Sleep Apnea and Spinal Cord Injury

Posted by Nurse Linda in Life After Paralysis on September 16, 2020 # Health

Sleep apnea is a condition where a person has difficulty or even stops breathing during sleep. This happens at any time when sleeping or napping. Breathing becomes difficult in spurts. When the body realizes that it is not getting enough air, a message is sent to the brain to wake up and breathe. You may or may not realize that this is happening because you don’t know what is going on when you are asleep. You may not even fully wake up when you start to rebreathe.

Individuals with spinal cord injury have a higher occurrence of sleep apnea than individuals without spinal cord injury. The higher the spinal cord injury, the more at risk you are. Sleep apnea is not connected to the AIS (ASIA) level, but those with complete motor injuries have more incidences at approximately 25 - 40 %.

Breathing is affected by several muscles of the body, with the main three being the diaphragm to pull the lungs down, which brings in air, the intercostal muscles are in between the ribs which expand the lungs out and around, and the abdominal muscles which assist the lungs in bringing in air. All three of these muscles must work in unison for air to come into the body. Weakness in any, some, or all the breathing muscles due to ineffective nerve communication to make the muscles work, can disrupt breathing, the ability to have a deep breath, or an effective cough. Spasticity can affect how muscles work or if they work in unison.side of person in wheelchair

Front of the neck sensation comes from nerves at C2-C4. Back of the neck sensation from nerves at C4-C5. A spinal cord injury at C2-C5 will affect the sensation of the neck area. The diaphragm is controlled by the phrenic nerve that exits the spinal cord at levels C3, C4, and C5. The intercostal muscles are controlled by spinal nerves T1 to T11. The abdominal muscles are controlled by spinal nerves T7 to L1. SCI that include these levels will affect breathing.

Surprisingly, the biggest risk factor for sleep apnea is an overabundance of fat tissue in the neck area. An obese neck combined with breathing nerve issues makes for a dangerous situation. According to the CDC, a healthy neck circumference of men should not exceed 13.9 inches. Women’s neck circumference should not exceed 12.5 inches. Some people are going to have larger necks due to their body size. If you are close to the ‘do not exceed’ measurement, check with your healthcare professional for an assessment of your health and risk factors. The neck is measured with a tape measure at the neck midpoint.

Much like individuals with a large abdomen due to fat, a large neck is also indicative of heart illnesses such as heart attack, high cholesterol, and high blood pressure. A large neck size can indicate problems such as central obesity, insulin resistance, diabetes, and gout. For those with spinal cord injury, neck size is one measure of obesity versus a large abdomen, which can be due to relaxed muscles as opposed to the fat collection.

Snoring or even periods of not breathing are signs of sleep apnea. Someone else might notice if you stop breathing, or if you are gasping for air. You probably will not know you have these symptoms because you are asleep when they occur. More likely, someone will tell you they are happening. Other symptoms of sleep apnea include waking with a headache, dry mouth, being irritable, an inability to concentrate, tiredness during the day, or even falling asleep during the day. Obesity, muscle weakness, and more difficulty when sleeping on your back also alert to sleep apnea. Medication can affect your breathing while sleeping, especially muscle relaxants.

There are three types of sleep apnea. Individuals with spinal cord injury or other nervous system issues might have any of the three types.

  1. Obstructive sleep apnea is the most common. It occurs due to throat muscles relaxing, which does not let air pass through.
  2. Central sleep apnea occurs when the message from the brain to breathe does not get through to the body.
  3. Complex sleep apnea is a combination of both obstructive and central sleep apnea.

Several assessments can be done to diagnose sleep apnea. A review of your symptoms will direct your healthcare professional for further investigation. Medications should be reviewed to assess their effect on breathing. Be sure to include all medications, those that are prescription as well as non-prescription.

Physical assessment includes observation of your breathing while awake, an examination of the mouth to look for visible obstruction, listening to your lungs, assessment of the oxygen in your blood either by use of the pulse oximeter (that clip that goes on your finger) or a blood test. Sometimes pulmonary function tests, which include how much air you take in and put out, are needed to assess the effects of spinal cord injury on breathing. Electromyography (EMG) or nerve conduction studies (NCS) might be done to assess spasticity.

A sleep study is the most effective assessment of sleep apnea. This is done at a sleep study center. Some appointments are given at night, but many appointments are during the day. You will be asked to stay awake the night before so you can sleep soundly during the day. A cardiac monitor, pulse oximeter, and perhaps an EEG will be used to measure your body’s responses to sleep and breathing. Be sure to check to make sure your needs will be met while you have your study. For example, is the bed surface pressure reducing, will someone turn you, catheterize and any other needs you might have due to spinal cord injury.

For individuals with spinal cord injury, if medications or spasticity is the source of your sleep apnea, alterations can be made to improve your breathing while sleeping. Medications might be able to be adjusted or changed to less suppressive types or doses.

Treatment for sleep apnea includes both noninvasive and invasive devices to maintain breathing while sleeping. Your sleep interventions should be used both during night sleeping and napping if needed during the day.

1.Continuous positive airway pressure (CPAP) is a device that delivers air pressure through a mask to keep airways open during sleep. It is the most used treatment. Alternatives include bilevel positive airway pressure (BPAP), a device that delivers more pressure with inhalation and less pressure as you exhale.

2.Adaptive Servo-Ventilation (ASV) is an airflow device that mimics the pattern of your normal breathing to replicate your breathing pattern when sleeping. It is recommended only for some types of sleep apnea.

3.Oral appliances to physically open the airway when sleeping has been used for some individuals depending on the type of sleep apnea. More commonly, they are used for obstructive sleep apnea. Oral appliances are the least effective but do work for some individuals.

Some people do not care for the face masks or devices used to deliver effective breathing. There are many options that are available. Be sure to ask about all the alternatives prior to making your choice. The oversized masks can be changed to nasal adaptors, the hose that connects to the machine can be aligned to go over your head instead of to the side, so you do not have to readjust it at night. All the options will need to be matched to your specific needs, but there are many choices.

Newer machines are much quieter than earlier developed ones. Also, some machines will clean your device, which saves a lot of time and energy.

Breathing devices can save your life and avoid health complications due to sleep apnea, but only if you use it consistently. Sleep apnea is a serious issue. There are effective treatments that are convenient and easy to use. Plus, a huge benefit is that you will sleep better and feel more rested. Nurse Linda

Pediatric Consideration:

Children with spinal cord injury and, myelomeningocele (spina bifida) and the Chiari II malformation (a condition where the brain extends into the spinal canal) are known to have increased sleep apnea and respiratory control deficits. It is important to monitor your child’s sleep pattern to assess for sleep apnea.

All children who snore should be assessed by a healthcare professional. Typically, childhood snoring can be due to adenoid or tonsil enlargements, which, when treated, resolve the issue. However, other causes after spinal cord injury will involve the same treatments as for adults with adjustments for the size of the child.

Other treatment options include weight loss as directed by a dietitian to ensure the child is receiving the nutrients needs for brain development and to avoid secondary complications of spinal cord injury. Internasal corticosteroids might be used if the condition is mild and felt to be temporary.

Continuous positive airway pressure devices are the most often used devices for pediatric treatment. The device cleaners will help you save time in maintaining the equipment and thereby the safety of your child. If a nap is involved at school, they will need to take their device with them. Establish who will be responsible for putting it correctly on the child.

Some facial masks and devices are designed with characters that are of interest to the pediatric patient. Most children do not like anything on their face. Practice time is needed for the child to become used to the device before trying to sleep with it. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.