12
2018
-
10
Sleep and sleep-related breathing disorders
In spring, one sleeps soundly without realizing dawn, and everywhere one hears the chirping of birds. The sound of wind and rain at night makes one wonder how many flowers have fallen. From Meng Haoran's "Spring Dawn," we can understand the author's deep slumber on a spring night. Humans spend one-third of their time sleeping, which is an important part of life. What is sleep and what is its significance? Sleep allows us to recover from fatigue and drowsiness. The secretion of human growth hormone increases during nighttime sleep, especially during slow-wave sleep. Growth hormone can prevent protein degradation due to prolonged fasting during sleep. Recent sleep studies have found that sleep has a role in "memory processing," including memory.
Author:
In spring, one sleeps soundly without realizing dawn, hearing birds chirping everywhere. The sound of wind and rain at night makes one wonder how many flowers have fallen. From Meng Haoran's "Spring Dawn," we can understand the author's deep slumber on a spring night. Humans spend one-third of their time sleeping, which is an important part of human life.
What is sleep and what is its significance? Sleep allows us to recover from fatigue and drowsiness. The secretion of human growth hormone increases during nighttime sleep, especially during slow-wave sleep. Growth hormone can prevent protein degradation due to prolonged fasting during sleep. Recent sleep research has found that sleep plays a role in "memory processing," including memory encoding, memory consolidation, brain function remodeling, and memory reconsolidation. In simple terms, the physiological significance of sleep is multifaceted, including energy conservation, avoiding unnecessary activities, evading crises, stopping the intake of excessive information, and consolidating memories.
Life experience tells us that sleep is as essential to us as eating and drinking. A day without sleep makes us uncomfortable, two days without sleep can lead to extreme fatigue and anxiety, and many people may collapse after three days or longer. Rats deprived of sleep for about 14 days will die. Foreign textbooks once recorded that a 17-year-old boy named Randy Gardner set a record of 11 days without sleep. On the second day of sleep deprivation, Randy Gardner began to feel irritable, nauseous, and experienced memory decline, making it difficult to even watch television. By the fourth day, he experienced mild hallucinations and extreme fatigue, and by the seventh day, he exhibited tremors and incoherent speech. Randy Gardner's case is an example of short-term acute sleep deprivation, while long-term severe chronic sleep deprivation can be life-threatening. Patients with severe obstructive sleep apnea syndrome (OSAS) experience chronic sleep deprivation. Once they fall asleep, the relaxation of the upper airway dilator muscles leads to the closure of already narrowed airways, causing the patient to wake up, open the airway, and resume breathing. This sleep cycle of OSAS leads to frequent interruptions in sleep, disrupting the continuity of sleep from light to deep, resulting in chronic sleep deprivation.
In 2001, representatives from the American Academy of Sleep Medicine, the Sleep Research Society, and sleep research societies from Finland, Switzerland, France, Germany, and Japan discussed the reclassification of sleep disorders, which was categorized into eight types in 2005: 1. Insomnia 2. Sleep-related breathing disorders 3. Central cause hypersomnia, etc. From the above classification, we can see that sleep-related breathing disorders are a major category, referring to respiratory disturbances that occur during sleep and the series of syndromes they cause. Based on whether there is a reduction or disappearance of respiratory effort during respiratory disturbance events, they are divided into central and obstructive sleep-related disorders. Below, we will focus on explaining and describing obstructive sleep apnea.
Snoring during sleep is considered a sign of sound sleep. Simple snoring that does not affect sleep quality, does not cause sleep interruptions or awakenings, cannot yet be definitively classified as a disease. However, if snoring leads to frequent awakenings, affects sleep quality, causes excessive daytime sleepiness, and is even associated with cardiovascular diseases, it is classified as a disorder and falls under the category of sleep-related breathing disorders. The understanding of sleep-related breathing disorders began in the 1970s with a re-examination of Pickwickian syndrome. Pickwickian syndrome was proposed by Bickelmann and others in the 1950s after studying a group of obese patients with excessive daytime sleepiness, using the image of a red-faced, chubby boy named Joe described by the famous British author Charles Dickens in his novel "The Pickwick Papers." In the following 10 to 20 years, doctors in Germany and France found that a significant number of patients with Pickwickian syndrome experienced repeated episodes of apnea during sleep, accompanied by frequent awakenings, leading to excessive daytime sleepiness, thus proposing obstructive sleep apnea syndrome (OSAS) as an independent disease type. OSAS is one of the greatest discoveries in the field of respiratory diseases in the past century.
Snoring during sleep, apnea, daytime sleepiness, and mouth breathing during sleep are typical manifestations of OSAS. Other common manifestations include restlessness during sleep, interrupted nighttime sleep, pseudo-insomnia, frequent nighttime urination, excessive sweating at night, and headaches or dry mouth upon waking. Common causes include: 1. Relative excess of soft tissue in the upper airway, which is the main cause of OSAS. Hypertrophy of the pharyngeal sidewall muscles may be a major factor leading to upper airway obstruction; excessive accumulation of fat in the pharynx, as well as hypertrophy of the adenoids, tonsils, and base of the tongue, are also important causes; hypertrophy of the adenoids and tonsils is the main cause of OSAS in children. The obstruction in OSAS can occur in the nasal cavity, nasopharynx, oropharynx, or laryngopharynx, with the soft palate at the back of the nasopharynx being the primary obstruction site. Additionally, retrognathia, micrognathia, dysfunction in maintaining upper airway patency, genetic predisposition, and endocrine diseases such as acromegaly and hypothyroidism may also be contributing factors.
