Sleep Apnea Psychology

Sleep apnea consist of three main categories: central, complex, and obstructive. CSA is electrical and occurs due to the loss of signal to the brain that controls breathing. Complex is a mixture of both OSA and CSA. OSA is mechanical and occurs during the loss of muscle tone during sleep. The sleep diagnoses explanation is in efforts to distinguish the differences between the sleep breathing disorders. The reviews primary focus is on the patient population diagnosed with the OSA.

Central and complex sleep apnea

Central sleep apnea is characterized by apneic events, at sleep, that is without respiratory effort, and lacking ventilatory drive to breathe effort (Eckert, Malhotra, & Jordan, 2009). The following factors contribute to CSA,

such as high-altitude periodic breathing, drug and/or substance abuse (opioids), Cheyne-Stokes breathing (congestive heart failure, or stroke patients) and idiopathic central sleep apnea (Eckert, Malhotra, & Jordan, 2009). CSA (central sleep apnea) becomes the primary diagnosis when 50% and greater of the apneic events, during a sleep test, are scored as central in nature.
Complex sleep apnea is identified by central sleep apneic events that unveil, or persist, despite the treatment of PAP therapy for obstructive sleep apnea (Khan & Franco, 2014). Typically, the patient will begin therapy, or a titration PSG, under a different diagnosis, such as OSA, and with the application of PAP therapy providing an unobstructed airway; apneic events persists becoming central in nature (Khan & Franco, 2014).
Obstructive sleep apnea
Obstructive sleep apnea is the most prevalent form of the sleep apnea diagnosis. Obstructive sleep apnea is the intermittent collapse of the soft tissue (due to loss of muscle tone) in the upper airway during sleep, leading to the following: sleep hypoxia, hypoxemia, intermittent reduction in intrathoraci pressure, hypercapniea, reoxygneation, and cortical arousals (Jean-Louis, et al., 2009).
During sleep, an obstructive event causes the body to compensate for the loss of upper airway patency, by initiating a series of cyclical events. As the collapsed upper airway obstructs, by either an apnea or hypopnea, the body begins to in increase its breathing effort. This triggers a response from the chemoreceptors to, increase chest wall movement, and restore the muscle tone in the upper airway causing an arousal (Jean-Louis, et al., 2009). This effort is due to the decrease in PO2, and increase in PCO2. Hyperventilation is assuming at this time in efforts to restore PO2 and PCO2 to normal levels. OSA, initially, leads to an elevated sympathetic activity, oxidative stress, endothelial dysfunction, systemic inflammation, increased coagulation, and metabolic dysregulation (Jean-Louis, et al., 2009).
OSA is common amongst adults, older adults, males, large necks, and obese individuals (Maurer, 2008).

The following signs can characterize OSA: snoring, excessive daytime sleepiness, morning headaches, sore throat, dry mouth, abrupt awakenings, memory loss and lack of concentration, depression, mood swings, frequent nighttime urination, and observed sudden awakenings. Often, these characteristics are recognized by the bed partner, or family member (Maurer, 2008).

OSA diagnosis

An in-lab PSG (polysomnography), attended by an RSPSGT technician, is the gold standard for diagnosing OSA. As stated by Berry, et al., (2012) a PSG is conducted overnight using the following: “electroencephalogram electromyogram, electro-oculogram, electrocardiogram, snore microphone, body position and leg movement, oronasal airflow, chest wall effort, and oxyhemoglobin saturation, as well as video recording.” There are three types of PSGs, consisting of the following:

• diagnostic, the initial test to establish diagnosis;

• titration, the follow-up PSG to establish optimal therapy pressures; and

• split-night, the PSG that involves both the diagnostic, and titration portion, of the test.

A split-night sleep study may not be available for everybody, depending on the PSG, sleep time, diagnosis, and titration efforts (Berry, et al., 2012).

There are three Types of sleep apnea severities, consist of the following:

• mild (AHI 5-15),

• moderate (AHI 15-30),

and
• Severe (AHI > 30) (Berry, et al., 2012).
The AHI (apnea/hypopnea index), is defined by the American Academy of Sleep Medicine (2007), stating the following: “Apneas characterized by a complete obstruction, or cease, in breathing for a minimum duration of 10 seconds. Hypopneas are characterized by a partial obstruction, or reduction, of airflow by a minimum of 30%, decreasing the oxygen saturation 4% from the baseline, for a minimum of 10 seconds” (Berry, et al., 2012).
OSA treatment and CPAP
Commonly, obstructive sleep apnea is treated with continuous positive airway pressure; and CPAP is accepted as the “gold standard” for treating OSA (Drager, et al., 2011).

Although, there are other methods of treating OSA, such as: lifestyle modifications, oral devices, surgery. Generally, lifestyle modifications in conjunction with CPAP therapy could lead to optimal outcomes, and subjective response. Habitual modifications for improving sleep include: quitting or not smoke, maintaining a healthy weight and diet, don’t eat right before bed, manage stress, avoid sleeping supine, and avoid taking depressants, such as: alcohol consumption or sleeping

aids.
Adherence to CPAP therapy improves daytime sleepiness, and the risks associated with neurocognitive and cardiovascular morbidity and mortality (Antonescu-Turcu & Parthasarathy, 2010). Ultimately, CPAP provides and maintains upper airway support from collapse by stenting the upper airway with continuous positive pressure. Additionally, CPAP can also increase positive intra-thoracic pressures and end-expiratory lung volume, decreases venous return and afterload, improving cardiac output (Antonescu-Turcu & Parthasarathy, 2010).
CPAP is a device equipped with servo-controlled air that adjusts flows (variable) by pushing and pulling air, triggered by the patient’s breathing, while the patient’s prescribed set pressure (constant) is being maintained (Antonescu-Turcu & Parthasarathy, 2010). PAP therapy is applied by using a CPAP machine, with a connected tube, that attaches to a mask interface with headgear. The mask interfaces are available in three different categorizes, which include:
• full face (nose and mouth),
• nasal (over the nose), and
• pillows (at the nares).
The mask interfaces are available in a variety of sizes, brands, colors. Typically, The PAP mask is fitted to the patient dependent of the patients’ needs, shape, pressure, comfort, and preference.