Misconceptions about Sleep Apnea and Weight: What makes you more at risk for Sleep Apnea?
There are quite a few misconceptions when it comes to the link between Weight and Sleep Apnea. Through my experience over the years, I quickly came to realize that people generally thought if you were overweight, you were more likely to either have or develop Sleep Apnea. I would have patients coming in with the preconceived notion that there’s no way they have Sleep Apnea because they are very thin, or would say their physician said they are not a typical candidate for Sleep Apnea. This was always interesting to me. The most common things that we should look at is anatomy and common risk factors, not just weight alone. In this article, I will discuss the misconceptions of weight in relation to Sleep apnea, as well as discuss the main things we look for when assisting physicians in the screening process for Sleep Apnea.
Yes, it is possible that if you are overweight your chances of having sleep apnea increases, but the reasoning is what is important. One of the reasons for this is let’s say you have a larger neck, there is likely going to be more tissue within your neck. When you’re in a very deep sleep, your body takes over your breathing, and you are in an unconscious state. The tissues and muscles within your neck relax and it actually does not take much before your airway can become obstructed due to the excess tissue. This however would also apply to someone that is very muscular in the neck area, or someone that is not overweight but they have a larger neck. Someone with a neck circumference of 17 inches or larger would have a higher risk of testing positive for sleep apnea. I have tested patients that were considered underweight or average, and they ended up presenting with severe sleep apnea. When the neck is very small, this could also be an issue. Yes, there may be less tissue, but there is also less space for the airway, so again when you’re relaxed in a deep sleep, it would be easy for the airway to obstruct. I have also tested patient’s over 300 pounds that did not have sleep apnea, or had very mild sleep apnea. So, it is not always determined by weight.
When talking about Anatomy, we also should look at the passing along of genetics. If your parents or grand-parents had Sleep apnea, the higher the chances that you could have sleep apnea as well. For example, if one of your parents had a recessed chin, or a higher Mallampati score, this could also transfer over to their children. Because sleep apnea is much more studied, and treatment is more readily available now. It is very important to get screened for sleep apnea if you have any of the typical signs & symptoms.
One of the most useful tools used to determine the risk of sleep apnea is not weight related at all, and it is called the Mallampati. The Mallampati can be used to help physicians determine if your oral cavity may be causing you to be more at risk for sleep apnea. This is a test that a health care professional can check just by looking at the back of your throat when you open your mouth very wide, and stick your tongue out as far as you can. There are 4 different classes of the Mallampati:
Class 2: Complete visualization of the Uvula.
Class 3: Visualization of the base of the Uvula only.
Class 4: The soft palate and Uvula is not visible at all.
The higher the Class, the higher your risk of sleep apnea. When you have a Class 3 or 4 Mallampati, the chances of your upper airway obstructing increases by quite a bit. When you are sleeping on your back especially, what may happen is your tongue also relaxes to the point where it can fall to the back of your throat and cause an obstruction. Class 4 patients usually snore. Snoring is actually an indication that air is still passing through the airway. I’m not saying snoring is a good thing as it can be disruptive to not only your sleep, but your partner’s as well. Snoring is when there is only a partial obstruction. Even with partial obstructions which we call Hypopnea, it can still lower your oxygen levels and cause stress to your heart depending on how often and how long they occur in the night.
A deviated septum is another example of upper airway obstruction. If you have a deviated septum, you may have issues breathing in your nose through one nostril, or when you lay down you can’t breathe through your nose at all. The reason why this could be an issue is because you’re not only dealing with the possibility that your tongue could fall back or the tissues in your neck could relax and block your airway, but also not being able to breathe properly through your nose as well. So now you have multiple points of concern. Some people are born with a deviated septum, and others may have had some physical trauma which caused the deviation. A Deviated septum would generally be repairable through surgery depending on the deviation. A general practitioner should be able to look up your nose to see if this may be an area of concern for you. You would then need to be referred to an Ear Nose Throat specialist would help determine if surgery would be an option to repair/reconstruct your nose to help improve your breathing.
In some cases, an Ear Nose Throat specialist may remove a patient’s Adenoids, Tonsils, Uvula, or even extensive Jaw surgery to help open the airway. This is not always effective because unfortunately some tissues do grow back. I am referring to any scar tissue or adenoids specifically, your tonsils will not grow back. My step father is an example of someone who had their Adenoids, Tonsils, and Uvula removed, which was a toll in itself. Having these tissues removed as an adult, the healing process was a bit longer than a child that would have had their tonsils removed. Even after the surgery, he still is required to use a CPAP machine. Because his oral space is quite small, and his Mallampati is 4, what ends up happening is he instantly obstructs as he’s falling asleep. He also has a larger neck which does not help the situation either. If a patient is recommended CPAP or BIPAP therapy, or surgery as an option for treatment of sleep apnea, I would always recommend trying the devices first. The surgery is invasive, and the healing process can be very uncomfortable. The success rate is also not very high.
Age and Sex is also quite important when we are talking about sleep apnea. Men are twice as likely to have sleep apnea than women. There are many different factors that are reviewed in studies when comparing men to women. Some of these factors include weight, hormones, breathing pattern, aging, and upper airway anatomy. Some women have no symptoms or risk factors when younger in life, but may still develop Sleep apnea when they are older, especially in the menopausal period. Progesterone & Oestrogen both can enhance the female’s ability to counteract with the upper airway collapsing during sleep. Progesterone helps prevent disturbances in sleep, which could increase more regular breathing at night. Once we age and these hormone levels decrease, the chances of obstructions and hypopneas occurring may increase. This is why it’s important to get screened for sleep apnea as an older woman if you have any new symptoms that develop later in life.
With Age, as you get older your skin, tissues, muscles, etc just don’t have the tone and elasticity they do when we are younger. Things start to relax more, and skin starts to sag, and the same happens to our tissues inside our bodies. Some people would be more likely to develop Sleep apnea later in life for this reason. It could be they were a class 2 or 3 Mallampati, or simply the tissues in the neck not holding the same elasticity as before. The body changes as we age, so it’s important we monitor any new symptoms that develop, as sleep apnea can affect your life negatively in many ways. It can also lead to many other health issues if left untreated.
Co-morbidities can also be a major indicator for sleep apnea. If you are diagnosed with any condition that weakens the connective tissues/muscles, conditions that also weaken your heart or ability to breathe normally could make you more likely to be more at risk as well. Some of the most serious co-morbidities for sleep apnea are stroke, heart disease, and diabetes. Cardiovascular, Cerebrovascular, and Respiratory comorbidities are very important for doctors to determine risk factors for sleep apnea. Atrial Fibrillation, atrial flutter, excessive irritability, depression, and high blood pressure can often be related to sleep apnea, so it is important to follow up with your physician to get screened for sleep apnea to at least rule in/rule out diagnosis.
As you can see, there are many different things we can look at when screening for Sleep Apnea, and weight is definitely not the end all be all when it comes to a physicians screening process. Screening for sleep apnea is of course very important, but the testing is where you see the actual results. Sleep apnea testing can consist of an at home sleep study that you complete in the comfort of your own home, or a Polysomnography; an overnight sleep study usually completed at the hospital or a private clinic. The PSG (polysomnography) can be used to help physicians diagnose a multitude of sleep disorders, not only Sleep apnea. I hope this article has given you some insight on the misconceptions of weight in relation to the screening process for sleep apnea, as well as the many risk factors related that should not be ignored.
by Anh LPN, Licensed Practical Nurse
Email: [email protected]