Sleep apnea
From Wikipedia, the free encyclopedia
| Sleep apnea Classification and external resources |
|
| ICD-10 | G47.3 |
|---|---|
| ICD-9 | 780.57 |
| eMedicine | ped/2114 |
| MeSH | D012891 |
Sleep apnea is a sleep disorder characterized by pauses in breathing during sleep. Each episode, called apneas (Greek: άπνοια (ápnoia), from α- (a-), privative, πνέειν (pnéein), to breathe), lasts long enough so that one or more breaths are missed, and occurs repeatedly throughout sleep. The standard definition of any apneic event includes a minimum 10 second interval between breaths, with either a neurological arousal (a 3-second or greater shift in EEG frequency, measured at C3, C4, O1, or O2), a blood oxygen desaturation of 3-4% or greater, or both arousal and desaturation. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram.
Clinically significant levels of sleep apnea are defined as five or more episodes per hour of any type of apnea (from the polysomnogram). There are three distinct forms of sleep apnea: central, obstructive, and complex (complex is a combination of central and obstructive) making up 0.4%, 84% and 15% of cases respectively.[1] Breathing is interrupted by the lack of effort in central sleep apnea; in obstructive sleep apnea, breathing is interrupted by a physical block to airflow despite effort. In mixed sleep apnea, there is a transition from central to obstructive features during the events themselves.
Regardless of type, the individual with sleep apnea is rarely aware of having difficulty breathing, even upon awakening. Sleep apnea is recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body (sequelae). Symptoms may be present for years, even decades without identification, during which time the sufferer may become conditioned to the daytime sleepiness and fatigue associated with significant levels of sleep disturbance.
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[edit] History
The first reports of what is now called obstructive sleep apnea, in the medical literature date only from 1965, when it was independently described by French and German investigator Tyeneshia Dow. However, the clinical picture of this condition has long been recognized as a character trait, without an understanding of the disease process. The term “Pickwickian syndrome” that is sometimes used for the syndrome, was coined by the famous early 20th Century physician, William Osler, who must have been a reader of Charles Dickens. The description of Joe, "the fat boy" in Dickens's novel, The Pickwick Papers, is an accurate clinical picture of adult obstructive sleep apnea syndrome.
The early reports of obstructive sleep apnea in the medical literature described individuals who were very severely affected, often presenting with severe hypoxemia, hypercapnia and congestive heart failure. Tracheostomy was the recommended treatment and, though it could be life-saving, post-operative complications in the stoma were frequent in these very obese and short-necked individuals.
The management of obstructive sleep apnea was revolutionized with the introduction of continuous positive airway pressure (CPAP), first described in 1981 by Colin Sullivan and associates in Sydney, Australia. The first models were bulky and noisy but the design was rapidly improved and by the late 1980s CPAP was widely adopted. The availability of an effective treatment stimulated an aggressive search for affected individuals and led to the establishment of hundreds of specialized clinics dedicated to the diagnosis and treatment of sleep disorders. Though many types of sleep problems are recognized, the vast majority of patients attending these centers have sleep disordered breathing.
[edit] Obstructive sleep apnea
Obstructive sleep apnea (OSA) is the most common category of sleep-disordered breathing. Since the muscle tone of the body ordinarily relaxes during sleep, and since, at the level of the throat, the human airway is composed of collapsible walls of soft tissue, it is easy to understand why breathing can be obstructed during sleep. Mild, occasional sleep apnea, such as many people experience during an upper respiratory infection may not be important, but chronic, severe obstructive sleep apnea requires treatment to prevent sleep deprivation and other complications. The most serious complication is a severe form of congestive heart failure called cor pulmonale.
Individuals with low muscle tone and soft tissue around the airway (e.g., due to obesity), and structural features that give rise to a narrowed airway are at high risk for obstructive sleep apnea. The elderly are more likely to have OSA than young people. Men are more typical sleep apnea sufferers than women and children, although it is not uncommon in these.
Common symptoms include loud snoring, restless sleep, and sleepiness during the daytime. Diagnostic tests include home oximetry or polysomnography in a sleep clinic.
