OSA in Children and Adults: is it a global epidemic?

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Obstructive Sleep Apnea (OSA) and other sleep-related breathing disorders have gained prominence in the public eye over the years. The world has come to value their waking hours and how they are largely influenced by the quality of sleep we can achieve on a daily basis. By 2019 estimates were starting to surface that the global burden among adults aged 30-60 years with detectable symptoms had crossed 1.3 billion which was greater than our country’s own sizeable population at the time!

Let’s explore what this condition can entail, before dive into the impact it’s had and its notoriety over the years:

The disorder tends to affect middle-aged overweight and obese individuals (predominantly males); having said that the real key determinants to be watched out for are large neck circumferences and excess body fat since there has been an alarming rise in complaints from children and young adults facing such symptoms at progressively younger ages.

As with most medical conditions nowadays OSA is also laid out on a spectrum of severity, but unlike other conditions which arguably divide the community by emphasizing the importance of one end and downplaying the other; here I would say it helps people understand the range of presentations of the illness and how best to de-escalate and enter remission. Symptoms range from habitual snoring to waking up during episodes of breathlessness during sleep and subsequent morning headaches and daytime sleepiness depending on extent of obstruction to airflow.

In addition, this also means that it can’t be pigeon-holed as something we are born with and destined to by the cruel fate of our genetics alone nor can it be relegated entirely to the fault of the environment in which we have been raised. The split is so even that a few poor decisions in our lifestyle could push anyone to lose touch with regular exercise and healthy sleep scheduling leaving them just a hop and skip away from finding a place on the spectrum.

The management and outlook start out easy to follow and positive such as general weight loss and changes in ones’ lifestyle (sleep habits) but quickly ramp up through oral appliances to help keep the airway open all the way to surgical procedures like tonsillectomies. The real burden on living with it is noticed when conditions worsen and oxygen need be provided through nasal tubes just to ensure a good night’s rest. Yet the common misconception that sedatives are prescribed to help induce sleep and the rest swept under the rug must be corrected, for only select patients are given medication in the form of stimulants to ward off daytime sleep.

Now that we’re on the same page it’s time to show that this global crisis has been around and talked about for longer than we might assume. While researching I was reminded of an excerpt nearing 2 centuries of age from The Posthumous Papers of the Pickwick Club (1836) by the late literary monument Charles Dickens’:

‘Mr. Lowton hurried to the door… The object that presented itself to the eyes of the astonished clerk was a boy – a wonderfully fat boy – …standing upright on the mat, with his eyes closed as if in sleep. He had never seen such a fat boy, in or out or a travelling caravan; and this coupled with the utter calmness and repose of his appearance… smote him in wonder’

This eventually had its effect of dubbing OSA informally as Pickwickian syndrome (traced back to a paper published by Dr. Caton in the British Medical Journal as early as 1889) thanks to the author’s poetic description of the aforementioned symptoms in this child, almost prophetic of its future growth of prevalence in the pediatric population which is a major cause for concern that we observe today.

As the threat of the condition has traditionally loomed over the adult population, it has typically been underdiagnosed and under-recognized in children; the sad irony of being that children can be at greater risk due to the subtle interplay between developmental disorders and the paradigm shift of malnutrition from under to overnutrition in the urban jungle that society ever crawls towards. The worst affected being those with both limited movement and muscle weakness like this with debilitating neurological issues like Spina Bifida which should inspire us to double our vigilance and care with pediatric checkups and the upbringing of our children.

In the midst of all this, one might ask where our nation stands and to what extent this disease with hitherto relatively ‘western’ backed studies has affected our people?

The latter half of the 2010s yielded much information to inquisitive medical researchers with much the same query with studies being conducted among both rural and urban demographics using OSA Knowledge and Attitude (OSAKA) questionnaires showing: 2.4-4.9% prevalence in men roughly double the 1-2% in women in the urban subgroup and the numbers on the rural side averaging 3.73% not far behind. While these percentages may seem small, we must bear in mind our population size as a whole and note that rural estimates alone when scaled reach 7 figure numbers that continue to soar. The studies question the viability and accessibility of Level III sleep study tech necessary to properly diagnose such patients in these settings and while no definitive solution is forthcoming, it is a great comfort to see that the medical community is taking an active interest which bodes well for strategies to combat this menace.

The disorder has thus penetrated developing countries and has been indiscriminate of color or race and has been on the agenda of the WHO and gained the recognition of the global medical community. Sleep Apnea awareness day is celebrated on the 5^th of May across the world as we pay respect to the struggles of the sufferers and ring the bell to warn the globe and give people the tools to prevent themselves from descending this slippery slope. Hand in hand with obesity a growing public knowledge of its impact is important as we come to terms with prevention being the only realistic cure and only way to secure the healthy genes for a healthy future population and ultimately a healthy humanity tomorrow.

Symptoms (arranged most specific to more generalized symptoms):
1. Repeated episodes of obstructed breathing/ breathlessness also known as hypopnea
2. Repeated episodes of cessation of breathing known as apnea (usually followed by waking in the middle of sleep)

Snoring

Involuntary bodily jerks while sleeping
Morning headaches
Dry mouth on waking

Daytime sleepiness

Management (arranged in order starting from options for mild to severe cases of OSA):
1. General steps (with mind to conservative management and prevention) –
  1. Weight loss
  2. Reduction of alcohol consumption and smoking cessation
  3. Improving sleep hygiene:
    1. Avoid sedatives for at least 4-6 hours before bedtime
    2. Experimenting with alternative sleeping positions
    3. Avoiding sleep deprivation
    4. Completing one’s dinner and last fluid intake 1-2 hours before bedtime
    5. Avoiding exposure to bright screens or light around bedtime
  4. Specific measures –
    1. Oral appliances for milder cases e.g. Sleep and Nocturnal Obstructive Apnea Redactor (SNOAR)
    2. Devices to help maintain oxygen saturation
      1. Nasal CPAP (Continuous Positive Airway Pressure) device
      2. Bi-level positive Airway Pressure (BiPAP) device

Surgical options for severe cases –
1. Nasal reconstruction
2. Tonsillectomy
3. Soft palate implants
4. Uvulopalatopharyngoplasty (UPPP)
5. Bimalleolar advancement
6. Tracheostomy (rarely)

Pharmacological (drug-based) treatment – Drugs not usually prescribed to aid sound sleep; CNS stimulants (modafinil, armodafinil) instead given to prevent daytime sleepiness.