was a tracheotomy. In 1981 researchers developed the continuous positive airway pressure (CPAP) device, a breathing apparatus worn during sleep to keep the airway from collapsing. Losing weight, avoiding alcohol and cigarettes, and not sleeping on one’s back can help minimize symptoms. When the CPAP isn’t effective, a procedure that uses radio-frequency waves can reshape tissues in the throat. For information about apnea, call the Sleep Apnea Association, in Washington, at 202-293-3650. To stop non-apnea snoring, try a flatter pillow. Puffy pillows keep the neck in a snore-promoting position.

Temperature
Lowering body temperature at bedtime may help insomniacs sleep better, says new research from New York Hospital-Cornell Medical Center. Taking a hot bath about 90 minutes before bedtime prompts a slight drop in body temperature, which may help you doze off. Your bedroom’s temperature is also a factor in how well you sleep: 60ºF to 65ºF is ideal.

Ultradian Rhythms
Adults sleep in these daily cycles, switching between REM (rapid eye movement) and non-REM sleep every 90 minutes in an astonishingly predictable pattern. The body produces much of its growth hormone during deep sleep, and an age-related drop in deep sleep may contribute to the bone density decline that leads to osteoporosis. So have that glass of warm milk before bed: You need the calcium.

Victims of Drowsy Drivers
Sleep-related crashes kill about 1,550 people each year and cause almost 40,000 nonfatal accidents, reports the National Highway Traffic Safety Administration, in Washington. These accidents are likeliest to occur after midnight and before 7 a.m., and are likelier than others to be fatal. Their sinister sign: no skid marks at the accident scene — a clue that the driver wasn’t awake to hit the brakes.

A 1999 NSF survey found that 17% of Americans had nodded off at the wheel. But even if a sleepy driver doesn’t doze, her reaction time can be delayed. Sleep deprivation also heightens the effects of alcohol. An adult who drinks the equivalent of two beers after four hours of rest averages 35 hazardous situations in a driving simulator, while someone who drinks the same amount after eight hours of sleep makes only five errors.

So how can you stay alert behind the wheel? The combination of a short nap and 200 milligrams of caffeine (the equivalent of roughly two cups of coffee) was the most effective emergency measure in a recent British study. Another strong deterrent: Check out the chilling memorial to victims of drowsy drivers at the Parents Against Tired Truckers Website, www.patt.org.

Websites
More information on sleep and sleep disorders can be found at the NSF Website, www.sleepfoundation.org, or by calling 888-41-AWAKE. For a list of sleep centers, check out the American Sleep Disorders Association site at www.asda.org.

Yawning
Despite the fact that we all do it, no one seems to know exactly why we yawn. Some experts hold that, like laughing or crying, yawning is a physical response to an emotional state — namely boredom — or fatigue. Frequent yawning may be a sign that you need to examine your sleep schedule.

Zinc
A deficiency of this mineral, or of iron, calcium or copper may be to blame for insomnia. If you’re losing sleep, try adding a multivitamin to your routine.

If you’re tired of feeling like you’re not at your best or like you’re not getting the sleep you need, then it’s time to take action! Sign-up for the National Sleep Foundation’s Sleep Challenge today!

Source:Reader’s Digest

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