a common part

Apnea in a dream - the respiratory disorder is potentially threatening the patient's life, defined as the asphyxia period of more than 10 seconds. During sleep, leading to the development of excess daytime sleepiness, hemodynamic disorders and cardiac instability. (C. Guilleminault, 1978)

During the respiratory stop during sleep, the oxygen content in the body falls, and carbon dioxide accumulates. These changes in the internal structure of the body stimulate the brain, which is forced to briefly wake up and give the muscle team to open the respiratory tract. After that, a person falls asleep, and everything repeats again. Depending on the severity of the disease, such phenomena may occur from 5 to 100 times per hour of sleep, and the total duration of the respiratory pause is 3-4 hours per night. These phenomena disrupt the structure of sleep, making it superficial, fragmented and unusable.

Obstructive apnea violates sleep process and usually leads to the emergence of fatigue, fatigue, drowsiness, irritability, memory problems, thinking, concentration of attention and personal changes. Patients with sleep apnea are more inclined to fall asleep in unsuitable time for this, more often fall into road accidents and accidents occur more often at work.

Obstructive sleep apnea has a negative effect on the cardiovascular system and contributes to the development of arterial hypertension and arrhythmias.

Obstructive sleep apnea have a negative impact on the course and worsen the forecast of chronic obstructive lung diseases (COPD, bronchial asthma).

The diagnosis of apnea in a dream is established in the presence of characteristic symptoms and markers of the disease that detect during clinical research and survey. To confirm the diagnosis use polysomnographic or printing (cardiorespiratory monitoring) Study.

The main method of treatment is non-invasive lung ventilation that supports constant positive pressure in the respiratory tract during sleep (CPAP therapy).

• Classification
  • Periodic Breath (Chein Stokes) and Central Apnea in Dream (CAC)

    Periodic Breath (Chein Stokes) and central apnea in a dream (CAC) is a disease defined as a respiratory stop during sleep, due to the termination of the intake of nerve pulses to the respiratory muscles. Periodic respiration denotes the regular appearance and disappearance of ventilation as a result of oscillations in the receipt of central respiratory pulses.

    In a number of patients, periodic respiration may include a short episode of apnea, which has a central genesis. In such cases, the central apnea can be regarded as a "complication" of periodic respiration. Since both of these types of pathological respiration are found in clinical practice And they are characterized by uniform fundamental pathogenetic mechanisms relating to one group of diseases.

• Epidemiology

  Studies of different years demonstrate the various prevalence of STS in the human population. Thus, in Stradling J.R studies with co-authors (1991) and Young T. With co-authors (1993), there are references for their time, the prevalence of SAGS was 5-7% of the total population over 30 years. About 1-2% of the specified group of persons suffered heavy forms of the disease. At symptomatic patients over 60 years old, the frequency of STGS increased sharply and accounted for 30% for men and 20% for women. At symptomatic patients over 65 years old, the frequency of the disease has already reached 60% regardless of gender.

  Currently, the Wisconsin Sleep Cohort Study, 2003, Wisconsin Sleep Cohort Study, 2003, is considered the most significant epidemiological study (Wisconsin Sleep Cohort Study, 2003), in which more than 12,000 patients took part. The study demonstrated that the prevalence of STS in the population is 10-12%, which means: in fact, every seventh resident of Europe and North America has chronic respiratory disorders in a dream. Such a high frequency of occurrence of the disease speaks of a "pandemic of the disease."

  Clinically significant respiratory disorders (RDI\u003e 15 sob / hour) are marked in 24% of men and 9% of women aged from 30 to 60 years. More than 36% of symptomatic patients with SAGS have concomitant pathology (IBS, hypertensive disease, Chronic obstructive disease of the lungs, bronchial asthma), significantly taking the disease.

• Code of the ICD-10 G47.3 - apnea in a dream.

Etiology and pathogenesis

The etiological factors of obstructive apnee-hypopne syndrome in a dream (STAGS) remain uninterrupted and poorly studied. The main ones are: an increase in body weight and obesity, stress, violation of metabolic processes, endocrine pathology, TSA defeat.

• Pathogenetic mechanisms obstructive apnea in a dream

  Despite close attention to various aspects of the etiology and pathogenesis of sleep apnea, clear ideas explaining all sides of this phenomenon, there is no time. The least challenged are the ideas about the processes underlying the development of ancient occlusion. respiratory tract.

• Sound phenomenon of vibration of soft tissues of pharynx - snoring

  The sound published by a number of patients with SAGS, called in everyday snoring, and sleep apnea is not synonymous. Snoring or snatching is called the sound resulting from the vibration of soft tissues of the rotoglotage region due to low muscle tone. Snoring is only a sign that the patient has a risk of developing sleep apnea.

  The process resembles the movement of water along the elastic tube. If water runs not normal, the tube will vibrate. The same happens with breathing paths when they are partially closed. Painting patients can be divided into several different categories. On the one hand, we see patients with snoring, which have no clinically significant problems. On the other hand, snoring patients suffering from sleep apnea. In the middle there will be patients who have snoring combined with increased resistance of the respiratory tract to the air flow. Such patients do not have the phenomena of sleep apnea, however, due to difficulty breathing and need to overcome the high resistance of the respiratory tract (the increasing work of breathing), they experience multiple awakening among sleep, which causes them to develop excess daytime sleepiness, lethargy and reduce efficiency.

• Pathogenesis of the central apnea in a dream

  The central sleep apnea is not an independent disease, but rather includes several types of disorders in which the main event is the cessation of the flow of central effector pulses to the respiratory muscles. As a result, the lung ventilation is reduced, which starts the main chain of events, similar to those described earlier in the obstructive sleep apnea syndrome (Fig. 5).

  
  Fig. 5. Graphic trends demonstrate the mechanism for the development of the central apnea of \u200b\u200bsleep and periodic respiration associated with an increase in the threshold level of the blood PACO 2, which supports the normal respiratory rhythm. Designations: Airflow (Flow); Hypopeloe (H), apnea (a), pulse (PULSE), blood saturation (SAO 2), desaturation episodes (DS), timeline (HC: MM: SS) (modified from Article Bradley TD, Phillipson EA: Central Sleep Apnea . CLIN CHEST MED 13: 493-505, 1992.).

  Based on theoretical, experimental and clinical data, two fundamental mechanisms were established, which determine the cessation of the receipt of central respiratory pulses at the time of sleep.

  The first mechanism involves the existence of explicit defects in the control system of respiratory function or disorders of neuromuscular transmission. Such disorders lead to syndrome of chronic alveolar hypoventilation, which manifests itself by hypercapper during the daytime. However, the most obvious mechanism of such violations becomes when sleep occurs when the minimum stimulating effect on behavioral, cortical and reticular factors, sending pulses in the neurons of the respiratory center in the stem portion of the brain. At this point in time, the respiratory function becomes extremely dependent on the damaged major disease of the metabolic system of respiratory control.

  In contrast to the central sleep apnea, which develops against the background of the existing disorders of the regulation system of the respiratory function and neuromuscular transmission, the attacks of periodic respiration are developing against the background of transient fluctuations or instability of the initially saved respiratory control system. Such violations are developing in a state of dorms or superficial sleep. Since there are no obvious violations of respiratory control over the flow of respiratory impulses, the PACO 2 level in the wakefulness state or slow sleep usually corresponds to the norm or somewhat reduced.

  Such temporary fluctuations in the PACO 2 level are most often occurring during the transition from the status of wakefulness into sleep state. In the time of wakefulness is usually supported high degree Ventilation of the lungs due to the regular intake of nervous respiratory impulses, which is why the level of PACO 2 is lower than in the period of deep sleep. The absence of the regularity of the receipt of such pulses in the transition from wakefulness to the SNU leads to the fact that the value of PACO 2 decreases and becomes lower permissible levelnecessary to maintain breathing in a state of sleep.

  In cases where the value of PACO 2 in the time of wakefulness is initially lower than the threshold value necessary to create a respiratory rhythm during sleep during the transition to sleep, the apnea will develop. It will exist until the PACO 2 value increases to the proper threshold level. If the moments of increasing Paco 2 and the moment of the onset of blue sleep coincide, the breath will acquire a rhythmic character without episodes of apnea or hypopne.

  However, for the state of transition from wakefulness to the SNA, repeated fluctuations of the activity of the Central nervous system. With each rapid transition from the state of sleeping to wakefulness, the level of PACO 2 increases, leading to "hypership of wakefulness". As a result, an increase in the ventilation of the lungs in accordance with the known receptor reaction during the wake-up period to increase CO 2 is observed, which leads to the development of the hyperpnee phase within periodic respiration. Changes in the ventilation of the lungs when moving from sleeping to wakefulness, mirroredly repeat such changes when moving from wakefulness to sleep. Such a cycle, which is an alternation of hypopne (or apnea) and hyperpnee is repeated until the stable sleep state is established.

