Cannabinoids and Sleep Apnea

Published by Jan Chaboya-Hembree

SLEEP APNEA

Definition

By Mayo Clinic staff
Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly and you feel tired even after a full night's sleep.
Sleep apnea occurs in two main types:
Obstructive sleep apnea, the more common form that occurs when throat muscles relax
Central sleep apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing
Additionally, some people have complex sleep apnea, which is a combination of both.
If you think you might have sleep apnea, see your doctor. Treatment is necessary to avoid heart problems and other complications.

Types of sleep apnea

Obstructive sleep apnea is the most common type of sleep apnea. It occurs when the soft tissue in the back of your throat relaxes during sleep, causing a blockage of the airway (as well as loud snoring).
Central sleep apnea is a much less common type of sleep apnea that involves the central nervous system, rather than an airway obstruction. It occurs when the brain fails to signal the muscles that control breathing. People with central sleep apnea seldom snore.
Complex sleep apnea is a combination of obstructive sleep apnea and central sleep apnea.

Causes

Causes of obstructive sleep apnea
Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), the tonsils and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in, and breathing momentarily stops. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so you can reopen your airway. This awakening is usually so brief that you do not remember it.

You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths, although this is rare. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you will feel sleepy during your waking hours.

People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they sleep well all night.

Causes of central sleep apnea
Central sleep apnea, which is much less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or have a difficult time getting or staying asleep. Like with obstructive sleep apnea, snoring and daytime sleepiness can occur. The most common cause of central sleep apnea is heart disease and, less commonly, a stroke. People with central sleep apnea may be more likely to remember awakening than are people with obstructive sleep apnea.

Causes of complex sleep apnea
People with complex sleep apnea have upper airway obstruction just like those with obstructive sleep apnea, but they also have a problem with the rhythm of breathing and occasional lapses of breathing effort.

Major signs and symptoms of sleep apnea:

Loud and chronic snoring
Choking, snorting, or gasping during sleep
Long pauses in breathing
Daytime sleepiness, no matter how much time you spend in bed
Other common signs and symptoms of sleep apnea include:
Waking up with a dry mouth or sore throat
Morning headaches
Restless or fitful sleep
Insomnia or nighttime awakenings
Going to the bathroom frequently during the night
Waking up feeling out of breath
Forgetfulness and difficulty concentrating
Moodiness, irritability, or depression

The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine.

When to see a doctor

Consult a medical professional if you experience, or if your partner observes, the following:

1. Snoring loud enough to disturb the sleep of others or yourself
2. Shortness of breath that awakens you from sleep
3. Intermittent pauses in your breathing during sleep
4. Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving

Many people do not think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. Talk to your doctor if you experience loud snoring, especially snoring tthat is punctuated by periods of silence.
Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.

Complications

Sleep apnea is a serious medical condition. Complications may include:
Cardiovascular problems. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive sleep apnea, your risk of high blood pressure (hypertension) can be up to two to three times greater than if you don't. The more severe your sleep apnea, the greater the risk of high blood pressure. However, obstructive sleep apnea increases the risk of stroke, regardless of whether or not you have high blood pressure. If there is underlying heart disease, these multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event. Studies also show that obstructive sleep apnea is associated with increased risk of atrial fibrillation, congestive heart failure and other vascular diseases.

In contrast, central sleep apnea usually is the result, rather than the cause, of heart disease.
Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. You may also feel irritable, moody or depressed. Children and adolescents with sleep apnea may do poorly in school or have behavior problems.
Complications with medications and surgery. Obstructive sleep apnea is also a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea and how it's treated. Undiagnosed sleep apnea is especially risky in this situation.
Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It is not uncommon for a partner to go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep deprived as well.

People with sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, a need to urinate frequently at night (nocturia), and impotence.
Gastroesophageal reflux disease (GERD) may be more prevalent in people with sleep apnea.
Children with untreated sleep apnea may be hyperactive and may be diagnosed with attention-deficit/hyperactivity disorder (ADHD).

