Sleep Apnea Treatment

Sleep apnea historic evolution

The apnea-hypopnea syndrome is one of the most common sleep disorders with a high prevalence of between 2 and 4% of the adult population. Described by Broadbent in 1877, it went unnoticed as a clinical entity of interest until almost thirty years ago . The eighties are marked by the beginning of the formal investigation and a growing theoretical and experimental disease, which has led us to today, when it is considered as an entity of the first order to evoke clinical interest and to investigate the subject and to proliferate multidisciplinary discussion forums.

The term sleep apnea applied to the pathology at hand is relatively recent use in the clinical literature. This does not mean that it is the case of a new disease. This was rather not be reached until the second half of the twentieth century defining precisely a symptom, that is believed to have affected the human being forever. References to the set of symptoms, that today are described under the term "apnea" already appeared at the beginning of medical history, and from ancient treatises and studies it was found in descriptions of respiratory disorders, that occur during sleep. The clinical picture described in these cases was daytime sleepiness, apneas or pauses in breathing during sleep, and intense snoring, that is, from the perspective now, defined as apnea hypopnea syndrome (OSAHS). The disorder and its peculiar symptomatic have a broad overview of terminology and different diagnoses, until the present time that sleep apnea is defined as a clinical entity based on daytime hypersomnolence, pauses in breathing during sleep caused by obstruction of the upper airway and severe snoring. The polysymptomatic gist of the syndrome has greatly hindered the work of doctors to find a differential diagnosis. The efforts of recent years have been aimed at finding an accurate description of sleep apnea, that annotates their symptoms and thus ensure an accurate diagnosis .

There is historical evidence in medical records show, that William Howard Taft, President of the United States between 1909 and 1913, suffered from obstructive sleep apnea as evidenced by his words: "I lost that tendency to sleepiness, which made me think of the fat of Pickwick. I have better color and my ability to work is greater. "William Howard Taft June 28, 1909 (President of the United States, 1909-1913). His clinical picture described excessive daytime sleepiness, snoring, hypertension and a marked deterioration in cognitive and psychosocial cost almost more than a diplomatic upset by his inability to stay awake. The absolute ignorance about the disease and its extent, poor in this epoque, allowed the United States Congress officially never questioning his ability to govern.

Although there are indications of sleep disorders in the Bible, the Greek origins of the study of Apnea are reflected in its etymology, pnoia or "desire to sleep." At the beginning of Western medicine, Hippocrates, the Greek father of medicine (460-377 BC) states already in the fourth century BC, the relationship between obesity and sudden death and also refers to "breath" of certain types sleep (Hippocrates, of morbis, liber II, sect V). The notion, the shorter life of the "open-mouth snorer", was common in classical antiquity and in Aelian Varia history (170-235 BC) we found one of the first descriptions of a patient with a symptomatic picture of apnea and its treatment: "A Dionysius of Heraclea, King of Pontus, greedy, obese, with great difficulty of breathing, was awakened with needles to avoid choking."

In these early Greco Roman sources, the condition is mainly associated with obese patients with daytime sleepiness and fatigue. In these early examples of patient obesity is the common denominator, and sleep disorders and breathing are presented as side effects of excess weight. That is the case of the Roman writer Pliny Secundus Gaius (23-79 BC), known as Pliny the Elder, whose extreme obesity made him to fall asleep during the day, snore loudly during sleep, and to submit to a breath sometimes syncopated " as if his tracks were blocked. " A similar symptoms of morbid obesity, hypersomnolence and chronic snoring also affected, according the sources, Magas of Cyrene (276-250 BC) king of the Ptolemaic dynasty.

