Obstructive sleep apnoea: a rest robber
Are you dragging yourself around in the daytime? Falling asleep at odd times and feeling foggy brained? Is your partner’s sleep being disrupted by your snoring? If so, Obstructive Sleep Apnoea (OSA) could be the cause. Margaret Hawkins from the Farmer’s Journal talks to Edel Hurley, Director and Clinic Manager of the Beacon Dental Sleep Medicine Clinic about the condition that affects about 20% of Irish people, many undiagnosed.
“Sleep is like an elixir and if people are not sleeping, it can cause havoc,” Clinical Manager Edel Hurley, says. “Obstructive Sleep Apnoea can cause a lot of disharmony in the home, with partners unable to sleep because of the snoring. If people are not sleeping they become irascible and this can result in escalating interpersonal difficulties.
Invariably, the spouse is the person who is on high alert that there is a problem. Sometimes patients come to us and they are already in a spare bedroom and the relationship might already be a bit fractious, so they do need support. If a spouse is helpful when someone develops any chronic illness, not just Sleep Apnoea, it does help to manage the problem, of course.”
Edel Hurley, Director and Clinic Manager of the Beacon Dental Sleep Medicine Clinic
“While everyone who has Sleep Apnoea snores, not everyone who snores has Sleep Apnoea” she says.
“This is important to note because snorers can be just snorers, however snoring can be the first indication of Sleep Apnoea.”
The most frequent signs of Obstructive Sleep Apnoea are:
– Loud snoring
– Noisy and laboured breathing
– Repeated short periods where breathing is interrupted by gasping or snorting
– Excessive daytime sleepiness
– Not feeling refreshed, when waking in the morning.
Obstructive Sleep Apnoea can also run in families, is more common in men however, it is also common in women, especially around the menopause, due to variations in circulating hormone levels, with a change in subsequent night-time sleep patterns.
OBESITY IS CAUSING AN INCREASED INCIDENCE
The numbers of people developing Sleep Apnoea has risen in the past few years, because of a current universal obesity pandemic.
“We saw an increase in patient contact and attendance at our clinic over and after the Covid pandemic. This is largely because people were at home, contributing to frequent snacking and under-exercising, which invariably led to weight gain
“Food wise, people who are undiagnosed, are often “dragging themselves” around in the daytime, more likely to eat foods which are highly calorific in an attempt to gain energy” she says, “however, that is unfortunately simply adding to the problem.”
Obesity has become a huge factor in Obstructive Sleep Apnoea, Worldwide. We have some fat pads in the oropharynx (the area at the back of the throat that descends into what is the larynx, trachea and down into the lungs) and these pads increase in size, as we gain weight. We cannot see this space, it cannot be monitored without visualisation.
“The airway becomes increasingly narrowed, so breathing may become progressively obstructed.”
As the person sleeps the muscles and soft tissues in the throat relax and collapse inward and cause a partial or total blockage of the airway. This blockage is called Obstructive Sleep Apnoea.
People with Sleep Apnoea don’t get consistent, restorative sleep because of the repeated airway size changes during the night. The combination of effort of breathing, a circulating high carbon dioxide level (due to reduction and/or cessation of breathing) triggers the brain through the Respiratory Centre to restart breathing, forcing the patient out of their deep sleep into taking a big breath, so that the airway re-opens and breathing restarts.
This is commonly described by a bed-partner as “witnessing their partner startle or jump, just as they restart breathing”. This physical narrowing of the airway causes chronic cycles of interruptions in breathing, which over time, left untreated is substantially damaging to health.
Untreated Snoring and/or Sleep Apnoea can cause a myriad of health problems from day-to-day waking up tired and a worrying feeling that they have had little or no sleep nor rest, resulting in a chronic daytime tiredness. This poor sleep leads to a propensity to fall asleep at various stages throughout the day, with poor mental concentration, often linked to mood swings, the development of high blood pressure, atrial fibrillation (an irregular heart beat), overeating (trying to gain energy) often leading to a cycle of weight gain, diabetes and many more preventable illnesses.
