Mixed Sleep Apnea Treatment
in Sacramento, CA

Understanding Mixed Sleep Apnea: A Complex Sleep Disorder

Do you find yourself experiencing both breathing pauses and airway blockages during sleep? You might be dealing with mixed sleep apnea (MSA), a complex sleep disorder that combines elements of both central sleep apnea and obstructive sleep apnea. This challenging condition requires specialized care to address its unique characteristics and ensure effective treatment.

At Sac Sleep & Breathing, Sacramento, CA, sleep specialist Dr. Scott Grivas provides care for patients with mixed sleep apnea, helping them achieve better sleep quality and overall health. Learn more about this complex form of sleep apnea below, or call our Sacramento practice at (916) 735-4060.

What Is Mixed Sleep Apnea?

Mixed sleep apnea, also known as complex sleep apnea, is a sleep disorder that occurs when a patient experiences both obstructive sleep apnea (OSA) and central sleep apnea (CSA) events during sleep. This combination creates a particularly challenging condition where patients may experience physical airway blockages, as well as periods where the brain fails to signal proper breathing. Studies show that approximately 15 percent of sleep apnea patients have this complex condition, making it more common than pure central sleep apnea but less common than obstructive sleep apnea alone.

Signs of Mixed Sleep Apnea

Some signs of mixed sleep apnea may include:

• Loud snoring followed by sudden quiet periods
• Gasping or choking episodes during sleep
• Frequent nighttime awakenings
• Morning headaches and dry mouth
• Excessive daytime sleepiness
• Difficulty maintaining concentration
• Mood changes and irritability
• Waking up feeling unrefreshed despite adequate sleep time

Understanding the Complexity of Mixed Sleep Apnea

Mixed sleep apnea can present in two primary ways:

Initial Mixed Sleep Apnea

Some patients naturally experience both central and obstructive events from the onset of their condition. These cases often require carefully coordinated treatment approaches to address both breathing disruptions.

Treatment-Emergent Mixed Sleep Apnea

Also known as complex sleep apnea syndrome, this form occurs when a patient initially diagnosed with obstructive sleep apnea develops central sleep apnea events during CPAP treatment. This emergence of central events can complicate the treatment process and may require adjustments to therapy.

Risk Factors for Mixed Sleep Apnea

Several factors can increase your risk of developing mixed sleep apnea:

• Heart conditions, particularly congestive heart failure
• Previous stroke or brain injury
• Use of certain medications, especially opioids
• Chronic kidney disease
• Age (more common in older adults)
• Obesity
• Family history of sleep apnea
• High-altitude residence or travel
• Male gender

Complications of Untreated Mixed Sleep Apnea

Cardiovascular Impact

• Increased risk of heart disease and heart failure
• Higher likelihood of irregular heartbeats
• Elevated blood pressure
• Greater risk of stroke
• Potential for pulmonary hypertension

Cognitive and Daily Function

• Impaired memory and concentration
• Increased risk of workplace accidents
• Higher likelihood of motor vehicle accidents
• Decreased work performance
• Poor decision-making ability

Quality of Life Effects

• Chronic fatigue
• Depression and anxiety
• Strained relationships due to sleep disruption
• Reduced overall life satisfaction
• Increased healthcare utilization

Complex Sleep Apnea Diagnosis Process

Initial Consultation

The process typically begins with a thorough consultation with a sleep specialist. During this appointment, the doctor reviews the patient’s complete medical history, including any existing health conditions, medications, and family history of sleep disorders. A detailed discussion of sleep patterns, habits, and symptoms takes place, which may include questions about snoring, gasping for air during sleep, daytime sleepiness, and morning headaches. The physician may also ask the patient to complete standardized questionnaires, such as the Epworth Sleepiness Scale, to assess the severity of daytime sleepiness.

Physical Examination

Following the initial consultation, a comprehensive physical examination is conducted. This examination includes an evaluation of the upper airway structure to identify potential obstructions or anatomical abnormalities. The doctor examines the nose, throat, and oral cavity while assessing body mass index (BMI) and neck circumference, as obesity is a significant risk factor for sleep apnea. Additionally, the physician checks blood pressure and heart rate to gather more information about the patient’s overall health.

Sleep Study (Polysomnography)

The gold standard for diagnosing CompSA is an overnight polysomnography (PSG) conducted in a sleep laboratory. This test involves monitoring brain wave activity through electroencephalography (EEG) to determine sleep stages and arousal. The study also records heart rhythm using electrocardiography (ECG) to detect cardiac abnormalities.

