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Frequently Asked Questions for Sleep Apnoea

Home / Frequently Asked Questions for Sleep Apnoea
What is Sleep Apnoea? + -

A layman’s definition of Sleep Apnoea is ‘the cessation of breathing during sleep’.  When breathing stops the levels of oxygen in the blood begin to drop.  After a short time the lack of oxygen causes a reflex response.  This response forces open the airway with a loud snort, maybe gasping breaths and loud snoring.  There may also be kicking and flailing of the arms.

Symptoms

How do I know if I have Sleep Apnoea?

One of the best people to help you answer this question is your spouse/partner.  People with sleep Apnoea generally have the following symptoms: –

Loud, frequent and irregular snoring:  The pattern of snoring is associated with episodes of silence that may last from 10 seconds to as long as a minute or more.  The end of an apnoea episode is often associated with loud snores, gasps, moans, and mumblings.  Not everyone who snores has sleep apnoea, and not everyone with apnoea necessarily snores (though most do).  This is probably the best and most obvious indicator.

Your spouse/partner indicates that you periodically stop breathing or appear to be choking during your sleep, or gasp for breath (witnessed apnoeas).

Excessive daytime sleepiness:  Falling asleep when you don’t intend to.  This could be almost anytime you are sitting down, such as during a lecture, while watching TV, while sitting at a desk, and even while driving a vehicle.  You may have sleep apnoea or another sleep disorder.  Even if you don’t literally fall asleep, excessive fatigue/tiredness could be a positive indicator.

Body movements/Limb Movements often accompany the awakenings at the end of each apnoea episode, and this, together with the loud snoring, will disrupt the spouse/partner’s sleep and often cause her/him to move to a separate bed or room.

Forgetfulness that is, affecting the short term memory, also a difficulty in concentrating, focusing and completing repetitive tasks.  Bouts of irritability, mood swings and depression are common.  If working, a dis-improvement in performance over a period of time is common.

Other symptoms include Hypertension (High Blood Pressure), Nocturia (frequent bathroom visits during the night), Type 2 Diabetes, Glaucoma.

Would I not be aware of all these symptoms myself ?

Probably not.  Most people with sleep apnoea do not realize that they are awakening to breathe many times during the night.  The arousal is slight, and people become accustomed to this, but it is enough to disrupt the pattern of sleep so that they get very little deep sleep (Stage N3) or REM sleep, and awaken feeling sleepy or even groggy.  A great many apnoea sufferers go through a large part (or ALL) of their lives unaware of their condition.

Likewise regarding daytime sleepiness: people with sleep apnoea often are not aware of feeling tired or unusually sleepy.  The disorder develops over a number of years, and they are not aware of the increasing symptoms and believe they feel “normal”.  Only after treatment do they realize how much more alert and energetic “normal” feels!

  • There are three different types of sleep apnoea:
    • obstructive
    • central
    • mixed

Obstructive Sleep Apnoea (OSA) is the most common;
Central Sleep Apnoea and Mixed Apnoea are rare.

Obstructive Sleep Apnoea

Obstructive sleep apnoea is caused by the obstruction and/or collapse of the upper airway (back of throat), usually accompanied by a reduction in blood oxygen saturation, often a ‘cardiac’ event and then an awakening (arousal) to activate breathing again.  This is called an apnoea event.

Why?

There are a number of factors:

Extra or loose tissue in the back of the throat, such as large tonsils, large uvula, large tongue or long/floppy soft palate.  There may also be an obstruction at the base of the tongue, turbinate problems or nasal blockages.

A decrease in the tone of the muscles holding the airway open.

There is growing evidence that the condition may be hereditary (receding jawline etc).

 

Central Sleep Apnoea

Central Sleep Apnoea is defined as a neurological condition where there is a cessation of all respiratory effort during sleep (the brain forgets to instruct the body to breathe), usually with decreases in blood oxygen saturation levels.  The person is aroused from sleep by an automatic breathing reflex, so may end up getting very little sleep at all.  Note that Central Sleep Apnoea, which is a neurological disorder, is very different in cause than OSA, which is a physical blockage/constriction – though the symptoms are very similar.