Self-help treatment for sleep apnea

While a diagnosis of sleep apnea can be scary, it is a treatable condition. In fact, there are many things you can do on your own to help, particularly for mild to moderate sleep apnea. Home remedies and lifestyle modifications can go a long way in reducing sleep apnea symptoms.

Lifestyle changes that can help sleep apnea

Lose weight. Even a small amount of weight loss can open up your throat and improve sleep apnea symptoms.
Quit smoking. Smoking is believed to contribute to sleep apnea by increasing inflammation and fluid retention in your throat and upper airway.
Avoid alcohol, sleeping pills, and sedatives, especially before bedtime, because they relax the muscles in the throat and interfere with breathing.
Avoid caffeine and heavy meals within two hours of going to bed.
Maintain regular sleep hours. Sticking to a steady sleep schedule will help you relax and sleep better. Apnea episodes decrease when you get plenty of sleep.

Bedtime tips for preventing sleep apnea

Sleep on your side. Avoid sleeping on your back, as gravity makes it more likely for your tongue and soft tissues to drop and obstruct your airway.
Try the tennis ball trick. In order to keep yourself from rolling onto your back while you sleep, sew a tennis ball into a pocket on the back of your pajama top. Or wedge a pillow stuffed with tennis balls behind your back.
Prop your head up. Elevate the head of your bed by 4 to 6 inches or elevate your body from the waist up by using a foam wedge. You can also use a special cervical pillow.
Open your nasal passages. Try to keep your nasal passages open at night using a nasal dilator, saline spray, breathing strips, or a neti pot.

Throat exercises to reduce sleep apnea

Studies show that throat exercises may reduce the severity of sleep apnea by strengthening the muscles in airway, making them less likely to collapse.

Press tongue flat against the floor of mouth and brush top and sides with toothbrush. Repeat brushing movement 5 times, 3 times a day.
Press length of tongue to roof of mouth and hold for 3 minutes a day.
Place finger into one side of mouth. Hold finger against cheek while pulling cheek muscle in at same time. Repeat 10 times then rest and alternate sides. Repeat sequence 3 times.
Purse lips as if to kiss. Hold lips tightly together and move them up and to the right the up and to the left 10 times. Repeat sequence 3 times.
Place lips on a balloon. Take a deep breath through your nose then blow out through your mouth to inflate balloon as much as possible. Repeat 5 times without removing balloon from mouth.

Treatments

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. 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. If an individual suspects he or she may have sleep apnea, communication with their doctor about possible preprocedure screening may be in order.

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. The Stanford Center for Excellence in Sleep Disorders Medicine achieved a 95% cure rate of sleep apnea patients by surgery. Maxillomandibular advancement (MMA) is considered the most effective surgery for sleep apnea patients, because it increases the posterior airway space (PAS). The main benefit of the operation is that the oxygen saturation in the arterial blood increases. In a study published in 2008, 93.3.% of surgery patients achieved an adequate quality of life. Surgery led to a significant increase in general productivity, social outcome, activity level, vigilance, intimacy and sex. 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. However, health professionals are often unsure as to who should be referred for surgery and when to do so: some factors in referral may include failed use of CPAP or device use; anatomy which favors rather than impeding surgery; or significant craniofacial abnormalities which hinder device use

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.
A 2009 study published in the American Journal of Respiratory and Clinical Care Medicine found that "oropharyngeal exercises derived from speech therapy may be an effective treatment option for patients with moderate" obstructive sleep apnea ,

Continuous Positive Airflow Pressure (CPAP) for sleep apnea

Continuous Positive Airflow Pressure, or CPAP for short, is the gold standard treatment for moderate to severe obstructive sleep apnea. In many cases, you’ll experience immediate symptom relief and a huge boost in your mental and physical energy. The CPAP device is a mask-like machine that provides a constant stream of air which keep your breathing passages open while you sleep. Most CPAP devices are the size of a tissue box.
If you have given up on sleep apnea machines in the past because of discomfort, you owe it to yourself to give them a second look. CPAP technology is constantly being updated and improved. The new CPAP devices are lighter, quieter, and more comfortable, so make sure your sleep apnea device is up to date.