“Patients will always restart breathing” says Ms Hurley. This is true, however it is the chronic nature of interrupted breathing and poor overnight oxygenation is what causes the chronic health damage. Many bedpartners worry about the snorer (who stops breathing for whatever period of time) will not restart breathing. In many incidences, the bedpartner then takes on a role of some responsibility at night-time, meaning their own sleep is interrupted through noise and ongoing anxiety that their partner may fail to breathe. This then becomes a vicious circle, with both bedpartnesr having poor sleep patterns.
FIT PEOPLE CAN BE AFFECTED TOO
While most people may develop Sleep Apnoea due to weight gain, particularly in the neck area, fit people can be affected too, Edel Hurley says. Sleep Apnoea is particularly related to a Phenotype i.e. a particular head and neck anatomy, which predisposes people to Sleep Apnoea. It can also be hereditary, running in families.
People with larger neck circumferences tend to be more vulnerable to Obstructive Sleep Apnoea. For men it’s a collar size of 17 inches or greater and in a woman, it is a collar size of 16 inches or greater.
“We’d see athletes who could have Sleep Apnoea, associated with the presentation of their head and neck anatomy, where their tongue may be larger and fall backwards, obstructing their airway, while they sleep” she says.
“In some people, their lower jaw may be receded slightly, again predisposing the patient to a narrowing of the airway. They may also have a predisposition to Sleep Apnoea because their airway is anatomically smaller, with a larger tongue, than that of other people.”
Obstructive Sleep Apnoea, as described above, is the most common form of Sleep Apnoea, she says.
CENTRAL SLEEP APNOEA IS MORE SERIOUS
“Central Sleep Apnoea is fortunately a less common neurological condition and people with it, have the potential of developing respiratory complications and many other associated problems, if not accurately diagnosed, treated and monitored”.
Overall, Sleep Apnoea is a very contemporaneous area of healthcare concern, it is multifactorial and often complex, she adds. The key to successful patient management is accurate diagnosis, precise patient treatment and follow-up with metrics which give treatment evaluation and patient education, with ongoing patient support.
“One thing you don’t want to do is immediately silence a snorer, because really, you don’t know what you’re silencing. Key steps should be taken to figure out what the presenting patient problem actually is and then work closely in collaboration with a multidisciplinary team of medical practitioners to optimally manage patients. These key steps ensure the correct intervention is put in place, for optimal patient outcome”
DANGEROUS DOWNSIDE – DROWSY DRIVERS
One of the dangerous downsides of Sleep Apnoea is ‘drowsy driving’ because of disrupted sleep. Those with undiagnosed and untreated obstructive sleep apnoea are 7 times more likely to have traffic accidents,statistics show.
“If a person is driving, operating machinery, responsible for safe management of any equipment, it is very important that they are appropriately diagnosed and treated, if they are suffering from Sleep Apnoea. Their adherence to prescribed treatment, whether that is a C.P.A.P. (Continuous Positive Airway Pressure, Mask therapy) machine or a Mandibular Advancement System device, is very important.
The simplicity or the complexity of the problem has to be figured out first. That can involve referral to a Dental Sleep Medicine Specialist, a Consultant Respiratory Specialist or an Ear Nose and Throat Specialist.
“When a person presents to us with a snoring condition we “disambiguate the presentation” i.e. figure out what exactly is the patient’s problem. If they meet specific assessment criteria as a snorer, they can be considered for a Mandibular Advancement Device. These are upper and lower arch intraoral device systems, which connect and are placed in the mouth at night-time. The setting on the device is determined by the clinical presentation and by what are called validation tools (tests), which will tell
us what is happening with the patient who is wearing the device.”
This device system may need to be adjusted if for example, the person gains or loses weight, over time.
“Mandibular Advancement Devices have a variety of arches which allow the jaw to move safely into different position. For example, if a patient has gained or lost weight, they may experience some breakthrough snoring, we can then adjust the device, to stop the snoring. It’s a bespoke device service, not a one-size-fits-all. Individual devices typically lasts for four to five years.” But does all testing involve an overnight stay in hospital?
