Made by DATEXIS (Data Science and Text-based Information Systems) at Beuth University of Applied Sciences Berlin
Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
Many studies indicate the effect of a "fight or flight" response on the body that happens with each apneic event is what increases health risks and consequences in OSA. The fight or flight response causes many hormonal changes in the body; those changes, coupled with the low oxygen saturation level of the blood, cause damage to the body over time.
Without treatment, the sleep deprivation and lack of oxygen caused by sleep apnea increases health risks such as cardiovascular disease, aortic disease (e.g. aortic aneurysm), high blood pressure, stroke, diabetes, clinical depression, weight gain and obesity.
The most serious consequence of untreated OSA is to the heart. Persons with sleep apnea have a 30% higher risk of heart attack or death than those unaffected. In severe and prolonged cases, increased in pulmonary pressures are transmitted to the right side of the heart. This can result in a severe form of congestive heart failure known as "cor pulmonale". Dyastolic function of the heart also becomes affected. One prospective study showed patients with OSA, compared with healthy controls, initially had statistically significant increases in vascular endothelial growth factor (P=.003) and significantly lower levels of nitrite-nitrate (P=.008), which might be pathogenic factors in the cardiovascular complications of OSA. These factors reversed to normal levels after 12 weeks of treatment by CPAP, but further long-term trials are needed to assess the impact of this therapy.
Elevated arterial pressure (i.e., hypertension) can be a consequence of OSA syndrome. When hypertension is caused by OSA, it is distinctive in that, unlike most cases (so-called essential hypertension), the readings do "not" drop significantly when the individual is sleeping (non-dipper) or even increase (inverted dipper).
OSA accompanied by daytime sleepiness is estimated to affect 3% to 7% of men and 2% to 5% of women, and the disease is common in both developed and developing countries. It is most commonly diagnosed in middle-aged males.
If studied carefully in a sleep lab by polysomnography (formal "sleep study"), it is believed that approximately 1 in 5 American adults would have at least mild OSA.
Sleep apnea can affect people regardless of sex, race, or age. However, risk factors include:
- being male
- excessive weight
- an age above 40
- large neck size (greater than 16–17 inches)
- enlarged tonsils or tongue
- small jaw bone
- gastroesophageal reflux
- allergies
- sinus problems
- a family history of sleep apnea
- deviated septum
Alcohol, sedatives and tranquilizers may also promote sleep apnea by relaxing throat muscles. Smokers have sleep apnea at three times the rate of people who have never smoked.
Central sleep apnea is more often associated with any of the following risk factors:
- being male
- an age above 65
- having heart disorders such as atrial fibrillation or atrial septal defects such as PFO
- stroke
High blood pressure is very common in people with sleep apnea.
Statistics on snoring are often contradictory, but at least 30% of adults and perhaps as many as 50% of people in some demographics snore. One survey of 5,713 American residents identified habitual snoring in 24% of men and 13.8% of women, rising to 60% of men and 40% of women aged 60 to 65 years; this suggests an increased susceptibility to snoring with age.
Among the causes of hypopnea are:
- anatomical defects such as nasal septum deformation or congenital narrowness of nasal meatus and the gullet
- acute tonsillitis and/or adenoiditis
- obesity or being overweight
- neuromuscular disease or any condition that entails weakened respiratory muscles
- hypoventilation syndromes involving compromised or failed respiratory drive
- use of sedatives e.g. sleeping pills
- alcohol abuse
- smoking
- aging
- others, most of which are also typical causes of airway obstruction, snoring and sleep apnea
The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans was affected by at least moderate sleep apnea. It also estimated that in middle-age as many as nine percent of women and 24 percent of men were affected, undiagnosed and untreated.
The costs of untreated sleep apnea reach further than just health issues. It is estimated that in the U.S. the average untreated sleep apnea patient's annual health care costs $1,336 more than an individual without sleep apnea. This may cause $3.4 billion/year in additional medical costs. Whether medical cost savings occur with treatment of sleep apnea remains to be determined.