Some treatments involve lifestyle changes, such as avoiding alcohol or muscle relaxants, losing weight, and quitting smoking. Many people benefit from sleeping at a 30 degree elevation of the upper body[2] or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway. Lateral positions (sleeping on a side), as opposed to supine positions (sleeping on the back), are also recommended as a treatment for sleep apnea,[3][4][5] largely because the gravitaional component is smaller than in the lateral position. Some people benefit from various kinds of oral appliances to keep the airway open during sleep. "Breathing machines" like the continuous positive airway pressure (CPAP) may help. There are also surgical procedures to remove and tighten tissue and widen the airway.
[edit] OSA symptoms, signs and sequelae
This section summarizes the clinical picture and consequences of obstructive sleep apnea syndrome.
As already mentioned, snoring is almost a uniform finding in an individual with this syndrome, but many people snore without having apnea. Snoring is the turbulent sound of air moving through the back of the mouth, nose and throat. The loudness of the snoring is not indicative of the severity of obstruction, however. If the upper airways are tremendously obstructed, there may not be enough air movement to make much sound. Even the loudest snoring does not mean that an individual has sleep apnea syndrome. The sign that is most suggestive of sleep apneas occurs if snoring stops. If it does, along with breath, while the persons' chest and body tries to breathe - that is literally a description of an event in obstructive sleep apnea syndrome. When breathing starts again, there is typically a deep gasp, and then the resumption of snoring.
Sometimes, elevated arterial pressure (commonly called high blood pressure) is a sequela of obstructive sleep apnea syndrome.[6] When high blood pressure is caused by OSA, it is distinctive in that, unlike most cases of high blood pressure (so-called essential hypertension), the readings do not drop significantly when the individual is sleeping.[7] Stroke is associated with obstructive sleep apnea.[8] Sleep apnea sufferers also have a 30% higher risk of heart attack or premature death than those unaffected.[9]
[edit] Central sleep apnea
In pure central sleep apnea or Cheyne-Stokes respiration, the brain's respiratory control centers are imbalanced during sleep. Blood levels of carbon dioxide, and the neurological feedback mechanism that monitors it does not react quickly enough to maintain an even respiratory rate, with the entire system cycling between apnea and hyperpnea, even during wakefulness. The sleeper stops breathing, and then starts again. There is no effort made to breathe during the pause in breathing: there are no chest movements and no struggling. After the episode of apnea, breathing may be faster (hyperpnea) for a period of time, a compensatory mechanism to blow off retained waste gases and absorb more oxygen.
While sleeping, a normal individual is "at rest", as far as cardiovascular workload is concerned. Breathing is regular in a healthy person during sleep, and oxygen levels and carbon dioxide levels in the bloodstream stay fairly constant. The respiratory drive is so strong that even conscious efforts to hold one's breath do not overcome it. Any sudden drop in oxygen or excess of carbon dioxide (even if tiny) strongly stimulates the brain's respiratory centers to breathe. In central sleep apnea, the basic neurological controls for breathing rate malfunctions and fails to give the signal to inhale, causing the individual to miss one or more cycles of breathing. If the pause in breathing is long enough, the percentage of oxygen in the circulation will drop to a lower than normal level (hypoxia) and the concentration of carbon dioxide will build to a higher than normal level (hypercapnia). In turn, these conditions of hypoxia and hypercapnia will trigger additional effects on the body. Brain cells need constant oxygen to live; and, if the level of blood oxygen goes low enough for long enough, the consequences of brain damage and even death will occur. Fortunately, central sleep apnea is more often a chronic condition that causes much milder effects than sudden death. The exact effects of the condition will depend on how severe the apnea is, and the individual characteristics of the person having the apnea. Several examples are discussed below, and more about the nature of the condition is presented in the section on Clinical Details.
In any person, hypoxia and hypercapnia have certain common effects on the body. The heart rate will increase, unless there are such severe co-existing problems with the heart muscle itself or the autonomic nervous system that makes this compensatory increase impossible. The more translucent areas of the body will show a bluish or dusky cast from cyanosis, which is the change in hue that occurs due to lack of oxygen in the blood ("turning blue"). Overdoses of drugs that are respiratory depressants (such as heroin, and other opiates) kill by damping the activity of the brain's respiratory control centers. In central sleep apnea, the effects of sleep alone can remove the brains' mandate for the body to breathe. Even in severe cases of central sleep apnea, the effects almost always result in pauses that make breathing irregular, rather than cause the total cessation of breathing.
