The Silent Epidemic: Unmasking Sleep Apnea and Embracing New Treatments
Snoring, a common annoyance in many households, often serves as a harbinger of a more serious underlying condition: sleep apnea. While once considered a mysterious ailment, sleep apnea has emerged as a significant public health concern, affecting an estimated 12% of American adults.
Sleep apnea, a condition characterized by repeated pauses in breathing during sleep, can significantly disrupt the quality of sleep, leaving sufferers feeling exhausted during the day. The condition primarily manifests in two forms: obstructive sleep apnea (OSA) and central sleep apnea (CSA).
OSA, the more prevalent form, occurs when the muscles in the back of the throat relax, causing the airway to become blocked. CSA, on the other hand, arises from a disruption in the brain’s signals to the muscles responsible for breathing. This disruption often results in the muscles failing to initiate breathing, leading to pauses in respiration.
While snoring is often associated with sleep apnea, it’s not a guaranteed indicator. Approximately 25% to 50% of people snore occasionally, without necessarily suffering from sleep apnea. Other symptoms that might point toward the condition include difficulty sleeping, waking up with a dry mouth, and experiencing excessive daytime sleepiness.
The consequences of untreated sleep apnea extend beyond mere fatigue. The condition can have serious long-term health implications:
- Heart disease: Untreated sleep apnea significantly increases the risk of developing heart disease.
- Diabetes: Sleep apnea is linked to an increased risk of developing diabetes.
- Brain damage: Research has demonstrated a correlation between sleep apnea and the development of brain damage.
- Early death: Studies have shown that individuals with sleep apnea have a higher risk of early death compared to those without the condition.
The detrimental effects of sleep apnea stem from the repeated deprivation of oxygen and surges in blood pressure occurring during each breathing pause. "The harm is twofold," explains Dr. Douglas Kirsch, a sleep medicine physician and spokesperson for the American Academy of Sleep Medicine, "One, when you pause in your breathing, your oxygen levels drop, and having low oxygen levels makes the heart and the brain less happy, and from there they can sustain injuries from repetitive decreases in oxygen." He further explains, "As well, when we start breathing again, because we always start breathing again, our blood pressure and our heart rate climb up, and that repetitive climb of blood pressure after every episode, night after night, again and again, that too can cause problems for the heart and the brain."
A Silent Epidemic Unmasked:
For a condition as prevalent as sleep apnea, its understanding and treatment have been relatively recent. It was only in 1965 that the term "sleep apnea" was officially coined, although written accounts of the condition can be traced back thousands of years. Prior to widespread use of the term "sleep apnea," cases were often referred to as "Pickwickian syndrome," a reference to a character in Charles Dickens’ The Pickwick Papers who exhibited many of the classic symptoms.
In the initial decades following its discovery, the primary treatment for sleep apnea involved a rather intrusive procedure: tracheostomy, a surgical intervention that involved cutting a hole in the windpipe and inserting a permanent tube to facilitate breathing during sleep. While this procedure continues to be used today in the most severe cases, it has largely been replaced by less invasive methods.
A Technological Revolution:
The early 1980s marked a pivotal moment in the treatment of sleep apnea with the development of the first continuous positive airway pressure (CPAP) machine. This groundbreaking invention, partly inspired by research on dogs with breathing difficulties, has become the gold standard for treating sleep apnea. CPAP machines work by delivering pressurized air through a mask worn during sleep, keeping the airway open and preventing breathing pauses.
Despite its effectiveness, CPAP therapy has its drawbacks. While advancements have made CPAP masks less cumbersome over time, many individuals find it challenging to adhere to the long-term use of CPAP. Some may experience discomfort or have medical conditions that prevent its use.
Beyond CPAP: Emerging Treatments:
Recognizing the limitations of CPAP, researchers and developers have been actively exploring alternative treatments for sleep apnea. One promising avenue has been the development of upper airway stimulation devices. These devices are implanted in the chest and neck, sending electrical impulses to the hypoglossal nerve, which controls tongue movement. During sleep, the device senses breathing patterns and uses stimulation to prevent the tongue from blocking the airway.
The Inspire implant, approved by the Food and Drug Administration in 2014, is the only currently available device of this type. While less intrusive than CPAP, upper airway stimulation devices are not suitable for everyone.
Other approaches to treating sleep apnea include dental devices designed to reposition the jaw or tongue. However, their effectiveness remains limited and they are not considered a widely accepted solution.
The Promise of New Medications:
The horizon for sleep apnea treatment is expanding with the development of medications specifically targeted at the condition. In April 2024, Eli Lilly announced promising early results from two Phase III trials testing tirzepatide, a drug originally developed for diabetes and obesity, for individuals suffering from both obesity and obstructive sleep apnea.
The trials revealed that tirzepatide not only led to significant weight loss, up to 20% of baseline weight, but also significantly reduced the frequency of apnea episodes, cutting them by up to two-thirds. Eli Lilly has submitted an application to the FDA for expanded approval of tirzepatide for the treatment of sleep apnea, potentially bringing a new therapeutic option to patients by the end of the year.
While tirzepatide holds promise, Dr. Kirsch highlights that it is not a one-size-fits-all solution. While obesity is a common risk factor for sleep apnea, it’s not the only one, and individuals without obesity can still develop the condition. Since tirzepatide’s effect on sleep apnea appears to primarily stem from its weight loss effects, it may not be effective for all sufferers. Additionally, less than half of the patients in the clinical trials experienced significant enough reduction in apnea to be considered resolved.
Beyond tirzepatide, other medications are in development that directly target the mechanisms underlying sleep apnea, such as pills designed to keep the airways open during the night. These medications hold even greater promise for addressing the root cause of the condition.
The Challenge of Awareness:
Despite the advancements in treatment options, a significant portion of individuals with sleep apnea remain undiagnosed. Studies have estimated that up to 80% of sleep apnea cases go undetected, a disparity that is even more pronounced in disadvantaged populations, such as those living in poverty. Furthermore, even after diagnosis, individuals from lower-income neighborhoods are less likely to pursue treatment.
Improving Awareness and Access to Care:
Improving awareness of sleep apnea and increasing access to care are crucial to address this silent epidemic. The development of wearable and nearable technologies offering convenient sleep apnea screening options is a promising step forward. In February 2024, the Samsung Galaxy Watch became the first FDA-approved wearable technology capable of detecting sleep apnea.
Dr. Kirsch emphasizes the importance of making diagnosis and treatment more accessible: "A lot of people I see didn’t want to come to see a sleep doctor because they didn’t want to do a sleep test in a laboratory. But now we can do those in the home, in some cases." He urges individuals to reach out to healthcare providers if they suspect they may be struggling with sleep apnea.
The future of sleep apnea treatment is brimming with hope, thanks to ongoing research and technological advancements. However, the most critical step is to ensure that individuals suffering from this condition receive timely diagnosis and appropriate treatment.
"Before we worry about the kind of treatment, let’s figure out how bad of a problem you have," says Dr. Kirsch, "because the severity of the problem sometimes changes how we think about the treatment."