With the development of the study on the twentieth century, the interest rises by the possible presence in the historical record and literary references to this type of sleep disorders associated with breathing difficulties, and compared the symptoms of apnea with respiratory problems of the past and the literary canon. One of the characters, who most fit the symptoms of sleep apnea is Sir John Falstaff, the protagonist of several plays of Shakespeare ("Henry IV" and "The Merry Wives of Windsor"), who is described as obese, a snorer and drowsy. Falstaff, who"snores like a horse" and who hardly breath, drink heavily, he falls asleep at inopportune moments throughout the day to day and have to be awakened. While we will never know if Shakespeare had sleep apnea in mind, describing the character, Falsfaff has passed into history of apnea, giving the name to a type of snorer, the " Falstaff snorer," which describes a snore depth associated with obese patients. No doubt the literary reference with a diagnosis of sleep apnea is more unequivocal, than that provided in 1837 by Charles Dickens in his novel "The posthumous papers of the Pickwick Club." This text describes a character named Joe Young called “the fat", who Dickens portrayed as obese, sleepy and with serious difficulties in breathing, who tends to fall asleep in the doorway, and emits a rhythmic sound while snoring. While symptoms may fit the clinical picture of various sleep disorders, the description of Dickens became the prototype of the patient affected by sleep apnea. The term Pickwickian syndrome was established initially as a medical name for apnea.

These historical touches serve to illustrate the fact, that apnea is not new to medical science, although the terms and meanings are used today. It has even tried, with varying success, to diagnose "a posteriori" apnea syndrome to many historical figures, including Napoleon Bonaparte, the composer Johannes Brahms, or Queen Victoria herself. However, the only case in history in which with no doubt we can confirm a diagnosis of sleep apnea is that of William Howard Taft, President of the United States between 1909 and 1913. Medical records confirm, that he suffered from obstructive sleep apnea, and describe a clinical condition of obesity, excessive daytime sleepiness, snoring, hypertension and a marked deterioration in cognitive and psychosocial cost almost more than a diplomatic upset by their inability stay awake. Ignorance of the disease and its scope allowed the United States Congress officially never questioning his ability to govern. Studies also described how the sleepiness that he suffered improved dramatically once he lost weight after leaving the presidency, which reinforces the diagnosis of sleep apnea.

Beyond literary fiction, medical history of apnea is marked by a multitude of names. With the advancement in respiratory studies in the eighteenth century, began to emerge early medical references to breathing problems in sleep. One of the pioneers in the study of the airways was the German surgeon Lorenz Heister (1683-1758) to whom we owe the modern use of the tracheotomy, he published in 1753 the clinical picture and treatment protocol for a patient with symptoms of choking and short of breath while sleeping, for whom it is recommending a lengthening of the airways.

It is not until the early nineteenth century, however, when doctors and psychiatrists systematically investigate the possible link between obesity and excessive sleepiness in the search for the reason to explain the origin of the syndrome. In 1829 William Wadd (1776-1829) published "Comments on corpulence, Lineaments of leanness, Mems on Diet and Dietetics." In this treatise on obesity for the first time he includes an analysis of the relationship between obesity, breathing difficulties and drowsiness, symptoms, which all referred to a significant lower weight. Wadd definitively fails to establish a cause-effect, but laid the foundations for a knowledge of that years later would be diagnosed as sleep apnea.

In 1875, British the physician Richard Caton (1842-1926 Liverpool) wins a spot in the history of medicine through the discovery of the electrical nature of the brain. Through a galvanometer he recorded the electrical brain activity in animals and opened the way for his colleagues to discover and explore, years later, alpha and beta waves in the human brain. This discovery was crucial for discovering human brain function. The development in understanding the mechanisms of brain waves can finally be able to study human brain activity during sleep and transcribe these electrical impulses as it would in future polysomnographic recordings. Over time, the polysomnogram (PSG) would become the most valuable tool for studying the behavior of the brain during sleep. These are pioneering studies on brain electrical activity and the possibility of establishing the first measurements with objective data, which lays the groundwork for the journey of Sleep Medicine, a discipline based on this finding would channel their efforts finally unveiled mechanisms of sleep.