“Not necessarily,” she says. Hospital based overnight sleep tests are called Polysomnography, as they gather data on a wide variety of sleep detail. “Dependent on the patient presenting medical assessment, some people need a Hospital Sleep test, based on the complexity of their presentation. However, since the pandemic some Home Sleep tests have become available. Again, which one of these CE certified tests is recommend for that individual patient, depends on the patient clinical presentation”
In more severe cases a Continuous Positive Airway Pressure (C.P.A.P.) machine is prescribed. This is a device that attaches over the face or nose (or both) and blows pressurised air into the airway during sleep, in order to keep the airway open overnight.
It involves a machine beside the bed that continuously delivers pressurised air through a hose, to a mask worn during sleeping hours. The mask selected for a C.P.A.P. prescription can be facial to include the nose and mouth or nasal only. Individual patient diagnosis, their anatomy and patient preference would be some of the considerations in mask selection.
IMPACT OF NOT BEING TREATED
Figuring out the simplicity or the complexity of the problem is very important because, from a physiological point of view, snoring is
overnight work, Edel states.
“When people snore at night they are using and losing energy that would normally be available to them for restorative sleep. Untreated Sleep Apnoea can potentially lead to blood pressure problems (because the flow of oxygenated blood is interrupted on a regular basis, damaging the blood vessels over time). It can also lead to other illnesses including, mood or depressive states and to diabetes, also because there is an interruption to oxygenated blood flow throughout the body.”
STICKING WITH TREATMENT IS VITAL
She highlights the importance of adhering to treatment. “We encourage people to take ownership and responsibility of their
diagnosis. Giving up on the C.P.A.P. machine after a few weeks, for example, is like saying you’re type one diabetic, but you don’t need insulin anymore. Some people may stop using the C.P.A.P. machine for a variety of reasons, dislike of the machine, the machine causing wakefulness overnight, partner disruption, mask discomfort, whatever it is, the problem should be discussed with the patient’s doctor or nurse, not simply abandoned. Some younger people are often frantic to have an alternative to using a machine, because as they may be in or forming new relationships, they don’t want to reveal these problems to their partner, especially in the context of a new relationship. The mandibular advancement device may provide an alternative for these people.”
Again, discussing their treatment prescription needs to best manage their condition with their healthcare team is very important.
DIAGNOSIS AS A RESULT OF OTHER CONDITION
Diagnoses of sleep apnoea often come about through general medical check-ups with the person often unaware they have the condition.
“You could have an instance where a person has a medical because he or she is looking for life assurance for a mortgage, for example,” she says.
“In one recent presentation, the patient had high blood pressure recorded at their medical examination, which in turn was an emerging symptom of Sleep Apnoea. Overnight Sleep testing was indicated to determine the extent of potential Sleep Apnoea, along with a full evaluation of symptoms.
The patient received appropriate treatment and their blood pressure is now managed, along with their medical prescription. A diagnosis of Sleep Apnoea may attract a slightly higher insurance premium, however, the fact that he or she is adhering to treatment for the condition, is the big green light (for getting the life assurance policy). Patient blood pressure will continue to return to be managed well, over time and the patient will also be a safer driver, a safer everything because he or she is now being actively treated, managing their condition”
TIP – APPS TO RECORD SNORING
There are several apps available which record snoring and bringing a recording with you when seeing a G.P. or Medical Consultant is very useful.
“The app on your phone records all night but make sure it’s on your side of the bed,” Edel adds. “We have had cases where both people in the bed discover that they have sleep apnoea.”
Note: 20% of the cost of sleep apnoea devices may be claimed back using Revenue’s Form Med 2 (dental expenses certified by dental practitioner). Some private health insurers may cover some component of the cost, depending on your policy.
This article was featured in the Farmer’s Journal: https://www.farmersjournal.ie/onstructive-sleep-apnoea-a-rest-robber-778230
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