Brain activity has two separate phases: sleep and wakefulness.
4 main disease groups are defined in the classification of sleep disorders:
Dyssomnias:
The patient has trouble initiating and maintaining sleep. Primary sleep disorders that cause complaints of insomnia (sleeplessness) or hypersomnia (sleeping more than necessary) fall into this group of diseases. Dysomnias, which include the largest portion of sleep disorders, include obstructive sleep apnea syndrome, central sleep apnea syndrome and central alveolar hypoventilation.
Parasomnias:
Parasomnias These are awakening disorders that occur with the activation of the central nervous system in the middle of sleep. Bruxism (teeth grinding during sleep), waking up due to nightmares, sleep enuresis, simple snoring not accompanied by respiratory disorders such as apnea, and sudden deaths during sleep (Sudden Death Syndrome) are disorders belonging to this group.
Psychological, Sleep disorders due to neurological or other medical diseases:
Sleep disorders encountered in these patients are due to another underlying disorder. Sleep disturbance is only one of the symptoms. Disorders such as chronic lung disease, stomach ulcers, gastroesophageal reflux disease (GERD), Parkinson's Disease, dementia, alcohol addiction, and anxiety disorders are examined in this group.
Possible sleep disorders:< br />
It includes sleep disorder problems that are not very pathological, such as sleeping too little or too much, and for which the necessary information to qualify as a disease is not available.
With the increase in the general health and socioeconomic level of the society, there has been an increase in the number of patients consulting doctors with complaints of snoring and stopping breathing during sleep (apnea). Following advances in the recognition of sleep physiology and disorders, sleep apnea syndrome due to snoring and airway obstruction has become a frequently diagnosed disease.
DEFINITIONS:
Snoring:
Noisy sleep due to partial obstruction of the upper respiratory tract
Apnea:
Nose and mouth breathing stops for more than 10 seconds
Apnea index:
For one hour during sleep number of apneas observed
Hypopnea:
A condition in which a 30-50% decrease in airflow lasts longer than 10 seconds. It can also be expressed as a decrease in respiratory movement or a decrease in oxygen saturation (O2 saturation) in the blood.
RDI:
(Respiratory Disturbance Index) is the sum of the number of apneas and hypopneas occurring in an hour.
Sleep, which concerns the ENT branch The disorders are simple snoring, upper airway resistance syndrome and obstructive sleep apnea syndrome.
Simple Snoring:
- The RDI is below 5,
- During sleep Simple snoring is mentioned in patients where the oxygen saturation in the blood is always above 90%
- The pressure measured in the esophagus during breathing does not fall below the –10cm water level.
- Upper Respiratory Tract Resistance ( Resistance Syndrome:
- RDI is below 5 per hour,
- Oxygen saturation is above 90%,
- The pressure measured in the esophagus drops below minus 10cm H2O. In this case, upper respiratory tract resistance syndrome is mentioned.
- In addition to snoring, these patients also have increased electrical activity during waking periods and in the diaphragm.
Obstructive sleep apnea syndrome: - RDI It is defined as being above 5 and
- Oxygen saturation being below 90%.
Sleep apnea; According to the apnea (complete cessation of breathing) index;
Apnea index: mild if between 5-20, moderate if between 20-40,
above 40 is considered severe sleep apnea.
The fact that hypopnea as well as apnea is important in these patients makes it more meaningful to use the RDI index, which is the sum of the apnea and hypopnea numbers, in the classification. Accordingly,
RDI: If it is between 5-30, it is mild; if it is between 30-50, it is moderate; if it is higher than 50, it is severe sleep apnea. mentioned
O2 saturation:&nb If sp; falls below 85%, there is moderate sleep apnea.
If it falls below 60%, there is severe sleep apnea.
FREQUENCY
With the increase in research on sleep, it has been determined that snoring and sleep apnea are more common than expected. Frequently encountered simple snoring may actually be mild sleep apnea. According to a study conducted in Italy, it was determined that 24% of men and 14% of women snored. While the rate of simple snoring is 10% in men under the age of thirty, the rate rises to 60% in men over the age of 60.
When the relationship between snoring and weight is investigated, it has been shown that the frequency of snoring and apnea increases in people who have 15% more than their ideal weight. In America, 24% of men and 9% of women between the ages of 30-60 had an apnea index of 5 or more (This means they have sleep apnea). While mild sleep apnea is common, moderate and severe sleep apnea is less common. While moderate obstructive sleep apnea is observed in 2% of adult men, severe sleep apnea is observed in 0.3% of men in the 35-60 age group.
