BY DR MIR ELIAS
One of the most consistent observations by health care providers across the world during the preceding 2 years of COVID-19 pandemic was that obese people who snore at night were at a much higher risk of morbidity and mortality due to COVID-19.
They were vulnerable just like elderly patients, those with underlying malignancies, cardiac disease, lung disease, kidney disease and those with uncontrolled diabetes mellitus.
Most of these people were unaware of the problem or never took it seriously enough to undergo evaluation even after being told about it in the past. It was like another hidden pandemic of an untreated chronic disease already rampant in the society beneath the ongoing covid-19 pandemic.
The disease that these people suffer from is known as obstructive sleep apnea/hypopnea syndrome (OSAHS) or simply obstructive sleep apnea (OSA). It is probably one of the most common diseases in adults across the globe. OSA affects 5% to 20 % of all individuals across the world.
The incidence increases with age. It is more common in males. It may also affect children with problems starting in the preschool age group (2 to 4 years) when their adenoid and palatine tonsils may enlarge abnormally. This enlargement may be enough to compromise the upper airway patency.
Obesity increases the chances of having OSA even though thin and lean people can also have severe OSA. As the name suggests these patients have apneas (complete cessation of breathing) or hypopneas (partial obstruction to breathing enough to cause decrease in oxygen levels or arousal).
This happens during sleep only because of collapse and/or obstruction in the soft tissues of the upper airways between vocal cords and nasal bones. It may lead to decreased oxygen levels in the body (hypoxemia), repeated arousals (awakenings from sleep) and cardiac disturbances.
This differentiates it from the so-called benign snoring in which these things do not happen and the only problem is the sound that may disturb the bed and room partner.
Since these disturbances happen only during sleep, the patient himself is usually unaware of these issues. These derangements can have short term as well as long term impact on almost all organ systems of the body.
And given its high prevalence, it creates a huge load of morbidity and mortality in the community.
In fact, OSA has become one of the most common causes driving cardiovascular/cerebrovascular morbidity and mortality.
Although the disease has been known for quite a long time now, surprisingly, the awareness among common masses and even experienced health care providers has not reached the level that it deserves.
This article is an attempt at sketching the overall presentation, the risks involved and the treatment modalities available for the patients.
When to suspect?
Snoring, choking and gasping during sleep.Everybody snores at one point or the other during his/her sleep. However habitual snoring, loud snoring and snoring that disturb the bed partner, needs evaluation. Since the person is asleep it is the bed partner who has more insight about the patient’s problem. If a bed partner witnesses the patient stopping or struggling for breathing in spite of effort (witnessed apneas) that is almost diagnostic of OSA. People who snore regularly also complain of dry mouth in the morning. In preschool children (age group of 2 to 4 years) adeno-tonsillar enlargement may lead to snoring as well as OSA.
Daytime sleepiness
This can be described as inability to remain awake during the day or constant urge to go to sleep. It is one of the most common symptoms of OSA and is often underestimated. It may be considered normal by people because of getting used to it over decades. People fall asleep during boring situations, monotonous environments and even during activities like reading newspapers, cutting vegetables, watching TV etc. In severe cases patients may fall asleep while having serious conversations, driving or operating heavy machinery leading to serious accidents and mishaps.
Fatigue
This is a subjective lack of physical or mental energy in an individual which interferes with daily activity. The patients complain of low stamina or short endurance for both physical and mental exercises. This usually makes people more sedentary, restricts occupational as well as recreational activities, which often leads to weight gain. This creates a vicious circle compounding the problem day by day.
Morning headache
Waking up with a dull bi-frontal headache which persists for a few hours in the morning is a common symptom in OSA. It affects around one third of the patients with OSA. This is usually not associated with nausea, vomiting or photophobia. Early morning headache in OSA usually denotes severe disease.
Insomnia
Almost one third of patients especially young females present with insomnia. This is usually characterized by repetitive awakenings from sleep (maintenance insomnia). Patients often complain of increased sleepiness and fatigue during the day and inability to sleep during the night. Patients may also complain of palpitations, anxiety and uneasiness during night hours.
Uncontrolled diabetes mellitus
OSA is one of the most common causes of poor sugar control in diabetics who are on a strict diet control and compliant to medications. OSA should be sought in all diabetics especially those with increased medication and insulin requirements. These patients may or may not be obese and may not be forthcoming with the classical symptoms and features of the disease.
Uncontrolled hypertension
OSA is one of the most common causes of secondary systemic hypertension. OSA should be suspected in all hypertension patients who are young, obese and those requiring increased dose or number of antihypertensive medications.
Elderly
The incidence of OSA increases with age in both sexes. The prevalence of OSA in elderly (after 60 years of age) can be as high as 20 %. Although the risks involved are higher, the symptoms are usually minimal. All features of OSA may be considered normal age-related changes by the patients as well as caretakers.
Obesity
Obesity increases the chances of having OSA by a factor of at least 5 in both males as well as females. Most of the people with morbid obesity have OSA. All patients with OSA however are not obese. In fact OSA is the one of the most common cause of cardiovascular and cerebrovascular morbidity and mortality in obese individuals. OSA, because of associated sleep disturbances, fatigue and sleepiness leads to further weight gain which creates a vicious circle and aggravates the problem day by day.
The author is DM Pulmonary, Sleep and Critical Care Medicineand works as Consultant Pulmonary Medicine, SKIMS Medical College, Bemina, Srinagar.
Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.