Dental devices and surgery for sleep apnea

If you have tried CPAP and self-help tips and your sleep apnea persists, you may benefit from a dental device or surgical treatment.
Dental devices for sleep apnea
Most dental devices are acrylic and fit inside your mouth, much like an athletic mouth guard. Others fit around your head and chin to adjust the position of your lower jaw. Two common oral devices are themandibular repositioning device and the tongue retaining device. These devices open your airway by bringing your lower jaw or your tongue forward during sleep.
Dental devices are only effective for mild to moderate sleep apnea. There are also a number of troubling side effects from using this type of treatment, including soreness, saliva build-up, nausea, and damage or permanent change in position of the jaw, teeth, and mouth.
It is very important to get fitted by a dentist specializing in sleep apnea, and to see the dentist on a regular basis for any dental problems that may occur.

Cannabinoids and Sleep Apnea

www.youtube.com/watch?v=nBpZunQHi8g

Research

One preclinical study is cited in the scientific literature investigating the role of cannabinoids on sleep-related apnea. Writing in the June 2002 issue of the journal of the American Academy of Sleep Medicine, researchers at the University of Illinois (at Chicago) Department of Medicine reported "potent suppression" of sleep-related apnea in rats administered either exogenous or endogenous cannabinoids. Investigators reported that doses of delta-9-THC and the endocannabinoid oleamide each stabilized respiration during sleep and blocked serotonin-induced exacerbation of sleep apnea in a statistically significant manner. No follow up investigations have taken place assessing the use of cannabinoids to treat this indication. However, several recent preclinical and clinical trials have reported on the use of THC, natural cannabis extracts and endocannabinoids to induce sleep and/or improve sleep quality.

Researh

Functional role for Cannabinoids in respiratory stability during sleep.Carley DW, Paviovic S, Janelidze M, Radulovacki M.Department of Medicine, University of Illinois at Chicago, 60612, USA.
STUDY OBJECTIVES: Serotonin, acting in the peripheral nervous system,can exacerbate sleep-related apnea, and systemically administered serotonin antagonists reduce sleep-disordered respiration in rats an bulldogs. Because Cannabinoid receptor agonists are known to inhibit the excitatory effects of serotonin on nodose ganglion cells, we examined the effects of endogenous (oleamide) and exogenous (delta9-tetrahydrocannabinol; delta9THC) cannabimimetic agents on sleep-related apnea.

DESIGN: Sleep architecture, respiratory pattern, and apnea expression in rats were assessed by polysomnography. A repeated measures, within-subjects, fully nested crossover design was used in which each animal was recorded on exactly 12 occasions.

PARTICIPANTS: Eleven adult male Sprague-Dawley rats were instrumented for chronic polysomnography.

INTERVENTIONS: Animals were recorded following intraperitoneal injection of various doses of delta9THC, oleamide, and serotonin, alone and in combination.

MEASUREMENTS AND RESULTS: Our data show that delta9THC and oleamide each stabilized respiration during all sleep stages. With delta9THC, apnea index decreased by 42% (F=2.63; p=0.04) and 58% (F=2.68; p=0.04) in NREM and REM sleep, respectively. Oleamide produced equivalent apnea suppression.

This observation suggests an important role for endocannabinoids in maintaining autonomic stability during sleep. Oleamide and delta9THC blocked serotonin-induced exacerbation of sleep apnea (p<0.05 for each), suggesting that inhibitory coupling between Cannabinoids and serotonin receptors in the peripheral nervous system may act on apnea expression.

CONCLUSIONS: This study demonstrates potent suppression of sleep-related apnea by both exogenous and endogenous Cannabinoids. These findings are of relevance to the pathogenesis and pharmacological treatment of sleep-related breathing disorders.