  Within such an event scheme, the severity of ventilation disorders depends on the state of the central nervous system, the differences between the indicators of the PACO 2 of wakefulness and sleep, as well as on the speed of the compensatory respiratory reaction in the wakefulness of CO 2 content. Any factor contributing to the increase in these indicators enhances the chance of developing periodic respiration and central sleep apnea. For example, during the residence at a significant height, alveolar hyperventilation of the lungs, which is due to hypoxia, helps reduce the indicator of PACO 2. At the same time, its value decreases significantly below the threshold value necessary to maintain the respiratory rhythm in a dream. Hypoxia leads to an increase in the rate of receptor reaction to CO 2.

  That is why periodic breathing with short episodes of central apnea, alternating with intense periods of hyperpnee, typically for persons staying at considerable height. Similarly, with any disease of the heart or lungs, which leads to hypoxia and alveolar hyperventilation during the time of wakefulness, there is a high probability of developing periodic respiration and central apnea in such patients when sleeping.

• Pathogenesis of disorders associated with sleep apnea

  The main sequence of events, leading to the development of obstructive sleep apnea, contributes to the emergence of derivatives of physiological reactions, which determine the development of characteristic clinical manifestations (symptoms) and complications of STS (Fig. 6).

  Fig. 6. Scheme of physiological consequences and clinical manifestations of sleep apnea (modified from the article Phillipson EA: Sleep Apnea. Med Clin North AM 23: 2314-2323, 1982.).

  What physiological changes occur during apnea?

  During the respiratory stop, the content of oxygen in the body falls, and carbon dioxide accumulates. These changes in the internal structure of the body stimulate the brain, which is forced to briefly wake up and give the muscle team to open the respiratory tract. After that, a person falls asleep, and everything repeats again. A man's sleep with obstructive apnea is the process of alternating two states: gained air and "dived" into sleep, the air ran out - "emerged" from sleep, woke up. Depending on the severity of the disease, such phenomena may occur from 5 to 100 times per hour of sleep, and the total duration of the respiratory pause is 3-4 hours per night. These phenomena disrupt the structure of sleep, making it superficial, fragmented and unusable. At the same time, they are multiple stresses for the body configured to rest, and changes the state of the autonomous nervous system regulating the function of the internal organs. During the respiratory stop of the obstructive type, respiratory movements are saved. Attempts to inhale through the closed respiratory tract lead to a significant drop in the pressure in the chest, which affects the internal baroreceptors and has a negative impact on the cardiovascular system.

  What consequences for the body has obstructive sleep apnea?

  Sleep is not the time, "crossed out" from the active life. Sleep is an active condition important to restore our mental and physical health every day. Obstructive apnea violates sleep process and usually leads to the emergence of fatigue, fatigue, drowsiness, irritability, memory problems, thinking, concentration of attention and personal changes. Patients with sleep apnea are more prone to falling asleep in unsuitable time for this and more often fall into road accidents and accidentally occur at work with them. Obstructive sleep apnea has a negative impact on the cardiovascular system. More than 50% of patients with sleep apnea, arterial hypertension is observed. The average level of blood pressure in morning time It is almost linearly increasing with increasing apnea frequency. Cardic impaired during sleep can also be due to obstructive apnea. More and more clinical data accumulates that obstructive apnea during sleep is the cause of strokes, especially among young men. The effect of obstructive apnea on the development of myocardial ischemia and myocardial infarction in individuals with the defeat of the heart vessels is allowed. Obstructive sleep apnea has a negative impact on the course and worsen the forecast of chronic obstructive lung diseases (COPD, bronchial asthma, chronic obstructive bronchitis, etc.).

  • Pathogenesis of cardiovascular disorders associated with apnea in a dream

    The development of cardiovascular disorders in patients with apnea in a dream is due to several physiological mechanisms. During the obstructive apnea, at the time of its occurrence or termination, an increase in systemic blood pressure is observed. Such an increase is the result of the activation of the sympathetic level of the nervous system and the reflex narrowing of the vessels due to acute asphyxia, the reaction of activation and changes in the intragenic pressure (Fig. 7).

    
    Fig.7 Recording the activity of the sympathetic level of the nervous system (from the small-bag nerve) and the dynamics of blood pressure in patients of soumps. At the beginning of the episode of the apnea (OSA), the influence of the sympathetic level of the nervous system on the muscles is suppressed. It increases as the saturation of arterial blood decreases with oxygen (not shown), reaching a maximum at the end of the episode of obstructive sleep apnea, after which such an effect is sharply suppressed when the lungs are inflated. Blood pressure raises (BP) reach a maximum immediately after reaching the point of the highest influence of the sympathetic level of the nervous system on the muscles with the development of the activation reaction (shown by arrows). On other channels from top to bottom: Elekrokulogram (EEG) Electroencephalogram (EEG), Electromogram (EMG), Electrocardiogram (ECG), and respiration dynamics (RESP) (adapted from Somers VK, Dyken Me, Clary MP, et al: Sympathetic Neural Mechanisms In Obstructive Sleep Apnea. J Clin Invest 96: 1897-1904, 1995.).

    After respiratory recovery, there is a decrease in blood pressure to the initial level. However, in contrast to healthy individuals, in patients of STS, the decrease in the average blood pressure during the sleep period is not observed. More than 50% of patients with SAGS during sleep, a systemic arterial hypertension was observed, due to the high and long activity of the sympathetic unit of the nervous system, an increased concentration of norepinephrine in the blood plasma, a violation of the vasodilating reaction of the endothelium. The results of experimental studies on animals with modeling of such disorder indicate that obstructive sleep apnea leads to a stable increase in blood pressure indicators during awakening.

    In recent years, a large number of clinical and experimental data is incorporated, indicating that in addition to systemic hypertension, obstructive sleep apnea has both acute and chronic negative effect on the function of the left ventricle of the heart. The acute effect is that against the background of an excessive negative intraction pressure created during the episodes of obstructive sleep apnea, there is a decrease in the impact volume of the heart and a minute cardiac output with an increasing postload load of the left ventricle and reducing its intellibration. Negative intrabriety pressure during sleep apnea is capable of achieving -90 cm H 2 O (-65 mm Hg. Art.), Which causes an increase in transmural pressure in the left ventricle of the heart, contributing to the development of post-load on this heart department. Its increase leads to a pronounced decrease in the preload of the left ventricle by influencing the interaction of the left and right heart departments.

    Such a mechanism for the effect of excessive negative intragenic pressure on the impact volume of the heart and the minute heart rate is most pronounced in patients with impaired function of the left ventricle. A acutely developing hemodynamic disorders caused by episodes of obstructive sleep apnea can contribute to the development of night angina and cardiogenic pulmonary edema, which were recorded in patients with SAGS in a number of studies.

    Periodic episodes of hypoxia observed during episodes of obstructive sleep apnea have a negative impact on the work of the left ventricle by influencing its contractility, preload and post-loading. Increased pressure in the pulmonary artery, due to hypoxia due to sleep apnea, prevents the devastation of the right ventricle and leads to a decrease in the speed of achieving diastole with both ventricles.

    Such effects, as well as the consequences of negative intraction pressure, can lead to a violation of the filling of the left ventricle. The role of hypoxia lies in a sharp increase in systemic blood pressure through stimulating effect on the sympathetic department of the nervous system. It is important that such effects are most pronounced in patients suffering from stagnant heart failure. As a result of the increase in post-loading of the left ventricle and stimulation sympathetic influences On the heart there is an increase in the need of the heart muscle in oxygen, which can lead to ischemia myocardium, night angina, as well as cardiac arrhythmias in patients with ischemic heart disease and obstructive sleep apnea. Given the causal relationship, a concept was developed, according to which a sudden death may occur against the background of STSAs. However, reliable data confirming this concept is absent.

    Nevertheless, Gula et.al. (2004) conducted a retrospective analysis of the data obtained during a survey of 112 patients who have passed a polysomnographic study and subsequently carrying out sudden death due to cardiovascular diseases. The patients were excluded from the study if the time of death was not known or the reason for sudden death was not related to the cardiovascular disease. The authors made a comparison of the frequency of sudden death associated with the disease of the heart, in the group of patients with soumps during the day in four 6 hours intervals (from 06 to 12 hours, from 12 to 18 hours, from 18 to 24 hours, and from 24 to 06 am) with a frequency of sudden cardiovascular death among the population. The comparison was also carried out with the expected frequency of death in 25%, if it occurred in all 4 intervals. Indicators of the frequency of sudden death for the entire population were taken from previously published data of a large-scale study study of sudden cardiovascular death.