Mixed Apnoea

Mixed Sleep Apnoea, as the name suggests, is a combination of Obstructive and Central Sleep Apnoeas’.

Severity

Severity of Sleep Apnoea is determined by the AHI (Apnoea Hypopnoea Index). This index is the average number of breathing cessations (greater than ten seconds) per hour of sleep.

Mild Apnoea equates to an AHI of between 5 and 14 (below 5 is considered normal)

Moderate Apnoea equates to an AHI of between 15 and 30

Severe Apnoea equates to an AHI above 30

While this scale is accepted internationally, it is somewhat ‘crude’ as it does not take into account the level of symptoms being experienced by the patient, the level of oxygen saturation in the blood and other forms of disruption.

In some cases, clinicians may refer to the Respiratory Disturbance Index (RDI), which, in simple terms is the AHI plus any Respiratory Effort Related Arousals (RERA). These events are not full Apnoeas or Hypopnoeas but are seen to disrupt sleep and are of a Respiratory nature.

So, while some sufferers’ may only technically suffer from Mild Apnoea, there are cases where their symptoms are more severe than those diagnosed with Severe Apnoea.

Best advice is that any form of Apnoea, regardless of severity, should be treated. If Mild/Moderate or Severe Apnoea remains untreated, it will deteriorate and there is a high risk of long term damage to some of the major organs in the body.

What are the treatment options? + -

There are only a few effective treatments for OSA. 

They fall into several categories:

weight loss/lifestyle changes

surgery

dental appliances

implantable devices

air splint device. 

The most popular and most effective is the latter one, a device which delivers air under slight pressure to the airway by way of a mask. This is a type of ‘air splint’ that keeps the airway open, thereby allowing the patient to breathe normally. There are different types of air splint devices, but are commonly referred to as CPAP (Continuous Positive Airway Pressure)

There is no guaranteed, permanent, device-free “cure” for sleep apnoea!

Weight loss/lifestyle change

It is wiser and safer to get professional treatment.  You can use the techniques below, in consultation with your sleep specialist/doctor, while your treatment progresses.  Sleep Apnoea is a disorder and as such cannot be cured, it can however be managed effectively.  There are several things doctors suggest you do that can greatly alleviate it:

If you’re overweight, loose it! Excess weight contributes to obstructive sleep apnoea in two ways:

Fat deposits in the neck tissue compress the airway and make it more likely to collapse.

Excess weight in the abdomen makes the breathing muscles operate inefficiently, which contributes to breathing difficulty when sleeping.

Weight loss by itself is very difficult (as many of us know).  Sometimes people are only able to lose their excess weight after treatment for sleep apnoea has begun, they are able to be more awake and vigorous, and increase their energy use.

Naturally, weight loss is just a generally very healthy thing (if you’re overweight – if your weight is normal, don’t starve yourself!)

Smoking

As with the loss of excess weight, this is, of course, just a good idea in general. However, quitting might also help your sleep apnoea in addition to its countless other health benefits, by returning lung capacity to normal.

Alcohol

Eliminate alcohol in the evening.  Alcohol depresses your breathing reflexes and significantly worsens sleep apnoea.

Apnoea sufferers should be very careful about excessive drunkenness. The same thing goes for sleeping pills, drugs, or anything that might affect your breathing.

Allergies and respiratory infections:

These cause nasal congestion, which narrows the airway and contributes to apnoea. Consult your physician for medications to treat these which will not interfere with sleep.

Medications:

Many common medications interfere with either the breathing reflex or sleep or both. Some of the most common are “sleeping pills”, tranquilizers, and short-acting beta blockers. Consult your sleep specialist and/or pharmacist about more suitable medications.

Air Splint Devices

Continuous Positive Airway Pressure (CPAP)

“Nasal CPAP” is the Gold Standard treatment for Sleep Apnoea and is the treatment of choice for most people with obstructive and mixed apnoea.  It is the most reliable and effective treatment for the condition. Millions of CPAP devices are now in use treating obstructive sleep apnoea worldwide.  An added advantage with this treatment is the elimination of snoring. 