Recommendation: Whole plant extracts, tinctures. Sativa x Indica hybrid

REFERENCES

[1] Carley et al. 2002. Functional role for cannabinoids in respiratory stability during sleep. Sleep 25: 399-400.
[2] Murillo-Rodriguez et al. 2003. Anandamide enhances extracellular levels of adenosine and induces sleep: an in vivo micro dialysis study. Sleep 26: 943-947.
[3] Nicholson et al. 2004. Effect of delta-9-tetrahydrocannabinol and cannabidiol on nocturnal sleep and early-morning behavior in young adults. Journal of Clinical Pharmacology 24: 305-313.
[4] Christine Perras. 2005. Sativex for the management of multiple sclerosis symptoms. Issues in Emerging Health Technologies 72: 1-4

References

1. "Sleep Apnea: What Is Sleep Apnea?". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services. 2009-05. Retrieved 2010-08-05.
2. Morgenthaler TI, Kagramanov V, Hanak V, Decker PA (September 2006). "Complex sleep apnea syndrome: is it a unique clinical syndrome?". Sleep 29 (9): 1203–9. PMID 17040008. Lay summary – Science Daily (September 4, 2006).
3. "Sleep Apnea: Key Points". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services.
4. a b c "FMCSA Sleep Apnea".
5. Redline S, Budhiraja R, Kapur V et al. (2007). "Reliability and validity of respiratory event measurement and scoring". J Clin Sleep Med 3 (2): 169–200. PMID 17557426.
6. AASM Task Force (1999). "Sleep–Related Breathing Disorders in Adults-Recommendations for Syndrome Definition and Measurement Techniques in Clinical Research". SLEEP 22 (5): 667–689. PMID 10450601.
7. Ruehland WR, Rochford PD, O'Donoghue FJ, Pierce RJ, Singh P, Thornton AT (2009). "The new aasm criteria for scoring hypopneas: Impact on the apnea hypopnea index". SLEEP 32 (2): 150–157. PMC 2635578. PMID 19238801.
8. Sériès, F.; Marc, I.; Cormier, Y.; La Forge, J. (1993). "Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome". Annals of internal medicine 119 (6): 449–453. PMID 8357109. edit
9. Whitelaw WA, Brant RF, Flemons WW (2005). "Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea.". Am J Respir Crit Care Med 171 (2): 188–93. doi:10.1164/rccm.200310-1360OC. PMID 15486338. Review in: ACP J Club. 2005 Jul-Aug;143(1):21
10. "Sleep Apnea: Who Is At Risk for Sleep Apnea?". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services.
11. Neill AM, Angus SM, Sajkov D, McEvoy RD (January 1997). "Effects of sleep posture on upper airway stability in patients with obstructive sleep apnea". American Journal of Respiratory and Critical Care Medicine 155 (1): 199–204. PMID 9001312.
12. Xiheng, Guo; Chen, Wang; Hongyu, Zhang; Weimin, Kong; Li, An; Li, Liu; Xinzhi, Weng (2003). The Study Of The Influence Of Sleep Position On Sleep Apnea. Cardinal Health.
13. Loord H, Hultcrantz E (August 2007). "Positioner--a method for preventing sleep apnea". Acta Oto-laryngologica 127 (8): 861–8.doi:10.1080/00016480601089390. PMID 17762999.
14. a b Szollosi I, Roebuck T, Thompson B, Naughton MT (August 2006). "Lateral sleeping position reduces severity of central sleep apnea / Cheyne-Stokes respiration". Sleep 29 (8): 1045–51. PMID 16944673.
15. Vennelle M; White S; Riha RL; Mackay T; Engleman HM; Douglas NJ. Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). SLEEP 2010;33(2):267-271.
16. Morris LG, Kleinberger A, Lee KC, Liberatore LA, Burschtin O (November 2008). "Rapid risk stratification for obstructive sleep apnea, based on snoring severity and body mass index". Otolaryngology--Head and Neck Surgery 139 (5): 615–8. doi:10.1016/j.otohns.2008.08.026.PMID 18984252.
17. Yan-fang S, Yu-ping W (August 2009). "Sleep-disordered breathing: impact on functional outcome of ischemic stroke patients". Sleep Medicine 10(7): 717–9. doi:10.1016/j.sleep.2008.08.006. PMID 19168390.