In layman's terms, snoring is the result of the relaxation of the uvula and soft palate. These tissues can relax enough to partially block the airway, resulting in irregular airflow and vibrations. Snoring can be attributed to one or more of the following:
- Throat weakness, causing the throat to close during sleep.
- Mispositioned jaw, often caused by tension in the muscles.
- Obesity that has caused fat to gather in and around the throat.
- Obstruction in the nasal passageway.
- Obstructive sleep apnea.
- Sleep deprivation.
- Relaxants such as alcohol or other drugs relaxing throat muscles.
- Sleeping on one's back, which may result in the tongue dropping to the back of the mouth.
Upper airway resistance syndrome or UARS is a common sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The primary symptoms include excessive fatigue and chronic insomnia. UARS can be diagnosed by polysomnography, and can be treated with lifestyle changes, dental devices, or CPAP therapy. UARS is similar to certain types of sleep apneas.
Hypopnea is a disorder that may result in excessive daytime sleepiness and compromised quality of life, including traffic accidents, diminished productivity in the workplace, and emotional problems.
Cardiovascular consequences of hypopnea may include myocardial infarction, stroke, psychiatric problems, impotence, cognitive dysfunction, hypertension, coronary heart disease, and memory loss.
Upper airway resistance syndrome is caused when the upper airway narrows without closing. Consequently, airflow is either reduced or compensated for through an increase in inspiratory efforts. This increased activity in inspiratory muscles leads to the arousals during sleep which patients may or may not be aware of.
A typical UARS patient is not obese and possesses a triangular face and misaligned jaw, which can result in a smaller amount of space behind the base of the tongue. Patients may have other anatomical abnormalities that can cause UARS such as deviated septum or nasal valve collapse. UARS affects equal numbers of males and females. It is unclear as to whether UARS is merely a phase that occurs between simple snoring and sleep apneas, or whether UARS is a syndrome that describes a deviation from normal upper airway physiology.
Children with UARS may experience symptoms due to minor anomalies of the facial bones or due to enlarged tonsils or adenoids.
Although "there has been no cure of chronic hypersomnia", there are several treatments that may improve patients' quality of life, depending on the specific cause or causes of hypersomnia that are diagnosed.
The following increase an individual's chances for acquiring VCD:
- Upper airway inflammation (allergic or non-allergic rhinitis, chronic sinusitis, recurrent upper respiratory infections)
- Gastroesophageal reflux disease
- Past traumatic event that involved breathing (e.g. near-drowning, suffocation)
- Severe emotional trauma or distress
- Female gender
- Playing a wind instrument
- Playing a competitive or elite sport
The exact cause of VCD is not known, and it is unlikely that a single underlying cause exists. Several contributing factors have been identified, which vary widely among VCD patients with different medical histories. Physical exercise (including, but not limited to, competitive athletics) is one of the major triggers for VCD episodes, leading to its frequent misdiagnosis as exercise-induced asthma. Other triggers include airborne pollutants and irritants such as smoke, dust, gases, soldering fumes, cleaning chemicals such as ammonia, perfumes, and other odours. Gastroesophageal reflux disease (GERD) and rhinosinusitis (inflammation of the paranasal sinuses and nasal cavity) may also play a role in inflaming the airway and leading to symptoms of VCD as discussed below.
Laryngeal hyperresponsiveness is considered the most likely physiologic cause of VCD, brought on by a range of different triggers that cause inflammation and/or irritation of the larynx (voice box). The glottic closure reflex (or laryngeal adductor reflex) serves to protect the airway, and it is possible that this reflex becomes hyperactive in some individuals, resulting in the paradoxical vocal fold closure seen in VCD. Two major causes of laryngeal inflammation and hyperresponsiveness are gastroesophageal reflux disease (GERD) and postnasal drip (associated with rhinosinusitis, allergic or nonallergic rhinitis, or a viral upper respiratory tract infection (URI)). Rhinosinusitis is very common among patients with VCD and for many patients, VCD symptoms are ameliorated when the rhinosinusitis is treated. GERD is also common among VCD patients, but only some experience an improvement in VCD symptoms when GERD is treated. Other causes of laryngeal hyperresponsiveness include inhalation of toxins and irritants, cold and dry air, episodic croup and laryngopharyngeal reflux (LPR).
