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Obstructive sleep apnoea (OSA) is clinically recognized as a disorder characterized by repeated episodes or complete or partial collapse of the upper airway during sleep and can occur at any age. In children OSA is often the result of enlarged tonsils or adenoids causing obstruction to the airway. In adults, OSA is more common in middle age. It is commoner in men than in women, although after menopause women may be more at risk. Symptomatic OSA is very common and occurs in about 4% of middle-aged men and in 2% of middle-aged women. However, minimally symptomatic or asymptomatic OSA is estimated to occur in about one out of five adults. Sleep apnoea is often associated with being overweight and thus having more fatty tissue around the neck. These fatty tissues compress on the relaxed muscles of the upper airway causing intermittent blockage of the airway during sleep. Others are born with a narrow airway or have a facial structure which leads to narrow airways. In this respect, one would also be at risk if there is a family history of OSA, as we would inherit our parent’s facial features. Asians have a narrower facial and jaw structure compared to Caucasians and thus have a greater tendency to develop OSA if they are overweight.
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Untreated OSA is recognized as an independent risk factor for several serious heath problems, including high blood pressure, heart disease, abnormal heart rhythms, stroke, Diabetes. It has been recognised as a cause for low testosterone levels in men. Despite increasing awareness and identification by health-care professionals, OSA frequently remains unrecognized and underdiagnosed, even in patients with moderate to severe disease.
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Frequently, it is the bed partner of the patient who complains of their loud snoring, gasping and choking during sleep. Occasionally patients may wake feeling breathless or with chest discomfort but more often than not, the patient may not notice a problem during sleep. Patients on the other hand complain of poor sleep quality, restless sleep, frequent wakening during sleep, waking feeling unrefreshed, waking with a dry mouth, falling asleep easily in sedentary situations, poor memory and concentration span, waking during the night to pass urine and diminished libido.
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Whilst signs and symptoms such as snoring, obesity, observed apnoeas and sleepiness in the day may suggest that a person has sleep apnoea, it is best to approach a sleep physician for a thorough assessment. During the consultation with the sleep specialist, he will obtain a complete sleep and medical history, including asking you about your sleep habits, as well as physical examination. He may then go on to order an overnight sleep study. This test measures your sleep, breathing and oxygen levels. Whilst there are many types of sleep studies available, the more accurate ones involve placing wires on the scalp to record your brain waves, eye movements and body movements during sleep. This can be performed in hospital or even in the comfort of your own home. If you prefer to have the test conducted in your home, your doctor will arrange for a sleep technician to bring the equipment out to your home where it is set up. The technician will then return for the equipment the following morning. In special circumstances, your doctor may request the technician to be present throughout the study.
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Ask your doctor about a sleep study if you have the following conditions:
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- Snoring
- Symptoms of poor sleep quality or unrefreshed sleep.
- Excessive daytime sleepiness.
- Heart disease
- Diabetes
- Stroke
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There are many treatment options for OSA, broadly consisting of lifestyle alterations and specific treatments. Your sleep specialist will discuss the various treatment options with you, taking into consideration your preferences, coexisting medical problems, the likelihood of success and side effects of each treatment.
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The treatment of choice for obstructive sleep apnoea in the majority of patients is called continuous positive airway pressure or CPAP. This involves a pump that provides air under gentle pressure to a mask that covers your nose or nose and mouth. This provides a pneumatic splint to your throat which holds it open through an air cushion effect, thereby preventing collapse or closure of the throat when the muscles which usually keep the throat open are relaxed during sleep. You only need to use CPAP at night in bed. In many modern CPAP machines, a computer chip is incorporated which detects changes in breathing flow patterns, allowing the machine to determine if there are any changes in airway patency throughout the night and with different stages of sleep. These “automatic machines” would therefore vary the pressure delivered, ensuring that your airway is kept open by the minimum pressure that is required. CPAP is almost always effective in controlling the symptoms and the long term effects of sleep apnoea. It stops the snoring and the machine noise is much quieter than the snoring was. It has also been proven in clinical studies to improve hypertension, Insulin resistance, cardiac function and to prolong life.
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In adults, surgical treatments and success vary and may not be effective in everyone. Surgery can be used to augment and improve the acceptance of CPAP, for example if there is nasal obstruction, preventing the effective use of a nasal mask. Surgical procedures may also be used in those who are intolerant of CPAP, but the success of these procedures remain low and are generally regarded as salvage therapy or a treatment of last resort. Relapse of OSA following successful surgery is variable and is frequently attributed to increasing weight and aging. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnoea surgery. Upper airway surgery for sleep apnoea has not been documented to produce improvements in cardiovascular risk and metabolic parameters in adults.
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Devices (mandibular advancement devices) that fit between the teeth and hold the jaw forward may help but these may not work for everyone. Generally these devices can be used if you have mild to moderate obstructive sleep apnoea, have a good set of your own teeth and have no problems with the jaw joint.
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As yet there is no effective drug for treating sleep apnoea. A number of other remedies have been marketed but none have been shown to be effective.
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In many people sleep apnoea results from being overweight. Losing weight may help or even cure the apnoea. However, if you have started CPAP treatment you should talk to your sleep physician before stopping treatment, even if you have lost weight. Losing weight is to be encouraged as it will improve your overall health.
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