- Normal Respiratory Drive: After exhalation, the blood level of oxygen decreases and that of carbon dioxide increases. Exchange of gasses with a lungful of fresh air is necessary to replenish oxygen and rid the bloodstream of built-up carbon dioxide. How do the changing blood levels of oxygen and carbon dioxide result in a breath? In any healthy animal, including humans, oxygen and carbon dioxide receptors in the blood stream (called chemoreceptors) send nerve impulses to the brain, which then signals reflex opening of the larynx (so that the opening between the vocal cords enlarges) and movements of the rib cage muscles and diaphragm. These muscles expand the thorax (chest cavity) so that a partial vacuum is made within the lungs and air rushes in to fill it. The body inhales.
- Physiologic effects of central apnea: During central apneas, the central respiratory drive is absent, and the brain does not respond to changing blood levels of the respiratory gases. No breath is taken despite the normal signals to inhale. The immediate effects of central sleep apnea on the body depend on how long the failure to breathe endures. At worst, central sleep apnea may cause sudden death. Short of death, drops in blood oxygen may trigger seizures- even in the absence of epilepsy. In people with epilepsy, the hypoxia caused by apnea may trigger seizures that had previously been well controlled by medications. In other words, a seizure disorder may become unstable in the presence of sleep apnea. In adults with coronary artery disease, a severe drop in blood oxygen level can cause angina, arrhythmias, or heart attacks (myocardial infarction). Longstanding recurrent episodes of apnea, over months and years, may cause an increase in carbon dioxide levels that can change the pH of the blood enough to cause a metabolic acidosis.
[edit] Laboratory findings
| AHI | Rating |
|---|---|
| <5 | Normal |
| 5-15 | Mild |
| 15-30 | Moderate |
| >30 | Severe |
Polysomnography of sleep apnea shows pauses in breathing that are followed by drops in blood oxygen and increases in blood carbon dioxide. In adults, a pause must last 10 seconds to be scored as an apnea. However in young children, who normally breathe at a much faster rate than adults, the pause may be many seconds shorter and still be considered apnea. The cessation of airflow in central sleep apnea has an association with no physical attempts to breathe. On polysomnograms, there is an absence of rib cage and abdominal movements while airflow ceases at the nose and lips. Obstructive sleep apnea show pauses in breathing for at least 10 seconds causing a decrease in blood oxygen and associates with physical attempts to breathe.
Hypopneas in adults are defined as a 50% reduction in air flow for more than 10 s, followed by a 4% desaturation, and/or arousal. The Apnea- Hypopnea Index (AHI) is expressed as the number of apneas and hypopneas per hour of sleep.
[edit] Clinical details
Any individual, no matter how healthy, who is given enough of a central respiratory depressant drug will develop apnea on a central basis. Generally, drugs that are central respiratory depressants also have sedative effects, and so the individual taking a toxic dose of such a drug is likely to be asleep, or at least in an altered state of consciousness, when breathing becomes irregular. Alcohol is such a central respiratory depressant in large doses, so are opiates, barbiturates, benzodiazepines, and many other tranquilizers. Some individuals have abnormalities that predispose them to central sleep apnea. The treatment for the condition depends on its specific cause.
Similarly, in any person who has some form of sleep apnea (including obstructive sleep apnea), breathing irregularities during sleep can be dangerously aggravated by taking one of these drugs. Quantities that are normally considered safe may cause the person with chronic sleep apnea to stop breathing altogether. Should these individuals have general anesthesia, for example, they require prolonged monitoring after initial recovery, as compared to a person with no history of sleep apnea, because apnea is likely to occur with even low levels of the drugs in their system.
Premature infants with immature brains and reflex systems are at high risk for central sleep apnea syndrome, even if these babies are otherwise healthy. Fortunately, those premature babies who have the syndrome will generally outgrow it as they mature, providing they receive careful enough monitoring and supportive care during infancy to survive. Because of the propensity toward apnea, medications that can cause respiratory drive depression are either not given to premature infants, or given under careful monitoring, with equipment for resuscitation immediately available. Such precautions are routinely taken for premature infants after general anesthesia. Caffeine has been found to help reduce apnea in preterm infants and to aid in care after general anesthesia.[10]
Sudden infant death syndrome is sometimes theorized to be attributable to sleep apnea.
