While they sleep, one billion individuals worldwide stop breathing. Do you count among them?

I believed I was going to pass away.

I was so worn out during the day that my knees would give way. As I was driving, my head would dip before I would catch it. I had lines of fatigue on my face.

I used to have nightly fits of sleep with trembling legs, then I would suddenly wake up gasping for air and with a beating heart.

My physician was perplexed. He requested blood tests, urine tests, and an electrocardiogram since he suspected that the cause of the palpitations at night might be heart disease.

No, my heart was healthy. My blood had no issues.

He placed a colonoscopy order. I had almost reached the appropriate age to have one by the time late 2008 came around. So that a gastroenterologist could thoroughly examine my intestines, I forced down the four liters of Nulytely.

When I came to, the doctor told me that my colon was clear. zero cancer. not even a single alarming polyp.

However. One item was present.

At one time while you were underwater, you stopped breathing, he stated. You ought to look into that. The issue can be sleep apnea.

I was unaware of it.

Dynamic changes occur throughout the body during sleep. Your respiration, blood pressure, and body temperature will all rise and fall as you go through its many phases. Except for the REM phases, which can make up to a quarter of your sleep, your muscles are generally still tense as they are when you are awake. Most key muscle groups greatly relax during periods. However, if your throat muscles unconsciously relax too much, your airway will close and get obstructed. Obstructive sleep apnea, from the Greek ápnoia, or "breathless," is the outcome.

Your air supply is repeatedly disrupted when you have sleep apnoea, which lowers blood oxygen levels. Then you start to move while gasping for air. The negative ramifications of this are numerous and severe, and it can occur hundreds of times per night.

The heart must work harder to pump blood more quickly in response to apnea in order to make up for the lack of oxygen. Variable oxygen levels can contribute to the development of arterial plaque, which raises the risk of heart disease, hypertension, and stroke. The US National Commission on Sleep Disorders Research estimated in the mid-1990s that 38,000 Americans died annually from heart disease made worse by apnoea.

Additionally, there is mounting evidence that the disease influences how glucose is metabolized, fosters insulin resistance, which can result in type 2 diabetes, and promotes weight gain.

The weariness from never getting a full night's sleep is another factor, and it's linked to memory loss, anxiety, and melancholy. Inattention brought on by sleep deprivation can also result in road collisions. According to a 2015 research of Swedish drivers, people who have sleep apnea are 2.5 times more likely to be in an accident than those who don't. Additionally, it increases absenteeism, and those with apnea are more likely to lose their employment than those without it.

According to one study, those with severe sleep apnea were overall three times more likely to pass away over the course of an 18-year period than those without.

However, there is a gap between the harm that the illness produces and the public's view of it as a threat, much like with smoking during the early decades after it was known to be fatal. According to a study commissioned by the American Academy of Sleep Medicine, which estimates that it affects 12% of US adults but that 80% of cases go untreated, they "fail to correlate sleep apnea with its many significant comorbidities." This prevalence is also seen globally; a 2019 study estimates that almost a billion people worldwide have mild-to-severe sleep apnea.

Currently, research is attempting to catch up. In-depth investigations into hypoxia—the body's response to low oxygen levels—as well as the development of novel surgical techniques and medical devices—have all been conducted in an effort to find a cure. But interest is missing at the highest echelons of medicine. Cancer and anemia were highlighted in the announcement that the 2019 Nobel Prize in Physiology or Medicine had been granted for research on how cells adapt to fluctuations in oxygen levels, but the most prevalent hypoxia-related illness of all, sleep apnoea, was not.

I have profound psychological insight into only one of the billion or so people suffering from sleep apnoea worldwide—me. Most of them are probably not even aware of their condition, let alone seeking treatment. My main concern was straightforward: how do I solve this? As the prospect that I might be dealing with an under-researched but potentially fatal health ailment began to dawn on me.

Despite the fact that there are enduring risk factors for sleep apnoea, such as obesity, a large neck or tonsils, a tiny jaw, or getting older, it doesn't manifest itself until after a person falls asleep. It can only be identified by keeping an eye on someone's sleep patterns.

So, at the beginning of 2009, motivated by both exhaustion and my doctor's advice, I scheduled a visit to a facility named Northshore Sleep Medicine in Northbrook, Illinois.

A sleep medicine expert named Lisa Shives welcomed me. She looked down my neck before advising me to participate in a polysomnogram, or sleep study, during which my heart rate, blood oxygen levels, breathing, and muscle and brain activity would be monitored.

A few weeks later, on a Thursday at 9pm (an odd time for a doctor's appointment), I went back for this. The weather was dark.

