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The later aims at establishing an "objective" diagnosis indicator linked to the quantity of apneic events per hour of sleep (Apnea Hypnea Index([[Apnea-hypopnea index|AHI]]), or Respiratory Disturbance Index ([[Respiratory Disturbance Index|RDI]])), associated to a formal threshold, above which a patient is considered as suffering from Sleep Apnea, and the severity of his sleep apnea can be then quantified.
The later aims at establishing an "objective" diagnosis indicator linked to the quantity of apneic events per hour of sleep (Apnea Hypnea Index([[Apnea-hypopnea index|AHI]]), or Respiratory Disturbance Index ([[Respiratory Disturbance Index|RDI]])), associated to a formal threshold, above which a patient is considered as suffering from Sleep Apnea, and the severity of his sleep apnea can be then quantified.
Nevertheless, due to the number and variability in the actual symptoms and nature of apneic events (hypopnea vs apnea, central vs. obstructive...), the variability of patients physiology, the intrinsic imperfections of the experimental setups and methods, this field is opened to debate.<ref>{{cite journal | author=Redline S, Budhiraja R, Kapur V ''et al.'' | title= Reliability and validity of respiratory event measurement and scoring |journal=J Clin Sleep Med |year= 2007 |volume=3|issue=2|pages=169–200 | pmid=17557426 }}</ref>
Nevertheless, due to the number and variability in the actual symptoms and nature of apneic events (hypopnea vs apnea, central vs. obstructive...), the variability of patients physiology, the intrinsic imperfections of the experimental setups and methods, this field is opened to debate.<ref>{{cite journal | author=Redline S, Budhiraja R, Kapur V ''et al.'' | title= Reliability and validity of respiratory event measurement and scoring |journal=J Clin Sleep Med |year= 2007 |volume=3|issue=2|pages=169–200 | pmid=17557426 }}</ref>
Within this context, the definition of an apneic event depends of several factors (e.g. patient's age) and account for this variability through a multi-criteria decision rule described in several, sometimes conflicting, guidelines.<ref>{{cite journal | author=AASM Task Force |year=1999 |title= Sleep–Related Breathing Disorders in Adults-Recommendations for Syndrome Definition and Measurement Techniques in Clinical Research |journal= SLEEP |volume= 22 |issue= 5 |pages=667–689 | pmid=10450601 }}</ref><ref>{{cite journal | author = Ruehland WR, Rochford PD, O'Donoghue FJ, Pierce RJ, Singh P, Thornton AT | year = 2009 | title = The new aasm criteria for scoring hypopneas: Impact on the apnea hypopnea index | url = | journal = SLEEP | volume = 32 | issue = 2| pages = 150–157 | pmid = 19238801 | pmc = 2635578 }}</ref> 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 3–4% or greater, or both arousal and desaturation.
Within this context, the definition of an apneic event depends of several factors (e.g. patient's age) and account for this variability through a multi-criteria decision rule described in several, sometimes conflicting, guidelines.<ref>{{cite journal | author=AASM Task Force |year=1999 |title= Sleep–Related Breathing Disorders in Adults-Recommendations for Syndrome Definition and Measurement Techniques in Clinical Research |journal= SLEEP |volume= 22 |issue= 5 |pages=667–689 | pmid=10450601 }}</ref><ref>{{cite journal | author = Ruehland WR, Rochford PD, O'Donoghue FJ, Pierce RJ, Singh P, Thornton AT | year = 2009 | title = The new aasm criteria for scoring hypopneas: Impact on the apnea hypopnea index | url = | journal = SLEEP | volume = 32 | issue = 2| pages = 150–157 | pmid = 19238801 | pmc = 2635578 }}</ref> 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 3–4% or greater, or both arousal and desaturation. Sometimes you can even have your period during sleep apnea episodes, in addition, it may cause brain erosion.


==Classification==
==Classification==

Revision as of 00:32, 16 January 2011

Sleep apnea
SpecialtyPulmonology, otorhinolaryngology Edit this on Wikidata

Sleep apnea (or sleep apnoea in British English) is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour.[1] Similarly, each abnormally low breathing event is called a hypopnea. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram, or "sleep study".

