Sleep Apnea Treatment Trials - Research Paper Example

? LITERATURE REVIEW: SLEEP APNEA TREATMENT TRIALS Sleep apnea is a sleeping disorder characterized by the cessation of airflow in the airways (apnea) and a reduction of oxygen intake by 50% and above (hypopnea) for 10 seconds or more per hour during sleep. The total number of both hypopnea and apnea during is known as the apnea-hypopnea index (AHI), and a higher equates to a severity in the sleep apnea. While several procedures such as surgical operations and continuous positive airway pressure (CPAP) are available to reduce the AHI and the effects of sleep apnea among patients, several other less-invasive alternative procedures are clinically-tested in assessing effectiveness levels. Based on various reports, it is suggested that in any kind of treatment for sleep apnea, a strict adherence to treatment methods is the key for prolonged AHI reduction among patients. Literature Review: Sleep Apnea Treatment Trials Sleep apnea is defined as the cessation of airflow through the nose or mouth for at least 10 seconds every sleeping hour, which decreases at least 3% oxyhemoglobin in the blood and a reduction of 50% in oxygen intake among patients (Noseda, et al., 2004). The total of apnea (due to obstruction) and hypopnea (airflow reduction) events during sleep is measured as the apnea-hypopnea index (AHI), and the number is positively correlated to the severity of sleep apnea. Possible causes are multifactorial, ranging from abnormal cranial structures, relaxed airway muscles or problems with respiratory control during sleep (Barnes, et al., 2009). Effects can range from excessive daytime sleepiness, dysfunction in the patient’s metabolism and neurocognition, cardiovascular disorders, and mood swings with a decreased quality of life (Ackel-D’Elia, et al., 2012; Kline, et al., 2012; Quan, et al., 2007). The most widely accepted methods to alleviate the symptoms of apnea are either surgery or the use of a continuous positive airway pressure (CPAP) mask, to increase the oxygen intake during sleep (Quan, et al., 2007; Sengul, et al., 2011). However, several researches have emerged that have significant or comparable results by using less-invasive procedures such as increasing physical activity levels or combining it with other methods, and while the issue of the low number of participants in some studies can be a hindrance to the acceptability of exercise as a way to reduce apnea effects, the number of trials that affirm positive effects must be looked upon to consider it as an effective and non-invasive alternative treatment for sleep apnea. Physical Activity Trials The increasing numbers of overweight and obesity triggered an increase in the number of patients suffering from sleep apnea, and one of the main reasons is that there is less physical activity that strengthens the muscles of the air passages and lungs, making the respiratory muscles weak and relaxed, preventing sufficient breathing of air (Barnes, et al., 2009; Giebelhaus, et al., 2000). In a study that compared a group of sleep apnea sufferers against a control-group, a simple six-minute walk test was used to assess breathing patterns, heart rate, blood pressure, and dyspnea (Alameri, Al-Kabab, & BaHammam, 2010). The study found out that while the physical activity did not cause drastic effects to the sleep apnea group, their hemodynamic responses were abnormal compared to the control group, concluding that a simple test can assess significant effects of mild physical activity otherwise unnoticeable by the patients. The study had limitations such as selection of low-risk participants for the control group, not investigating other contributing factors in exercise limitation, and conducting the study on a single ethnic group. However, further studies that are comprised by various ethnic groups may be studied and physical activity programs may be used in combination with their methods to establish the possibility of using the procedure for sleep apnea prognosis. The effects of exercise in sleep apnea on any kind of body-mass index (BMI), age, or race was researched for three years with a large sample size (n=1104) and yielded substantial evidence that the lack of physical activity could increase the risks of developing the disorder (Peppard & Young, 2004). The researchers concluded that the effects of additional exercise to any body type are the same: reduced daytime sleepiness; decreased sleep fragmentation and snoring, among others. While the study had a long timeframe and a large number of participants, there are still some limitations such as the use of surveys which created bias in the participants of the study and their reported improvement in sleep. Also, the variety of exercises among the participants were unable to rule out which kind of physical activity could create the most effective regimen for sleep apnea improvement, initiating other researches to focus on what type of exercise could have much more significant effects in sleep apnea improvement. In another experiment which tried to relate physical activity to an improvement in sleep apnea symptoms was conducted to assess both physical (pulmonary functions, AHI) and emotional (improved quality of life) effects on patients (Sengul, et al., 2009). Two groups consisting of a control group (no exercise) and an experimental group (exercise) were assessed after 12 weeks, and while there were no significant differences between respiratory and anthropomorphic measurements, the improvement on the exercise capacity, AHI, and quality of sleep and life were reported to be significant, concluding that despite the lack of significant effects on weight or respiration, additional physical activity could greatly affect the quality of sleep and improvement in quality of life among sleep apnea patients. The clinical trial was able to use both a control group without exercise and with exercise, which enables the researchers to create sound conclusions. Better and much more reliable results can be obtained using larger sample sizes and longer timeframes for the trial. Many experiments regarding the effects of moderate or heavy exercise on sleep apnea alleviation were conducted due to some subjects reporting a significant improvement in their quality of life and AHI, despite some reporting to have no improvement with their apnea. In a study which focused on the effects of additional exercise to the overall tone of pharyngeal muscles was able to establish the connection between added physical activity and the improvement of breathing muscles leading to an improvement in sleep apnea (Giebelhaus, et al., 