18. Bixler EO, Vgontzas AN, Lin HM, et al. (November 2008). "Blood pressure associated with sleep-disordered breathing in a population sample of children". Hypertension 52 (5): 841–6. doi:10.1161/HYPERTENSIONAHA.108.116756. PMID 18838624.
19. Leung RS (2009). "Sleep-disordered breathing: autonomic mechanisms and arrhythmias". Progress in Cardiovascular Diseases 51 (4): 324–38.doi:10.1016/j.pcad.2008.06.002. PMID 19110134.
20. Silverberg DS, Iaina A, Oksenberg A (January 2002). "Treating obstructive sleep apnea improves essential hypertension and life". American Family Physician 65 (2): 229–36. PMID 11820487.
21. Grigg-Damberger M (February 2006). "Why a polysomnogram should become part of the diagnostic evaluation of stroke and transient ischemic attack". Journal of Clinical Neurophysiology 23 (1): 21–38. doi:10.1097/01.wnp.0000201077.44102.80. PMID 16514349.
22. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V (November 2005). "Obstructive sleep apnea as a risk factor for stroke and death". The New England Journal of Medicine 353 (19): 2034–41. doi:10.1056/NEJMoa043104. PMID 16282178.
23. Kumar R, Birrer BV, Macey PM, et al. (June 2008). "Reduced mammillary body volume in patients with obstructive sleep apnea". Neuroscience Letters 438 (3): 330–4. doi:10.1016/j.neulet.2008.04.071. PMID 18486338.
24. Kumar R, Birrer BV, Macey PM, et al. (June 2008). "Reduced mammillary body volume in patients with obstructive sleep apnea". Neuroscience Letters 438 (3): 330–4. doi:10.1016/j.neulet.2008.04.071. PMID 18486338. Lay summary – Newswise (June 6, 2008).
25. Dernaika T, Tawk M, Nazir S, Younis W, Kinasewitz GT (July 2007). "The significance and outcome of continuous positive airway pressure-related central sleep apnea during split-night sleep studies". Chest 132 (1): 81–7. doi:10.1378/chest.06-2562. PMID 17475636.
26. Thomas RJ (March 2005). "Effect of added dead space to positive airway pressure for treatment of complex sleep-disordered breathing". Sleep Medicine 6 (2): 177–8. doi:10.1016/j.sleep.2004.11.004. PMID 15716223.
27. a b c "How Is Sleep Apnea Treated?". National Heart, Lung, and Blood Institute.
28. Machado MA, Juliano L, Taga M, de Carvalho LB, do Prado LB, do Prado GF (December 2007). "Titratable mandibular repositioner appliances for obstructive sleep apnea syndrome: are they an option?". Sleep & Breathing 11 (4): 225–31. doi:10.1007/s11325-007-0109-y. PMID 17440760.
29. White DP, Zwillich CW, Pickett CK, Douglas NJ, Findley LJ, Weil JV (October 1982). "Central sleep apnea: Improvement with acetazolamide therapy". Archives of Internal Medicine 142 (10): 1816–9. doi:10.1001/archinte.142.10.1816. PMID 6812522.
30. a b "Sleep Apnea". Diagnosis Dictionary. Psychology Today.
31. Mayos M, Hernández Plaza L, Farré A, Mota S, Sanchis J (February 2001). "[The effect of nocturnal oxygen therapy in patients with sleep apnea syndrome and chronic airflow limitation"] (in Spanish). Archivos de Bronconeumología 37 (2): 65–8. PMID 11181239.
32. Breitenbücher A, Keller-Wossidlo H, Keller R (November 1989). "[Transtracheal oxygen therapy in obstructive sleep apnea syndrome]" (in German).Schweizerische Medizinische Wochenschrift 119 (46): 1638–41. PMID 2609134.
33. Hsu AA, Lo C (December 2003). "Continuous positive airway pressure therapy in sleep apnoea". Respirology 8 (4): 447–54. doi:10.1046/j.1440-1843.2003.00494.x. PMID 14708553.
34. Li KK, Riley RW, Powell NB, Troell R, Guilleminault C (November 1999). "Overview of phase II surgery for obstructive sleep apnea syndrome".Ear, Nose, & Throat Journal 78 (11): 851, 854–7. PMID 10581838.
35. Prinsell JR (November 2002). "Maxillomandibular advancement surgery for obstructive sleep apnea syndrome". Journal of the American Dental Association 133 (11): 1489–97; quiz 1539–40. PMID 12462692.
