CERTIFICATE

This is to certify that Mr. Shubham

Chauhan , a student
of Class XI-A, BAL
BHARATI PUBLIC SCHOOL, Sector-21, NOIDA has
done an investigatory research work on the
medical problem, "SLEEP APNEA, under my
guidance and supervision.
He has taken very keen interest and
demonstrated a great quest for understanding
the problem as well as ways and means to
allevate it. It is indeed worth appreciating him
and dedication that he has displayed in the
pursuit of carrying out this research work.
(Ms.Vidhi oberoi )
BBPS, NOIDA

ACKNOWLEDGEMENT
Out of my sheer interest and a small child
like curiosity, I chose this topic of Sleep
Apnea to carry out the research work.
But, I knew not that what a herculean task, I
had laid my hands on felt like a novice
entering into the sea without a wee bit of
swimming. With this kind of a beginning, for
a brief spell, I felt as though I had lost the
battle before the war bell had rung. At this
hour, my mom and dad came to my rescue
with their enlivening and motivating words,
anecdotes to uplift my sagging morale.
Having mustered courage and re- kindled
desire and interest, I set on my journey
interacting with my esteemed faculty, Ms.
Vidhi Oberoi about how I should chalk out
my map to pursue this research work. She
,like a true readily came forward and guided
me the path and goal posts that I should
follow and keep in mind to do justice to the
research work. With this steering , I moved
forward but got caught many times with

roadblocks, stumbles and hurdles. Holding

my head, I used to feel how I am going t
overcome this.
Thanks a ton to also the internet, which
has brought information & Knowledge to the
nook and corner of every room in every
household and the highly utilitarian google
- search engine, which enabled me to do a
good amount of review of literature. I owe
my earnest and heartfelt gratitude to each
one of those mentioned above but for
whom/which this research pursuit would
have not seen the light of the day.
( Shubham Chauhan)
Class XI A
BBPS, NOIDA
2015-2016

INDEX
1.Introduction to Sleep Apnea
2.Types of Sleep Apnea
3. Symptoms
4.Diagnosis
5. Risk Factors
6.CPAP for Sleep Apnea
7.Self-Help Treatments
8.Case study : Sleep Apnea
9.Bibliography

INTRODUCTION TO SLEEP APNEA

WHAT IS SLEEP APNEA?
Sleep apnea, also spelled sleep apnoea, is
a sleep disorder characterized by pauses
in breathing or instances of shallow or infrequent
breathing during sleep. Sleep apnea is classified
as a dyssomnia, meaning abnormal behavior or
psychological events occur during sleep.

ANATOMY
When breathing is paused, carbon dioxide
builds up in the bloodstream. Chemoreceptors in
the blood stream note the high carbon dioxide
levels. The brain is signaled to wake the person
sleeping and breathe in air. Breathing normally
will restore oxygen levels and the person will fall
asleep again.

TYPES OF SLEEP APNEA

OBSTRUCTIVE SLEEP APNEA
It is the most common type of sleep
apnea and is caused by obstruction of
the upper airway. It is characterized by
repetitive pauses in breathing during sleep,
despite the effort to breathe, and is usually
associated with a reduction in blood oxygen
saturation. These pauses in breathing, called
"apneas" (literally, "without breath"), typically
last 20 to 40 seconds.
CENTRAL SLEEP APNEA
It is a sleep-related disorder in which the effort
to breathe is diminished or absent, typically for

10 to 30 seconds, either intermittently or in

cycles and is usually associated with a reduction
in blood oxygen saturation.
COMPLEX SLEEP APNEA
Complex sleep apnea is a comboination of
obstructive sleep apnea and central sleep
apnea.