    The frequency of sudden death due to heart diseases turned out to be significantly higher in patients with soumps during the time interval from 24 to 06 o'clock in the morning than the total population (46% against 21%), and above the expected death rate (46% against 25%). On the contrary, the frequency of cases of sudden cardiovascular death in patients with soumps turned out to be significantly lower in the time interval from 06 to 12 hours than the total population (20% versus 41%), and significantly lower in the time interval from 12 to 18 hours (9 % against 26%).

    Heavy forms of soumps, determined on the basis of the ratio of apnee-hypopnoe, are interconnected with a higher relative risk of sudden death from cardiovascular diseases (1.87% and 2.61%) than in patients with light and medium severity of the disease, as well as Compared with the whole population. The authors assume that in patients with soumps against the background of repeated episodes of apnea, various pathophysiological mechanisms can act, contributing to an increase in the risk of sudden cardiovascular death, namely: hypoxemia, myocardial ischemia, arrhythmia, improving the activity of the sympathetic unit of the nervous system, arterial hypertension, platelet aggregation factors . They also suggested that some cases of sudden night death, due to diseases of the heart and blood vessels, in general, may be unrecognized SAGS syndrome.

    Although this study managed to demonstrate an increased frequency of sudden death over the period from 24 to 06 in the morning in patients of SAGS, it has its drawbacks to be considered. The population of participants in this study was represented by the elderly (the average age was 70 years), and in the study, only historical control was used.

    Currently, an increasing amount of research has evidenced by the relationship between obstructive sleep apnea and a chronic disruption of the left ventricular function. Interest in such works is due to the fact that the ability to obstructive sleep apnea cause pronounced left ventricular failure in the absence of long-term arterial hypertension, coronary heart disease or violation of the myocardial function was not reliably established. However, a number of patients with stagnant heart failure, against the background of eliminating obstructive sleep apnea, there has been a significant improvement in the reference fraction of the left ventricle, as well as a decrease in the severity of shortness of breath during exercise. It should be noted that in patients of STGPs there is a stable increase in the activity of the sympathetic level of the nervous system, as well as an increase in the concentration of norepinephrine in blood plasma. However, it is known that the survival rate of patients with stagnant heart failure is inversely proportional to the activity of the sympathetic influences of the nervous system on the heart and the concentration of norepinenenal in the plasma in the blood, which is a possible explanation of the negative effects of obstructive sleep apnea on the survival of such patients with a combination of two pathologies.

    Obstructive sleep apnea can influence the cardiovascular system through stimulation of platelet aggregation capacity, through strengthening blood coagulation, increase the content of inflammation mediators, as well as oxygen reactive forms. All of these factors take part in the process of atherogenesis and the formation of arterial thrombus. In the treatment of STS, it is observed a significant decrease in the production of reactive forms of oxygen, a decrease in the expression of adhesion molecules and adhesion of leukocytes to endothelial cells, as well as a decrease in the level of endothelial growth factor. An increasing amount of research suggests that the obstructive sleep apnea may be an independent risk factor for the development of metabolic syndrome, increasing insulin resistance. In the treatment of this disease, an increase in insulin sensitivity is noted, independent of a decrease in body weight.

    In 10-15% of patients, SAGS develops permanent pulmonary hypertension, which leads to the insufficient of the right heads of the heart. It was proved that during episodes of obstructive sleep apnea, a sudden spasm of pulmonary vessels occurs. In the wakefulness state in such patients, the pressure in the pulmonary artery, as a rule, corresponds to the norm. With the existing constant night pulmonary hypertension during the daytime, hypoxemia and hypercapnia are noted, which complement the pronounced violation of blood saturation with oxygen during the night. Violations of the gas composition of arterial blood during the daytime, as a rule, are due to a combination of obesity with the obstruction of the respiratory tract and a decrease in respiratory pulse transmission. Nevertheless, remains uninterrupted, is the isolated night hypoxemia interrelated with the development of the lack of right-wing heart departments? 10-15% of SAGS patients develop chronic hypercaps. The combination of insufficiency of the right-hand departments of the heart, obesity and dayly sleepiness is called "Picklie Syndrome" or obesity syndrome-hypoventilation. With the existence of a chronic excess carbon dioxide, obesity, a light or moderate degree of respiratory tract, as well as a decrease in the sensitivity of chemoreceptors with a decrease in respiratory impulse transmission, is noted. The combination of such disorders contributes to a decrease in the protective mechanisms of hyperventilation, developing between the night obstruction episodes, thereby preventing the elimination of violations of the gas composition of arterial blood characteristic of the episodes of obstructive sleep apnea.

Clinic and complications

• Basic symptoms
  • Group of common symptoms
    • Night snoring.
    • Frequent night awakening, restless sleep.
    • Increase body weight.
    • Stop breathing during sleep (according to the evidence of others).
  • A group of neurophysiological disorders
    • Excess daytime drowsiness.
    • "Energy reduction", fatigue.
    • Reducing the concentration of attention, memory.
  • A group of violations from the cardiovascular system
    • Increased blood pressure (among patients with arterial hypertension, 35% of patients identify obstructive sleep apnea).
    • 3-4 times more frequent development of myocardial infarction and strokes.
    • Heart arrhythmias.
    • Development of chronic heart failure.
    • "Pickwick Syndrome" is a combination of deficiencies of the right-hand hearts, obesity and daylights.

• Main clinical manifestations of obstructive apnea in a dream

  Clinical manifestations of apnea in a dream are divided into two groups.

  • First group of clinical symptoms

    Affects neuropsychological and behavioral spheres. According to they develop directly due to repeated awakening arising to stop each episode of sleep apnea, although they cannot be excluded their relationship with repeating periods of cerebral hypoxia.

    Frequently observed in patients of soumps are neuropsychological and behavioral reactions. They are expressed in the form of excess daytime drowsiness, "reducing energy", fatigue, which occupy a leading place among patient complaints. On the early stages Diseases excess daytime drowsiness is developing mainly in a passive state, for example, while watching television transmissions or during reading is sitting. However, as the disease progressing, excess daytime drowsiness affects all forms of daily activity and acquires the character of a pronounced disabled factor associated with risk.

    When conducting tests with an assessment of the ability to concentrate attention when driving vehicles, it was established the fact of its significant violation in patients in PAGS. At the same time, the main indicators of the frequency of road accidents in patients with sleep apnea significantly exceeded those in the control group. Very often, the manifestations of excess daytime sleepiness are interrelated with a variety of intelligent disorders, reduced memory, mindset disorders, as well as identity changes.

    However, although all these symptoms are due to fragmentation of sleep, the absence of deep sleep stages, with the same severity of respiratory disorders in such patients in the daytime is observed various degree The severity of the specified symptoms. In addition, the patient is very often not aware of its existence of excess daytime sleepiness or violations of higher cerebral functions. That is why, during the collection of anamnesis of the disease, a conversation with family members of the patient plays an important role.

  • Second group of clinical symptoms

    Includes cardiovascular and respiratory manifestations, which are largely, but not exclusively, due to episodes of recurrent night asphyxia.

    The most frequent respiratory manifestation observed at night is a loud snoring, indicating the narrowing of the upper respiratory tract. As a rule, snoring exists in a patient for many years until the development of other symptoms. However, in many patients, only years later, it acquires a non-permanent character and periodically interrupts the episodes of silence (silence), which corresponds to the occlusion periods (apnea). A sign of the completion of the episode of apnea is usually very loud sorry on the breath, which is accompanied by the movements of the body and the impustary movements of the limbs.

    Often patients do not know about the presence of these features, presenting complaints only on restless sleep or his disorder. About such events more often testify those who sleep with them in the same room. Rarely rarely the patient is completely awakened at night with complaints about the suffocation, the lack of air or insomnia. Most often, patients make complaints about the absence of a sense of "restoration of forces" after sleep, on the perishes of consciousness and disorientation, and in some cases, on the headache observed in the mornings or when awakening.

    Cardiovascular manifestations of apnea in a dream require a separate explanation. To date, an increasing number of epidemiological studies indicate the presence of a positive correlation between STS and a number of cardiovascular complications, despite the fact that the presence of direct causal relationship has not yet been established.

    The most reliable results obtained about the relationship of obstructive sleep apnea with systemic arterial hypertension.