There are three forms of sleep apnea: central (CSA), obstructive (OSA), and complex or mixed sleep apnea (i.e., a combination of central and obstructive) constituting 0.4%, 84% and 15% of cases respectively.[2] In CSA, breathing is interrupted by a lack of respiratory effort; in OSA, breathing is interrupted by a physical block to airflow despite respiratory effort, and snoring is common.

Regardless of type, an individual with sleep apnea is rarely aware of having difficulty breathing, even upon awakening.[3] Sleep apnea is recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body (sequelae). Symptoms may be present for years (or even decades) without identification, during which time the sufferer may become conditioned to the daytime sleepiness and fatigue associated with significant levels of sleep disturbance.

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 later aims at establishing an "objective" diagnosis indicator linked to the quantity of apneic events per hour of sleep (Apnea Hypnea 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 his sleep apnea can be then quantified. Nevertheless, due to the number and variability in the actual symptoms and nature of apneic events (hypopnea vs apnea, central vs. obstructive...), the variability of patients physiology, the intrinsic imperfections of the experimental setups and methods, this field is opened to debate.[4] Within this context, the definition of an apneic event depends of several factors (e.g. patient's age) and account for this variability through a multi-criteria decision rule described in several, sometimes conflicting, guidelines.[5][6] 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 3–4% or greater, or both arousal and desaturation. Sometimes you can even have your period during sleep apnea episodes, in addition, it may cause brain erosion.

Classification

Obstructive sleep apnea

Main article: Obstructive sleep apnea

Obstructive sleep apnea (OSA) is the most common category of sleep-disordered breathing. The muscle tone of the body ordinarily relaxes during sleep, and at the level of the throat the human airway is composed of collapsible walls of soft tissue which can obstruct breathing during sleep. Mild occasional sleep apnea, such as many people experience during an upper respiratory infection, may not be important, but chronic severe obstructive sleep apnea requires treatment to prevent low blood oxygen (hypoxemia), sleep deprivation, and other complication.

Individuals with low muscle tone and soft tissue around the airway (e.g., because of obesity) and structural features that give rise to a narrowed airway are at high risk for obstructive sleep apnea. The elderly are more likely to have OSA than young people. Men are more likely to suffer sleep apnea than women and children are, though it is not uncommon in the latter two population groups.[7]

The risk of OSA rises with increasing body weight, active smoking and age. In addition, patients with diabetes or "borderline" diabetes have up to three times the risk of having OSA.

Common symptoms include loud snoring, restless sleep, and sleepiness during the daytime. Diagnostic tests include home oximetry or polysomnography in a sleep clinic.

Some treatments involve lifestyle changes, such as avoiding alcohol or muscle relaxants, losing weight, and quitting smoking. Many people benefit from sleeping at a 30-degree elevation of the upper body[8] or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway. Lateral positions (sleeping on a side), as opposed to supine positions (sleeping on the back), are also recommended as a treatment for sleep apnea,[9][10][11] largely because the gravitational component is smaller in the lateral position. Some people benefit from various kinds of oral appliances to keep the airway open during sleep. Continuous positive airway pressure (CPAP) is the treatment of choice [12] . There are also surgical procedures to remove and tighten tissue and widen the airway.

As already mentioned, snoring is a common finding in people with this syndrome. Snoring is the turbulent sound of air moving through the back of the mouth, nose, and throat. Although not everyone who snores is experiencing difficulty breathing, snoring in combination with other conditions such as overweight and obesity has been found to be highly predictive of OSA risk.[13] The loudness of the snoring is not indicative of the severity of obstruction, however. If the upper airways are tremendously obstructed, there may not be enough air movement to make much sound. Even the loudest snoring does not mean that an individual has sleep apnea syndrome. The sign that is most suggestive of sleep apneas occurs when snoring stops.

Other indicators include (but are not limited to): hypersomnolence, obesity BMI >30, large neck circumference (16 in (410 mm) in women, 17 in (430 mm) in men), enlarged tonsils and large tongue volume, micrognathia, morning headaches, irritability/mood-swings/depression, learning and/or memory difficulties, and sexual dysfunction.

