Sleep Apnea 101, Or Why Snoring isn't as Funny as You Think

So what's the deal–you've got a sleep problem or something?

I have a severe case of a sleep disorder called sleep apnea. A lot of people who know me know that much, but I get the sense people frequently don't know if it's okay to ask me about it, or are afraid I'm tired of explaining it over and over (which is at least a little true). I've mostly dealt with the explaining by getting to the point where I can rattle it off really fast and without thinking too hard about it, but recently it's gotten so quick and rote that I think people just nod along until I get through my routine, without really understanding it. So I decided to write it down.

This post will cover the basics of the disorder in general, and some specific details of my case, for any out there who may be curious. 

OK, you have Sleep Apnea. So what the heck is that?

I could write out a long technical explanation, but wouldn't you rather watch a video of it all being explained to and then repeated by an adorably confused Shaquille O' Neal? Of course you would: 

That video is courtesy of the Division of Sleep Medicine at Harvard Medical School, which has an excellent and comprehensive website if you're curious for more detail.

So, some people stop breathing while they're asleep, then their brain wakes them up just enough to start breathing again, then they fall back asleep and stop breathing, so their brain wakes them up, then they fall back asleep and stop breathing... Rinse and repeat and you can lie down and close your eyes for 12 hours but "wake up" in the morning feeling like you got no rest at all. 

Could a mutant healing factor fix sleep apnea? The world may never know.

In addition to just being tired all the time, it can also lead to long-term problems, including heart problems and even depression.

Well, that sounds like it sucks. Is it possible I might have sleep apnea?

We've reached the truly PSA-esque section of this article. I know several people who, when I explained what my deal was said "Oh, I wonder if I have that, too." If you're thinking that, get a sleep study done. Go to your health insurance online provider network-use your parents', get Obamacare, whatever, go into their system and find a sleep study center in their network and schedule an appointment.

It might seem weird to spend a bunch of money (and depending on the center and insurance, it might not be as bad as you think) but you're essentially screening for a chronic problem, which can save you money in the long run (the cost of a sleep-stress related heart attack at 50 will be much higher than this study, I assure you).

From the Mayo Clinic Sleep Apnea guidelines:

The most common signs and symptoms of obstructive and central sleep apneas include:

• Loud snoring, which is usually more prominent in obstructive sleep apnea
• Episodes of breathing cessation during sleep witnessed by another person
• Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty staying asleep (insomnia)
• Excessive daytime sleepiness (hypersomnia)
• Attention problems
• Irritability

Consult a medical professional if you experience, or if your partner notices, the following:

• Snoring loud enough to disturb the sleep of others or yourself
• Shortness of breath, gasping for air or choking that awakens you from sleep
• Intermittent pauses in your breathing during sleep
• Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving

Is it the same for everyone who has it?

No, there are varying types and levels of severity. Apnea events fall into two broad categories:

Obstructive Apneas- Here the main problem is that muscles around your throat relax too much as you sleep, so your airway closes and you struggle to breathe, trying to gasp unsuccessfully, just like someone choking on a foreign obstruction. If you have these primarily, you're diagnosed with Obstructive Sleep Apnea, the most common and easiest to treat.

Central Apneas- Less common and a bit harder to treat are apneas that are caused not by your airway being obstructed, but rather because the brain (central nervous system) is for whatever reason failing to send the electrical signal to even attempt a breath, so you don't even try to breathe. Primarily having these is called–shocker–Central Sleep Apnea, which is less common and a little harder to deal with.

Some lucky scamps get a combination of both, which is called Complex Sleep Apnea, and is both the hardest treatment to get used to as well as the most complicated to diagnose. (Guess which one I have! Hint: it's this one.)

I know, right?

So How Bad Can it Get?

The severity of any given case is measured primarily by what's called the apnea/hypoapnea index, or AHI. Apneas are defined as complete cessations of breathing, and hypoapneas are periods of overly shallow breathing or an abnormally low respiratory rate. AHI is the average number per hour of apnea and hypoapnea events lasting at least 10 seconds.

Based on the AHI, the severity of Sleep Apnea is classified roughly as follows:

• None/Minimal: AHI < 5 per hour
• Mild: AHI ≥ 5, but < 15 per hour
• Moderate: AHI ≥ 15, but < 30 per hour
• Severe: AHI ≥ 30 per hour

The most severe cases can get up over 100 AHI, and those are the people who present as essentially narcoleptic–falling asleep in the middle of conversations, or even while driving, that level of disruption. 

