Harvard Men's Health Watch

Sleep apnea solutions

Weight loss and breathing-assist therapy are the keys to overcoming this common male ailment.

Nighttime snoring and persistent daytime fatigue are telltale signs of obstructive sleep apnea (OSA). In this common condition in men, the upper airway pinches closed repeatedly overnight, fragmenting sleep and starving the brain of oxygen.

Lifestyle changes can sometimes improve OSA. These include losing weight if you are overweight; avoiding alcohol in the evening, because it tends to worsen underlying apnea; and sleeping on your side to help keep the airways open.

The most effective treatment for OSA is wearing a facemask tethered to a bedside air pump, a system called continuous positive airway pressure (CPAP) therapy. But some OSA sufferers struggle with mask discomfort and spurn their CPAP. That leaves them oxygen-
deprived and fatigued, raising the risk of accidents and putting undue stress on the heart.

But new CPAP users should not give up the fight too soon. Finding a well-fitting mask is essential. "If you give up after trying the first mask you got, then you really didn't give it a fair chance," says Dr. Sanjay Patel, associate professor of medicine at Harvard Medical School. "Tell your doctor the mask is causing you trouble, and ask if there is something else you can try."

Fortunately, mask providers usually offer a 30-day money-back tryout period for a wide variety of equipment. It's important to make CPAP work if you can, because the alternatives are limited and not as effective.

Stop-Bang

Check yourself for OSA

Having three or more of these indicators suggests possible sleep apnea. Discuss it with your physician.

S Snore: Have you been told that you snore?

T Tired: Do you often feel tired during the day?

O Obstruction: Do you know if you briefly stop breathing while asleep, or has anyone witnessed you do this?

P Pressure: Do you have high blood pressure or are you on medication to control high blood pressure?

B Body mass index: A body mass index (BMI) over 30 puts you at risk for OSA.

A Age: Are you 50 or older? OSA becomes more common with age.

N Neck: Do you have a neck circumference more than 17 inches (in men)?

G Gender: Are you male? Men are at greater risk of OSA.

Image: Thinkstock

OSA basics

Normally, when you fall asleep the tissues in the upper airway sag a bit, but you continue to breathe freely. In OSA, the airway periodically collapses entirely, closing off the back of the throat. This triggers apnea—the temporary cessation of normal breathing.

You may have no idea you have apnea until a sleeping partner notices the choking or gasping as you awaken briefly, trying to catch a breath. But it's also true that you can have OSA and not snore.

In older men, OSA can be mistaken for nocturia—the need to rise frequently at night to urinate. One possible explanation is that the struggle to breathe may create excess pressure in the abdomen, which presses on the bladder. Also, men with OSA awaken more frequently, creating more opportunities to think, "I need to go to the bathroom."

If your doctor suspects OSA, you may need to book a night at a sleep lab. There, sensors monitor your breathing, sleep rhythms, chest movement, and blood oxygen while you sleep. For ordinary OSA, however, it's becoming common to conduct the test at home with equipment you hook up yourself. A sleep study that shows five or more apnea episodes (interruptions) per hour, coupled with next-day fatigue, spells a diagnosis of OSA. In a bad case of OSA, the incidents can total dozens to hundreds per night.

Treating OSA greatly improves quality of life. Frequent awakenings and oxygen starvation lead to fatigue, memory impairment, and a higher risk of falls and car accidents. And the snoring and gasping can be a real ordeal for the person who shares your bed, too.

OSA and your heart

Untreated, OSA puts stress on the entire cardiovascular system. Blood pressure rises at night and may remain elevated throughout the next day. People with untreated OSA are at higher risk of heart problems and stroke, but the evidence is not very strong right now that using CPAP lowers it. Clinical trials are under way to establish whether consistent CPAP use prevents heart attack and stroke.

CPAP lowers blood pressure, but not dramatically. "It's not as big as what you typically get with blood pressure medications, but it's similar to the effect of changing to a low-salt diet," Dr. Patel says.

Home sleep testing: A new option

Confirming obstructive sleep apnea (OSA) has usually required an overnight trip to the sleep lab. How-ever, it is becoming more common for people to undergo the test at home using equipment they operate themselves. This is helpful to people who have trouble sleeping in strange surroundings.

Home sleep studies are best for people who have garden-variety OSA caused by sagging airways, as opposed to an underlying neurological problem or lung disease. It's also a lot cheaper than a trip to a sleep lab, so your health insurance may require you to opt for a home study.

Troubles with CPAP?

CPAP and other variations of the therapy require you to wear a mask all night. Full-face masks fit over both the mouth and nose; nasal masks fit just over the nose. New styles come out every year, and premium masks are light and fit comfortably. None of these mask options is inherently superior
to the others. The best mask is simply the one that you can keep on for most
of the night.

Most people get used to CPAP, and some even find that it soothes them to sleep. However, some people can't get used to it. The alternatives are limited and not that effective for most people. The main ones are as follows:

Supplemental oxygen. For people with moderate to severe OSA, some doctors may recommend supplemental oxygen at night to blunt the cardiovascular effects of apnea. However, the evidence that this helps is not very strong. In a recent clinical trial in The New England Journal of Medicine, supplemental oxygen had no effect on average 24-hour blood pressure.

Surgery. Various surgical procedures have been developed to reduce snoring or correct the underlying structure of the airways. "Unfortunately, the smaller procedures are not generally effective in curing OSA, while the larger procedures are fairly major operations that can take one to two months of time for recovery," Dr. Patel says. "As a result, surgery is not a great option for most people."

Oral appliance. Your dentist can make a special nighttime oral appliance to shift the jaw forward and keep the airway open. It doesn't work for everyone, and you can't use one if you wear dentures. But for someone with mild to moderate OSA who has not been able to stick to CPAP, wearing a dental appliance every night can, on average, reduce the monthly tally of breathing interruptions.

OSA and obesity

Being overweight is probably the greatest single risk factor for OSA. "Getting everyone to their ideal body weight could probably eliminate half of all sleep apnea," Dr. Patel says.

But the association between weight and OSA differs among individuals. If you are not overweight, you can still have OSA. And you can lose a significant amount of weight and still have apnea.

Still, losing weight in addition to using CPAP consistently adds extra blood pressure control. Weight loss also can reduce the number of breathing interruptions you experience at night.

Dr. Patel says that significant weight loss is most likely to reverse OSA in people with mild cases. "There have been a number of trials that suggest that in mild sleep apnea, losing weight might be enough to get rid of the sleep apnea," he says. However, he adds, "It's difficult to predict in an individual how much weight you would have to lose."

But either way, you can't go wrong by maintaining a healthy weight. "Using CPAP will help you to feel better, but weight loss on top of that will give you greater improvement in your cardiovascular health," Dr. Patel says.