Breathing-Related Sleep Disorder
- Author: Mary E Cataletto, MD; Chief Editor: Eduardo Dunayevich, MD more...
Background
The term breathing-related sleep disorder refers to a spectrum of breathing anomalies ranging from chronic or habitual snoring to upper airway resistance syndrome (UARS) to frank obstructive sleep apnea (OSA) or, in some cases, obesity hypoventilation syndrome (OHS).
Data from the Wisconsin sleep cohort study of patients without obvious barriers to health care access estimate that 93% of women and 82% of men with moderate-to-severe sleep apnea were undiagnosed.[1] Significant cardiovascular morbidity (including systemic hypertension and congestive heart failure) as well as increased mortality rates have been associated with both OSA and OHS. While large-scale studies of the prevalence of sleep-disordered breathing in children are lacking, Guilleminault et al report estimates of 5-6% and raise concerns about the impact of the obesity epidemic on sleep in children.[2]
The aim of this article is to increase the reader's awareness of the importance of sleep-disordered breathing in daily practice.
For related information, see Medscape's Insomnia and Sleep Health Resource Center.
Pathophysiology
Complex interactions among the central and peripheral nervous systems, upper airway musculature, and neurotransmitters may result in partial or complete collapse of a portion or portions of the upper airway. Basic factors, such as airway anatomy (eg, adenotonsillar hypertrophy), nasal obstruction, presence and distribution of body fat, and muscle tone, may contribute, alone or in combination, to the presence and severity of this disorder. Recent data suggest that the primary defect is an anatomically small or collapsible pharyngeal airway in combination with a sleep-related fall in upper airway muscular tone.
Patients with neuromuscular disease have additional risk factors that may predispose them to sleep-disordered breathing. These include CNS involvement, chest wall deformity with restrictive lung disease, diaphragmatic weakness, increased upper airway resistance, and impaired respiratory chemosensitivity.
Epidemiology
Frequency
United States
According to estimates, at least 2-4% of the adult population experience sleep-related breathing disorders.[3, 4] In a study by Young and associates, 24% of men and 9% of women aged 30-60 years were reported to have sleep-disordered breathing.[1] Caples et al reviewed pooled data from 4 large prevalence studies on OSA and found that 20% of adult Caucasians with BMI between 25 and 28 kg/m2 had an apnea hypopnea index (AHI) of 5 or greater and that approximately 6% of these same patients had AHIs of 15 or greater.[5]
Patients with neuromuscular diseases may have sleep-disordered breathing. Duchenne muscular dystrophy (DMD), amyotrophic lateral sclerosis, postpolio syndrome, and myasthenia gravis are among those with increased incidence of sleep-disordered breathing.
Prevalence studies in the elderly population show significantly higher rates, with the rate for elderly men reported as 28-67% and the rate for elderly women as 20-54%. In the subset of patients with severe OSA, men have an 8-fold increased frequency. Prevalence rates in children are estimated to be 5-6%.[2]
Mortality/Morbidity
Obesity, advanced age, and snoring have been found to be important factors in the progression of sleep-disordered breathing.
Morbidity with OSA falls into 2 major categories, as follows:
- Neuropsychiatric or psychosocial: This includes excessive daytime sleepiness, poor concentration and memory, decreased performance, irritability, depression, and disturbed social relationships. This population has a significantly increased risk of motor vehicle accidents, with reports of a 7-fold increased risk in patients with an AHI greater than 5.
- Cardiovascular: Systemic hypertension occurs in 45-90% of patients with OSA. Pulmonary hypertension has been reported in 15-20%.[6]
Children with sleep-disordered breathing have an increased use of healthcare services (2.6 fold increase) with deficits in school performance and IQ, as well as a higher prevalence of neuropsychiatric disorders.[7]
Race
Comparison date between African American and Caucasian adults when corrected for BMI suggest that prevalence of sleep-disordered breathing in African Americans is at least equal to and may in fact exceed that of their Caucasian peers.
Sex
- Male sex appears to be related to a significant increase in the prevalence of sleep-disordered breathing, presumably because of hormonal influences. Testosterone in particular is associated with increased severity of sleep-related breathing disorders. In the subset of patients with severe obstructive sleep apnea, men outnumber women by eight fold.
- Sex hormones play a role in the modulation of upper airway musculature. In adults, the prevalence in males exceeds that of females by 3 fold in middle age. In women with OSA, apneas tend to cluster during REM sleep. In men with OSA, apneas predominate in the supine position.
- No sex difference exists before puberty, and, after menopause, the differences again become small. The increase in frequency of sleep-related breathing disorders in women who are postmenopausal may be related to decreases in progesterone levels.
Age
- In children, those born prematurely have been found to be 3-5 times more likely to have sleep-disordered breathing compared with their full-term counterparts. Childhood OSA has its peak incidence between ages 2-8 years, corresponding to the time when tonsils and adenoids are the largest in relationship to upper airway size. Prevalence for habitual snoring in school age children is estimated to be 12-20%.[7]
- Both snoring and sleep-related breathing disorders increase in frequency with advancing age, at least until age 60 years. Older persons exhibit both central and obstructive apnea. The pattern of apnea in older persons having AHI greater than 5 resembles typical sleep apnea in regard to duration and degree of desaturation. However, the effect on general health in elderly people with OSA appears to be minimal.
- In elderly people, little to no relationship seems to exist between sleep apnea and typical risk factors such as excess weight and increased airway resistance. The mechanisms underlying sleep apnea in elderly people are purportedly be different, and they may reflect a gradual increase in sleep instability, which results in both central apnea and OSA.
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