I was led by a technician into a little bedroom that had a double bed and an armoire. A horizontal window behind the bed provided a view of an equipment-filled area that resembled a lab. I put on some flannel pajamas before calling the technician back. I was given a fishnet shirt to wear to keep the cables in place after she inserted electrodes over my chest and head.

I noticed myself in the mirror on the armoire. I mumbled to my reflection, "A poor appearance." I unavoidably came across as middle-aged due to my round, haggard face and the squares of tape holding the electrodes to my cheek, forehead, and chin. and worn out.

I turned out the light at around ten o'clock and promptly went to sleep.

At 4.30 in the morning, I groggily offered to attempt to go back to sleep, but the technician informed me that they had six hours of data and that I may leave. She informed me that my apnoea was "severe" after I had dressed and that Dr. Shives will provide further information later. Instead of treating myself to a celebration brunch as planned, I just went home. I was afraid rather than hungry.

A few weeks later, I returned to Northshore, but this time it was daytime. Shives put me in front of a screen with a small black-and-white film of me dozing off in the corner, along with a variety of colored squiggles and numbers. It was frightening, like witnessing a dead version of myself at a crime scene.

Speaking of passing away, Shives informed me that I had been without breath for approximately two minutes, or 112 seconds.

Using a pulse oximeter, a person's blood oxygen saturation should be between 95% and 100%. A value in the upper 80s may be experienced by those who have chronic obstructive pulmonary disease. Mine had occasionally fallen to 69%.

The severity of that In a surgical guide, the World Health Organization advises that if a patient's blood oxygenation falls to 94% or less, they should be examined right once to discover if their airways are obstructed, their lungs have collapsed, or there is an issue with their circulation.

My options were scant. Shives suggested that I have an operation called a uvulopalatopharyngoplasty, which involves removing tissue from my soft palate and expanding my airway at the back of my throat. However, it would be bloody, and recovery might be difficult and protracted. Shives suggested it but promptly ruled it out, which I later believed was done to lessen the impact of the second possibility—the mask.

After sleep apnoea was discovered, there was just one treatment available for the first 15 years. You might require a tracheotomy, a surgical treatment that involves making a small incision in your throat called a tracheostomy to bypass your failing upper airway. Although it provided dependable relief, it also had severe problems of its own.

After years of groundbreaking research on sleep disorders, Alan Schwartz, a professor of medicine at Johns Hopkins University in Baltimore, recently announced his retirement. "In the early days, doctors didn't know much," he adds. "When I started in the 1980s, the most severe apnoea patients were just the tip of the iceberg. Due to inadequate oxygenation of their body tissues, they would awaken with headaches. Feeling quite weary, as you might anticipate. Depressed, their moods had changed, and they had a short fuse.

Despite these problems, patients were naturally reluctant to undergo a tracheotomy, which is now only done in the most urgent medical situations and is considered "a surgical treatment of last resort."

Angela Cackler of Hot Springs, Arkansas, who was diagnosed with sleep apnoea in 2008, though she thinks it started when she was "small," claims that she was always a very loud, aggressive snorer who would wake up in the middle of the night gasping.

2012 saw her heart failing.

I went to the emergency department because I was quite exhausted and under the weather, recalls Angela. It was heart failure, I learned. They said that they will perform a tracheotomy the following morning.

And after seven years, how has she adjusted to the tracheostomy?

It's a struggle to fight, she claims. "Cleaning takes up a lot of time. It's awful. Work it is. Your breathing is abnormal. Your inbuilt humidifier has completely disappeared. You need to add to that. The major disadvantage for her is that it prevents her from swimming, which is a pastime she used to enjoy. She despises the glances that people give her as well.

Having stated that, the treatment succeeded in curing her apnea. I can breathe better and sleep better, and I don't snore.

Will she request it again?

She responds, "If I had to do it again, sure, without a doubt." It has kept me alive.

The life-altering side effects of tracheotomies, despite the fact that they are effective in treating sleep apnoea, drove Colin Sullivan, who is currently a professor of medicine at the University of Sydney, to develop the Continuous Positive Airway Pressure machine, or CPAP, which would later become the new standard of care.

He had gone to the University of Toronto in the late 1970s to assist sleep scientist Eliot Phillipson in his investigation of respiratory regulation in sleeping dogs. Through a tracheostomy, experimental gases were administered to dogs as part of the study. When Sullivan got back to Australia, he created a mask that could be worn around a dog's snout in order to distribute the gases that way.

He was motivated to try to adapt the dog mask for use by people by a human patient who was slated for a tracheotomy but "hungry to know if there was anything else that might work," in Sullivan's words.