2000). While the study concluded that additional exercise can strengthen weak respiratory muscles, there is a need to re-assess this claim due to the low numbers of participants (n=11) as well their lack of cardiovascular problems or ailments, which could affect the results of the tests. Another study by Kline and colleagues also focused on the effects of additional physical activity on sleep apnea using both aerobic exercises plus resistance training, and stretching. There were significant improvements to the subjects in the aerobic and resistance exercise groups compared to the stretching-only group, suggesting that improvements in sleep apnea can be observed upon adhering to exercise regimens but without altering other aspects in everyday living such as food intake (Kline, et al., 2011). However, the study needs to be conducted again in order to further establish the results since some participants backed out before the study was finished, and the reduction of the few numbers (resistance + aerobics, n=27,stretching, n=16) could create bottleneck effects or bias. There were also other effects that the researchers must also have to take into account, thus the researchers reported other results of the tests in another article in the following year. The researchers submitted a related report which is concerned with the relationship of daytime functioning, sleepiness, depressive symptoms, mood and quality of life before and after participants participated in resistance plus aerobic exercise or stretching (Kline, et al., 2012). It is assumed that the participants of the studies were the same ones from the study published in the previous year due to the similarities of the number of participants per regimen (resistance + aerobics, n=27, stretching, n=16). The study concluded that some aspects such as sleepiness, functional impairment symptoms, fatigue, and quality of life were reported by the exercise subjects to have improved in comparison with the stretching-only group, but the changes in the severity of apnea were not significant enough to have caused the changes. Similar to the previous article, it is suggested that the study be conducted to larger groups, and also within a longer timeframe to further solidify the claims of the study. Disordered breathing among sleep apnea patients was observed to become less severe along with the increase in physical activities, and an experiment by Qang, et al. was able to assert this claim using a 3-hour per week program in both genders (n=4275). The study was able to conclude that a minimum of three hours of vigorous physical activity per week was able to reduce disordered sleeping during sleep, but there were greater ties between gender and obesity since the males and obese were able to report greater significant differences as opposed to females and those below the obese BMI category (Qang, et al., 2007). The study’s limitation is similar to Peppard and Young’s study due to relying only on self-reported improvements as well as the use of surveys in the experiments, which limits the variety of participants and creates high variation between the reported and the actual intensity of said physical activities. It is recommended that clinical trials be conducted to assure the uniformity of means and measurements as well as participant traits. Physical Activity in Combination with Other Interventions The previous studies mentioned solely focused on increased physical activity alone as a way of decreasing the effects of sleep-apnea among patients. Other researches focusing on the combination of physical activity and another intervention are also available. A group of scientists combined the effects of using CPAP along with additional physical activity and measuring the effects on subjective daytime sleepiness, physical functioning, and general health perception among a group of males with BMI ranging from overweight to obese (Ackel-D’Elia, et al., 2012). Researchers concluded that while there are no significant differences between CPAP alone and CPAP + physical activity among patients, those with additional exercise reported to have better quality of life based on self-assessments. The study could have additional trials focusing on the effects of the two treatments to females as well as increasing the number of participants and the length of the study, in order to remove gender bias and increase the reliability of data by increasing the sample population. In another study, added physical activity combined with a diet program was also conducted to assess whether there would be significant effects on weight reduction and reduction of sleep apnea among middle-aged obese patients of both genders (Barnes, et al., 2009). Assessment was done for 16 weeks, and a follow-up was done after 12 months. It was concluded that aside from the significant weight reduction among participants, their AHI were also reduced and the quality of life improved, even if the sleep apnea was not fully treated. While the duration of the study is reasonable, there were only 10 participants and this limitation makes the results rather unreliable, thus additional studies with increased number of participants can be conducted to reaffirm the results. Summary and Conclusion All of the studies critiqued were able to establish the relationship between additional physical activity and the improvement in the quality of life and sleep among sleep apnea patients. While most of the clinical trials used a sample size of less than 100 with some inconsistencies between the parameters for both the control and experimental groups, as well as the reliance on survey and self-reports to those with larger sample sizes, due to the number of trials and published articles concerning the positive effects of physical activity on sleep apnea symptoms, these researchers were able to report that the patients indeed have perceived significant improvements in the quality of their lives and sleeping. This can be attributed to the improvement of the tone and strength of respiratory muscles due to heavy breathing while undergoing vigorous physical activities, which then prevents the relaxation of muscles and improvement of breathing during sleep. Thus the majority of the studies were able to establish the importance of additional physical activity in improving sleep apnea symptoms without heavily relying on invasive procedures or on CPAP alone. 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Sengul, Y., Ozalevli, S., Oztura, I., Itil, O., & Baklan, B. (2011). The effect of exercise on obstructive sleep apnea: a randomized and controlled trial. Sleep and Breathing, 15:49-56. Read More