Sleep-disordered breathing, including sleep apnea and snoring, affects more than 40 million people in the United States alone. Snoring and sleep apnea cause not only social issues for patients, but can cause serious medical problems as well. The social tension of loud snoring can be severe enough to result in divorce, or at least separate sleeping quarters. If not properly treated, sleep apnea can lead to heart problems, stroke and even death. Dr. Kimmelman works closely with each patient to properly diagnose and treat snoring and sleep apnea through the latest treatment options available. He specializes in the Pillar Procedure, an innovative, in-office treatment that offers a safe, effective alternative to surgery and the life-long therapy of wearing the CPAP air mask each night as you sleep.

What is Sleep Apnea?
Sleep apnea is defined as the interruption of breathing during sleep. It is a serious, potentially life-threatening condition that is far more common than generally understood. It owes its name to the Greek word apnea, meaning “want of breath.” There are two types of sleep apnea: central and obstructive. Central sleep apnea, which is less common, occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations. Obstructive sleep apnea (OSA) is far more common and occurs when air cannot flow into or out of the person’s nose or mouth, although efforts to breathe continue. As a result, people with sleep apnea do not spend the proper proportion of sleep time in its deepest phases, leaving them to awaken unrefreshed and tired despite hours in bed.

What is the difference between snoring and sleep apnea?
Both snoring and sleep apnea fall into the category of sleep-disordered breathing. Simple snoring represents a mild disorder where breathing becomes very loud but the upper airway is only partially obstructed during sleep.

Snoring is a common symptom of obstructive sleep apnea. However, unlike mild snoring, OSA is a serious medical disorder that occurs because the airway is totally obstructed during sleep and the patient stops breathing completely for 10 seconds or more. In one night, a sleep apnea patient may experience 20 to 30 or more "apneic events" (or involuntary breathing pauses). If your partner hears loud snoring punctuated by silences and then a snort or choking sound as you resume breathing, this pattern could signal sleep apnea.

What causes snoring?
The noisy sounds of snoring occur when the passages at the back of the mouth and throat narrow, causing instability in the soft palate tissue. The instability then causes these tissues to vibrate, which results in snoring. Several parts of your airway may be contributing to your snoring - nasal passages, uvula, tongue base, and soft palate. If you snore, it is likely that the palate is a prime contributor.

Is snoring a bad problem?
Snoring can affect bedroom harmony and may cause daytime sleepiness and irritability if there is associated sleep apnea. It is all too common a problem, causing as much as 80 percent of snoring couples to sleep separately. Approximately 45 percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. Furthermore, there is an increasing body of evidence linking sleep disorders (both snoring and sleep apnea) to long-term health problems such as hypertension and stroke.

I/my bedmate snore(s). Do I have apnea?
If you or your bed partner snore, it is possible that you have sleep apnea. Not all snorers have OSA. Pay attention to the sound and pattern of snoring. If it is a steady, regular snoring, or is loud and frequent with periodic bursts punctuated by periods of silence, normal breathing, and/or gasping for air, it may be OSA. Dr. Kimmelman recommends that you visit him to properly diagnose the problem.

How many people suffer from sleep apnea?
In the United States alone, more than 12 million people suffer from sleep apnea, and approximately 10 million people are unaware that they have this condition.

Who Gets Sleep Apnea?
Sleep apnea occurs in all age groups and both sexes but is more common in men – although it may be under-diagnosed in women – and possibly young African Americans. It has been estimated that as many as 12 million Americans have sleep apnea. Sleep apnea is more common in men. One out of 25 middle-aged men and 1 out of 50 middle-aged women have sleep apnea that causes them to be fatigued during the day.

What Causes Sleep Apnea?
Sleep apnea can have a variety of causes including (in order of occurrence):

How Does Sleep Apnea Occur?
As airway tissues relax during sleep, the airway can narrow or become blocked during sleep. In many people, it is the soft palate and tongue that relax and cause the obstruction. Sleep apnea is most common in obese people, who are more likely to have obstructed airways. Ingestion of alcohol and sleeping pills increases the frequency and duration of breathing pauses in people with sleep apnea.

Are There Any Side Effects of Sleep Apnea?
Because of the serious disturbances in their normal sleep patterns, people with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffer. The consequences of sleep apnea range from annoying to life-threatening. They include symptoms suggesting depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. Untreated sleep apnea patients are at least 3 times more likely to have automobile accidents. It has been estimated that up to 50 percent of sleep apnea patients have high blood pressure. The risk of heart attack and stroke may also increase in those with sleep apnea.

