(OSA)Obstructive sleep apnoea

Obstructive sleep apnoea is a potentially serious sleep disorder. It causes breathing to repeatedly stop and start during sleep. There are several types of sleep apnoea, but the most common is obstructive sleep apnoea. This type of apnoea occurs when your throat muscles intermittently relax and block your airway during sleep. A noticeable sign of obstructive sleep apnoea is snoring.

• OTreatments for obstructive sleep apnoea are available. One treatment involves using a device that keep your airway open while you sleep. Another option is a mouthpiece to thrust your jaw forward during sleep. In more severe cases, surgery may be an option too.

  Symptoms

  Signs and symptoms of obstructive sleep apnoea include:

  • Excessive daytime sleepiness
  • Loud snoring
  • Observed episodes of breathing cessation during sleep
  • Abrupt awakenings accompanied by gasping or choking
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Difficulty concentrating during the day
  • Experiencing mood changes, such as depression or irritability
  • High blood pressure
  • Night time sweating
  • Decreased libido

  When to see a doctor

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

  • Snoring loud enough to disturb your sleep or that of others
  • Waking up gasping or choking
  • Intermittent pauses in your breathing during sleep
  • Excessive daytime drowsiness, which may cause you to fall asleep while you’re working, watching television or even driving a vehicle

  Many people may not think of snoring as a sign of something potentially serious, and not everyone who snores has obstructive sleep apnoea.

  Be sure to talk to your doctor if you experience loud snoring, especially snoring that’s punctuated by periods of silence. With obstructive sleep apnoea, snoring usually is loudest when you sleep on your back, and it quiets when you turn on your side. Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness may be due to other disorders, such as narcolepsy.

  Causes

  Obstructive sleep apnoea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula — a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.

  When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood and cause a build up of carbon dioxide. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don’t remember it.

  You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths. 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’ll probably feel sleepy during your waking hours. People with obstructive sleep apnoea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnoea think they slept well all night.

  Risk factors

  Anyone can develop obstructive sleep apnoea. However, certain factors put you at increased risk, including:

  • Excess weight. Around half the people with obstructive sleep apnoea are overweight. Fat deposits around the upper airway may obstruct breathing.However, not everyone with obstructive sleep apnoea is overweight and vice versa. Thin people can develop the disorder, too.
  • Narrowed airway. You may inherit naturally narrow airways. Or, your tonsils or adenoids may become enlarged, which can block your airway.
  • High blood pressure (hypertension). Obstructive sleep apnoea is relatively common in people with hypertension.
  • Chronic nasal congestion. Obstructive sleep apnoea occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways.
  • Smoking. People who smoke are more likely to have obstructive sleep apnoea.
  • Diabetes. Obstructive sleep apnoea may be more common in people with diabetes.
  • Sex. In general, men are twice as likely as women to have obstructive sleep apnoea.
  • A family history of sleep apnoea. If you have family members with obstructive sleep apnoea, you may be at increased risk.
  • Asthma. Recent research has found an association between asthma and the risk of obstructive sleep apnoea.

  Complications

  Obstructive sleep apnoea is considered a serious medical condition. Complications may include:

  • Daytime fatigue and sleepiness. The repeated awakenings associated with obstructive sleep apnoea make normal, restorative sleep impossible. People with obstructive sleep apnoea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving.Children and young people with obstructive sleep apnoea may do poorly in school and commonly have attention or behaviour problems.
  • Cardiovascular problems. Sudden drops in blood oxygen levels that occur during obstructive sleep apnoea increase blood pressure and strain the cardiovascular system. Many people with obstructive sleep apnoea develop high blood pressure (hypertension), which can increase the risk of heart disease.The more severe the obstructive sleep apnoea, the greater the risk of coronary artery disease, heart attack, heart failure and stroke. Men with obstructive sleep apnoea appear to be at risk of heart failure, while women with obstructive sleep apnoea don’t.Obstructive sleep apnea increases the risk of abnormal heart rhythms (arrhythmias). These abnormal rhythms can lower blood oxygen levels. If there’s underlying heart disease, these repeated multiple episodes of low blood oxygen could lead to sudden death from a cardiac event.
  • Complications with medications and surgery. Obstructive sleep apnoea also is a concern with certain medications and general anaesthesia. These medications, such as sedatives, narcotic analgesics and general anaesthetics, relax your upper airway and may worsen your obstructive sleep apnoea.If you have obstructive sleep apnoea, you may experience worse breathing problems after major surgery, especially after being sedated and lying on your back. People with obstructive sleep apnoea may be more prone to complications after surgery.Before you have surgery, tell your doctor if you have obstructive sleep apnoea or symptoms related to obstructive sleep apnoea. If you have obstructive sleep apnoea symptoms, your doctor may test you for obstructive sleep apnoea prior to surgery.
  • Eye problems. Some research has found a connection between obstructive sleep apnoea and certain eye conditions, such as glaucoma. Eye complications can usually be treated.
  • Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. Some partners may even choose to sleep in another room. Many bed partners of people who snore are sleep deprived as well. People with obstructive sleep apnoea may also complain of memory problems, morning headaches, mood swings or feelings of depression, and a need to urinate frequently at night (nocturia).