Breathing patterns are measured through various sensors, including a nasal pressure transducer and an oronasal thermal sensor, along with chest and abdominal effort belts. Continuous monitoring of blood oxygen levels is performed using pulse oximetry, while body movements and limb activity are also recorded. Video and audio recordings may be made to observe snoring and body positions throughout the night.

Split-Night Study

In some cases, a split-night study may be conducted. During this study, the first part of the night is used for diagnostic purposes. If significant sleep apnea is detected during this initial phase, the second part of the night is utilized to titrate positive airway pressure (PAP) therapy.

CPAP Titration

A crucial step in diagnosing CompSA is observing the patient’s response to CPAP therapy. If central apneas persist or emerge during CPAP titration despite the resolution of obstructive events, it suggests CompSA. The apnea-hypopnea index (AHI) is calculated before and during CPAP use to assess the presence of CompSA.

Follow-up Studies

In some cases, additional studies may be necessary to confirm the diagnosis. A full-night CPAP titration study may be conducted to determine optimal pressure settings for treatment. Home sleep apnea testing (HSAT) might also be used for follow-up; however, it is generally not recommended for the initial diagnosis of CompSA due to its complexity.

Differential Diagnosis

The sleep specialist must carefully differentiate CompSA from other forms of sleep-disordered breathing such as Obstructive Sleep Apnea (OSA), and Central Sleep Apnea (CSA), as well as Treatment-emergent Central Sleep Apnea.

Additional Evaluations

Depending on the individual case, further tests may be ordered to rule out underlying medical conditions or neurological causes of central apneas. Blood tests can help identify any contributing factors, while imaging studies such as MRI or CT scans may be used if neurological issues are suspected. If heart-related problems are a concern, evaluation by a cardiologist may also be necessary.

Treatment Options for Mixed Sleep Apnea

Treatment for mixed sleep apnea often requires a multi-faceted approach:

Advanced PAP Therapy

• Positive airway pressure (PAP) therapy remains the cornerstone of treatment for mixed sleep apnea, with several advanced options available:
• Adaptive servo-ventilation (ASV) is often considered the gold standard for treating mixed sleep apnea. This sophisticated device continuously monitors the patient’s breathing patterns and adjusts pressure delivery in real-time. ASV can effectively suppress both obstructive and central events, making it particularly useful for patients with complex sleep apnea.
• BiPAP with a backup rate provides variable pressure levels for inhalation and exhalation, along with guaranteed breaths if the patient’s respiratory rate falls below a set threshold. The backup rate ensures a minimum number of breaths per minute, addressing the central component of mixed sleep apnea.
• Auto-adjusting CPAP (APAP) may be suitable for milder cases of mixed sleep apnea. These devices can automatically adjust pressure levels throughout the night based on the patient’s changing needs. While primarily designed for obstructive events, some patients with mild central apneas may benefit from APAP therapy.

Supplemental Treatments

• Oxygen therapy may be indicated for patients who experience significant oxygen desaturation during sleep, particularly those with central sleep apnea components. This supplemental oxygen can help stabilize breathing patterns and reduce the frequency of apneas.
• Positional therapy is another important supplemental treatment that can benefit patients whose sleep apnea worsens in certain sleeping positions, typically when lying on their back. This therapy involves using devices or techniques to encourage side sleeping, which can help maintain a more open airway throughout the night.
• Medication adjustments are sometimes necessary as part of the treatment plan. Certain medications, particularly sedatives or opioids, can exacerbate sleep apnea symptoms. A healthcare provider may review and modify a patient’s medication regimen to minimize negative impacts on breathing during sleep.
• Treatment of underlying medical conditions is crucial in managing mixed sleep apnea effectively. Conditions such as heart failure, chronic pain, or nasal congestion can contribute to or worsen sleep apnea symptoms. Addressing these underlying issues can lead to significant improvements in sleep quality and overall health.

Lifestyle Modifications

• Weight management programs are often recommended, as excess weight is a significant risk factor for sleep apnea. Even modest weight loss can lead to substantial improvements in symptoms.
• Sleep position training is an essential aspect of lifestyle modification. Patients are educated on optimal sleeping positions and may use special pillows or positional devices to maintain these positions throughout the night.
• Alcohol and sedative avoidance is strongly encouraged, especially in the hours before bedtime. These substances can relax the throat muscles and worsen sleep apnea symptoms.
• Establishing a regular exercise routine is beneficial for weight management and improving overall sleep quality and cardiovascular health. Exercise can help strengthen the muscles involved in breathing and promote better sleep architecture.
• Maintaining a consistent sleep schedule is crucial for patients with mixed sleep apnea. Going to bed and waking up at the same time each day helps regulate the body’s internal clock and can improve the quality and quantity of sleep.