Obstructive Sleep Apnea Syndromes - Sleepy vs. Non-Sleepy

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Obstructive Sleep Apnea: An Overview

Obstructive Sleep Apnea (OSA) is by far the most common form of sleep apnea, affecting millions of Americans with a vast majority (nearly 80 percent) going undiagnosed and therefore untreated. Obstructive sleep apnea is caused by a blockage of the airway from a collapse of the tongue and soft palate during sleep. For those patients with severe sleep apnea syndromes, these apnea events can happen up to hundreds of times a night, causing extremely fragmented sleep experiences and often leading to insomnia, headaches, and fatigue, as well as a number of other health problems resulting from reduced oxygenation of the blood. While Central Sleep Apnea (CSA), which is caused by lapses within the respiratory control centers of the brain, and Mixed or Complex Apneas, which involve combinations of obstructive and central syndromes, are often separated into subcategories based on their symptomatology and relations to other diseases, the separation of Obstructive Sleep Apnea into sleepy and non-sleepy syndromes is a relatively recent development. While these patterns were recognized back in the 1990s, they have received more attention in recent years as treatments have become more specialized and public awareness of the disorder has increased. Obstructive Sleep Apnea is almost always treated with prescriptions and/or recommendations for Continuous Positive Airway Pressure (CPAP) therapy, but the specifics of sleepy and non-sleepy OSA syndromes allow medical professionals to recommend additional treatment responses based on the likely progression of the symptoms. For example, sleepy OSA is characterized by high rates of obesity, and to offset disease progression and related comorbidities, CPAP therapy is often paired with dietary restrictions, exercise regimens, and other lifestyle changes to best suit the needs of the patient.

Syndrome Developments

When doctors and sleep specialists began to notice persistent cases of Excessive Daytime Sleepiness (EDS) among OSA patients, concerns arose that among these populations, CPAP therapy was treating the apnea events but not the arousals. Over time, patterns emerged that distinguished the two groups in other ways as well, for example, those with chronic EDS tended to be of younger age, and with early signs of atypical snoring. In response, a system of standardized prognostics and specific treatment recommendations have been developed to better address the problems of each syndrome. Using polysomnography (sleep testing), the Epworth Sleepiness Scale, and Apnea-Hypopnea Index data, sleep professionals use both objective and subjective measures to identify these syndrome characteristics. What has emerged is a clear identification of two distinct syndromes, each with its own characteristic symptoms, demographics, and predictors.

Sleepy vs. Non-Sleepy OSA

SLeepy and Non-Sleepy OSA syndromes are defined by the nature and severity of accompanying EDS symptoms. Sleepy OSA includes EDS that often persists irrespective of apnea treatments such as CPAP therapy. This is the primary distinction between the two syndromes, as those with Sleepy OSA often have EDS symptoms even when apnea events are suppressed. On its own, EDS is a significant predictor of Cardiovascular Disease (CVD) and is associated with high mortality and an increased risk of metabolic syndromes such as diabetes. Being young, male, and with a high Body Mass Index (BMI) are predictors of both EDS and Sleepy Type OSA, but the relationship between these conditions can vary in complexity from one case to another. Often referred to as Sleepy Severe OSA, the Sleepy OSA syndrome is more serious a condition not only due to its symptoms, but because it more often affects younger patients. In general, Sleepy OSA patients have worse sleep-related breathing (higher AHI), and their sleep patterns are much lighter and more fragmented than Non-Sleepy OSA patients. But this, surprisingly, does not include sleep onset latency (or difficulty falling asleep at bedtime). Sleep latency is much more prevalent among Non-Sleepy OSA patients who are older and less likely to wake once asleep. Furthermore, Sleepy OSA patients have much higher rates of loud snoring, nighttime choking or coughing, and pediatric sleep problems. Research published in the journal Laryngoscope in 2010 identified the two OSA syndromes in terms of their most salient differences. After collecting data on nearly 1,000 patients, the researchers were able to easily identify the two syndromes and their defining characteristics. Sleepy OSA was characterized by young, often overweight or obese patients with a number of sleep-related breathing problems that woke them througout the night. Almost all Sleepy OSA patients had daytime sleepiness issues. Non-Sleepy OSA patients were of different ages, weights, and had a range of sleep-related breathing symptoms, but were usually older, and had more issues with sleep onset than arousals. Daytime sleepiness was much less an issue for Non-Sleepy OSA patients. Above all, apnea events were more numerous and much more severe among the Sleepy OSA examples, and the study’s conclusions provided an outline for proper diagnosis and treatment of the syndromes.

Treatment Implications

Due to its persistent nature, EDS is often treated independently of sleep apnea syndromes. But this is something that current research is striving to better understand. The link between OSA and EDS varies from patient to patient, and this is yet another reason why individual treatment plans are absolutely essential for optimal care. Treating any sleep apnea syndrome with CPAP therapy will have a number of benefits for the health of the patient. In particular, positive effects on blood pressure, insulin resistance, cardiovascular problems, and endothelial dysfunction risk factors are critical to the treatment of Sleepy OSA syndromes. It is also important to note that CPAP therapy will have a positive effect on the body as a whole, and this, while perhaps not affecting EDS directly, will still contribute to healthier sleep behavior in the long term. Both of these syndromes will be treated primarily with CPAP or other PAP therapy options, but the more severe Sleepy patients will likely require additional treatments, recommendations, and in some cases, medication or surgery to address the more serious underlying health problems. There is some controversy regarding the use of PAP therapy to treat Non-Sleepy OSA patients who see might less value in its outcomes. Since sleep apnea in all its forms is potentially life threatening and leads to a number of comorbidity issues, the argument against PAP therapy compliance is not strong. Nevertheless, skepticism exists among patients, mostly Non-Sleepy OSA patients, who experience less disorder symptoms (during waking hours) and may not fully recognize the benefits of the therapy. Compliance has been problematic for a large percentage of sleep apnea patients, and should be encouraged regardless of the specifics of the syndrome. In general, any sleep apnea diagnosis should be treated with full compliance, and without exception.

Further Considerations

An article published in the European Respiratory Journal made the suggestion that daytime sleepiness issues, referred to in European publications as Residual Excessive Sleepiness, may be linked to “overlap syndromes” such as Obesity Hypoventilation Syndrome (OHS) or Chronic Obstructive Pulmonary Disease. Among young Sleepy OSA patients with a high BMI, these “overlap syndromes” can create problems for treatment, as the often complex relations between comorbidities can develop overlapping symptoms as well. In addition, there are questions regarding the specific pathogenesis of the two OSA types, and current research Since CPAP can effectively reduce AHI and oxygen desaturation levels (ODI) among all cases of OSA, it is without question that PAP therapy remains both the gold standard and the starting point for sleep apnea treatment. But with these increasingly complex developments in the world of sleep apnea science and medicine, there are additional considerations that should always be addressed. The identification of these characteristic patterns of OSA syndromes allow medical professionals to diagnose these prevalent conditions early, and with increasing accuracy that ultimately leads to more effective treatments for the patients.