Sullivan made a fiberglass mask with tubing attached by using plaster casts of patients' noses. A head harness made from the interior of a cycling helmet was attached to the blower, which was recovered from a vacuum cleaner.

He and his colleagues wrote about how CPAP "totally averted the upper airway blockage" when five patients had the mask placed over their noses in a 1981 publication.

After a few years of development, Sullivan had a patented version of the gadget that apnea sufferers could use outside of a lab setting. Millions of people use CPAP devices now, but success frequently needs tenacity.

According to Steve Frisch, a psychotherapist in the Chicago area who started using the mask in 2002, "there was an adjustment time." "During the first two years, I occasionally but frequently woke up without the mask on. I don't remember ever taking it off.

He quickly adjusted to the mask, which made a tremendous difference in his health.

According to Frisch, one benefit is that he sleeps more soundly. "I snooze more frequently. I don't have a beating heart when I wake up. When I doze off during the day, I don't wake up gasping for air.

However, as more patients were treated and CPAP machine technology advanced (allowing them to now automatically upload data to the cloud for analysis), doctors encountered the unwelcome finding that their main course of treatment frequently failed.

"In the late 1980s, we would sit down with a patient and inquire about how the mask was working out for them.

Schwartz recalls this. The patient would inflate their assessment of the mask's effectiveness. "We never realized how little they were using their machines until we started putting electronic chips in the devices in the late Nineties."

Doctors discovered that the masks were frequently not being worn at all since the chips registered how long the masks were used. A 2012 New York Times article stated, "The mask is like something from a bad science fiction movie: large, cumbersome and intrusive." According to studies, between 25 and 50 percent of users give up on their device during the first year.

Of course I did.

The first night I wore the CPAP, while once again being observed at Northshore, I did feel better. I felt more energetic than I have in years when I woke up alert and refreshed.

But after that first blissfully restorative night, the mask's beneficial effects significantly diminished. Outside of the lab, I was unable to duplicate the advantages. The first C in CPAP stands for continuous, which denotes that air is pushed in both when you breathe in and out. I would awaken gasping because you are battling it as you exhale. The mask, which was affixed to my face, was in a constant embrace. Even though my eyes were closed, air would occasionally seep out around the edges and dry them.

Then there was the unspoken embarrassment of climbing into bed with my wife and attaching a hose that resembled a ribbed hairdryer to this breathing apparatus. She made an effort to make the situation seem positive.

"You have the face of a fighter pilot!

", she quip-a-long. I had no idea how fortunate I was because other mask-users' wives make fun of them. (One Polish user remembered her husband calling her "Elephant nose!" and "Alien!" before he went to sleep in the guest room.)

Despite these issues, the masks are now widely used. However, I was one of the many who was unable to wear one. Most nights, I would wake up at some point and rip the mask off. I would check the statistics in the morning to see how little it was accomplishing. When I returned to Northshore, Shives would tinker with the pressure settings or nudge me to try different masks. I frequented the place a lot and started to feel like a regular. Nothing appeared to function.

You know, if you shed 30 pounds, the problem may go away, Shives finally replied, irritated.

That looked to be a strategy.

Obesity increases the likelihood of having sleep apnea even if it is possible to be skinny.

I'm 5'9" and was 150 pounds when I got my college degree. I weighed 210 pounds in 2009.

I thus made the decision to reduce weight in 2010. I set a goal of losing the 30 pounds that Shives advised. And I had a strategy, which I referred to as the "Alcoholism Diet." I learned two crucial lessons about quitting addictive substances like alcohol or sweets in 2006 when I stopped drinking.

First, you must completely eliminate them—not just a little or a lot. It is not effective to drink just a little. The threat must be entirely removed. Likewise with calorie-dense foods. Therefore, no donuts, ice cream, cake, candy, or cookies. Zero. I kept track of my calorie intake and worked out hard to evaluate myself.

Time was the second crucial aspect. It took me a full calendar year to lose the 30 pounds because the weight crept on over a long period of time. I succeeded in losing weight, dropping from 208 pounds on January 1 to 178 pounds on December 31. It was helpful that, should I be successful, I had a pithy opening to use in my newspaper column bragging about the victory.

It began, "Unlike you, I kept my New Year's resolutions."

What else was helpful?

" I typed. "I had sleep apnea, a crippling illness, and a doctor told me if I lost 30 pounds, it might go away."

In an unusual turn of events, the apnoea was suddenly a benefit, encouraging dieting. And shedding the pounds was the key. no more masks

I'm shocked that I publicly acknowledged having apnea. It was humiliating. I have no idea why. It wasn't like the condition was one that was typically associated with shame. It wasn't comparable to gonorrhea. I think it just came out as a weak complaint from an old, obese man. At the railway station in the morning, I would bemoan the elastic marks on the red, flabby faces of my fellow commuters. I detested the idea of being one of them.