VCD has long been strongly associated with a variety of psychological or psychogenic factors, including conversion disorder, major depression, obsessive-compulsive disorder, anxiety (especially in adolescents), stress (particularly stress relating to competitive sports), physical and sexual abuse, post-traumatic stress disorder, panic attacks, factitious disorder and adjustment disorder. It is important to note that anxiety and depression may occur in certain patients as a "result" of having VCD, rather than being the cause of it. Psychological factors are important precipitating factors for many patients with VCD; although exercise is also a major trigger for episodes of VCD, some patients experience VCD co-occurring with anxiety regardless of whether or not they are physically active at the time of the VCD/anxiety episode. Experiencing or witnessing a traumatic event related to breathing (such as a near-drowning or life-threatening asthma attack, for example), has also been identified as a risk factor for VCD.
VCD has also been associated with certain neurologic diseases including Arnold-Chiari malformation, cerebral aqueduct stenosis, cortical or upper motor neuron injury (such as that resulting from stroke), amyotrophic lateral sclerosis (ALS), parkinsonism syndromes and other movement disorders. However, this association occurs only rarely.
Secondary hypersomnias are extremely numerous.
Hypersomnia can be secondary to disorders such as clinical depression, multiple sclerosis, encephalitis, epilepsy, or obesity. Hypersomnia can also be a symptom of other sleep disorders, like sleep apnea. It may occur as an adverse effect of taking certain medications, of withdrawal from some medications, or of drug or alcohol abuse. A genetic predisposition may also be a factor. In some cases it results from a physical problem, such as a tumor, head trauma, or dysfunction of the autonomic or central nervous system.
Sleep apnea is the most frequent cause of secondary hypersomnia, affecting up to 4% of middle-aged adults, mostly men. Upper airway resistance syndrome (UARS) is a clinical variant of sleep apnea that can also cause hypersomnia. Just as other sleep disorders (like narcolepsy) can coexist with sleep apnea, the same is true for UARS. There are many cases of UARS in which EDS persists after CPAP treatment, indicating an additional cause, or causes, of the hypersomnia and requiring further evaluation.
Sleep movement disorders, such as restless legs syndrome (RLS) and periodic limb movement disorder (PLMD or PLMS) can also cause secondary hypersomnia. Although RLS does commonly cause EDS, PLMS does not. There is no evidence that PLMS plays "a role in the etiology of daytime sleepiness. In fact, two studies showed no correlation between PLMS and objective measures of EDS. In addition, EDS in these patients is best treated with psychostimulants and not with dopaminergic agents known to suppress PLMS."
Neuromuscular diseases and spinal cord diseases often lead to sleep disturbances due to respiratory dysfunction causing sleep apnea, and they may also cause insomnia related to pain. "Other sleep alterations, such as periodic limb movement disorders in patients with spinal cord disease, have also been uncovered with the widespread use of polysomnography."
Primary hypersomnia in diabetes, hepatic encephalopathy, and acromegaly is rarely reported, but these medical conditions may also be associated with the secondary hypersomnias sleep apnea and periodic limb movement disorder (PLMD).
Chronic fatigue syndrome and fibromyalgia can also be associated with hypersomnia. Regarding chronic fatigue syndrome, it is "characterized by persistent or relapsing fatigue that does not resolve with sleep or rest. Polysomnography shows reduced sleep efficiency and may include alpha intrusion into sleep EEG. It is likely that a number of cases labeled as chronic fatigue syndrome are unrecognized cases of upper airway resistance syndrome" or other sleep disorders, such as narcolepsy, sleep apnea, PLMD, etc.