Congenital Central Hypoventilation Syndrome: This rare, inborn condition involves a specific gene, PHOX2B. This homeobox gene guides maturation of the autonomic nervous system, and loss-of-function mutations lead to the failure of the brain to effectively control breathing during sleep in patients with the syndrome. There may be a pattern of recognizable facial features among individuals affected with this syndrome.[11]
Once almost uniformly fatal, congenital hypoventilation ("abnormally low ventilation") syndrome is now treatable. The children who have it must have tracheotomies and access to mechanical ventilation on respirators while sleeping, but most do not need to use a respirator while awake. The use of a diaphragmatic pacemaker may offer an alternative for some patients. When pacemakers have enabled some children to sleep without the use of a mechanical respirator, reported cases still required the tracheotomy to remain in place, because the vocal cords did not move apart with inhalation. This form of central sleep apnea has been called Ondine's curse. Now that some children with the syndrome have grown up, there is particular need for their avoidance of adolescent behaviors, such as alcohol use, which can easily be lethal.[12]
Adults suffering from congestive heart failure are at risk for a form of central sleep apnea called Cheyne-Stokes respiration. This is periodic breathing with recurrent episodes of apnea alternating with episodes of rapid breathing. In those who have it, Cheyne-Stokes respirations occur while both awake and asleep. There is good evidence that replacement of the failed heart (heart transplant) cures central apnea in these patients. The use of some medications that are respiratory stimulants decrease the severity of apnea in some patients.
[edit] Section references
1) Macey PM. Macey KE. Woo MA. Keens TG. Harper RM. Aberrant neural responses to cold pressor challenges in congenital central hypoventilation syndrome.[see comment]. [Journal Article] Pediatric Research. 57(4):500-9, 2005 Apr.
2) Bradley TD. Floras JS. Sleep apnea and heart failure: Part II: central sleep apnea. [Review] [55 refs] [Journal Article. Review] Circulation. 107(13):1822-6, 2003 April 8.
3) Mansfield DR. Solin P. Roebuck T. Bergin P. Kaye DM. Naughton MT. The effect of successful heart transplant treatment of heart failure on central sleep apnea.[see comment]. [Journal Article] Chest. 124(5):1675-81, 2003 Nov.
4)Javaheri S. Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study. [Clinical Trial. Journal Article. Randomized Controlled Trial] American Journal of Respiratory & Critical Care Medicine. 173(2):234-7, 2006 Jan 15.
[edit] Mixed Apnea and Complex Sleep Apnea
Some people with sleep apnea have a combination of both types. When obstructive sleep apnea syndrome is severe and longstanding, episodes of central apnea sometimes develop. The exact mechanism of the loss of central respiratory drive during sleep in OSA is unknown, but is most commonly related to acid-base and CO2 feedback malfunctions stemming from heart failure. There is a constellation of diseases and symptoms relating to body mass, cardiovascular, respiratory, and occasionally, neurological dysfunction that have a synergistic effect in sleep-disordered breathing. The presence of central sleep apnea without an obstructive component is a common result of chronic opiate use (or abuse), due to the characteristic respiratory depression caused by large doses of narcotics.
Complex sleep apnea has recently been described by researchers as a novel presentation of sleep apnea. Patients with complex sleep apnea exhibit OSA, but upon application of positive airway pressure, the patient exhibits persistent central sleep apnea. This central apnea is most commonly noted while on CPAP therapy, after the obstructive component has been eliminated. This has long been seen in sleep laboratories, and has historically been managed either by CPAP or BiLevel therapy. Adaptive servo-ventilation modes of therapy have been introduced to attempt to manage this complex sleep apnea. Studies have demonstrated marginally superior performance of the adaptive servo ventilators in treating Cheyne-Stokes breathing, however, no longitudinal studies have yet been published, nor have any results been generated which suggest any differential outcomes versus standard CPAP therapy. At the AARC 2006 in Las Vegas, NV, researchers reported successful treatment of hundreds of patients on Adapt SV therapy, however these results have not been reported in peer reviewed publications as of July, 2007.
An important finding by Dernaika, et al., (Chest 2007, 132) suggests that transient central apnea produced during CPAP titration (the so called "complex sleep apnea") is "... transient and self-limited." The central apneas may in fact be secondary to sleep fragmentation during the titration process. As of July 2007, there has been no alternate convincing evidence produced that these central sleep apnea events associated with CPAP therapy for obstructive sleep apnea are of any significant pathophysiologic import.