One of the earliest references to the apnea, already established as a specific syndrome, published in 1877 by W.H. Broadbent, a physician at St. Mary's of London. In an article published in "The Lacent" the symptoms were first mentioned, that today are diagnosed as sleep apnea. Detailing a rare medical case, he describes in a very exact way apnea as a sleep breathing disorder during which the patient is snoring, interspersed with periods when breathing ceases. The intervals, as Broadbent says, are getting longer over night. Broadbent was considering several theories attempting to explain this medical phenomenon, none of them were considered as a satisfactory solution. He did not diagnose and establish a specific disease, but the very precisely description fits the clinical picture, which subsequently affects OSAHS patients . Here is the description that accompanied the patients medical history:

“When a person, especially if he is advanced in years, is sleeping on his back in deepest sleep, and snoring loudly ,it occurs very often that a total silence for two, three or four breaths is produced, in which for breathing the chest doesn’t open finally the air enters with a loud snort, accompanied by a sharp snort, after which occurs several deep breaths to compensate the loss of air. After a while, breathing returns to normal rhythm. In the case that I mean, well described, there is the cessation of snoring at regular intervals and the respiratory pause stretched enough to attract attention, and sometimes becoming worrisome. ”.

In 1898, Walter A. Wells in a study published in The American Journal of Medical Sciences, finally linked sleep disorders with nasal airway obstruction, noting that patients in which the obstruction of the airways is reduced, decreased their level sleepiness significantly. Years later, Silas Weir Mitchell, a neurologist and American toxicologist, wrote in 1890 the first treaty about respiratory disorder produced during sleep, and cemented the foundations for what would be the beginning of a long effort to learn the pathogenesis of respiratory disorders occurring in humans during sleep.

The growing scientific literature of the period already begins to lay the foundations of symptomatic of sleep apnea, snoring, hypersomnia, obesity and hypoxemia overall symptom picture, but still undetected, the global aspect as pathology unit. There are plenty of studies, that accurately describe the breathing difficulties at night and excessive daytime sleepiness of patients, and we strongly convey the suffering of the subjects during the end of the century. While none of the doctors and researchers came to this range of symptoms associated with a single disease and a single disorder, each of them contributes its bit from very different disciplines.

It will not be until the twentieth century, when they finally come to unveil the mysteries of a so elusive disease. In the early twentieth century apnea was still not a clinical entity recognized as such. Although there were reports of patients with obesity and hypersomnolence, it was the canadian physician William Osler (1849-1919), who unequivocally associated with snoring, excessive sleepiness and obesity for the first time defining these patients as "pickwician" in a nod to Dickens literature characters. Osler noted that there was an association between obesity and hypersomnolence and described obesity-hypoventilation syndrome in 1918. Although this approach that relates the diseases of apnea with overweight people has been maintained to date (and is perhaps the most repeated profile in patients with airway obstruction) apnea can be caused by other reasons and factors, that are far more complex that were missed in this first phase of the clinical literature. Not until 1956 when the apnea is defined under the term "Pickwickian syndrome" in a medical journal.

In an article in the American Journal of Medicine, Sidney Burwell, a cardiologist and professor of medicine at Harvard Medical School, coined the term "Pickwickian syndrome" based on Charles Dickens' literary reference to Joe in the Pickwick Club. In the article, Burwell thus offers the first description of a patient with OSAHS. In collaboration with his team, he assigned the term to patients with complex clinical symptoms of obesity, somnolence, alveolar hypoventilation and periodic breathing disorders, as described by Dickens in his book: "Fat Joe had a deep sleep, he fell asleep standing, while knocking at the door. " Joe, this sleepy youngster born from the imagination of Charles Dickens, came to immortalize the posthumous papers of the Pickwick Club for medical history. Although after the sleep apnea has been often called Pickwickian syndrome, this term is now reserved only for patients with obesity and hypoventilation..

In the mid-'50s, studies grouped and linked under the same umbrella the basic keystone symptomatics of apnea: snoring, hypersomnia (excessive sleepiness day and night), obesity, hypoxemia (low oxygen partial pressure in blood), hypercapnia (excessive concentration of carbon dioxide in the blood) and in more serious cases, cardiac arrest. We are one step away so we can talk about sleep apnea in contemporary clinical sense. It is during these years that investigations arouse interest in the field of sleep medicine, a discipline to explore and thanks to the countless possibilities that opens the neurological research. Sleep medicine as a discipline off on the 50's, what ultimately contributes to progress in the pioneering study of sleep apnea. A decade later, in 1965 Henri Gastaut, provides the definitive approach. After attending the presentation of the results achieved by the German Wolfgang Kuhl and his colleague Richard Jung at the annual conference of the European Society of Neurology in 1964, Gastaut established a research group at the Neurological Institute of Marseille, and his studies in these years are the one, that allow to include the Pickwick syndrome in sleep disorders. This is accomplished in large part to use for the first time in the field of sleep disorders, polysomnographic studies, that are still currently one of the instruments and basic tools for the diagnosis and the best weapon we have for physicians to study these disorders.