Similarly to chronic fatigue syndrome, fibromyalgia also may be associated with anomalous alpha wave activity (typically associated with arousal states) during NREM sleep. Also, researchers have shown that disrupting stage IV sleep consistently in young, healthy subjects causes a significant increase in muscle tenderness similar to that experienced in "neurasthenic musculoskeletal pain syndrome". This pain resolved when the subjects were able to resume their normal sleep patterns.
Chronic kidney disease is commonly associated with sleep symptoms and excessive daytime sleepiness. For those on dialysis, approximately 80% have sleep disturbances. Sleep apnea can occur 10 times as often in uremic patients than in the general population and can affect up to 30-80% of patients on dialysis, though nighttime dialysis can improve this. About 50% of dialysis patients have hypersomnia, as severe kidney disease can cause uremic encephalopathy, increased sleep-inducing cytokines, and impaired sleep efficiency. About 70% of dialysis patients are affected by insomnia, and RLS and PLMD affect 30%, though these may improve after dialysis or kidney transplant.
Most forms of cancer and their therapies can cause fatigue and disturbed sleep, affecting 25-99% of patients and often lasting for years after treatment completion. "Insomnia is common and a predictor of fatigue in cancer patients, and polysomnography demonstrates reduced sleep efficiency, prolonged initial sleep latency, and increased wake time during the night." Paraneoplastic syndromes can also cause insomnia, hypersomnia, and parasomnias.
Autoimmune diseases, especially lupus and rheumatoid arthritis are often associated with hypersomnia, as well. Morvan's syndrome is an example of a more rare autoimmune illness that can also lead to hypersomnia. Celiac disease is another autoimmune disease associated with poor sleep quality (which may lead to hypersomnia), "not only at diagnosis but also during treatment with a gluten-free diet." There are also some case reports of central hypersomnia in celiac disease. And RLS "has been shown to be frequent in celiac disease," presumably due to its associated iron deficiency.
Hypothyroidism and iron deficiency with or without (iron-deficiency anemia) can also cause secondary hypersomnia. Various tests for these disorders are done so they can be treated. Hypersomnia can also develop within months after viral infections such as Whipple's disease, mononucleosis, HIV, and Guillain–Barré syndrome.
Behaviorally induced insufficient sleep syndrome must also be considered in the differential diagnosis of secondary hypersomnia. This disorder occurs in individuals who fail to get sufficient sleep for at least three months. In this case, the patient has chronic sleep deprivation although he or she is not necessarily aware of it. This situation is becoming more prevalent in western society due to the modern demands and expectations placed upon the individual.
Many medications can also lead to secondary hypersomnia. Therefore, a patient's complete medication list should be carefully reviewed for sleepiness or fatigue as side effects. In these cases, careful withdrawal from the possibly offending medication(s) is needed; then, medication substitution can be undertaken.
Mood disorders, like depression, anxiety disorder and bipolar disorder, can also be associated with hypersomnia. The complaint of EDS in these conditions is often associated with poor sleep at night. "In that sense, insomnia and EDS are frequently associated, especially in cases of depression." Hypersomnia in mood disorders seems to be primarily related to "lack of interest and decreased energy inherent in the depressed condition rather than an increase in sleep or REM sleep propensity". In all cases with these mood disorders, the MSLT is normal (not too short and no SOREMPs).
Although this is a congenital lesion, airway sounds typically begin at age 4–6 weeks. Until that age, inspiratory flow rates may not be high enough to generate the sounds. Symptoms typically peak at age 6–8 months and remit by age 2 years.
Late-onset laryngomalacia may be a distinct entity, which can present after age of 2 years
Choking is caused by an object from outside the body, also called a foreign body, blocking the airway. The object can block the upper or lower airway passages. The airway obstruction is usually partial but can also be complete.
Among children, the most common causes of choking are food, coins, toys, and balloons. In one study, peanuts were the most common object found in the airway of children evaluated for suspected foreign body aspiration. Foods that pose a high risk of choking include hot dogs, hard candy, nuts, seeds, whole grapes, raw carrots, apples, popcorn, peanut butter, marshmallows, chewing gum, and sausages. The most common cause of choking death in children is latex balloons. Small, round non-food objects such as balls, marbles, toys, and toy parts are also associated with a high risk of choking death because of their potential to completely block a child's airway.