    The connection of the apnea in a dream with the development of arterial hypertension is confirmed by the results of large-scale cross and prospective coherent studies, testifying to a reliable increase in the risk of prevalence and the development of arterial hypertension in such patients. At the same time, among the overall population of patients with arterial hypertension, approximately 35% of patients revealed obstructive sleep apnea.

    In a number of studies in patients with "poorly controlled" drugs with arterial hypertension, the prevalence of obstructive sleep apnea was 85%. The results of the largest cross study Sleep Heart Health Study (2001), dedicated to the study of the health status associated with cardiac activity and SHO, testify to the presence of a high dependence of obstructive sleep apnea with coronary heart disease, acute brainwater impairment and stagnant heart failure, regardless of availability other well-known risk factors.

    In patients with chronic heart failure, the presence of apnea in a dream complicates the course of the main disease due to negative influence On the function of the left ventricle of the heart. This is manifested in particular, in the development of myocardial ischemia, night angina and cardiac arrhythmias in patients with ischemic heart disease and obstructive sleep apnea ().

    Apnea in a dream may be accompanied by such complications as the development of myocardial infarction and stroke in a dream (including with death). Studies show that the risk of myocardial infarction and stroke in patients with sleep apnea is 3-4 times higher than those without a night apnea.

    Of interest is the study of Marin et.al. (2005) The number of 1651 people spent in the test group. Of these, 264 were healthy male volunteers, 377 men were "familiar" ratchers, 403 men suffered from a light or moderate degree of SAGS, and 607 men had a serious course of the disease (among which 372 had a crash therapy, and 235 participants refused treatment) . Crop therapy was recommended for all patients with an apnee-hypopne of sleep index\u003e 30 episode / hour or if there was a combination of excess daytime sleeping with polycythemia, heart failure under the apnea-hypopne index from 5 to 20 episode / hour. It should be noted that 36% of patients with a severe form of STAGS abandoned the trouser therapy. They were supervised in order to assess the natural course of the disease compared with the subjects, agreeing on treatment. Healthy subjects were comparable to patients suffering from a severe form of SAUGS on body mass index and age. The ultimate goal of the study was to study the frequency of mortal and not deadly cardiovascular complications. The deadly cardiovascular complications were a fatal outcome due to myocardial infarction or stroke. Not deadly cardiovascular complications included cases of the development of myocardial infarction or stroke, coronary insufficiency requiring surgical or percutaneous intervention.

    When analyzing a 10-year dynamic observation, it was established that the frequency of the occurrence of deadly and not fatal CSO is significantly higher in patients with a severe form of STS, which the therapy was not carried out (respectively, 1.05 and 2.13 per 100 people per year) compared to: 1) with healthy volunteers (respectively 0.3 and 0.45 per 100 people per year); 2) with patients who had only "familiar" snoring (respectively 0.34 and 0.58 per 100 people per year); 3) with patients of STAGS, which was carried out by therapy (respectively, 0.35 and 0.64 per 100 people per year). The ratio of the chances of cardiovascular death in different groups of patients amounted to: 1) in patients with the usual snore - 1.03; 2) in non-therapy of patients with SAUGS light or moderate severity - 1.15; 3) in non-treatment of patients with patients of severe flows - 2.87; 4) In patients with SAGS receiving Cupra-therapy - 1.05.

    The authors concluded that the risk of death and not deadly complications are significantly higher in patients with severe SAGS patients who did not receive treatments than in healthy volunteers. Crop therapy contributed to a decrease in such risk. The usual snoring has not correlated with a reliable increase in the risk of fatal and non-meaning cardiovascular complications compared to healthy persons.

    There are data indicating the possibility of the onset of sudden death during sleep in patients with obstructive night apnea ().

• Main clinical manifestations of central apnea in a dream

  In a number of patients, recurrent episodes of central sleep apnea are not associated with any clinical manifestations or physiological disorders. Consequently, they are clinically not significant. In other patients, the sequence of events characterizing the central apnea leads to the development of clinical symptoms and complications similar to that with obstructive sleep apnea.

  Since several different mechanisms are able to cause central sleep apnea, clinical manifestations are characterized by a variety.

  In cases where the central apnea is the consequence of the disease that led to the impairment of respiratory control or neuromuscular transmission, in the clinical picture, repetitive episodes of heart failure and the features of chronic alveolar hypothen syndrome, such as: CO 2 delay, hypoxemia, pulmonary hypertension, referee failure and polycythemia. Restless dream headache in the morning chronic fatigue And excess daytime drowsiness are also often found in such patients, due to night hypoxemia, hypercaps, violations of the main characteristics of sleep.

  On the contrary, in cases of central sleep apnea, caused by transient fluctuations of the receipt of central respiratory impulses at the occurrence of sleep actually, there is no hypercup in the daytime, as there are no complications on the part of cardiac and pulmonary systems. In such patients, there are more signs of disturbed sleep, frequent awakening at night, fatigue in the morning hours, as well as daytime sleepiness. In many patients, the central apnea is secondary in relation to stagnant heart failure. Patients with heart failure and central apnea in a dream may also complain about insomnia and paroxysmal night shortness.

  Strengthening the activity of the sympathetic unit of the nervous system in day and night against the background of a central apnea in a dream in patients with chronic heart failure can lead to the progression of violations of the myocardial function and promotes the progression of the underlying disease. These patients are more often a stomach tachycardia than patients without a central apnea in a dream. The development of ectopic ventricular contractions is interconnected in such patients, both with a respiratory cycle and with SAO 2 reductions. The main reason for such a relationship remains unknown. Presumably ectopic ventricular reductions are a consequence of hypoxia, the increased activity of the sympathetic department of the nervous system, periodically repeated sharp lifts of blood pressure, as well as the result of a significant increase in the volume of the left ventricle. Since one-third of patients with chronic heart failure there is a sudden death from heart arrhythmias, such causal relationships need further study.

  Increased mortality among patients with chronic heart failure in combination with central sleep apnea compared to patients with chronic heart failure without apnea may be associated with the effects of one or more of these factors.

Diagnostics

• Clinical diagnostics

  To identify apnea in a dream there are highly reliable clinical symptoms and objective disease markers, allowing during a questionnaire survey to identify a certain form of hypovential respiratory disorder.

  How do you think you just feel fatigue or wait and fall in the following situations?

  This applies to ordinary situations from your real life. If you did not happen to such situations now, try to imagine how they would have affected you. Select the number that is most suitable for your possible behavior in the specified situations:

  0 \u003d not asna never 1 \u003d a small chance to sleep 2 \u003d moderate chance to sleep 3 \u003d high chance to fall asleep

  Situation	Point
  1. Reading sitting in a chair
  2. Look inside the telecast sitting in the chair
  3. Passive sitting in public places (sitting in the theater, at the meeting, etc.)
  4. As a passenger in the car within no less than a hour trip to a flat road
  5. If you lie to rest after lunch, in the absence of other cases (not siesta)
  6. Sitting and talking with someone
  7. Sitting in a chair after breakfast in a quiet room, without taking alcohol
  8. Driving a car stopped for a few minutes in a road traffic jam

  NORM	Initial	Moderate	Pronounced	Extreme degree
  0-5	6-8	9-12	13-18	19 or more

  • Symptoms of the disease
    • Excessive ("excess") day drowsiness in various situations, combined with frequent night awakening. Excess daytime drowsiness reflects the response of the central nervous system to the severity of the breakdown of the sleep architecture and the degree of night hypoxia. It is the higher, the more significant are sleep and breathing disorders.
    • A loud night snoring, which interferes with the patient or people around him, combines with episodes of respiratory pauses, occurs at any body position. The "snoring" is the oscillations of the soft tissues of the rotoglotor ring (Fig. 2), due to their hypertrophy, muscle atony, or changes in the spatial configuration (narrow) under the influence of external and internal factors (Table 1).
  • Disease markers

    Related to them absolute signswhich can be measured by instrumental methods using weights, wagist, centimeter, tonometer.

    • Rosto / weight ratio (BMI) - the ratio of body weight in kg per patient growth square in meters.
    • Patient neck coverage - neck circumference size in cm, measured by collar line.
    • Blood pressure (blood pressure) - blood systolic and diastolic pressure of the patient in the sitting position, expressed in MM.R.T. and measured by the Korotkov method.
    • The day-to-sleep index is a malicious subjective assessment by the patient of daylight 8 points (situational states), according to a 5-point progressive scale from 0 to 3, where "0" is the lack of sleepiness, and "3" is the offensive of sleep in the specified situation.

    Indicators estimated as markers are an integral part of any physical and anthropometric examination of patients with suspicion of apnea in a dream (Table 1.2).