FINDINGS
There is daytime sleepiness that varies depending on the severity of the disease. Patients experience sleep problems during the day, no matter how long their sleep time is at night. Since they do not sleep well at night, they wake up in the morning feeling unrested. In patients with very high apnea index and/or RDI, falling asleep is observed even while talking and driving. Headache, which is evident in the morning and subsides later, is observed in 20% of cases. Forgetfulness, lack of attention, and impaired concentration are the main accompanying symptoms throughout the day.
Patients with sleep apnea are 2-7 times more likely to have a traffic accident than normal people.
The most important complaint that causes patients to consult a doctor is snoring. It is important for the patient's bed partner to be present during the interview in order to obtain an accurate history.
Poor sleep quality can lead to anxiety disorders, decreased cognitive abilities, aggression and depression in patients. It can open. Sexual dysfunctions are also common in patients with snoring and sleep apnea syndrome. Underlying sexual dysfunction are hormonal changes that occur with fatigue, reluctance, psychological disorders and insomnia.
Frequent urination at night is a frequently observed finding in patients with sleep apnea. Especially in children, the increase in the amount of carbon dioxide in the blood causes bladder contraction disorders, frequent urinary incontinence, and frequent urination in adults.
Patients continue to gain weight as a result of fat metabolism disorders that are frequently seen in these patients. As the weight problem increases, metabolic changes become more evident, making it increasingly difficult for the patient to lose weight. Night sweating, which is evident in the chest and neck area, is another symptom seen in such patients.
Gastroesophageal reflux problem (GERD) also arises with the increase in negative intrathoracic pressure in patients with sleep-disordered breathing. By treating reflux, up to 30% improvements in apnea symptoms have been detected polysomnographically.
Problems such as high blood pressure, pulmonary hypertension, heart rhythm disorders, cardiovascular disorders and stroke are frequently encountered in patients with sleep apnea syndrome. The risk of death in patients with an apnea index above 20 is much higher than normal; Therefore, patients need to be treated as soon as possible.
DIAGNOSIS
Sleep apnea syndrome is a disorder that can be complex and involves many systems. The main diagnostic methods used to diagnose patients are as follows:
- General physical examination
- ENT examination
- Nasal examination with a bendable fiberoptic endoscope
- Imaging methods (Tomography, MRI, measurement of facial structures and air passage dimensions - Cephalometric analysis)
- Polysomnography (Sleep test) is the gold standard in diagnosing sleep apnea.
1. General physical examination:
Sleep apnea syndrome is a complex disease and can occur due to many different reasons. For this reason, only examination of the upper respiratory tract of patients is important for diagnosis and diagnosis. It will not be sufficient for treatment planning. The patient's alcohol use, whether he has gained significant weight in recent months, and his metabolic status (diabetes, thyroid diseases) should be questioned, and biochemical tests should be performed when necessary. Considering that the patient's mood may increase the complaints, it should be questioned whether the patient is depressed and whether he or she is using sedative medication. The general condition of the patient (overweight, lower jaw position, upper jaw development disorders) and the determination of the area of obstruction in breathing are important in determining the selection and success of the treatment approach.
Many studies have shown that there is a relationship between blood pressure and sleep apnea syndrome. Due to the increase in hormones that increase blood pressure, blood pressure remains high not only at night but also throughout the day.
Height-weight and neck thickness:
It is important to measure the height, weight and neck circumference of patients presenting with suspicion of sleep apnea.
< br /> In adult men, a neck circumference greater than 43.18 cm is considered a risk factor. Sleep apnea syndrome was detected in 30% of men in this group. For women, the critical value is 38.10 cm.
The most practical measurement method of the ratio between height and weight, which is an important parameter in snoring and sleep apnea syndrome, is the calculation of body mass index (BMI), expressed in kg/m2. The average BMI in adults over 20 years of age is around 25.5kg/m2. A BMI over 27.8 in men and 27.3 in women is considered obesity.
2. ENT examination:
The upper respiratory tract consists of a hard bone-cartilage skeleton and the soft tissues connected to them. It starts from the nose and lips and ends in the larynx. A detailed examination of the upper respiratory tract is required in a patient presenting with suspicion of sleep apnea. Since the examination is not performed during sleep, the aim of the examination is to reveal areas of obstruction and collapse rather than to diagnose sleep apnea syndrome.
Facial skeletal structure:
In the first examination of the patient, the structure of the upper jaw and lower jaw and the relationship between the closing of the teeth are roughly evaluated. face iske
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