But it turns out that I erred in thinking that winning a battle in a single year meant winning the war. The weight I had lost eventually found me again, with 20 of the 30 slowly creeping back on over the following ten years. And along with them, the apnea returned. Not that I was aware of it until I had spine surgery in the summer of 2019. At Northwestern Memorial Hospital in Chicago, a pre-surgery form questioned if I occasionally snored, if I was frequently exhausted, and if I had ever had sleep apnea diagnosed.

Yes, again and again.

According to Phyllis Zee, director of the Center for Circadian and Sleep Medicine at Northwestern University's Feinberg School of Medicine, it is crucial to evaluate people for sleep apnea because it may pose a risk when undergoing surgery. It may also increase the likelihood of unfavorable results in the future.

Despite efforts by medical research to raise awareness, the majority of apnoea sufferers are unaware of their condition, therefore queries concerning snoring and fatigue are crucial.

Obstructive sleep apnoea may affect up to 40% of the general German population, however just 1.8% of hospital in-patients were found to have it in a 2017 German study. The authors speculated that this may be because both patients and hospital staff are not well informed about the illness.

According to Ravindra Gupta, an anesthesiologist and the medical director of Northwestern Memorial Hospital's post-anesthesia care center, "Our choice of anesthesia might change based on sleep apnea." "When you start adding several medications, those effects build up and overlay one on another," says the author. "Several medications can cause the airway to collapse."

People with apnoea need to be watched for longer after surgery, according to Gupta.

According to a New England Journal of Medicine article, sleep apnea is "epidemic" among US surgical patients. One in four elective surgery candidates have it, but for some populations, the rate is significantly higher. For example, eight out of ten patients receiving treatment for obesity have, posing a number of dangers.

According to the authors, patients with sleep apnea who are having orthopedic or general surgery tend to be more likely to experience pulmonary issues and require critical care services, both of which dramatically raise medical expenses.

My disclosing that I had previously received a sleep apnoea diagnosis on the pre-surgical questionnaire had an immediate impact. My spine surgery was completed quickly—a week after I first discussed my MRI with a surgeon—but during that short time, the hospital requested that I complete a home sleep study to see how severe my apnea was. I bought a package that included instructions on how to wear sensor bands around my chest, a pulse oximeter on my finger, and a clip under my nose to track my breathing instead of traveling to a sleep center. There was no EEG, and one issue with these take-home tests is that the equipment cannot tell whether you are genuinely asleep or not when the readings are being taken.

However, reducing the expense and discomfort of testing gives optimism that more people will learn they have apnoea - the cost and time required for an in-lab polysomnogram are thought to be one reason why diagnosis rates are so low.

I was discovered to have moderate apnoea during the examination, which the anesthesiologist used as justification for placing me under anesthesia.

Philip Smith, a professor of medicine at the Johns Hopkins School of Medicine and an expert in respiratory illness and sleep apnea, asserts that losing weight is therapeutic. The issue is that nobody can do it.

It becomes obvious that there is a "major unmet need" when you consider the fact that many patients are unable to utilize CPAP, according to Schwartz. As a result, numerous other treatments have been introduced over the previous 20 years.

For individuals who couldn't bear the mask, a dental appliance was introduced in the middle of the 1990s.

David Turok, a general dentist with a specialty in apnoea, claims that obstructive sleep apnoea occurs in the rear of the mouth. In essence, your tongue pulls back into your airway since it doesn't have enough room to move around in your mouth. By pumping air down, CPAP pushes the tongue out of the way. The tongue moves forward with the lower jaw thanks to an oral appliance.

Think of it as a brace that widens the airway at the back of the throat by using the upper teeth as an anchor to force the lower teeth, and the lower jaw that they are connected to, forward.

The oral appliance is a subpar alternative, just like CPAP. It can be painful because it holds the jaw in an unusual posture, and repeated use might alter your bite and cause the jaw to remain forward. Your teeth's alignment may be slightly modified by the pressure of it.

However, most of Turok's patients in his years of research on apnoea treatments have found success with an oral appliance.

However, he adds, "These are mild-to-moderate cases. "CPAP is preferred for people with severe sleep apnea. Never do I say that you have a choice. You must first give CPAP a try.

He claims that jaw advancement surgery is a better option than enlarging the soft tissue of the throat for treating apnoea in people who cannot adjust to either CPAP or oral appliances.