    Table 1. Symptoms and Markers of SoGS
    

    Symptoms	Markers
    Loud chronic night snoring.	Significant increase in body weight (≥120% of ideal weight or BMI\u003e 29 kg / m 2)
    Periods of intercepting breathing or "respiratory damper" during sleep	Collar size (neck circumference size): - Men ≥43 cm, - Women ≥40 cm.
    Pronounced daily drowsiness (especially in persons managers by the vehicle).	Hell more than 140/90 mm.rt.
    Accidents in production or road accidents caused by day drowsiness or daytime fatigue	Nose-pharyngial narrowings type 1, 2, 3 by Fujita
    Weakening of the concentration of attention against fatigue or daytime fatigue	Pulmonary hypertension, lonantic Heart

    
    Table 2. Dreaming scales (daylight index)
    

    Situation condition	Point
    1. Reading a book, sitting in a chair
    2. Look inside the telecast sitting in the chair
    3. Passive presence in public places (sitting in the theater, at the meeting)
    4. As a passenger in the car within no less than a hour trip to a flat road
    5. If you lie to rest after lunch, in the absence of other cases
    6. Sitting and talking with someone
    7. Sitting in a chair after breakfast in a quiet room, without taking alcohol
    8. Driving a car stopped for a few minutes in a road traffic jam

    The clinical diagnosis is established in the case of a patient: BMI\u003e 29 kg / m 2, patient neck coverage\u003e 43 cm, Hell\u003e 140/90 mm.rt.st., dayline index\u003e 9 points, complaints about loud snoring. In other cases, as well as at an afflicting picture of the disease, a functional and laboratory diagnostics is required.

• Functional and laboratory diagnostics

  This diagnostic procedure provides for the functional monitoring of the basic necessary parameters in the night time to confirm the obstructive or central apnea syndromocomplex.

  Since such a procedure can be carried out both in a special functional diagnostic department (sleep laboratory) and at home (screening surveys), the procedure is divided into a "polysomnographic examination" and cardioresis monitoring or "Printing examination".

• Determination of the severity of the disease

  To establish the severity of the disease, the formula of the addition of severity in the amount of apnee-hypopne events for one astronomical hour and the maximum one-time decrease in the saturation of arterial blood oxygen fixed during the sleep period is used.

  Respiratory index (RDI) - respiratory disorders index reflects the number of respiratory disorders in one hour of sleep. RDI is more often associated with an apnee-hypopne of sleep index than with a formal index "clean" episodes of apnea in a dream.

  In accordance with the number of respiratory disorders, it is customary to allocate:

  Severity coas	Number of events of impaired breathing per hour (RDI)
  	Apnea (AI)	Apnea + Hypopeloe (AHI)
  Norm
  Light form	5-10	10-20
  Moderate form	10-15	20-30
  Heavy form	>15	> 30

  
  

  Saturation index (SAO 2) is the saturation of arterial blood oxygen.

  Depending on its one-time decline in the episode of the respiratory disorder, the severity of the disease, determined by the RDI index, must be changed accordingly:

  Severity coas	MIN SAO 2)
  Without changes	>90 %
  Increased by 1 degree	85% - 90%
  Increased by 2 degrees	80% - 85%
  Increased by 3 degrees

  
  

  Thus, if Rdi \u003d 15 sobes / hour, and MIN SAO 2 \u003d 85%, the rule of addition of gravity determines such a state as:

  light form SAGS + increase by 2 degrees \u003d severe SAGS

  This severity setting algorithm over the past 9 years has found its practical application and has proven its effectiveness in 10486 patients.

• Diagnostic criteria

  The clinical diagnosis is established in the case of a patient: BMI\u003e 29 kg / m 2, patient neck coverage\u003e 43 cm, Hell\u003e 140/90 mm.rt.st., dayline index\u003e 9 points, complaints about loud snoring.

  In other cases, as well as at an afflicting picture of the disease, a functional and laboratory diagnostics is required.

  The definition during the functional-laboratory diagnostics of the RDI index indicators (the number of events of impaired breathing per hour), equal to more than 5 in the case of apnea or more than 10 in the case of apnea + hypopne, allows you to put a clinical diagnosis "apnea in a dream".

application

The International Classification of Sleep Disorders (MKRS) used in modern doubt was adopted in 1990, only 11 years after the introduction of the first classification of sleep disorders (adopted in 1979) - the diagnostic classification of sleep and awakening disorders.

Such a quick, for medical standards, the replacement was dictated, first of all, the need to systematize avalanche-like increasing flow of information on sleep medicine.

Such an intensification of research in the field of sonological has largely contributed to the opening in 1981 effective method The treatment of obstructive apnea syndrome in a dream using the auxiliary ventilation mode. This contributed to a significant increase in the practical direction of the doubt, increased the amount of investment in sleep research, which in a short time gave results not only in the field of studying breathing in a dream, but also in all related industries.

The diagnostic classification of sleep disorders and waking up 1979 was based on the syndromological principle. The main sections in it were insomnia (disorders of initiation and maintain sleep), hypersmia (disorder with excessive daylight), paramy and disorder Sleep-wake cycle. The practice of applying this classification showed the insufficiency of the syndromological approach, since the clinical manifestations of many sleep disorders include symptoms relating to different categories on this rubricification (for example, central apnea syndrome in a dream is manifested both complaints about night sleep disorders and at high day drowsiness) .

In this regard, a new, more progressive pathophysiological approach to the heading of sleep disorders, proposed by N. Kleitman in 1939 was used in the new classification. According to this, two subgroups were allocated among primary sleep disorders:

1. disssony (included disorders flowing both with complaints with insomnia and day drowsiness)
2. parassia (where the disorders are included in the sleep process, but not the cause of complaints about insomnia or daylight) (see Appendix)

According to the pathophysiological principle, the dissismini was divided into sleep disorders internal, external and associated biological rhythm disorders.

Accordingly, this rubricification, the main causes of sleep disorders occurred either from the inside of the body (internal) or from the outside (external). Secondary (i.e., due to other diseases), sleep disorders, as in the previous classification, were presented in a separate section.

It is of interest to the allocation of the last (fourth) section in the ICDS - "proposed sleep disorders". It included those sleep disorders, knowledge of which at the time of the adoption of the classification were still insufficient for reasonable allocation into a separate category of sleep disorders.

Basic principles of the organization MKSR

1. Classification is based on encodings international Classification Size IX revision, its clinical modification (ICD-1x-km) (see Appendix). In this classification, for designating sleep disorders, codes are predominantly used # 307.4 (inorganic etiology disorder) and # 780.5 (organic etiology disorders) with the corresponding addition of additional digits after the point. For example: central alveolar hypoventilation syndrome (780.51-1). Despite the fact that since 1993, for the purposes of coding diagnoses in medicine, the next, tenth of the ICD, corresponding to it, is not yet given to the ICDS. However, there are tables for comparing the encoding of sleep disorders for the ICD-10 (see Table 1.10).
2. The MKSS uses an axial (axial) system of organization of the diagnosis, which allows the most fully to display the main diagnosis of sleep disorders, used diagnostic procedures and concomitant diseases.

   On the axis, the diagnosis of sleep disorders (primary or secondary) is determined.

   For example: A. Overstructive apnea syndrome in a dream 780.53-0.

   The B axis contains a list of procedures on which confirmation of a diagnosis of sleep disorders. The most commonly used polysomnography data and multiple sleep latency test (MTLS).

   For example: A axis C contains data on the presence of concomitant diseases in the ICB-IX.
   For example: S. Arterial Hypertension 401.0

3. For the most complete description The patient's states and in order to maximize the standardization of diagnostic procedures, information on each axes A and B can be supplemented with the use of special modifiers. In the case of an axis, and this allows you to reflect the current stage of the diagnostic process, the features of the disease and leading symptoms. Relevant modifiers are set in square brackets in a specific sequence. We present their clarification in accordance with this sequence.

   Diagnosis Type: Presumable [P] or Final [F].

   The presence of remission (for example, during the treatment of obstructive apnea syndrome in a dream by auxiliary ventilation)

   The rate of development of sleep disorders (if it is important for diagnostics). It is placed in parentheses after a diagnosis of sleep disorders.

   The severity of sleep disorder. 0 - not defined; 1 - lightning; 2 - moderate; 3 - heavy. Put after the modifier of the final or estimated diagnosis.

   The course of sleep disorders. 1 - acute; 2 - subacute; 3 - chronic.

   The presence of basic symptoms.