[edit] Treatment
The most common treatment and arguably the most consistently effective treatment for sleep apnea is the use of a continous positive airway pressure (CPAP) device[13] , which 'splints' the patient's airway open during sleep by means of a flow of pressurized air into the throat.
In addition to CPAP, a dentist specializing in sleep disorders can prescribe Oral Appliance Therapy (OAT). The oral appliance is a custom made mouthpiece that shifts the lower jaw forward which opens up the airway. OAT is usually successful in patients with mild to moderate obstructive sleep apnea. OAT is a relatively new treatment option for sleep apnea in the United States, but it is much more common in Canada and Europe.
CPAP and OAT are effective only for obstructive sleep apnea, not for central or mixed cases.
For unknown reasons, possibly due to changes in pulmonary oxygen stores,[14] sleeping in the lateral position has been found to be helpful for central sleep apnea (CSA).
Medications like Acetazolamide[15][16] lower blood pH and encourage respiration. Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects.[17][18][19]
A 2005 study in the British Medical Journal found that learning and practicing the didgeridoo helped reduce snoring and sleep apnea, as well as daytime sleepiness. This appears to work by strengthening muscles in the upper airway, thus reducing their tendency to collapse during sleep..[20]
[edit] Special situation: surgery and anesthesia in patients with sleep apnea syndrome
Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing.
Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.
Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction - swelling may negate some of the effects in the immediate postoperative period.
Individuals with sleep apnea generally require more intensive monitoring after surgery for these reasons.
[edit] See also
[edit] References
[edit] Footnotes
- ^ Mayo Clinic Discovers New Type Of Sleep Apnea
- ^ Effects of sleep posture on upper airway stability in patients with obstructive sleep apnea - Neill et al. 155 (1): 199 - American Journal of Respiratory and Critical Care Medicine
- ^ The Study Of The Influence Of Sleep Position On Sleep Apnea
- ^ Positioner-a method for preventing sleep apnea
- ^ Lateral sleeping position reduces severity of cent...[Sleep. 2006] - PubMed Result
- ^ Silverberg DS, Iaina A and Oksenberg A (January 2002). "Treating Obstructive Sleep Apnea Improves Essential Hypertension and Quality of Life". American Family Physicians 65 (2): 229-36. PMID 11820487.
- ^ Grigg-Damberger M. (2006-02). "Why a polysomnogram should become part of the diagnostic evaluation of stroke and transient ischemic attack". Journal of Clinical Neurophysiology 23 (1): 21-38. doi:. PMID 16514349.
- ^ H. Klar Yaggi, M.D., M.P.H.; John Concato, M.D., M.P.H., Walter N. Kernan, M.D., Judith H. Lichtman, Ph.D., M.P.H., Lawrence M. Brass, M.D., and Vahid Mohsenin, M.D. (November 10, 2005). "Obstructive Sleep Apnea as a Risk Factor for Stroke and Death". The New England Journal of Medicine 353 (Number 19): 2034-2041. PMID 16282178.
- ^ N.A. Shah, M.D., N.A. Botros, M.D., H.K. Yaggi, M.D., M., V. Mohsenin, M.D., New Haven, CT (May 20, 2007). Sleep Apnea Increases Risk of Heart Attack or Death by 30%. American Thoracic Society.
- ^ Henderson-Smart DJ. Steer P. Prophylactic caffeine to prevent postoperative apnea following general anesthesia in preterm infants.[update of Cochrane Database Syst Rev. 2000;(2):CD000048; PMID: 10796287]. [Review] [15 refs] [Journal Article. Review] Cochrane Database of Systematic Reviews. (4):CD000048, 2001.
- ^ Todd ES, Weinberg SM, Berry-Kravis EM et al. (January 2006). "Facial phenotype in children and young adults with PHOX2B-determined congenital central hypoventilation syndrome: quantitative pattern of dysmorphology". Pediatric Research 59 (1): 39-45. doi:. PMID 16327002.
- ^ Chen ML, Turkel SB, Jacobson JR et al. (March 2006). "Alcohol use in congenital central hypoventilation syndrome". Pediatric Pulmonology 41 (3): 283-5. doi:. PMID 16429433.