SYMPTOMS OF SLEEP APNEA

Common effects of sleep apnea include daytime fatigue, a

slower reaction time, and vision problems. OSA may increase
risk for driving accidents and work-related accidents. If OSA
is not treated, one has an increased risk of other health
problems such as diabetes. Even death could occur from
untreated OSA due to lack of oxygen to the body. Moreover,
people are examined using "standard test batteries" in order
to further identify parts of the brain that may be adversely
affected by sleep apnea, including those that govern:
"executive functioning", the way the person plans and
initiates tasks
paying attention, working effectively and processing
information when in a waking state
using memory and learning.
Due to the disruption in daytime cognitive state, behavioral
effects are also present. These include moodiness,
belligerence, as well as a decrease in attentiveness and
drive. Another symptom of sleep apnea is waking up in sleep
paralysis. In severe cases, the fear of sleep due to sleep
paralysis can lead to insomnia. These effects become very hard
to deal with, thus the development of depression may
transpire.
There is also evidence that the risk of diabetes among those
with moderate or severe sleep apnea is higher. There is also
increasing evidence that sleep apnea may also lead to liver
function impairment, particularly fatty liver diseases
(see steatosis). Finally, because there are many factors that
could lead to some of the effects previously listed, some
people are not aware that they have sleep apnea and are
either misdiagnosed, or just ignore the symptoms
altogether.

DIAGNOSIS

The diagnosis of sleep apnea is based on the conjoint

evaluation of clinical symptoms (e.g. excessive daytime
sleepiness and fatigue) and of the results of a formal
sleep study (polysomnography, or reduced channels home
based test). The latter aims at establishing an
"objective" diagnosis indicator linked to the quantity of
apneic events per hour of sleep (Apnea Hypopnea
Index(AHI), or Respiratory Disturbance Index (RDI)),
associated to a formal threshold, above which a patient
is considered as suffering from sleep apnea, and the
severity of their sleep apnea can then be quantified.
Mild OSA (Obstructive Sleep Apneas) ranges from 5 to
14.9 events per hour of sleep, moderate OSA falls in the
range of 1529.9 events per hour of sleep, and severe
OSA would be a patient having over 30 events per hour
of sleep.
Nevertheless, due to the number and variability in the
actual symptoms and nature of apneic events (e.g.,
hypopnea vs apnea, central vs obstructive), the
variability of patients' physiologies, and the intrinsic
imperfections of the experimental setups and methods,
this field is opened to debate. Within this context, the
definition of an apneic event depends on several factors
(e.g. patient's age) and account for this variability
through a multi-criteria decision rule described in
several, sometimes conflicting, guidelines.One example
of a commonly adopted definition of an apnea (for an
adult) 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) or a blood oxygen desaturation of 34% or
greater, or both arousal and desaturation.

RISK FACTORS

Sleep apnea can affect people regardless of sex, race, or

age. Risk factors include being male, overweight, obese, or
over the age of 40; or having a large neck size (greater than
1617 inches), enlarged tonsils, enlarged tongue, small jaw
bone, gastroesophageal reflux, allergies, sinus problems,
family history of sleep apnea, or deviated septum causing
nasal obstruction.Alcohol, sedatives and tranquilizers also
promote sleep apnea by relaxing the throat. People who
smoke have sleep apnea at three times the rate of people
who have never smoked. All the factors above may
contribute to obstructive sleep apnea. Central sleep apnea is
more influenced by being male, being older than 65 years,
having heart disorders such as atrial fibrillation, and stroke
or brain tumor. Brain tumors may hinder the brain's ability to
regulate normal breathing. High blood pressure is also very
common in people with sleep apnea.

CPAP FOR SLEEP APNEA

For moderate to severe sleep apnea, the most common
treatment is the use of a continuous positive airway pressure (CPAP) or
automatic positive airway pressure (APAP) device. These
splints the persons airway open during sleep by means of
pressurized air. The person typically wears a plastic facial
mask, which is connected by a flexible tube to a small
bedside CPAP machine.
With proper use, CPAP improves outcomes and decreases
the risk of death due to heart disease. Long term
compliance; however, is an issue with more than half of
people not appropriately using the device.
Although CPAP therapy is effective in reducing apneas and
less expensive than other treatments, some people find it
extremely uncomfortable. Patients complain of feeling
trapped, having chest discomfort, and skin or nose irritation.
Other side effects a patient may experience are dry mouth,
dry nose, nosebleeds, sore lips and gums. Many patients
refuse to continue the therapy or fail to use their CPAP
machines on a nightly basis, especially in the long term.
]

CASE STUDIES
CASE IMr. N, a 40-year-old lawyer, was referred to the sleep disorders center with
the chief complaints of chronic fatigue and exhaustion. A routine workup for
fatigue was negative.