How Do I Know If I Have Sleep Apnea?
One of the best people to help you answer this question is your bed partner. People with sleep apnea generally have the following symptoms:

Remember that only a physician can properly diagnose sleep apnea.

How is Sleep Apnea Diagnosed?
Diagnosis of sleep apnea is not simple because there can be many different reasons for disturbed sleep. Several tests are available for evaluating a person for sleep apnea. They include:

Polysomnography is a test that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, airflow, and blood oxygen levels. This test is both to diagnose sleep apnea and to determine its severity. It is performed by spending the night at a sleep center.

SNAP testing is a take at home study that the patient self administers. A special tape recorder analyzes the breathing sounds made by the sleeper and can determine the frequency of apneas and their duration. Dr. Kimmelman has this device available for take home use by his patients.

How Is Sleep Apnea Treated?
Dr. Kimmelman will recommend the specific therapy for sleep apnea tailored to the individual patient based on medical history, physical examination, and the results of polysomnography. Medications are generally not effective in the treatment of sleep apnea. Oxygen is sometimes used in patients with central apnea caused by heart failure. It is not used to treat obstructive sleep apnea.

Mechanical Devices
Continuous positive airway pressure (CPAP) is the most common mechanical treatment for sleep apnea. In this procedure, the patient wears a mask over the nose during sleep, and pressure from an air blower forces air through the nasal passages. The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. Nasal CPAP prevents airway closure while in use, but apnea episodes return when CPAP is stopped or it is used improperly. Due to factors including feelings of claustrophobia, nasal stuffiness, social factors and inconvenience, compliance rates for CPAP are as low as 50 percent. Dental appliances that reposition the lower jaw and the tongue have been helpful to some patients with mild to moderate sleep apnea or who snore but do not have apnea. A dentist or orthodontist is often the one to fit the patient with such a device. Dental appliances can cost as much as $2000. Studies have shown these appliances to be effective when worn, but compliance rates for dental appliances are as low as 60 percent due to discomfort, TMJ or jaw pain, mucosal dryness, tooth discomfort, and hypersalivation. Close follow-up during long-term therapy with oral appliances is necessary in order to detect potentially relevant orthodontic changes.

Surgery
Some patients with sleep apnea may need surgery. Although several surgical procedures are used to increase the size of the airway, none of them is completely successful or without risks, as most involve the use of general anesthetic. These surgical procedures typically involve lengthy recovery times and are expensive to administer. More than one procedure may need to be tried before the patient realizes any benefits. Some of the more commonly administered surgical procedures include:

Uvulopalatopharyngoplasty (UPPP) is a procedure performed in the operating room under anesthesia in order to cut away excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate). The success of this technique may range from 30 to 60 percent and the healing process is prolonged and painful.

Laser-assisted uvulopalatoplasty (LAUP) is done to eliminate snoring but has not been shown to be effective in treating sleep apnea. This procedure involves using a laser device to eliminate tissue in the back of the throat. Like UPPP, LAUP may decrease or eliminate snoring but not eliminate sleep apnea itself. Elimination of snoring, the primary symptom of sleep apnea, without influencing the condition may carry the risk of delaying the diagnosis and possible treatment of sleep apnea in patients who elect to have LAUP. To identify possible underlying sleep apnea, sleep studies are usually required before LAUP is performed.

Somnoplasty
Somnoplasty is a procedure that uses electricity to burn the tissue of the soft palate and uvula to reduce their size. This is an office procedure that requires a local anesthetic, and there is moderate to severe pain for several days.

The Pillar Procedure
The Pillar Procedure is a minimally invasive, first-line treatment option for mild to moderate palatal sleep apnea and snoring. The procedure places three tiny inserts in the patient’s soft palate, causing the palate to stiffen. The stiffening helps to prevent or lessen blockages of the airway – effectively treating sleep apnea and substantially reducing the severity of snoring in most individuals. Pillar inserts are 18 mm in length and made from a woven soft polyester material that has been used for many years in implantable medical products. The Pillar Procedure is conducted in a single, short, in-office setting using local anesthetic and is completely reversible. More Information on The Pillar Procedure...

