Sleep Disorders: Sleep Apnea and UARS (Upper Airway Resistance Syndrome)

Sleep apnea refers to the finding of significant numbers of breathing events during sleep that result in a cessation of breathing for ten seconds or more resulting in either a de-saturation and/or respiratory micro-arousal (with the potential to result in lighter stages of sleep and overall non-restorative sleep). The range is highly variable and individuals can have very long apneas lasting longer than 60 seconds or meet the criteria of ten seconds. Hypopneas are baby apneas, with diagnostic criteria of ten seconds in duration followed by a de-saturation and/or respiratory arousal.

Hallmark symptoms of possible Sleep Apnea:

• Excessive daytime sleepiness
• Hard to wake up in the morning
• Finally awake several hours later and then tired again late morning
• Loud snoring
• Gasping or choking episodes during sleep
• Drowsy when driving
• Asleep the minute they sit down
• Personality changes, increased anger, low frustration tolerance
• Hyperactivity in children
• Cognitive deficits related to memory and frontal processes seen on neuropsychological evaluation

Alerting factors of possible UARS:

• Mouth breathing
• Bad breath
• Unresolved respiratory conditions
• Hyperactivity in children
• A child or adult who has been sleeping on his side for a long time
• A family history of snoring and diagnosed apnea that is not necessarily weight related
• Respiratory events of apnea and hypopneas occur in the side or back position when measured on the overnight sleep study
• There is evidence of jaw and facial changes
• High palette, small mouth, history of mouth breathing, snoring
• Learning difficulties, long term memory problems and deficits involving the frontal processes measured on neuropsychological evaluation

These are the individuals whereby removal of the tonsils and adenoids typically does not alleviate the problem. These are the children who after having a honeymoon period following the surgery return to having similar problems seen pre-surgery. When this situation treatment options narrow to a CPAP or examination of ways to open the airway.

Examination of Options

An examination of the structure of the individual’s face, size of their tonsils, and a cursory examination of the airway is routinely suggested. Depending upon the outcome of this initial exam, referral to a sleep center would be in order. At the sleep center, a sleep medicine specialist will examine the airway more in depth and determine the need for a sleep study. A sleep interview completed by a behavioral sleep specialist rules out extraneous factors such as insufficient sleep or the presence of a sleep disorder that would not require an overnight sleep study. The behavioral specialist and sleep medicine specialist work together to determine the need for a sleep study and if a nap study is needed to rule out causal factors for excessive daytime sleepiness. If the problem is psychological or emotionally related, then the treatment will ultimately involve use of the behavioral therapies, requiring the services of a specialist in behavioral sleep medicine.

If a sleep problem is obviously linked to enlarged tonsils and/or adenoids, the next step may be a discussion with the primary care physician regarding a referral to an ear, nose, and throat (ENT) doctor. A sleep study provides important additional documentation to the clinical assessment and confirmation of surgical needs and/or benefit to the person.

An overnight sleep study provides sufficient information to determine whether surgery is the best option by analyzing variables of:

• Number of respiratory micro arousals (the index or number of times there was an arousal which tends to shift the person into a lighter stage of sleep that is usually non- restorative)
• Amount of restorative sleep for the brain and the body the person is actually getting, especially the separation of stage III from stage IV
• The apnea/hypopnea index (an hourly rate of documented breathing events)
• The apnea/hypopnea index (for REM (more problematic) vs. non-REM sleep)
• Number, degree and duration of de-saturations occurring during a respiratory event
• The respiratory index based upon body position
• End tidal CO2 and de-saturation highs and lows throughout the study as well as averages
• Presence of tachycardia and/or bradycardia
• Presence of snoring

If surgery is decided upon, there is a specific method of removing the tonsils that research reveals changes (or does not change) the presence of sleep apnea. The suggested course is for the child or adult to have a sleep study three to six months post-surgery. If six months post-surgery results in a positive sleep study once again for apneic events, the decision depending upon the severity would be to complete a CPAP sleep study and/or refer to the dentist for an airway evaluation.

If CPAP is pursued, the following issues are critical for future compliance:

• Trial use and determination of an interface device that will work for that person. The best example is the mouth breather who becomes claustrophobic because they were fitted with a face mask as opposed to using alternative devices for their mouth or nose.
• Consideration of a heated humidifier
• Pressure that the person can adequately tolerate.
• Examination of the CPAP sleep study to see if there was restorative sleep which mean analysis of the micro-arousals. Good restorative sleep tends to be predictive of excellent CPAP compliance whereas the exact opposite will occur if sleep remains just as poor as the original sleep study.

An alternative that can be implemented with or without CPAP is the use of positioning devices to change the airway. Success will depend upon the knowledge and artistry of the dental specialist and their knowledge of airway problems and sleep. Additional surgical options are available, one of the most positive outcomes involves directly addressing the airway.

As a Neuropsychologist attempting to find the causal factor behind an already diagnosed memory or learning problem, the sleep study provides the data to clinically ascertain if the severity is sufficient to explain the test findings or if the diagnostic evaluation needs to remain ongoing. If the sleep study when clinically analyzed does not appear equivalent to the neuropsychological test findings as well as parent, spouse, work and school concerns, then referral for a 24-hour or longer electroencephalogram (EEG) may be discussed with the treating physician. If looking for an ongoing process in the brain primary causal factors tend to be related to either sleep or seizure or both. The key place where treatment tends to go awry evidenced by a worsening condition can easily be related to undiagnosed respiratory sleep problem or seizure events. Well documented in the research is the risk of seizure occurring in the presence of a brain injury.

In summation:

Children and adults diagnosed with sleep apnea face the risk for impact to brain processes. Often the CPAP, a lifetime on a breathing machine, is their only alternative, although new devices are being developed. If an adult tolerates the CPAP receiving the benefit of vastly improved restorative sleep, they will remain compliant and happy. Children however tend to quickly grow tired of the machine that initially was quite interesting and novel to them. Facial redness, discomfort during the night results in inadvertently disconnecting themselves from the machine. It then becomes important to search for the best alternative to address the sleep apnea identified by the sleep study based upon the level of severity. It is critical given the importance of the sleep study that the quality of the study is sufficiently accurate and provides the necessary data to accurately analyze the child’s breathing disorder.

The issue for children suffering from sleep apnea is twofold as they face the results of sleep deprivation (that can have considerable impact upon their emotional and behavioral status as well as retention of new learning) and the effects of de-saturation upon their memory and frontal processes.

Finally interfacing with the school and family is absolutely crucial to enlist their understanding and help them to cope with a child who is often behaviorally out of control, displaying symptoms of impulsivity and hyperactivity which remain impervious to intervention (given the unresolved causal factor of daytime sleepiness). The degree of intrusiveness displayed by these children in their environment is matched by their sensitivity and degree of hurt if disciplined. Cognitive and emotional deficits associated with the frontal processes are seldom understood and virtually impossible variables to treat in the classroom setting.

Thus the child suffering from sleep apnea presents symptoms that are overwhelming and resistant to intervention unless the apnea is resolved in some manner. Similarly adults become easily angered, upset, and emotionally labile when continually suffering from poor non-restorative sleep, while remaining at high risk physically.

United Psychological Services has a board certified pediatric behavioral sleep specialist and a dentist specializing in devices that change the airway. You may also consult a specialist in your area.