Sleep medicine as a discipline take off from the 50's what ultimately contributes to progress in the pioneering study of sleep apnea. A decade later, in 1965, Henri Gastaut provides the definitive approach. After attending the presentation of the results achieved by the German Wolfgang Kuhl and his colleague Richard Jung at the annual conference of the European Society of Neurology in 1964, Gastaut established a research group at the Neurological Institute of Marseille, and their studies in these years allowed to include the Pickwick syndrome in sleep disorders. This is accomplished, owed in large part to the use, for the first time in the field of sleep disorders, of polysomnographic studies that are still currently one of the instruments and basic tools for the diagnosis and the which are the best weapon we have for physicians the study of these disorders.

In this decade, many investigations continue to explore the broad spectrum of clinical conditions presenting obstructive sleep apnea and expanding the field of knowledge of the discipline. One of the principal architects of this development is the Italian Elio Lugaresi, a neurologist expert in sleep disorders, who had completed his initial studies with Dr. Gastaut. Elio Lugaresi is the recognized pioneer and revolutionary in sleep medicine in the seventies and his work is a reference in sleep medicine. The contribution of Lugaresi is invaluable in the study and understanding of the pathophysiology and consequences of sleep disorders. This work was officially recognized by the medical community, being awarded with the prestigious Prix Interbrew-Baillet Latour de La Sante in 2004 in the form of sleep disturbance for their contribution to the field of sleep medicine. Thanks to Lugaresi disorders are normalized such as insomnia, chronic snoring, obstructive sleep apnea, restless leg syndrome or fatal familial insomnia

In the same decade, studies carried out by Christian Guilleminault and William C. Dement at Stanford University (USA), in patients with non obesity relation but with nocturnal hypertension generalize the use of AHI (index of apnea / hypopnea) to diagnose sleep apnea and measure their severity, whose use is still valid today. The Stanford group studies end up validating the term sleep apnea syndrome in its final designation covering patients with a multiple symptomatology including obesity, hypersomnia and respiratory changes during sleep. Guilleminault and colleagues were the first to do clinical studies involving observation of sleep, and post specific patient cases. Thanks to his work the syndrome of resistance of the upper airway (SRUA) is identified, a intermediate condition between simple snoring and obstructive sleep apnea syndrome. Thanks to scientific work on both sides of the ocean, sleep apnea syndrome is a clinical entity for now long.

In 1972, before the advance in the number of publications, in Italy the first symposium on respiratory disease related to sleep was organized, held in the city of Rimini. This is the first scientific forum in which the study arises from what we now call sleep apnea hipopnea syndrome, and it presents new treatment modalities. Until now the only alternative therapy offered to patients with sleep apnea was the solution in the form of surgical tracheostomy. While this treatment could reduce symptoms in a large number of patients involved invasive surgery, some of them assumed this treatment with suspicion. However, during the next decade, to the patients were not offered alternative therapeutic steps than the surgical way.

In 1981, the Australian physician Colin Sullivan gives a qualitative leap in improving the quality of life for OSA patients. It is the architect of the development and incorporation of the CPAP machine (Continuous Positive Airway Pressure), a mechanism that facilitates continuous pressure breathing during sleep to patients and opens new hopes in the investigation. Sullivan published in the medical journal "The Lacet" their experience with five patients with severe OSAHS treated with CPAP with highly satisfactory results. In the nineties we took part in the appereance of the emergence of mandibular advancement devices and its proven effectiveness, and with them appears a qualitative revolution in the treatment of apnea for their effectiveness, tolerability and ease of use, they impact positively on the acceptance of patients over other therapeutic alternatives. From here on it opens the way to highly effective treatments as valid alternatives to more aggressive surgery. While CPAP machines improve in design during the eighties by reducing its size and level of noise, remain an uncomfortable treatment and due to negative psychological consequences for patients. For years CPAP remains the only available option for treating sleep apnea.