Pediatric Obstructive Sleep Apnea
Sleep disordered breathing (SDB) is a common problem for adults leading to hypertension, heart attack, stroke, and early death. Other consequences are bedroom disharmony, excessive daytime sleepiness, weight gain, poor performance at work, failing personal relationships, and increased risk for accidents, including motor vehicle accidents.

Sleep disordered breathing in children, from infancy through puberty, is in some ways a similar condition but has different causes, consequences, and treatments. A child with SDB does not necessarily have this condition as an adult.

The premiere symptom of sleep disordered breathing is snoring that is loud, present every night regardless of sleep position, and is ultimately interrupted by complete obstruction of breathing with gasping and snorting noises. Approximately 10 percent of children are reported to snore. Ten percent of these children (one percent of the total pediatric population) have obstructive sleep apnea.

When an individual, young or old, obstructs breathing during sleep, the body perceives this as a choking phenomenon. The heart rate slows, the sympathetic nervous system is stimulated, blood pressure rises, the brain is aroused, and sleep is disrupted. In most cases a child’s vascular system can tolerate the changes in blood pressure and heart rate. However, a child’s brain does not tolerate the repeated interruptions to sleep, leading to a child that is sleep deprived, cranky, and ill behaved.

Consequences Of Untreated Pediatric Sleep Disordered Breathing  

• Snoring: A problem if a child shares a room with a sibling and during sleepovers.
• Sleep Deprivation: The child may become moody, inattentive, and disruptive both at home and at school. Classroom and athletic performance may decrease along with overall happiness. The child will lack energy, often preferring to sit in front of the television rather than participate in school and other activities. This may contribute to obesity.
• Abnormal Urine Production: SDB also causes increased nighttime urine production, and in children, this may lead to bedwetting.
• Growth: Growth hormone is secreted at night. Those with SDB may suffer interruptions in hormone secretion, resulting in slow growth or development.
• Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD): There are research findings that identify sleep disordered breathing as a contributing factor to attention deficit disorders.

Diagnosis Of Sleep Disordered Breathing
The first diagnosis of sleep disordered breathing in children is made by the parent’s observation of snoring. Other observations may include obstructions to breathing, gasping, snorting, and thrashing in bed as well as unexplained bedwetting. Social symptoms are difficult to diagnose but include alteration in mood, misbehavior, and poor school performance. (Note: Every child who has sub par academic and social skills may not have SDB, but if a child is a serious snorer and is experiencing mood, behavior, and performance problems, sleep disordered breathing should be considered.)

A child with suspected SDB should be evaluated by an otolaryngologist – head and neck surgeon. If the symptoms are significant and the tonsils are enlarged, the child is strongly recommended for T&A, or tonsillectomy and adenoidectomy (removal of the tonsils and adenoids). Conversely, if the symptoms are mild, academic performance remains excellent, the tonsils are small, and puberty is eminent (tonsils and adenoids shrink at puberty), it may be recommended that SDB be treated only if matters worsen. The majority of cases fall somewhere in between, and physicians must evaluate each child on a case-by-case basis.

There are other pediatric sleep disorder diagnoses. Sudden infant death syndrome (SIDS) and apparent life threatening episode (ALTE) are considered forms of sleep disordered breathing. Children with these conditions warrant thorough evaluation by a pediatric sleep specialist. Children with craniofacial abnormalities, primarily abnormalities of the jaw bones, tongue, and associated structures, often have sleep disordered breathing. This must be managed and the deformities treated as the child grows.

The sleep test is the standard diagnostic test for sleep disordered breathing. This test can be performed in a sleep laboratory or at home. Sleep tests can produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observation and clinical evaluation.

Treatment Of Sleep Disordered Breathing
Enlarged tonsils are the most common cause for SDB, thus tonsillectomy/adenoidectomy is the most effective treatment for pediatric sleep disordered breathing. T&A achieves a 90 percent success rate for childhood SDB. Of the nearly 400,000 T&As performed in the U.S. each year, 75 percent are performed to treat sleep disordered breathing.

Not every child with snoring should undergo T&A. The procedure does have risks and possible complications. Aside from the mental anguish experienced by the parent and child, potential problems include: anesthesia risks, bleeding, and infection.

Information on Pediatric Obstructive Sleep Apnea has been provided by American Academy of Otolaryngology- Head and Neck Surgery.