  Diagnosis

  To diagnose your condition, your doctor may make an evaluation based on your signs and symptoms, an examination, and tests. Your doctor may refer you to a sleep specialist in a sleep centre for further evaluation.

  You’ll have a physical examination, and your doctor will examine the back of your throat, mouth and nose for extra tissue or abnormalities. Your doctor may measure your neck and waist circumference and check your blood pressure.

  A sleep specialist may conduct additional evaluations to diagnose your condition, determine the severity of your condition and plan your treatment. The evaluation may involve overnight monitoring of your breathing and other body functions as you sleep. Tests to detect obstructive sleep apnoea include:

• Polysomnography. During this sleep study, you’re hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. You may have a full-night study, in which you’re monitored all night, or a split-night sleep study.In a split-night sleep study, you’ll be monitored during the first half of the night. If you’re diagnosed with obstructive sleep apnoea, staff may wake you and give you continuous positive airway pressure for the second half of the night.This test can help your doctor diagnose obstructive sleep apnoea and adjust positive airway pressure therapy, if appropriate. This sleep study can also help rule out other sleep disorders, such as periodic limb movements of sleep or narcolepsy, which also can cause excessive daytime sleepiness, but require different treatment.

• Home sleep apnoea testing. Under certain circumstances, your doctor may provide you with an at-home version of polysomnography to diagnose obstructive sleep apnoea. This test usually involves measurement of airflow, breathing patterns and blood oxygen levels, and possibly limb movements and snoring intensity.

  Your doctor also may refer you to an ear, nose and throat doctor to rule out any anatomic blockage in your nose or throat.

  Treatment

  Lifestyle changes

  For milder cases of obstructive sleep apnoea, your doctor may recommend lifestyle changes:

  • • Lose weight if you’re overweight.
    • Exercise regularly.
    • Drink alcohol moderately, if at all, and don’t drink several hours before bedtime.
    • Quit smoking.
    • Use a nasal decongestant or allergy medications.
    • Don’t sleep on your back.

  If these measures don’t improve your sleep or if your apnoea is moderate to severe, then your doctor may recommend other treatments. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.

  Therapies

• Continuous positive airway pressure (CPAP)

• Oral device

Positive airway pressure. If you have obstructive sleep apnea, you may benefit from positive airway pressure. In this treatment, a machine delivers air pressure through a piece that fits into your nose or is placed over your nose and mouth while you sleep.Positive airway pressure reduces the number of respiratory events that occur as you sleep, reduces daytime sleepiness and improves your quality of life.The most common type is called continuous positive airway pressure, or CPAP (SEE-pap). With this treatment, the pressure of the air breathed is continuous, constant and somewhat greater than that of the surrounding air, which is just enough to keep your upper airway passages open. This air pressure prevents obstructive sleep apnoea and snoring.Although CPAP is the most consistently successful and most commonly used method of treating obstructive sleep apnoea, some people find the mask cumbersome, uncomfortable or loud. However, newer machines are smaller and less noisy than older machines.Also, with some practice, most people learn to adjust the mask to obtain a comfortable and secure fit. You may need to try different types to find a suitable mask. Several options are available, such as nasal masks, nasal pillows or face masks.If you’re having particular difficulties tolerating pressure, some machines have special adaptive pressure functions to improve comfort. You also may benefit from using a humidifier along with your CPAP system.CPAP may be given at a continuous (fixed) pressure or varied (autotitrating) pressure. In fixed CPAP, the pressure stays constant. In autotitrating CPAP, the levels of pressure are adjusted if the device senses increased airway resistance.Bilevel positive airway pressure (BiPAP), another type of positive airway pressure, delivers a preset amount of pressure when you breathe in and a different amount of pressure when you breathe out.CPAP is more commonly used because it’s been well-studied for obstructive sleep apnoea and has been shown to effectively treat obstructive sleep apnoea. However, for people who have difficulty tolerating fixed CPAP, BiPAP or autotitrating CPAP may be worth a try.Don’t stop using your positive airway pressure machine if you have problems. Check with your doctor to see what adjustments you can make to improve its comfort. In addition, contact your doctor if you still snore despite treatment, if you begin snoring again or if your weight changes.