The term "sleep-disordered breathing" is commonly used in the U.S. to describe the full range of breathing problems during sleep in which not enough air reaches the lungs (hypopnea and apnea). Sleep-disordered breathing is associated with an increased risk of cardiovascular disease, stroke, high blood pressure, arrhythmias, diabetes, and sleep deprived driving accidents.[14][15][16][17] When high blood pressure is caused by OSA, it is distinctive in that, unlike most cases of high blood pressure (so-called essential hypertension), the readings do not drop significantly when the individual is sleeping.[18] Stroke is associated with obstructive sleep apnea.[19]

In the June 27, 2008, edition of the journal Neuroscience Letters, researchers revealed that people with OSA show tissue loss in brain regions that help store memory, thus linking OSA with memory loss.[20] Using magnetic resonance imaging (MRI), the scientists discovered that sleep apnea patients' mammillary bodies were nearly 20 percent smaller, particularly on the left side. One of the key investigators hypothesized that repeated drops in oxygen lead to the brain injury.[21]

Central sleep apnea

Main article: Central sleep apnea

In pure central sleep apnea or Cheyne-Stokes respiration, the brain's respiratory control centers are imbalanced during sleep. Blood levels of carbon dioxide, and the neurological feedback mechanism that monitors them, do not react quickly enough to maintain an even respiratory rate, with the entire system cycling between apnea and hyperpnea, even during wakefulness. The sleeper stops breathing and then starts again. There is no effort made to breathe during the pause in breathing: there are no chest movements and no struggling. After the episode of apnea, breathing may be faster (hyperpnea) for a period of time, a compensatory mechanism to blow off retained waste gases and absorb more oxygen.

While sleeping, a normal individual is "at rest" as far as cardiovascular workload is concerned. Breathing is regular in a healthy person during sleep, and oxygen levels and carbon dioxide levels in the bloodstream stay fairly constant. The respiratory drive is so strong that even conscious efforts to hold one's breath do not overcome it. Any sudden drop in oxygen or excess of carbon dioxide (even if tiny) strongly stimulates the brain's respiratory centers to breathe.

In central sleep apnea, the basic neurological controls for breathing rate malfunction and fail to give the signal to inhale, causing the individual to miss one or more cycles of breathing. If the pause in breathing is long enough, the percentage of oxygen in the circulation will drop to a lower than normal level (hypoxaemia) and the concentration of carbon dioxide will build to a higher than normal level (hypercapnia). In turn, these conditions of hypoxia and hypercapnia will trigger additional effects on the body. Brain cells need constant oxygen to live, and if the level of blood oxygen goes low enough for long enough, the consequences of brain damage and even death will occur. Fortunately, central sleep apnea is more often a chronic condition that causes much milder effects than sudden death. The exact effects of the condition will depend on how severe the apnea is and on the individual characteristics of the person having the apnea. Several examples are discussed below, and more about the nature of the condition is presented in the section on Clinical Details.

In any person, hypoxia and hypercapnia have certain common effects on the body. The heart rate will increase, unless there are such severe co-existing problems with the heart muscle itself or the autonomic nervous system that makes this compensatory increase impossible. The more translucent areas of the body will show a bluish or dusky cast from cyanosis, which is the change in hue that occurs owing to lack of oxygen in the blood ("turning blue"). Overdoses of drugs that are respiratory depressants (such as heroin, and other opiates) kill by damping the activity of the brain's respiratory control centers. In central sleep apnea, the effects of sleep alone can remove the brain's mandate for the body to breathe.

  • Normal Respiratory Drive: After exhalation, the blood level of oxygen decreases and that of carbon dioxide increases. Exchange of gases with a lungful of fresh air is necessary to replenish oxygen and rid the bloodstream of built-up carbon dioxide. Oxygen and carbon dioxide receptors in the blood stream (called chemoreceptors) send nerve impulses to the brain, which then signals reflex opening of the larynx (so that the opening between the vocal cords enlarges) and movements of the rib cage muscles and diaphragm. These muscles expand the thorax (chest cavity) so that a partial vacuum is made within the lungs and air rushes in to fill it.
  • Physiologic effects of central apnea: During central apneas, the central respiratory drive is absent, and the brain does not respond to changing blood levels of the respiratory gases. No breath is taken despite the normal signals to inhale. The immediate effects of central sleep apnea on the body depend on how long the failure to breathe endures. At worst, central sleep apnea may cause sudden death. Short of death, drops in blood oxygen may trigger seizures, even in the absence of epilepsy. In people with epilepsy, the hypoxia caused by apnea may trigger seizures that had previously been well controlled by medications [verification needed]. In other words, a seizure disorder may become unstable in the presence of sleep apnea. In adults with coronary artery disease, a severe drop in blood oxygen level can cause angina, arrhythmias, or heart attacks (myocardial infarction). Longstanding recurrent episodes of apnea, over months and years, may cause an increase in carbon dioxide levels that can change the pH of the blood enough to cause a metabolic acidosis.