My untreated AHI turned out to be 41. So, doing some quick math–41 events at least 10 seconds each is 410 seconds, or roughly 7 minutes. So at minimum, I was spending 7 minutes out of every hour, over 10%, of my time either struggling to breathe or totally choked. Yeah, it really messed me up for a long time.

Me untreated, every day by about 1pm.

How's it treated?

The most common treatment is called CPAP–continuous positive airway pressure. It fixes obstructive apneas by pressurizing your respiratory system, essentially inflating your airway like one of those long balloon animal balloons, so it can't collapse. Or (if you want a more medical analogy) it's like stinting a blood vessel, but using a set air pressure instead of an implanted device.

Various flavors of sleep apnea use different types, like Auto CPAP, Bi-PAP, V-PAP, Auto V-PAP, Adaptive Pressure Support Servo-Ventilators, etc. etc. They handle the way air is delivered differently, whether they change the pressure level or keep it constant, whether they force you to breathe in a steady pattern or whether they adapt around irregularities, that sort of thing. 

Mine is an ASV Bi-Pap, which means it's providing continuous pressure at a low level to stop obstructive apneas, slightly raising the pressure to help on inhalations, dropping that pressure whenever I exhale, and will pulse really hard (basically becoming a respirator for a moment) when I have a central apnea. That combination of complicated and sudden pressure changes is one of the hardest to tolerate.

Me IRL, trying to sleep.

Successful treatment is characterized by how low it makes your AHI, with <5 being the goal, and how much you can tolerate using it (ideally all night, every night).

How successful is your treatment?

I started treatment at the same time I went back for fall semester of my senior year (senior year 2.0, that is). At first, I was on a simple CPAP for a few weeks and noticing no difference–they hadn't yet realized my case was Complex because the central apneas only manifested recognizably once the CPAP was applied (it had to do with the higher air pressure changing the rate of my blood CO₂ elimination–apparently one of the weirdest responses my doctor has ever seen to treatment and part of why the saga of figuring it out took so long for me).

I got a new machine, which improved my AHI a lot but I could only tolerate an average 1-2 hours per night. Even that much, though, took me from basically nonfunctional (I'd say 15% capacity) to a minimal functionality (30%? 40%?), so I went through most of Nov-February drifting between terrible 0-0.5 hour nights and the good 3-3.5 hour nights. Then in March I got a minor cold over spring break and couldn't tolerate the machine at all for almost three weeks, which nearly made me drop out again. It brought me back to the worst depression I'd ever felt (yeah, the sleep issues gave me clinical depression) right when I needed to be writing my thesis.

I struggled back from that hole though, going on anti-depressants and finally getting well, plus I got diagnosed with ADD (which I've also apparently had all along, probably in part due to the sleep apnea as well) and for a variety of reasons being on Adderall helped normalize my sleep so I finished out the year getting a solid 4-5 hours a night.

I took last summer off mostly to really seriously focus in on changing my treatment course to increase my machine toleration rate. My doctor and I checked in about every week, making lots of incremental tweaks on pressure settings or medication rhythms and tracking the effects. I tried three or four different types and models of breathing masks. Eventually, around mid-July this year, I finally got my nightly sleep with machine treatment up to 6-8 hours a night, with an AHI of around 2.

I've lost 20-30 pounds over the past summer, I have vastly more energy and focus, I'm happier, and I actually often wake up spontaneously after about 8-9 hours instead of my previous nightly 11-14 hours if I didn't have an alarm set. I'm not 100% consistent, occasionally allergies or just a couple late nights will throw off either my ability to tolerate the machine or my sleep patterns, and I'll be a little more out of it, but no more (I think) than most people if they get poor sleep for a while. I'm especially more resilient it seems to only one night interruptions, so as long as it doesn't get bad for days in a row I'm almost unaffected.

It's been over two years of dealing with this shit. I deserve this GIF.

Let me know if you guys have any more questions about my situation specifically, the disorder generally, or if you want to talk about your sleep concerns (I'm obviously not a medical doctor, but I'm happy to be a friendly ear.)

Sleep well everyone!

(AND GET A SLEEP STUDY IF YOU THINK YOU MIGHT NEED ONE)

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Up All Night by Counting Crows