Seventy respiratory interruptions per hour, some of them lasting two minutes. This is how the worst nights of José Manuel Fernández Pérez, 52, have passed since 2017. He remembers that waking up each day was a combination of “headache, sleep, permanent fatigue and burning, a lot of burning; all day with Almax and Omeoprazole”. But he was unaware of those respiratory stops, so he never related his days of fatigue with those fatal nights. His family doctor did and sent him to the pulmonologist. One night monitored in the Sleep Respiratory Disorders Unit of the Virgen de las Nieves University Hospital in Granada allowed him to name his problem, obstructive sleep apnea (OSA). A disease that not only affects him, but those who live with him: “He had tremendous snoring, which could be heard three rooms away, and my wife woke me up from time to time, frightened by my movements,” he says. That is the life, with its pluses and minuses, of almost five million people affected by OSA in Spain.
That figure, according to doctors Germán Sáez Roca and Carlos Martín Carrasco, from the unit in Granada that treated this patient, affects 13% of men and 8% of women and, based on reports from various patients of this type of apnea, harms a much larger number, since it seriously affects couples who share a bed. Apnea, for those who are next to you, is an endless succession of snoring and respiratory pauses that can be frightening. For this reason, as in the case of Manuela Extremera, a patient who is preparing for intense nocturnal monitoring the night that EL PAÍS visits the Sleep Disorders Unit of the Granada hospital, “the night is a coming and going.” “I would go to the sofa so as not to disturb my husband and other times it was he who would leave, fed up with my snoring.”
Extremera comments on it while Rosa Moreno, a nurse who has worked in this unit for 27 years, works to carefully place the 30 electrodes —now wireless— that Extremera will require for her polysomnography, the most complete study possible in this area. It will last from when the patient falls asleep, around 11 at night, until seven in the morning. Once the inmates fall asleep (four on the day of the report), Moreno or her partner María José will spend the night attentive to the screens that monitor those electrodes and the speakers and cameras that record their movement and sounds.
OSA is diagnosed when, while we sleep, there are more than five total or partial closures of the upper airway that last more than 10 seconds. Doctors Sáez and Martín have come to see stops of almost three minutes —“very exceptional cases”, they say—. This alternating but frequent shortness of breath has serious repercussions on the health of those who suffer from it. Paco Bullejos, 59, is also preparing to spend the night in the hospital. Aside from the fatigue, he has “lots of migraines, severe back pain, and a feeling of weight on his shoulders.” He has gone through the neurologist, through the digestive and, finally, has reached the pulmonologists. His hope is that they find the source of his problems and he doesn’t have to stop while he drives from time to time to rest.
Bad habits and evolution
That is a common circumstance in OSA patients, doctors say. Hardly anyone comes directly to your unit. Sometimes, family doctors, from the symptoms, detect it quickly. Sometimes, it is another specialist who refers them. The origin of this apnea is, generally, obesity and poor lifestyle habits, but not only. Half jokingly, half seriously, Dr. Martín attributes this problem to “human evolution”: “When we lost our snout, OSA arose.” Martín refers to the second great reason for apnea, certain craniofacial alterations, or in another way, certain morphologies of the face –mainly nose and mouth– that cause breathing difficulties when lying down.
Ana Muñoz is the third of the four patients who sleep in the sleep disorders unit and is more in line with the usual pattern of apnea: “I snore a lot and in the hospital where I work, at night, the colleagues tell me that I transpose . That scares me and that’s why I’ve come.” For transposing, she refers to frequent and long respiratory stops. “I have been tired for years, but now I am afraid.”
The usual solution to apnea is, in principle, easy. A machine that facilitates breathing, the CPAP, at the cost of certain paraphernalia. It is a mask that you have to put on your face and that is attached to the little noiseless machine. “If it makes a noise, it is always less than snoring,” says Dr. Sáez humorously. In cases where OSA is due to obesity and poor lifestyle habits, a study by the University of Granada tried a few weeks ago that it is possible to improve the lives of these patients to the point where they can sleep without CPAP. Up to 60% of the patients who have participated in the study by Almudena Carneiro Barrera and Jonatan Ruiz, from the Sleep and Health Promotion Laboratory of the University of Granada, have been able to leave the machine that assisted them every night thanks to a program of eight weeks, demanding and supervised, of improvement in the habits of nutrition, doing physical exercise and giving up alcohol and tobacco.
José Manuel Fernández, the two-minute stop patient, is one of them: “I started walking three kilometers, I reached 19 and now I stay at 6 or 8 at a good pace. I have reduced sugar, fat and alcohol and I have lost weight”. That is the solution on the part of the patients. Easy to say and difficult to execute, recognize those who have gone through the program. Hence, it is not often that patients manage to wean themselves off CPAP.
Side effects can go beyond tiredness and headaches. OSA is a risk factor that can, under certain circumstances, trigger stroke, cognitive impairment in the elderly, depression and other ailments, in addition to the perceived poor performance at work and higher accident rates both at work and while driving vehicles. But the message is that, if well treated, the patient, with CPAP, with better lifestyle habits, with maxillofacial or obesity surgery or some other methods, can live with their problem and lead a normal life.
Nighttime rest is measured not so much in hours of sleep as in sleep cycles completed. A cycle lasts between an hour and a half or two and has five phases, the first two, superficial, the two intermediate, the fundamental ones, deep and the last one, the REM, of transition. The problem with apnea is that it often prevents the passage from the superficial to the deep, taking us back to the beginning or even the REM phase, skipping the deep and restorative phase. Dr. Martín explains that rest requires “at least three complete cycles in a row” that will take between five and six hours, but “the ideal is between three and five cycles”, something that will take us from seven and a half hours onwards, according to each person.
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