Mixed apnea and complex sleep apnea

Some people with sleep apnea have a combination of both types. When obstructive sleep apnea syndrome is severe and longstanding, episodes of central apnea sometimes develop. The exact mechanism of the loss of central respiratory drive during sleep in OSA is unknown but is most commonly related to acid-base and CO2 feedback malfunctions stemming from heart failure. There is a constellation of diseases and symptoms relating to body mass, cardiovascular, respiratory, and occasionally, neurological dysfunction that have a synergistic effect in sleep-disordered breathing. In some cases, a side effect from the lack of sleep is a mild case of narcolepsy (EDS) where the subject has had minimal sleep and this extreme fatigue over time takes its toll on the subject. The presence of central sleep apnea without an obstructive component is a common result of chronic opiate use (or abuse) owing to the characteristic respiratory depression caused by large doses of narcotics.

Complex sleep apnea has recently been described by researchers as a novel presentation of sleep apnea.[dubious – discuss] Patients with complex sleep apnea exhibit OSA, but upon application of positive airway pressure the patient exhibits persistent central sleep apnea. This central apnea is most commonly noted while on CPAP therapy after the obstructive component has been eliminated. This has long been seen in sleep laboratories and has historically been managed either by CPAP or BiLevel therapy. Adaptive servo-ventilation (ASV) modes of therapy have been introduced to attempt to manage this complex sleep apnea. Studies have demonstrated marginally superior performance of the adaptive servo ventilators in treating Cheyne-Stokes breathing; however, no longitudinal studies have yet been published, nor have any results been generated that suggest any differential outcomes versus standard CPAP therapy. At the AARC 2006 in Las Vegas, NV, researchers reported successful treatment of hundreds of patients on ASV therapy; however, these results have not been reported in peer-reviewed publications as of July 2007.

An important finding by Dernaika et al. suggests that transient central apnea produced during CPAP titration (the so-called "complex sleep apnea") is "…transient and self-limited."[22] The central apneas may in fact be secondary to sleep fragmentation during the titration process. As of July 2007, there has been no alternate convincing evidence produced that these central sleep apnea events associated with CPAP therapy for obstructive sleep apnea are of any significant pathophysiologic importance.[needs update]

Research is ongoing, however, at the Harvard Medical School, including adding dead space to positive airway pressure for treatment of complex sleep-disordered breathing.[23]

Treatment

For mild cases of sleep apnea, a treatment which is a lifestyle change is sleeping on one's side, which can prevent the tongue and palate from falling backwards in the throat and blocking the airway. Another is avoiding alcohol and sleeping pills, which can relax throat muscles, contributing to the collapse of the airway at night.[24]

For moderate to severe sleep apnea, the most common treatment is the use of a continuous positive airway pressure (CPAP) device,[24] which 'splints' the patient's airway open during sleep by means of a flow of pressurized air into the throat. The patient typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine. The CPAP machine generates the required air pressure to keep the patient's airways open during sleep. Advanced models may warm or humidify the air and monitor the patient's breathing to ensure proper treatment. Although CPAP therapy is extremely effective in reducing apneas and less expensive than other treatments, some patients find it extremely uncomfortable. Many patients refuse to continue the therapy or fail to use their CPAP machines on a nightly basis.

In addition to CPAP, dentists specializing in sleep disorders can prescribe Oral Appliance Therapy (OAT). The oral appliance is a custom-made mouthpiece that shifts the lower jaw forward, opening up the airway. OAT is usually successful in patients with mild to moderate obstructive sleep apnea.[25] OAT is a relatively new treatment option for sleep apnea in the United States, but it is much more common in Canada and Europe.

Several levels of obstruction may be addressed in physical treatment, including the nasal passage, throat (pharynx), base of tongue, and facial skeleton. Surgical treatment for obstructive sleep apnea needs to be individualized in order to address all anatomical areas of obstruction. Often, correction of the nasal passages needs to be performed in addition to correction of the oropharynx passage. Septoplasty and turbinate surgery may improve the nasal airway. Tonsillectomy and uvulopalatopharyngoplasty (UPPP or UP3) are available to address pharyngeal obstruction. Base-of-tongue advancement by means of advancing the genial tubercle of the mandible may help with the lower pharynx. A myriad of other techniques are available, including hyoid bone myotomy and suspension and various radiofrequency technologies.