   The use of modifiers for axis B allows you to take into account the results of diagnostic tests, as well as methods for the treatment of sleep disorders. Polysnography is considered the main procedures in somnology (# 89.17) and MTLS (# 89.18). To encode the results of these studies, the modifier system is also used.

It should be noted that such a very bulky coding system of sonological diagnoses is used mainly for scientific purposes, as it allows to provide standardization and continuity of research in various centers. In everyday clinical practice, a shortened encoding procedure is commonly used without the use of modifiers. At the same time, the diagnosis of sleep disorders looks like this:

4. The following principle of the ICDA organization is the standardization of text. Each sleep disorder is described by a separate chapter in accordance with a certain plan, which includes:

1. synonyms and keywords (turns on the terms used earlier and used now to describe sleep disorder, for example - Pickwick syndrome);
2. determination of disorder and its main manifestations;
3. associated manifestations and complications of disorder;
4. four and forecast;
5. predisposing factors (internal and external factors increasing the risk of disorder);
6. prevalence (the relative representation of persons with at a certain point in time is a violation);
7. the age of debut;
8. sexual ratio;
9. heredity;
10. pathogenesis of suffering and pathologists;
11. complications (non-associated manifestations);
12. polysomnographic and MTLS change;
13. changes in the results of other paraklinic research methods;
14. differential diagnosis;
15. diagnostic criteria (a set of clinical and paraclinical data, on the basis of which this disorder can be diagnosed);
16. minimum diagnostic criteria (shortened variant of diagnostic criteria for general practice or for the setting of presumptive diagnosis, in most cases it is based only on clinical manifestations of this disorder);
17. gravity criteria (standard separation on a light, middle and heavy degree of disorder severity; differ for most sleep disorders; The Specific Numerical Values \u200b\u200bof Indicators are avoided to determine the severity of the disorder - preference is given to clinical judgment);
18. duration criteria (standard separation into sharp, subacute and chronic disorders; In most cases, concrete border values \u200b\u200bare given);
19. bibliography (authoritative sources relating to the main aspects of the problem).

In 1997, a revision of some MKS provisions were carried out, which did not touch, however, the basic principles of organizing this classification. Only the clarification of some definitions of sleep disorders and criteria for gravity and duration was made. The revised classification is called MKRS-R, 1997, but many Somologists still refer to the previous version of the ICDS. There is a work on introducing into the classification iCB-X encodings. However, the official document on this occasion was not released. For practical purposes, predominantly encoding F51 (inorganic etiology sleep disorders) and G47 (sleep disorders) are used (see Annex).

The problem of sleep becomes very relevant due to an increase in the intensity of life, an increase in stressful situations, the number of information incoming during the day.

And from all these problems can be distinguished by one, very significant from a psychological point of view - the problem of snoring or, speaking by scientifically, the problem of night apnea syndrome. According to statistics, snoring is found more than 20% of the population, while often it is not about physiological phenomenon, which may occur periodically (for example, against the background of the nasal congestion), but about illness.

Information for doctors. There is a separate code on the ICD 10, under which the obstructive night apnea syndrome is encrypted - G47.3. When issuing a diagnosis, the degree of manifestations should be indicated, the number of respiratory stop periods per night, the severity of the concomitant syndromes (cognitive, emotional-volitional disorders, etc.).

The term obstructive sleep apnea syndrome itself means the presence of periodic moments of respiratory stop in a dream due to lowering the soft sky, larynx and other reasons accompanied by snoring, a decrease in blood saturation with oxygen, sleep fragmentation and daily drowsiness. Often, during the respiratory stop, a person wakes up or a shift of sleep phases occurs, as a result, chronic lack of sleep and fatigue develops. According to statistics among persons over 40 years old, snoring is found more than 30%, and a full-fledged apnea syndrome in a dream can be diagnosed approximately every twentieth person.

The reasons

Reasons for the development of apnea in a dream. Obesity may result in this state, bulbar disorders after strokes, muscle weakness during myasthenia, lateral amyotrophic sclerosis. Also, the causes of the COC may be hypothyroidism, adenoid growths, brain discirculatory processes. As a rule, a combination of causes and, almost always, there is either hereditary predisposition to syndrome or obesity.

Symptoms

All symptoms of sleep apnea can be divided depending on the frequency. Very often found:

• Snore.
• Stop breathing in a dream more than 1 time.
• Dissatisfaction with sleep.
• Irritability.
• Drowsiness during the day.

Often a person has the following signs:

• Attacks of suffocation at night.
• Reduced potency and libido.
• Headache, mainly in the morning.

Rarely, but there are also an apnea syndrome in a dream - a night outbuilding cough, urinary incontinence, vestibulo-coordinator disorders and other symptoms.

Diagnostics

Setting the diagnosis of obstructive sleep apnea should be clinically and being instrumental confirmed. For clinical diagnosis, it should reveal a minimum of three significant features from the following:

• Stop breathing at night.
• Loud snoring at night.
• Excessive daily drowsiness.
• Nicturia (increased urination at night).
• Dissatisfaction with sleep due to its violation for more than three months.
• Enhance arterial pressure by more than 20 mm.rt. In the mornings either directly at night.
• Obesity is high.

At the same time, the more clinical signs It will be revealed, the more reliable diagnosis. The only objective method of diagnosing apnea during sleep is. Recording registers the presence of snoring, its duration, intermittentness of the roto-nasal flow, pulse, blood saturation with oxygen, removal of electrical activity of the brain (), etc. In the presence of Cases, blood saturation oxygen periodically drops to 50-60% and lower, which is fraught with the lesion of the brain. Also, when coas, changes are developing on ECG during respiratory stops. Screening method of research in the presence of snoring may be pulse oximetry - a study method that will allow estimating the saturation index of blood oxygen at night.

Presentation of the author

Treatment

The treatment of obstructive sleep apnea syndrome must necessarily be carried out by neurologist doctors in close cooperation with endocrinologists, cardiologists and doctors of other specialties. After all, the threat of this state is the high risk of cardiovascular disasters, weighting of any somatic pathology, reducing the quality of life of people.

Prevention and partly treatment of the disease should be directed to a decrease in body weight (it is necessary to achieve body mass index in the interval 22-27), strengthening the muscles of the larynx (work with the ENT doctor), the decision of the endocrinological (correction of the level of sugars when sugar diabetes, normalization of hormone levels thyroid gland With its pathology) and other problems. Most important and regular exercise stress. In this regard, even a banal rule of 10 thousand steps will help, it is supposed to be the minimum cardion for a day.

Symptomatic methods of treatment of COAS is.

Unfortunately, there are no convincing data on the effectiveness of certain drugs. There were many studies regarding the influence of drugs on snoring and the course of obstructive sleep apnea syndrome, however, most studies occupied a short period of time (1-2 nights) and the results obtained were modest. So, some effects showed such drugs as acetazolamide, paroxetine, but they were not always well tolerated and little influenced daily symptoms (the data of the cochraine laboratory).

(Constant Positive Airway Pressure - Constant Positive Air Pressure) The device is a compressor that creates a constant positive air pressure at night. Thus, it is possible to avoid the episodes of stopping the breath or significantly reduce their frequency. Therapy with these devices continues for months and even years, until it is possible to eliminate the reasons that led to the apnea syndrome. Sometimes, in the elderly, high risks of sudden death, the frequent episodes of the respiratory stop, the impossibility of eliminating the causes of the disease therapy is carried out for life. The only restriction on the widespread use of this treatment method is high cost. The price of devices begins from 50 thousand rubles and is rarely paid from the means of social support or medical insurance funds.

Sources of literature:

R.V. Buzunov, I.V. Leghead of snoring and obstructive sleeping syndrome // Tutorial for doctors. Moscow-2010.

Buzunov R.V., Yeroshina V. A. The dependence of the severity of the obstructive apnea syndrome during sleep from an increase in body weight after the patients has a symptom of snoring // Therapeutic archive. - 2004.- No. 3.- S. 59-62.

Vain A.M. and others. Syndrome apnea in a dream and other respiratory disorders associated with sleep: clinic, diagnosis, treatment // Eidos Media.-2002.

Yeroshina VA, Buzunov R.V. Differential diagnosis obstructive and central sleep apnea during a polysomnographic study // Therapeutic archive. - 1999.- №4.- S. 18-21.

Kurlykina N.V., A.V. Pevzner, A.Yu. Litvin, P.V. Galicin, I.E. Chazov, S.F. Sokolov, S.P. Golitsyn. The possibility of treatment of patients with long-term night asistolines and obstructive sleep apnea syndrome by creating a constant positive air pressure in the upper respiratory tract. // "Cardiology" -2009-№6.- Volume 49.- p.36-42.