Children younger than age three are especially at risk of choking because they explore the environment by putting objects in their mouth. Also, young children are still developing the ability to chew food completely. Molar teeth, which come in around 1.5 years of age, are necessary for grinding food. Even after molar teeth are present, children continue developing the ability to chew food completely and swallow throughout early childhood. In addition, a child's airway is smaller in diameter than an adult's airway, which means that smaller objects can cause an airway obstruction in children. Infants and young children generate a less forceful cough than adults, so coughing may not be as effective in relieving an airway obstruction. Finally, children with neuromuscular disorders, developmental delay, traumatic brain injury, and other conditions that affect swallowing are at an increased risk of choking.
In adults, choking often involves food blocking the airway. Risk factors include using alcohol or sedatives, undergoing a procedure involving the oral cavity or pharynx, wearing oral appliances, or having a medical condition that causes difficulty swallowing or impairs the cough reflex. Conditions that can cause difficulty swallowing and/or impaired coughing include neurologic conditions such as strokes, Alzheimer disease, or Parkinson disease. In older adults, risk factors also include living alone, wearing dentures, and having difficulty swallowing.
Children and adults with neurologic, cognitive, or psychiatric disorders may experience a delay in diagnosis because there may not be a known history of a foreign body entering the airway.
PND is suggested to be a cause of extra-oral halitosis, especially when a sinus infection is also present. Acid reflux or heartburn is believed to aggravate and in some cases cause post-nasal drip. Post-nasal drip can be a cause of laryngeal inflammation and hyperresponsiveness, leading to symptoms of vocal cord dysfunction (VCD).
First-generation antihistamine has been suggested as first-line therapy to treat post-nasal drip.
Choking is the fourth most common cause of unintentional injury-related death in the US. Many episodes are not reported because they are brief and resolve without seeking medical attention. Among reported events, the majority of episodes (80%) occur among children younger than age 15, with fewer episodes (20%) among age 15 and older. The death rate from choking is low at most ages but increases starting around age 74. Choking due to a foreign object resulted in 162,000 deaths (2.5 per 100,000) in 2013, compared to 140,000 deaths (2.9 per 100,000) in 1990.
Although laryngomalacia is not associated with a specific gene, there is evidence that some cases may be inherited. Relaxation or a lack of muscle tone in the upper airway may be a factor. It is often worse when the infant is on his or her back, because the floppy tissues can fall over the airway opening more easily in this position.
The risk may be reduced by administering a non-particulate antacid (e.g. Sodium Citrate) or an H-antagonist like Ranitidine.
Transient tachypnea of the newborn occurs in approximately 1 in 100 preterm infants and 3.6-5.7 per 1000 term infants. It is most common in infants born by Cesarian section without a trial of labor after 35 weeks' gestation. Male infants and infants with an umbilical cord prolapse or perinatal asphyxia are at higher risk. Parental risk factors include use of pain control or anesthesia during labor, asthma, and diabetes.
Airway obstruction is a blockage of respiration in the airway. It can be broadly classified into being either in the upper airway or lower airway.
Very few risk factors for choanal atresia have been identified. While causes are unknown, both genetic and environmental triggers are suspected. One study suggests that chemicals that act as endocrine disrupters may put an unborn infant at risk. A 2012 epidemiological study looked at atrazine, a commonly used herbicide in the U.S., and found that women who lived in counties in Texas with the highest levels of this chemical being used to treat agricultural crops were 80 times more likely to give birth to infants with choanal atresia or stenosis compared to women who lived in the counties with the lowest levels. Another epidemiological report in 2010 found even higher associations between increased incidents of choanal atresia and exposure to second-hand-smoke, coffee consumption, high maternal zinc and B-12 intake and exposure to anti-infective urinary tract medications.
Airway obstruction may cause obstructive pneumonitis or post-obstructive pneumonitis.