Because bone repair takes place in place of tissue healing, Turok claims that recovery is simpler. Even though, there are some disadvantages to the procedure, such as the requirement to have your lower jaw broken in two locations and have your mouth wired shut thereafter.

However, if you don't know you have apnoea, treatments are pointless. Turok points out that dentists have a crucial role to play in diagnosing the issue because it continues to go untreated in so many people for such a long time.

He claims that "sleep apnoea is very much an oral condition." Every dentist should be on the lookout for sleep apnea, even if not every dentist should treat it.

Hypoglossal nerve stimulation (HNS), in which a modest electrical charge is applied to make the tongue contract and prevent it from falling backward while you sleep, is another method that is essentially an electrical version of the oral appliance.

Smith states that the initial work was begun roughly 20 years ago. The pacemaker is "extremely tiny and is similar to a cardiac pacemaker."

An electrical lead that has been tunneled beneath the skin connects the pacemaker device to the hypoglossal nerve, which regulates the tongue, near the jaw. The pacemaker device is implanted in soft tissues immediately below the collarbone. By pressing a button on the remote control, the patient who is utilizing the device turns it on just before bed.

This "upper-airway stimulation led to considerable improvements in objective and subjective evaluations of the severity of obstructive sleep apnea," according to a 2014 study financed by Inspire Medical Systems, a manufacturer of HNS devices.

According to Schwartz, who has provided consulting services to several businesses considering HNS, "It's actually fairly well tolerated." If you are awake, you may notice that your tongue is becoming more rigid or is migrating slightly forward. Patients generally sleep through it fairly well.

But the National Institute for Health and Care Excellence in the UK advises reserving judgment. It states that there is "little quantity and quality of current evidence on the safety and efficacy of hypoglossal nerve stimulation for moderate to severe obstructive sleep apnoea."

Despite the wide variety of treatments, there is agreement on how to treat obstructive sleep apnea: use the mask and make an effort to lose weight.

You'll need to discover something else that does the trick if that doesn't.

Although CPAP is "the recommended first-line therapy," according to Lawrence Epstein, past president of the American Academy of Sleep Medicine and assistant medical director of the sleep disorders service at Brigham and Women's Hospital in Boston, treatment is ultimately "more about knowing all the options and trying to tailor the therapy to what the patient has and what they would be willing to use."

While obstructive sleep apnoea is thought to be a singular disorder, it is actually caused by a variety of factors, including muscle tension, obesity, and the shape of the face and throat. As a result, not every treatment is effective for every patient.

"Our treatments are quite successful, but they all have drawbacks. It involves matching the appropriate patient to the appropriate treatment.

There is really only one test, he adds, adding that "we still have a ways to go" in terms of improving the course of treatment: "Make sure it works."

That treatment becoming a pill in the future is the source of great hope.

According to Smith of Johns Hopkins, "neurochemistry is the future." "We are able to treat a mouse's apnea. Due to the fact that sleep apnea is a neural-chemical issue, you will most likely be able to take medication within the next ten years, possibly five. Schwartz is more cautious and believes "it's a combination of the two," but he has also been looking into hormones secreted by fat cells. It's not obesity itself, not fat pressing on the airway, but fat excreting particular hormones that makes the airway collapse.

Additionally, encouraging human trials exist. Dronabinol, a synthetic version of a cannabinoid present in cannabis, is "safe and well tolerated" and lessens the severity of sleep apnea when compared to a placebo, according to a 2017 study co-authored by Phyllis Zee.

At the time of publication, Zee stated that "the CPAP equipment treats the physical problem but does not address the cause." The medication affects the brain and nerves that control the muscles of the upper airway. It modifies the brain's neurotransmitters that the muscles use to communicate.

Other encouraging indicators exist. Atomoxetine and oxybutynin were the two medications used in combination in a small double-blind worldwide research that revealed they "greatly decreased" apnoea, reducing airway blockages during sleep by at least 50% in all of the subjects.

The wait, however, can be prolonged for someone like me who is now having apnoea problems.

According to Schwartz, "they've been saying we'll have some medicine to deal with the problem in 20 years." "The only issue is that there has been a continuous 20-year backlog. I'm sure we'll make it there. There are a few potential pharmaceutical strategies that could emerge.

Healthcare and patience go hand in hand, whether it's waiting for the correct specialist to become available, for new treatments to slowly enter the market, or even for lifestyle modifications to take effect. For me, it meant returning to a long-term eating plan and scheduling a visit with a Northwestern sleep physician.

I contacted Northwestern in July after my surgery and discovered the apnoea had reappeared as a sign of how many people are affected by this issue. They promised to put me on the first available appointment, which won't be until late October.