SLEEP-DISORDERED BREATHING IN COMMUNITY-DWELLING ELDERLY.//SLEEP.- 1991.-14 (6). - R.486-95.

Brooks, D. R., L. Horner, L. Kimoff, L. F. Kozar, C. L. Renderteixeira, and E. A. Phillipson. 1997. Effect of Obstructive Sleep Apnea Versus Sleep Fragmentation On Responses to Airway National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Comittee. The Seventh Report of the Joint National Committee On Prevention, Detection, Evaluation, And Treatment of High Blood Pressure: The JNC 7 Report. Jama. 2003. - 289.- R.2560 -2572.

ELMASRY A, LINDBERG E, BERNE C, ET AL. SLEEP-DISORDERED BREATHING AND GLUCOSE METABOLISM IN HYPERTENSIVE MEN: A POPULATION-BASED STUDY.// J. Intern. MED.-2001.- 249.- P.153-161.

Rudman D., Feller A.G., Nagraj H.S. et al. Effects of Human Grout Hormone In Men Over 60 Year // N. ENGL J. MED.- 1990.- Vol. 323.- P. 1-6.
Sanner BM, Konermann M, Doberauer C, Weiss T, Zidek W. Sleepdisorderd Breathing in Patients Referred for Angina Evaluation-Association with Left Ventricular Dysfunction. // Clin Cardiol. - 2001.-24.- R. 146 -150.

Night apnea syndrome (Code of ICD-10 - G47.3) is a common violation in which a short-term cessation of breathing is observed during sleep. The person himself may not know that he has a breath stop in a dream. If the respiratory stops are very short, the person does not wake up and does not feel discomfort. If the respiratory stops are too significant, the brain wakes up and wakes up the body to eliminate the existing oxygen starvation.

Thus, a person can wake up a few times overnight and feel the sharp lack of air. Night apnea is an extremely dangerous state, since under certain circumstances, it can lead to a too long stop of breathing and entail a heart stop and fatal brain hypoxia. The night apnea syndrome is dangerous in that its development can cause death even young people. In rare cases, the fatal outcome of the attacks of the night apnea is observed in children.

Classification of night apnea types

There are a lot of approaches to the classification of such a condition, as a sleepy apnea syndrome. Allocate 3 main forms of this pathological condition, including obstructive, central and mixed. Each of these forms of development has its own features of development. For example, the obstructive night apnea is formed due to occlusion or falling up the upper respiratory tract, and the regulation of the CNS remains normal. In addition, in this case, the activity of respiratory muscles is preserved. Such a variant of the development of the night apnea includes a number of individual syndromes, including:

• syndrome of the pathological variant of snoring;
• syndrome of obesity-hypoventilation;
• conventional hypoventilation syndrome;
• syndrome of the combining obstruction respiratory tract.

The so-called hypoventilation syndrome develops due to a sustainable reduction in the possibility of ventilation of lungs and blood saturation with oxygen. In the pathological snatch, the movement of the walls of the larynx prevents the normal breath and exhale. The syndrome of obesity-hypoventilation is usually observed in a very full people and is a consequence of the disorder of gas exchange, and due to the resistant reduction in blood saturation with oxygen, night and daytime attacks of hypoxia are observed.

With the central form of the night apnea syndrome, the reasons for the development of such a pathological condition are rooted in organic damage to the structures of the brain, as well as the primary innate insufficiency of the respiratory center in the brain. In this case, the cessation of breathing in a dream is a consequence of violation of the intake of nerve impulses controlling the operation of the respiratory muscles.

With a mixed form of a sleepy apnea syndrome, a respiratory disorder is a consequence of a combination of damage to the central nervous system and the obstruction of the respiratory tract various etiology. This option apnee is rare. Among other things, there is a classification that takes into account the severity of the manifestations of the sleepy apnea syndrome. Easy, medium and severe degree of flow of such a respiratory impairment in a dream.

Etiology and pathogenesis of the development of the night apnea

Each form of night apnea syndrome has its own specific causes of development. Usually the central shape of the night apnea is a consequence:

• brain injuries;
• squeezing the rear cranial fossa of various etiology;
• squeezing the stem department of the brain;
• parkinsonism;
• alzheimer-Peak Syndrome.

A rare cause of a disturbance of the respiratory center, usually leading to respiratory stops in a dream in children, congenital abnormalities of the development of cerebral structures are congenital abnormalities. In this case, the attacks of breathing are observed, accompanied by the symbol of the skin. In this case, the pathology of the heart and lungs are absent.

The obstructive form of the night apnea is most often observed in people who suffer from severe endocrine diseases or have a large amount of excess weight. In addition, provoke such a variant of the course of the disease can stress exposure. In some cases, the obstructive form of the night apnea is a consequence of congenital anatomical features of the structure of the nasopharynx.

For example, there is often a similar disorder of respiration in people who have too narrow nasal moves, an enlarged soft sky, a pathological shape of a sky tongue or hypertrophied almonds. An important point in the development of the obstructive form of the night apnea is hereditary predisposition, since certain defects may be observed in members of one family bound by blood relations.

Usually the obstructive form of the night apnea develops due to the pharyngal collapse, which occurs in the phase of deep sleep. During the episode of the apnea, hypoxia is observed, but the signals reach it to the brain, so it sends a response impulse to awakening.

When a person awakens, lung ventilation and respiratory work restores.

Symptomatic manifestations and complications of the night apnea

With a light version of the night apnea, which can even take place in the people in excellent physical form, a person may not suspect that he has short-term breath ceases in a dream. We usually notice the problem only those who are or asleep next to a person suffering from this disease. With more severe variants of the disease, its characteristic features include:

• strong snoring;
• restless sleep;
• frequent awakening;
• physical activity in a dream.

However, apnea is reflected not only on a man's dream, but also on his everyday life. Given that the dream in people suffering from apnea, restless, this is also reflected in day-to-day activity. Often, people, patients apnea, have excessive drowsiness throughout the day, fast fatigue, reduced performance, memory deterioration and ability to focus attention, as well as increased irritability.

Due to the insufficient nutrition of body tissues with oxygen during periods of sleep, people suffering from night apnea, over time, there is an additional health problem. First of all, the lack of oxygen is reflected on the metabolism, therefore people having a disturbance of the respiratory function during sleep, often gain quick weight. In men, against the background of this disorder, the development of sexual dysfunction is often observed.

If not treated with night apnea syndrome, the lack of oxygen is reflected in the cardiovascular system, so this category of people often occurs the strongest attacks of angina, signs of heart failure and arrhythmia different types. Approximately 50% of sick people have concomitant pathologies, including COPD, bronchial asthma, ischemic heart disease or arterial hypertension.

The night apnea syndrome gradually leads to the development of complications. In most cases, there is a rapid and significant deterioration in the quality of life. Even if earlier a person did not have problems with the heart, in the presence of frequent cases of cessation of breathing in a dream of the disease of the cardiovascular system develop rapidly.

Often, atherosclerosis and ischemic heart disease, which can manifest themselves expressed symptoms, are much faster on the background of apnea. Among other things, the night apnea syndrome provokes aggravation of chronic diseases available in humans. In children, the attacks of the night apnea syndrome can provoke urine incontinence at night.

Methods for diagnosing night apnea

The diagnosis of attacks of the apnea syndrome and the severity of their flow is based on the data obtained from the relatives of the patient. Relatives of the patient must watch a sleeping person for a few nights and record the duration of respiratory stops in a dream.

In a medical institution, doctors usually determine the body weight index, measure the neck circumference and inspect the respiratory tract to anomalies that interfere with normal breathing in a dream.

If the otolaryngologist cannot determine the availability of a problem necessary measure is the consultation of the neurologist.

In this case, it is often necessary to conduct directional polysomnography, which suggests long-term registration of electric potential and respiratory activity. Only comprehensive diagnostics allows you to determine the exact causes of the problem and assign adequate treatment.

In this video, the snoring and night apnea says:

Methods of treatment of night apnea syndrome

Currently, the night apnea is treated with conservative and surgical approaches. The treatment technique completely depends on the cause of the disease. If a person has a obstructive form of a sleepy apnea syndrome, the necessary measure is often the behavior of surgical operations. As a rule, surgery gives a positive effect in the presence of nasopharynx defects in patient. Depending on the defects in humans, the nasal partition, adenoidectomy, tonsonyctomy, and some other types of operations can be corrected, which make it possible to eliminate breathing disorders.

In the event of light forms of the night apnea, it is possible to correct the situation using non-drugs.

