Apnea (meaning "without breath") is the term used when someone stops breathing for very short periods of time, usually 10 to 20 seconds in adults and longer than 2 breath cycles in children. Obstructive Sleep Apnea (OSA) is defined by sleep abnormalities that consist of complete and partial upper airway obstruction during sleep, a reduction in the amount of air entering the lungs with an abnormally high level of carbon dioxide in the blood, and oxygen loss.
Sleep apnea in the general population is very common. About 40% of the population may suffer from some form of sleep apnea but many go undiagnosed. Most obstructions occur as a result of the upper airway tissues collapsing around the throat and blocking the body’s ability to take in oxygen. Children and adults with Down syndrome (DS) are more susceptible to this because their upper airway tissues tend to be larger and more crowded. Their flattened mid-face, narrowed nasopharyngeal area, low tone of the muscles of the upper airway, enlarged adenoids and/or tonsils puts them at high risk for OSA.
Signs and Symptoms of Obstructive Sleep Apnea
Some symptoms that you could observe if you suspect that someone has sleep apnea are: snoring, witnessed gasping or choking, frequent night-time awakenings, restless sleep or sleep with head in unusual positions, night sweats, excessive daytime sleepiness, irritability and/or hyper-activity, and dry mouth issues. Parents may not notice symptoms or they may be in doubt about them. The research literature reports poor correlation between parent reports of symptoms and the results of sleep apnea testing in people with DS. It is important to recognize if someone close to you has OSA. This is a sign that they are not getting enough quality sleep and can cause many behavioural effects such as irritability, lack of motivation as well as negative health effects.
When a child sleeps, their brain goes through different sleep stages. A deep refreshing sleep is cycled in and out throughout the night but can be disturbed by the noise of snoring. This type of fragmented sleep puts the brain in an “on notice” mode therefore inhibiting the ability to achieve restorative sleep. The child appears to sleep well but the brain never actually gets the rest it needs to function at peak performance.
OSA can also cause detrimental effects to our bodily functions by decreasing the amount of oxygen available to our vital organs and increasing carbon dioxide in the blood. Damage to the brain can occur, and the low blood oxygenation can cause an increase in the blood pressure in the lungs as the body tries to get more oxygen. This is called pulmonary hypertension and can cause the right side of the heart to become enlarged as well as other cardiac complications.
Diagnosing Sleep Apnea
The best way to diagnose sleep apnea is a sleep study. For children, an overnight sleep study can be done at BC Children’s Hospital. Their sleep is monitored using different parameters such as heart rate, ECG, blood pressure, oxygen levels, airway obstructions, periodic limb movements and brain waves. A respirologist or sleep specialist will interpret the study and give a diagnosis. If you suspect that your child may have sleep apnea, speak to your family doctor. Your doctor will determine if a sleep study is appropriate and can send a referral directly to BC Children’s Hospital.
For adults, a sleep study monitor can be provided in the community so that it can be worn in the comfort of their home. It will measure heart rate, oxygen levels, airway obstructions, chest expansion and abnormal breathing patterns. A recommendation for this sleep study can be made to a Respiratory Therapist by a family physician. Once the sleep study is completed and interpreted by a sleep specialist, the report is sent back to the family physician for review. The physician may refer the patient for treatment, send the patient for further evaluation to an ENT (Ear Nose Throat) specialist, dentist or orthodontist, for upper airway assessment, or refer for an overnight polysomnogram at a hospital.
Sleep Apnea Treatment
Sleep apnea is treatable and can be quite simple. The treatments are determined depending on sleep study results. Continuous positive airway pressure (CPAP) is usually the treatment of choice and is tolerated by children and adults with DS very well. It involves wearing a nasal mask which is attached to a CPAP machine during sleep. The CPAP machine outputs air through the mask at a desired pressure to keep the airway open and prevent snoring from occurring. This allows the patient to have an uninterrupted sleep and prevents pulmonary hypertension by allowing proper inhalation of oxygen and exhalation of carbon dioxide. There is usually a period of acclimatization to the treatment. But after a certain amount of time, the child or adult will start to feel better. They will feel more rested after waking up and be more energetic during the day.
Surgery is another form of treatment and is often done for children. Soft airway tissues such as the adenoid, tonsils and/or soft palate may be surgically removed to open the airway. An Ear Nose Throat specialist will be able to determine if it’s is a good option to perform the surgery.
Dentists and orthodontists can also evaluate options for oral appliances to see if upper airways can be opened through jaw positioning devices.
For more information, please talk to your health care physician or a respiratory therapist.
Editorial Comment - DSRF
Sleep Disordered Breathing may be a significant problem for children, adolescents and adults with Down syndrome. DSRF is inviting families, health practitioners, and researchers to discuss the recommendations of the American Academy of Pediatrics: Health Supervision for Children with Down Syndrome, and how these can be adapted to the Canadian health care system. In collaboration with the Children’s Sleep Network the DSRF will be hosting a series of events in order to facilitate a public discussion about sleep disordered breathing in children, adolescents, and adults with Down syndrome.