Patient History and Examination

History of Present Illness: The patient reported a 10-year history of long

working hours and lack of personal activities, such as exercise and vacation, in
pursuit of a promising law career and hopes of making partner. During this time,
Mr. N had developed a habit of snacking to stay awake during late nights at work.
Coupled with the lack of exercise, Mr. N gradually gained 95 pounds. His current
weight is 278 lbs. (height = 69 inches; BMI = 41.05).

Mr. N described increased fatigue throughout the previous 6 years. Recently, this
has become an embarrassment as he occasionally falls asleep in important
meetings. Mr. N previously attempted to restart an exercise program but reports he
simply lacked the energy. Friends describe him as burned out.

Medication History: Previous treatment with the stimulant Modafinil was not
effective.

Social History: Single. Intensely focused on his career with no time for any other
pursuits. Does not smoke or drink alcohol, except on rare social occasions. He
drinks at least 12 cups of coffee per day to stay awake.

Family History: Father snores heavily.

Review of Sleep Pattern: Mr. N has a normal sleep schedule (11:30 PM 7

AM) and reports he sleeps soundly. However, he arises from bed un-refreshed and
occasionally awakens during the night gasping for air. Presence of snoring could not
be confirmed by interview because Mr. N sleeps alone and has no recent bed
partners.

Evaluation and Diagnosis

Mr. N spent a night in a sleep lab. During the first diagnostic part of the study he
fell asleep almost instantly and slept soundly for about 3.5 hours. However, his AHI
was 49 with O2 saturation frequently dipping into the low 80s. A CPAP trial was
carried out during the second part of the study. Results indicated CPAP at 13 cm
H2O eliminated Mr. Ns disordered breathing during all sleep stages, even when
sleeping on his back.

Treatment and Follow-up

Mr. N. was prescribed nightly CPAP at 13 cm H 2O. Within 1 week he had regained
much of his former mental sharpness and physical energy. However, his nostrils and
his throat always felt excessively dry the morning following CPAP. Although an
added heated humidifier helped alleviated some discomfort, Mr. N never became
entirely comfortable with CPAP treatment. Despite his discomfort, he continued to
use it nightly. His regained energy allowed him to begin an intensive weight loss
program through diet and exercise.
One year later, Mr. Ns weight was stable at 195 lbs. (a loss of 83 lbs.; current BMI =
28.79). A follow-up sleep study without CPAP indicated that he had a very mild level
of sleep-related respiratory disturbance. CPAP was discontinued with no return of
daytime sleepiness.

CASE II
J.B. is a 61-year-old man who is a busy physician and has had type 2 diabetes for
11 years. He suffers from gastroesophageal reflux disease daily and has moderate
depression. For 11 years, he has maintained a weight of 210220 lb (BMI of 31
kg/m2), and he does not have hypertension or hypercholesterolemia. J.B. has no
other known diabetes complications. He uses a low-carbohydrate meal plan and a
bicycle exercise program. However, he snores and reports being excessively sleepy
all the time.
J.B. has no family history of diabetes or sleep apnea. During the past year, he has
not been able to get his plasma glucose levels to < 200 mg/dl. His hemoglobin
A1c (A1C) has been 7.5% (lab norm) on the past two visits. The patient denies
polyuria or nocturia. He is in bed for 8 hours per night. His wife does not
complain about his nighttime snoring, but she describes herself as a heavy sleeper.
The bed partner is often the first to complain of sleep apnea. In this case, J.B.'s
wife is not bothered. However, fellow physicians who travel with J.B. on medical
mission trips joke and complain about his snoring and gasping. J.B. now requests a
private room for these trips to avoid the complaints. He did not share this
information with his diabetes care team.

J.B. is excessively sleepy, yet he sleeps 8 hours nightly. Colleagues and family
who sleep in adjacent rooms have told him that he snores and gasps throughout
the night. Published research demonstrates that 50% of men with type 2 diabetes
have sleep apnea. These factors are sufficient to suspect sleep apnea and inquire
further.

BIBLOGRAPHY
https://en.wikipedia.org/wiki/Sleep
_apnea
http://spectrum.diabetesjournals.o
rg/content/19/3/190.full
Google.com

 http://sleepdisorders.sleepfoundat
ion.org/sleep-related-breathingdisorders/case-study/

SHUBHAM CHAUHAN
XI - A