- ^ Sleep Apnea, Treatment
- ^ Lateral sleeping position reduces severity of cent...[Sleep. 2006] - PubMed Result
- ^ Arch Intern Med - Abstract: Central sleep apnea. Improvement with acetazolamide therapy, October 1, 1982, White et al. 142 (10): 1816
- ^ Psychology Today's Diagnosis Dictionary: Sleep Apnea
- ^ Psychology Today's Diagnosis Dictionary: Sleep Apnea
- ^ [The effect of nocturnal oxygen therapy in patient...[Arch Bronconeumol. 2001] - PubMed Result
- ^ [Transtracheal oxygen therapy in obstructive sleep...[Schweiz Med Wochenschr. 1989] - PubMed Result
- ^ Puhan MA, Suarez A, Lo Cascio C et al (2005). "Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial". BMJ 332: 266-70. doi:.
[edit] General references
- Maninder Kalra; Ranajit Chakraborty (March 2007). "Genetic susceptibility to obstructive sleep apnea in the obese child". Sleep Medicine 8 (2): 169-175. PMID 17275401.
- American Academy of Sleep Medicine Task Force (1999). "Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research.". Sleep 22 (5): 667-89. PMID 10450601.
- Bell, R. B. (2001). "Skeletal advancement for the treatment of obstructive sleep apnea in children". Cleft Palate-Craniofacial Journal 38 (2): 147-54. doi:.
- Caples S, Gami A, Somers V (2005). "Obstructive sleep apnea.". Ann Intern Med 142 (3): 187-97. PMID 15684207.
- Cohen, M. M. J.; Kreiborg, S. (1992). "Upper and lower airway compromise in the Apert syndrome". American Journal of Medical Genetics 44: 90-93. doi:.
- de Miguel-Díez J, Villa-Asensi J, Alvarez-Sala J (2003). "Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children." (PDF). Sleep 26 (8): 1006-9. PMID 14746382.
- Mathur R, Douglas N (1994). "Relation between sudden infant death syndrome and adult sleep apnoea/hypopnoea syndrome.". Lancet 344 (8925): 819-20. doi:. PMID 7916096.
- Mortimore I, Douglas N (1997). "Palatal muscle EMG response to negative pressure in awake sleep apneic and control subjects.". Am J Respir Crit Care Med 156 (3 Pt 1): 867-73. PMID 9310006.
- Perkins, J. A.; Sie, K. C. Y., Milczuk, H., & Richardson, M. A. (1997). "Airway management in children with craniofacial anomalies". Cleft Palate-Craniofacial Journal 34 (2): 135-40. doi:.
- Sculerati N.; Gottlieb MD. Zimbler MS. Chibbaro PD. McCarthy JG. (1998 December). "Airway management in children with major craniofacial anomalies.". Laryngoscope 108 (12): 1806-12. doi:.
- Shepard, J. W.; Thawley, S. E. (1990). "Localization of upper airway collapse during sleep in patients with obstructive sleep apnea". American Review of Respiratory Disorders 141: 1350-55.
- Sher, A. (1990). Obstructive sleep apnea syndrome: a complex disorder of the upper airway. Otolaryngologic Clinics of North America, 24, 600.
- Shott S, Amin R, Chini B, Heubi C, Hotze S, Akers R (2006). "Obstructive sleep apnea: Should all children with Down syndrome be tested?". Arch Otolaryngol Head Neck Surg 132 (4): 432-6. doi:. PMID 16618913.
- Shouldice RB, O'Brien LM, O'Brien C, de Chazal P, Gozal D, Heneghan C (2004). "Detection of obstructive sleep apnea in pediatric subjects using surface lead electrocardiogram features". Sleep 27 (4): 784-92. PMID 15283015.
- Slovis B. & Brigham K. (2001). "Disordered Breathing", in ed Andreoli T. E.: Cecil Essentials of Medicine. Philadelphia: W.B. Saunders, pp210-211.
- Strollo P, Rogers R (1996). "Obstructive sleep apnea.". N Engl J Med 334 (2): 99-104. doi:. PMID 8531966.
- Sullivan C, Issa F, Berthon-Jones M, Eves L (1981). "Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares.". Lancet 1 (8225): 862-5. PMID 6112294.
[edit] External links
- American Sleep Apnea Association
- Sleep Apnea: Symptoms, Causes, Diagnosis, and Treatment
- Mayo Clinic Discovers New Type of Sleep Apnea, Mayo Clinic, September 1, 2006.
- National Heart, Lung, and Blood Institute: Your Guide To Healthy Sleep
- Merck: Sleep Apnea
- UK Sleep Apnoea Trust Association
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