Illustration of surgery on the mouth and throat

Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or throat, procedures done at either a doctor's office or a hospital. Small shots or other treatments, sometimes in a series, are used for shrinkage, while the insertion of a small piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues.[24]

Possibly owing to changes in pulmonary oxygen stores, sleeping on one's side (as opposed to on one's back) has been found to be helpful for central sleep apnea with Cheyne-Stokes respiration (CSA-CSR).[11]

Medications like Acetazolamide[26][27][failed verification] lower blood pH and encourage respiration. Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects.[dubious – discuss][27][failed verification][28][29]

Surgery

CPAP is the most consistently safe and effective treatment for obstructive sleep apnea but it is not a cure, and people are less likely to use it in the long term.[30] The Stanford Center for Excellence in Sleep Disorders Medicine achieved a 95% cure rate of sleep apnea patients by surgery.[31] Maxillomandibular advancement (MMA) is considered the most effective surgery for sleep apnea patients,[32] because it increases the posterior airway space (PAS).[33] The main benefit of the operation is that the oxygen saturation in the arterial blood increases.[33] In a study published in 2008, 93.3.% of surgery patients achieved an adequate quality of life based on the Functional Outcomes of Sleep Questionnaire (FOSQ).[33] Surgery led to a significant increase in general productivity, social outcome, activity level, vigilance, intimacy and sex, and the total score postoperatively was P = .0002.[33] Overall risks of MMA surgery are low: The Stanford University Sleep Disorders Center found 4 failures in a series of 177 patients, or about one out of 44 patients.[34]

Several inpatient and outpatient procedures use sedation. Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing or collapses in a patient’s airways.[35] Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.

Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the effects in the immediate postoperative period. Once the swelling resolves and the palate becomes tightened by postoperative scarring, however, the full benefit of the surgery may be noticed.

Sleep apnea patients undergoing any medical treatment must make sure his or her doctor and/or anesthetist are informed about their condition. Alternate and emergency procedures may be necessary to maintain the airway of sleep apnea patients.[36] If an individual suspects he or she may have sleep apnea, communication with their doctor about possible preprocedure screening may be in order.

Alternative treatments

A 2005 study in the British Medical Journal found that learning and practicing the didgeridoo helped reduce snoring and sleep apnea as well as daytime sleepiness. This appears to work by strengthening muscles in the upper airway, thus reducing their tendency to collapse during sleep.[37]

Epidemiology

The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans were affected by at least moderate sleep apnea.[38][39] It also estimated that in middle-age as many as nine percent of women and 24 percent of men were affected, undiagnosed and untreated.[38][39][40]

The costs of untreated sleep apnea reach further than just health issues. It is estimated that in the U.S. the average untreated sleep apnea patient's annual health care costs $1,336 more than an individual without sleep apnea. This may cause $3.4 billion/year in additional medical costs. Whether medical cost savings occur with treatment of sleep apnea remains to be determined.[41]

History

The clinical picture of this condition has long been recognized as a character trait, without an understanding of the disease process. The term "Pickwickian syndrome" that is sometimes used for the syndrome was coined by the famous early 20th century physician, William Osler, who must have been a reader of Charles Dickens. The description of Joe, "the fat boy" in Dickens's novel The Pickwick Papers, is an accurate clinical picture of an adult with obstructive sleep apnea syndrome.

The early reports of obstructive sleep apnea in the medical literature described individuals who were very severely affected, often presenting with severe hypoxemia, hypercapnia and congestive heart failure.

The management of obstructive sleep apnea was revolutionized with the introduction of continuous positive airway pressure (CPAP), first described in 1981 by Colin Sullivan and associates in Sydney, Australia.[42] The first models were bulky and noisy, but the design was rapidly improved and by the late 1980s CPAP was widely adopted. The availability of an effective treatment stimulated an aggressive search for affected individuals and led to the establishment of hundreds of specialized clinics dedicated to the diagnosis and treatment of sleep disorders. Though many types of sleep problems are recognized, the vast majority of patients attending these centers have sleep-disordered breathing.