36. a b c d Lye KW, Waite PD, Meara D, Wang D (May 2008). "Quality of life evaluation of maxillomandibular advancement surgery for treatment of obstructive sleep apnea". Journal of Oral and Maxillofacial Surgery 66 (5): 968–72. doi:10.1016/j.joms.2007.11.031. PMID 18423288.
37. Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C (2000). "Long-Term Results of Maxillomandibular Advancement Surgery". Sleep & Breathing4 (3): 137–140. doi:10.1007/s11325-000-0137-3. PMID 11868133.
38. MacKay, Stuart (June 2011). "Treatments for snoring in adults". Australian Prescriber (34): 77-79.
39. Johnson, T. Scott; Broughton, William A.; Halberstadt, Jerry (2003). Sleep Apnea-The Phantom of the Night: Overcome Sleep Apnea Syndrome and Win Your Hidden Struggle to Breathe, Sleep, and Live. New Technology Publishing. ISBN 978-1-882431-05-2.[page needed]
40. http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_LivingWith.html
41. Puhan MA, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O (February 2006). "Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial". BMJ 332 (7536): 266–70. doi:10.1136/bmj.38705.470590.55. PMC 1360393.PMID 16377643.
42. Kátia C. Guimarães, Luciano F. Drager, Pedro R. Genta, Bianca F. Marcondes and Geraldo Lorenzi-Filho Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome American Journal of Respiratory and Critical Care Medicine Vol 179. pp. 962-966, (2009)
43. a b Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (April 1993). "The occurrence of sleep-disordered breathing among middle-aged adults". The New England Journal of Medicine 328 (17): 1230–5. doi:10.1056/NEJM199304293281704. PMID 8464434.
44. a b Lee W, Nagubadi S, Kryger MH, Mokhlesi B (June 1, 2008). "Epidemiology of obstructive sleep apnea: a population-based perspective". Expert Rev Respir Med 2 (3): 349–64. doi:10.1586/17476348.2.3.349. PMC 2727690. PMID 19690624.
45. Young T, Peppard PE, Gottlieb DJ (May 2002). "Epidemiology of obstructive sleep apnea: a population health perspective". American Journal of Respiratory and Critical Care Medicine 165 (9): 1217–39. doi:10.1164/rccm.2109080. PMID 11991871.
46. ^ Kapur V, Blough DK, Sandblom RE, et al. (September 1999). "The medical cost of undiagnosed sleep apnea". Sleep 22 (6): 749–55.PMID 10505820.
47. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. (April 1981). "Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares". Lancet 18;1 (8225): 862–5. doi:10.1016/S0140-6736(81)92140-1. PMID 6112294.
General references
Kalra M, Chakraborty R (March 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.
"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. August 1999. PMID 10450601.
Bell RB, Turvey TA (March 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.
Caples SM, Gami AS, Somers VK (February 2005). "Obstructive sleep apnea". Annals of Internal Medicine 142 (3): 187–97.doi:10.1001/archinte.142.1.187. PMID 15684207.
Cohen MM, Kreiborg S (September 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.
de Miguel-Díez J, Villa-Asensi JR, Alvarez-Sala JL (December 2003). "Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children". Sleep 26 (8): 1006–9. PMID 14746382.
Mathur R, Douglas NJ (September 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.
Mortimore IL, Douglas NJ (September 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.
Perkins JA, Sie KC, Milczuk H, Richardson MA (March 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.
? Sculerati N, Gottlieb MD, Zimbler MS, Chibbaro PD, McCarthy JG (December 1998). "Airway management in children with major craniofacial anomalies".The Laryngoscope 108 (12):