President Joe Biden uses a machine to keep his airways clear while he sleeps because he has a condition known as sleep apnea, White House officials say.
According to the American Medical Association, sleep apnea probably affects about 30 million people in the US. Some people with sleep apnea use what’s called a continuous positive airway pressure (CPAP) machine, which includes a mask that a user fastens to their face at night to help them breathe better while they sleep.
Officials revealed that Biden uses a CPAP machine after reporters recognized indentations on his face from the strap that held the device in place. Documents released as far back as 2008 show that Biden is known to experience sleep apnea, which can become more common as people age.
Scientific American spoke with Christine Won, medical director of the Yale Centers for Sleep Medicine, about sleep apnea, its causes, and treatment with CPAP machines.
[An edited transcript of the interview follows.]
What is Sleep Apnea?
Obstructive sleep apnea occurs because there is a problem with the structure or function of the upper airway. When we fall asleep, the upper airway loses its muscle tone, and if your airway is narrow, it can lead to obstruction. This can cause people to snore, but it can also completely block the airway and prevent people from ventilating properly. This can lead to low oxygen levels; it can lead to sleep disturbances. People can sometimes wake up abruptly because of this and sleep is fragmented.
Are there different types of sleep apnea?
Yes, [in addition to obstructive sleep apnea, there is a type called] central sleep apnea, which is much less common. It generally affects older men and people with heart disease, although it sometimes occurs in healthy individuals. This type of sleep apnea results from the brain not communicating with the respiratory muscles to breathe during sleep, and so there are pauses in breathing.
What Are the Symptoms of Sleep Apnea?
Both types of sleep apnea can disrupt sleep because the person may wake up abruptly from not getting enough oxygen. Snoring is more common in obstructive sleep apnea. And then both types, because they can interfere with sleep, can lead to daytime symptoms like drowsiness or brain fog, things like that.
How common is sleep apnea?
Sleep apnea is common in the adult population. Prevalence increases with weight gain, so it is much more common in obese people. It becomes more common as we get older. It is also twice as common in men as in women for reasons that are unclear.
There are many people with sleep apnea who go undiagnosed. I think the current data suggests that only about 20 percent of people with sleep apnea are actually diagnosed.
Why do you think so many people go undiagnosed?
Probably a bit of education – not knowing what the symptoms of sleep apnea are, not knowing that waking up often during the night, unrefreshing sleep, things like this could be a sign of sleep apnea and not just ‘normal’. There may be a little resistance to getting a sleep study, and there may be a little resistance to accepting CPAP as a form of therapy for this.
What Causes Sleep Apnea?
The structural problem is that the airway can become narrowed for a variety of reasons. There may be excess fat in the neck tissues. The soft palate can be superfluous and low hanging, actually blocking the airway. The base of the tongue can be very large and bulky, again, narrowing the airway. Some people may have very large tonsils and adenoids [lymphatic tissue near the tonsils] that can block the airway. Also, jaw anatomy can affect the size of the airway – people with very small jaws or sunken jaws can narrow their airway.
And some people can have very wide, open airways while they’re awake, and they don’t have any of those anatomical problems that I just described. But when they fall asleep, the muscle tone of the airways decreases significantly, which can lead to airway collapse. It’s not clear why. But the upper airway is actually a large muscular tube: it is not supported by bony structures, so muscle tone is important to maintain the integrity of the airway. That may be why aging is linked to an increased risk of sleep apnea, as with age all of our muscles become a bit more relaxed.
What are common treatments for sleep apnea?
CPAP is the most common treatment for sleep apnea because it is very effective, so in other words, wearing it will almost always eliminate obstructive sleep apnea. The problem is that many people have trouble tolerating CPAP, so it’s not an effective treatment for everyone.
Other treatments include oral appliances fitted by your dentist. You place the device in your mouth at night and it pulls your lower jaw forward so the airway doesn’t collapse while you sleep. That’s a reasonable treatment option for people who are young and thin and generally have mild sleep apnea.
There are also many surgeries, such as maxillomandibular displacement surgery, which is a pretty big surgery where they cut open your jaw and move it forward — sometimes up to an inch — to open the airway in the back. Tonsillectomy and adenoidectomy are actually mainstays for children with sleep apnea, not usually for adults.
A newer form of therapy is upper airway stimulation. It is essentially like a pacemaker for the tongue. But it’s not a therapy for everyone – there are specific criteria and a specific population that would benefit from it.
And not all sleep apnea needs to be treated. We know that sleep apnea is associated with cardiovascular disease and risk. What we don’t know is how much CPAP therapy has benefits [people or who will benefit from it]. So even if you are diagnosed with sleep apnea, it does not automatically mean that you will turn to CPAP therapy. You would have a discussion with your doctor about it [questions such as] “How symptomatic are you? What cardiovascular risks do you have? How severe is your sleep apnea?” Based on these things, your doctor will decide whether you would benefit from the treatment or not.
How do CPAP devices work?
They are actually inverted vacuum cleaners. They have a motor that generates positive pressure that is transferred into the pharynx through a tube and a mask. And it works like a pneumatic splint, and it just keeps the airway open so it doesn’t collapse.
How Easy Is It To Get A CPAP Machine?
They are very accessible: if you have been diagnosed with sleep apnea and you meet specific criteria from an insurance point of view, it is easy to prescribe and obtain one.
It’s somewhat difficult for patients to maintain their CPAP or get new supplies because insurance sometimes requires you to meet these stats to use it for 70 percent of nights for 30 consecutive days for at least four hours a night. It’s kind of hard because a lot of people don’t go straight to CPAP. Some people do – like the first night, they love it; it’s the best night’s sleep of their lives. But other people, it takes some getting used to, because this machine on your face blows pressure. It’s a foreign sensation.
What should people do if they think they have sleep apnea?
They should definitely discuss this with their doctor, who can further screen and evaluate their symptoms and decide if they are at risk and then refer them for a sleep study.