Mouthpiece (oral device). Though positive airway pressure is often an effective treatment, oral appliances are an alternative for some people with mild or moderate obstructive sleep apnoea. These devices may reduce your sleepiness and improve your quality of life.These devices are designed to keep your throat open. Some devices keep your airway open by bringing your jaw forward, which can sometimes relieve snoring and obstructive sleep apnoea. Other devices hold your tongue in a different position.If you and your doctor decide to explore this option, you’ll need to see a dentist experienced in dental sleep medicine appliances for the fitting and follow-up therapy. A number of devices are available. Close follow-up is needed to ensure successful treatment.

Surgery or other procedures

Surgery is usually considered only if other therapies haven’t been effective or haven’t been appropriate options for you. Surgical options may include:

• Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which your doctor removes tissue from the back of your mouth and top of your throat. Your tonsils and adenoids may be removed as well. UPPP usually is performed in a hospital and requires a general anesthetic.Doctors sometimes remove tissue from the back of the throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) to treat snoring. These procedures don’t treat obstructive sleep apnea, but they may reduce snoring.
• Upper airway stimulation. This new device is approved for use in people with moderate to severe obstructive sleep apnoea who can’t tolerate CPAP or BiPAP. A small, thin impulse generator is implanted under the skin in the upper chest. The device detects your breathing patterns and when necessary, stimulates the nerve that controls movement of the tongue.A study on the device found that it led to significant improvement in obstructive sleep apnoea symptoms and improvements in quality of life.
• Jaw surgery. In this procedure, called maxillomandibular advancement, the upper and lower parts of your jaw are moved forward from the rest of your facial bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely.
• Surgical opening in the neck. You may need this form of surgery if other treatments have failed and you have severe, life-threatening obstructive sleep apnoea.In this procedure, called a tracheostomy, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. Air passes in and out of your lungs, bypassing the blocked air passage in your throat.
• Implants. This minimally invasive treatment involves placement of three tiny polyester rods in the soft palate. These inserts stiffen and support the tissue of the soft palate and reduce upper airway collapse and snoring. This treatment is recommended only for people with mild obstructive sleep apnoea.
• Other types of surgery may help reduce snoring and sleep apnoea by clearing or enlarging air passages, including:
• Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated septum)
• Surgery to remove enlarged tonsils or adenoids

Lifestyle and home remedies

In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnoea. Try these tips:

• Lose weight. If you’re overweight or obese, even a slight loss of excess weight may help relieve constriction of your airway. Losing weight can also improve your health and quality of life, and may reduce your sleepiness during the day.

   

• Exercise. Exercising, such as aerobic exercise and strength training, can help improve your condition. Aim to exercise about 150 minutes a week, and generally try to exercise most days of the week.

• Avoid alcohol and medications such as tranquilizers and sleeping pills. Alcohol can worsen obstructive sleep apnoea and sleepiness and may lead to weight gain. Certain medications also can worsen your sleep.

• Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.

• Keep your nasal passages open while you sleep. If you have congestion, use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using nasal decongestants or antihistamines, because some medications may only be recommended for short-term use.

  For obstructive sleep apnoea, some basic questions to ask your doctor include:

  • What’s the most likely cause of my symptoms?
  • Is my condition likely temporary or long lasting?
  • What kinds of tests do I need? Do I need to go to a sleep clinic?
  • What treatments are available and which do you recommend for me?
  • I have other health conditions. How can I best manage these conditions together?
  Don’t hesitate to ask other questions that occur to you during your appointment.