For example, often in people suffering from such a breakdown, the syndrome is manifested exclusively in the position lying on the back, so if you manage to teach the patient to sleep on my side, then the symptoms of apnea disappear. Among other things, eliminate the attacks of a sleepy apnea syndrome allows a raised head end of the bed. As a rule, it is enough for it to be raised by 20 cm.

Medicase treatment allows us to achieve a pronounced result only in some cases. Usually, people suffering from apnea, the doctor can recommend to bury a drop in the nose of a drop of xylometazoline, which contributes to improving nasal respiration.

Contribute to the elimination of attacks of night apnea rinsing weak solutions essential oils. In some cases, when other methods of treatment did not provide the necessary effect, the use of vehicle hardware ventilation can be shown, that is, the spell therapy.

Through a special device, a normal level ventilation level is maintained, which makes it possible to prevent the development of apnea attacks. The use of such devices allows you to prevent the development of hypoxia and deterioration of a person in the daytime.

This video refers to the obstructive sleep apnea syndrome:

The use of similar devices is often prescribed to people suffering from a sleepy apnea syndrome against the background of excessive body weight. This method of therapy is one of the most efficient, as 100% eliminates the risk of human death from hypoxia during sleep.

- A condition in which the systematic stopping of breathing is recorded during sleep. It has several varieties - central, obstructive and mixed. For each type, their reasons are characteristic. Obstructive apnea syndrome (Code of ICD 10 G47.3) is the most common form of the disease among men. In women, she meets 2 times less.

Development mechanism

When a person falls asleep, his body and muscles relax, but the work of the internal organs continues. Air in the lungs circulates the same way as during the day, just a little slower. At night, when a reduction in the muscle tone is observed, the respiratory tract is blocked, as a result of which a temporary stop of breathing is recorded.

From the lack of oxygen, the patient wakes up, the muscle tone increases and the work of the lungs is resumed. But it is only for him to dive into sleep, how again everything happens on the same scenario. For one night, the number of similar episodes can reach 100 times.

Immediately it is worth noting that there is another concept as hypnosis. This condition in its signs is similar to obstructive apnea, but has some differences. In the first case, an incomplete blockage of the respiratory tract is marked. The process of oxygen flow into the lungs is not interrupted, but becomes superficial, which is the cause of a strong snoring. However, take a similar symptom for the sign of the development of this disease, as it is characteristic of other pathologies.

Reducing muscle tone can provoke various factors. But in independence from the root cause, the consequences of the apnea syndrome are the same - when stopping the breath, oxygen ceases to flow into the body and carbon dioxide is removed. This, in turn, leads to hypoxia, from which the brain suffers greatly. Its cells begin to collapse, which is why the concentration of attention and performance is reduced. At the same time, the person himself becomes irritable, depressive, and sometimes at all aggressive.

It should be noted that the appearance of such episodes is considered the norm and for an ordinary person, but only in the event that they arise no more than 5 times per night. If the number of attacks is significantly higher, it already indicates the presence of a disease that requires immediate treatment.

Important! If you tighten with the therapy of the syndrome, the respiratory stop will gradually increase. A long-term absence of oxygen in the body causes serious consequences and can lead to a fatal outcome!

Classification

Depending on the severity of the disease, it is divided into 3 degrees:

• Little - up to 15 respiratory stops per night.
• Middle - from 15 to 50;
• Heavy - over 50.

The true cause of the development of apnea is the reduced muscle tone of the pharynx, as a result of which, during sleep, the respiratory tract is marked and the violation of their passability. Various factors can provoke such a state. The most popular of them are:

1. Congenital anomalies characterized by a narrow airway passage (an example of this is a large language or small lower jaw size).
2. Anatomical defects (curved nose partition, polyps, tumors, etc.).
3. Excess body weight.
4. Disorders of the endocrine system, the emergence of which is accompanied by the swelling of the larynx (hypothyroidism, acromegaly).
5. Neurological diseases (myopathy, stroke).
6. Abuse of alcoholic beverages.
7. Reception of some drugs that reduce muscle tone.
8. Obstructive pulmonary pathology.
9. Allergy.
10. Smoking.

Symptoms

With long-term apnea, the patient appears signs characteristic of the Violation of the CNS:

• Chronic fatigue.
• Reduced memory, inhibition.
• Irritability, depressed condition.
• In men, a violation of an erectile function, in women - frigidity.
• Increased sweating.
• Headaches in the morning clock.
• Uncontrolled movements of the limbs during sleep.
• Snore.

In children clinical picture Also may include:

• Loge in physical and mental development.
• Urinary incontinence.
• Increased aggressiveness.
• Difficult breathing in a child.
• Anemia.

It should be noted that it is based only on these symptoms, the diagnosis is impossible to carry out a diagnosis, since such a clinical picture is also characteristic of other diseases. Therefore, before starting treatment, you need to undergo a comprehensive study.

Complications

Systematic respiratory stop during sleep can provoke serious consequences. For example:

1. Sharp blood pressure jumps. Against the background of a lack of oxygen, as a result of which the body is trying to independently fill its deficit, enhancing blood circulation, which causes a strong increase in blood pressure. Such states are dangerous, as they lead to the wear of the cardiovascular system.
2. Heart failure. Again, arises as a result of hypoxia. It is dangerous with death.
3. Myocardial infarction. Sharp jumps hell provoke violation of vascular heart functions.
4. Stroke. With a severe degree of hypoxia, a breaking of vessels in the brain and internal hemorrhage occurs, which becomes the cause of this pathology, which can also lead to sudden death.

Important! These states are dangerous for a person, as they can lead to a heart stop in everything. And the more the "age" of the syndrome, the higher the risks of their occurrence!

Diagnostics

To make sure the development of this disease in humans, it is necessary to undergo a comprehensive examination, which includes:

1. Polysomnography. Registers certain functions of the body during sleep - the presence of snoring, the work of the lungs, the flow of oxygen into the blood, movement chest, brain activity, muscle tone, etc. This is the only diagnostic method that allows you to identify the development of the syndrome.
2. Halter monitoring ECG and pneumogram. These studies are carried out simultaneously. The first registers the work of the heart, the second - respiratory movements.
3. Respiratory monitoring. It is carried out during sleep. In fact, the same as polysomnography, but has one advantage - to be carried out using a portable apparatus that can be used at home.
4. SlipvideoEndoscopy. It implies inspection of the nasal passages, pharynx and larynx using special equipment (endoscope). It is also done as long as a person sleeps. The procedure takes about 10 minutes. During this time, it allows you to visually determine the disturbance of the respiratory system.
5. Pulse oximetry. Resets the level of body saturation oxygen in a dream.

In addition, the patient will also need to pass blood tests and urine, and also consult with narrower specialists - an endocrinologist, a otolaryngologist, a neuropathologist and others. If there is a need, it will be necessary to pass the ECG, magnetic resonance tomography, CT. Only after receiving all the information on the functioning of the body of the patient, the doctor will be able to put an accurate diagnosis and decide on the further tactics of treatment.

Methods of therapy

Therapeutic measures directly depend on the degree of development of apnea. If a child or an adult suffers from obesity, first of all, it will be necessary to get rid of excess weight. For this purpose, a low-calorie diet is prescribed, enriched with vitamins and minerals. At the same time, a person will have to adhere to some rules:

1. Eating food 4-5 times a day at equal periods of time, in small portions. The last meal must accounted for 3-4 hours before sleep. In the evening it is allowed to drink only water.
2. Refuse smoking and drinking alcoholic beverages.
3. Monitor the level of humidity in the room where he sleeps.
4. Regular cleaning, to avoid the accumulation of dust, which can provoke the puffiness of the nasal passages.
5. Take the right body position during sleep. When apnea is prohibited to sleep on the back, since in this case the structures of lungs and nasopharynses are as close as possible, which several times increases the likelihood of the next episode of the respiratory stop. You need to sleep on my side. At the same time, the head should be higher than the body level by 10-15 cm.
6. Monitor the patency of the nasal holes. If a person has diseases in which air traffic disorders are recorded, it is necessary to use various preparations (for example, vasoconstrictor drops) or plates that contribute to lifting and swelling.
7. The use of special intrarocratic devices. Following this item is required in that situation when the patient has anatomical defects of the oral cavity and pharynx.
8. Refusal to receive preparations that have a sedative effect, as they contribute to a decrease in muscle tone, which only aggravates the flow of apnea.

If the patient with breathing problems are associated with a curved partition or the presence of neoplasms in the nasopharynk, then in this case a surgical intervention will be required, which will eliminate the root cause of apnea and restore the process of passing air through the respiratory tract.