See also

References

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General references

  • Kalra M, Chakraborty R (2007). "Genetic susceptibility to obstructive sleep apnea in the obese child". Sleep Medicine. 8 (2): 169–75. doi:10.1016/j.sleep.2006.09.003. PMID 17275401. {{cite journal}}: Unknown parameter |month= ignored (help)
  • "Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force". Sleep. 22 (5): 667–89. 1999. PMID 10450601. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Bell RB, Turvey TA (2001). "Skeletal advancement for the treatment of obstructive sleep apnea in children". The Cleft Palate-craniofacial Journal. 38 (2): 147–54. doi:10.1597/1545-1569(2001)038<0147:SAFTTO>2.0.CO;2. PMID 11294542. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Caples SM, Gami AS, Somers VK (2005). "Obstructive sleep apnea". Annals of Internal Medicine. 142 (3): 187–97. doi:10.1001/archinte.142.1.187. PMID 15684207. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Cohen MM, Kreiborg S (1992). "Upper and lower airway compromise in the Apert syndrome". American Journal of Medical Genetics. 44 (1): 90–3. doi:10.1002/ajmg.1320440121. PMID 1519659. {{cite journal}}: Unknown parameter |month= ignored (help)
  • de Miguel-Díez J, Villa-Asensi JR, Alvarez-Sala JL (2003). "Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children". Sleep. 26 (8): 1006–9. PMID 14746382. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Mathur R, Douglas NJ (1994). "Relation between sudden infant death syndrome and adult sleep apnoea/hypopnoea syndrome". Lancet. 344 (8925): 819–20. doi:10.1016/S0140-6736(94)92375-2. PMID 7916096. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Mortimore IL, Douglas NJ (1997). "Palatal muscle EMG response to negative pressure in awake sleep apneic and control subjects". American Journal of Respiratory and Critical Care Medicine. 156 (3 Pt 1): 867–73. PMID 9310006. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Perkins JA, Sie KC, Milczuk H, Richardson MA (1997). "Airway management in children with craniofacial anomalies". The Cleft Palate-craniofacial Journal. 34 (2): 135–40. doi:10.1597/1545-1569(1997)034<0135:AMICWC>2.3.CO;2. PMID 9138508. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Sculerati N, Gottlieb MD, Zimbler MS, Chibbaro PD, McCarthy JG (1998). "Airway management in children with major craniofacial anomalies". The Laryngoscope. 108 (12): 1806–12. doi:10.1097/00005537-199812000-00008. PMID 9851495. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Shepard JW, Thawley SE (1990). "Localization of upper airway collapse during sleep in patients with obstructive sleep apnea". The American Review of Respiratory Disease. 141 (5 Pt 1): 1350–5. PMID 2339852. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Sher AE (1990). "Obstructive sleep apnea syndrome: a complex disorder of the upper airway". Otolaryngologic Clinics of North America. 23 (4): 593–608. PMID 2199896. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Shott SR, Amin R, Chini B, Heubi C, Hotze S, Akers R (2006). "Obstructive sleep apnea: Should all children with Down syndrome be tested?". Archives of Otolaryngology--Head & Neck Surgery. 132 (4): 432–6. doi:10.1001/archotol.132.4.432. PMID 16618913. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Shouldice RB, O'Brien LM, O'Brien C, de Chazal P, Gozal D, Heneghan C (2004). "Detection of obstructive sleep apnea in pediatric subjects using surface lead electrocardiogram features". Sleep. 27 (4): 784–92. PMID 15283015. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Andreoli, Thomas E.; Cecil, Russell La Fayette; Carpenter, Charles C. J.; Griggs, Robert C.; Loscalzo, Joseph (2001). "Disordered Breathing". Cecil essentials of medicine. Philadelphia: W.B. Saunders. pp. 210–211. ISBN 978-0-7216-8179-5.
  • Strollo PJ, Rogers RM (1996). "Obstructive sleep apnea". The New England Journal of Medicine. 334 (2): 99–104. doi:10.1056/NEJM199601113340207. PMID 8531966. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Sullivan CE, Issa FG, Berthon-Jones M, Eves L (1981). "Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares". Lancet. 1 (8225): 862–5. doi:10.1016/S0140-6736(81)92140-1. PMID 6112294. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
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