Polysomnography (PSG) monitoring is currently considered the "gold standard" for diagnosing OSAS. PSG is a technique that monitors various physiological activities of the body during sleep and wakefulness. In practical applications, it can continuously and synchronously record electroencephalograms, electrocardiograms, electrooculograms, electromyograms, and respiratory activities (including blood oxygen saturation and breathing patterns). A fiberoptic nasopharyngoscope can be used to visually examine the airway from the nasal cavity to the glottis to assess the diameter of the nasal, palatine, and laryngeal airways, which helps identify obstruction sites and is very helpful in determining surgical methods and sites. Treatment for OSAS should adopt a comprehensive approach, including weight loss, avoiding triggers, correcting underlying physical diseases that cause and exacerbate OSAS, oral appliances, and surgery. In severe cases, positive airway pressure therapy during sleep is required.
Children are a special group, with significant differences in physiological structure, disease development, and outcomes compared to adults. Obstructive sleep apnea syndrome can occur in children from infancy to their teenage years. Epidemiological studies abroad have reported that 20% of children snore intermittently during sleep, with 10% to 12% being simple snoring, and the incidence of OSAS is 1% to 3%. OSAS in children is not a standalone disease; its development can lead to a series of adverse consequences. Studies have found that OSAS significantly affects children's physical development, leading to slow growth, developmental delays, cardiovascular diseases, and even death. Other data show that behavior and cognitive abilities are also impaired in children with OSAS. The causes of OSAS in children differ significantly from those in adults, with no obvious differences in gender, age, or body mass index. Obesity is a major cause of OSAS in adults, but it is not as pronounced in children. Hypertrophy of the adenoids and tonsils is the most common cause of OSAS in children. Studies have shown that 90% of children with OSAS have obstruction at the level of the adenoids and tonsils, and surgical removal of hypertrophied adenoids and tonsils is the main method for treating this condition in children, with an effective rate of over 90% in children without jaw deformities or neurological diseases. Unlike adults, positive airway pressure (CPAP) is not recommended as a routine method for treating OSAS in children.
The following introduces a typical case of a recent surgery for a 1 year and 2 month old child. The patient, Wang --, male, has been experiencing snoring, runny nose, mouth breathing, breath-holding, and daytime sleepiness for over 4 months. Dr. Huang Yang, the deputy chief physician of pediatrics at our hospital, conducted a polysomnography which showed a sleep apnea index of 34 and a minimum blood oxygen level of 50%. This means that the child experiences 34 episodes of sleep apnea or hypoventilation per hour during nighttime sleep, and there is severe hypoxia during sleep. The family reported that they were afraid to sleep at night and had to wake the child whenever he was breath-holding. Once, the child's apnea lasted more than 3 to 4 minutes, prompting them to call emergency services. Therefore, it is necessary to understand the concepts of apnea and hypoventilation. Obstructive apnea is defined as the presence of chest and abdominal movements while airflow through the mouth and nose stops for more than two breathing cycles; hypoventilation is defined as a peak airflow reduction of more than 50% for at least two breathing cycles, with a drop in blood oxygen saturation of more than 4%. An episode of apnea in children is defined as airflow cessation through the mouth and nose for greater than or equal to 5 seconds, while hypoventilation is defined as a 50% reduction in airflow amplitude lasting more than 5 seconds. Therefore, this child has more than 170 seconds of apnea per hour of sleep. Based on the above medical history, the diagnosis of severe pediatric OSAS is very clear. We subsequently conducted a comprehensive physical examination of the child and performed a CT scan of the nasal area, as well as a nasopharyngoscopy of the upper airway. The CT scan indicated significant sinusitis, and the airway at the level of the nasopharynx and soft palate was quite narrow. The images from the nasopharyngoscopy also showed severe narrowing of the nasopharynx and soft palate airway (see images 1-5). Images one and two from the nasopharyngoscopy showed adenoid hypertrophy in the child, with purulent secretions on the surface, and narrowing of the nasopharyngeal airway; image three showed complete obstruction of the nasopharyngeal and soft palate airway during inhalation, which can manifest as apnea during nighttime sleep; images four and five showed that the oropharyngeal, tonsillar, and base of tongue airways were clear. We have reason to believe that the child's condition can improve or even be cured after surgery. With the excellent cooperation of the operating room nurses and anesthesiologist Gao Xia, the surgery was successful. The procedure involved adenoidectomy and modified plasma-assisted uvulopalatopharyngoplasty. Postoperatively, the child's apnea was eliminated, with only mild snoring, and the minimum blood oxygen saturation was above 94%, allowing for a smooth discharge. This case also reminds us that when the cause of upper airway obstruction is clearly identified, active treatment and surgery should be pursued, regardless of age.
After years of effort, it can now be said that our hospital has reached a leading level in the diagnosis and treatment of pediatric sleep-disordered breathing, comparable to the best in the country. Additionally, the efficiency and safety of the pediatric sleep unit, along with the cooperation of the anesthesiology and surgical nursing staff, are the guardians of our development.
Related Content
Health Hotline
Address: No.18, Zhongshan Road, Lanshan District, Linyi City, Shandong Province
Outpatient service hours: 8:00-20:00 (24 hours a day)
Night clinic: 24 hours (24 hours a day)
Public Number
Video Number
Tiktok