It involves using a small air flow device connected via a hose to a nasal or full face mask you wear while you sleep – much like a regular oxygen mask, with straps to keep it in place.  Essentially, this device blows air into your nose, or nose and mouth to keep your airway from collapsing and creating an obstruction to breathing.  It increases the air pressure in your airway, thereby stopping its collapse.  It isn’t as unpleasant as it sounds – most people get used to the sensation quickly.

Admittedly, having to wear a face mask to bed isn’t the most attractive thing in the universe.  Most bed partners are usually happy to live with that rather than snoring! And it is infinitely preferable to the effects of apnoea, both the fatigue and the other physical effects (additional strain on the heart).  The exact results vary, but a great many people report significant changes in their lives when they start using CPAP – they feel more awake, more alive – “like a whole different person”, in some cases.

Auto Adjusting Positive Airway Pressure (APAP)

In the belief that the reduction of total airway flow would provide greater comfort to the patient and encourage patients to use the airway pressure treatment on a regular basis, APAP devices were introduced. These devices incorporate flow and pressure sensors and automatic regulation systems to ensure that the correct air pressure is delivered to the airway, only when required (rather than the same constant pressure).

The algorithms used in these devices are designed to offer greater patient comfort insofar as the overall pressure is reduced, if the changes in pressure reduce or eliminate apnoea, snoring, or flow limitation.

Bi-Level Positive Airway Pressure

Bi-level positive airway pressure is a type of Non-Invasive Ventilation (NIV).  Instead of providing air at a constant, fixed pressure all night, the machine “senses” how much air a person needs, based on inspiration and expiration, and varies its level of pressure accordingly.  On inspiration, a higher pressure is needed to prevent Apnoea’s, hypopneas, or snoring.  But on expiration the patient typically requires several centimetres less pressure.

What is the purpose of this?  Well, some people find that they simply cannot sleep with regular CPAP due to the constant air pressure.  Bi-level pressure helps this problem by providing less pressure when you are breathing out (exhaling) and more when you are breathing in (inspiring).

Bi-level pressure devices are significantly more expensive than regular CPAP.

Adaptive Servo Ventilators (ASV)

These devices are the very latest technology for treating Central Sleep Apnoea, Cheynes Stokes Respiration and other ‘difficult to treat’ conditions. As the name suggests they are a type of Non-Invasive Ventilation (NIV) and are best described as a further advance in Bi Level therapy.

 

Oral Appliances

Oral Appliances also referred to as Dental devices have been in use for almost as long as Continuous Positive Airway Pressure (CPAP).

Oral Appliances have been referred to as ‘second line’ treatment (after CPAP), but advances in technology and the skills of certain dentists have improved their results in treating certain types of Apnoea. Typically, they have proven successful in treating mild and moderate apnoea, in the main.

Oral Appliance Therapy (OAT) is safe and in some cases an effective alternative to CPAP. OAT may be indicated for cases of mild to moderate apnoea, under the guidance of a sleep physician (consultant). OAT is also indicated in severe sleep apnoea for those who cannot tolerate CPAP and whose sleep apnoea does not improve sufficiently with weight loss and other measures. Your sleep physician may wish you to have a further sleep study whilst wearing your appliance to verify its effectiveness. Although not routinely recommended in those with severe apnoea, many in this situation will do very well with an appliance, but their effectiveness is certainly not enough to recommend their routine use and again it must be stressed that the most effective treatment for moderate to severe apnoea remains CPAP. 

FOR SUCCESSFUL TREATMENT WITH AN ORAL APPLIANCE, THE TRAINING, SKILL AND EXPERIENCE OF THE DENTIST IS PARAMOUNT.

There are two distinct groups of OAT:

1. Mandibular Advancement Devices (MADs), sometimes referred to as Mandibular Splints

These are the more successful type of appliance and are the most commonly used. These specialised dental devices should be provided by a dentist with suitable training and understanding of this treatment. As most dental schools worldwide do not routinely provide this training for dentists, it is often provided by dentists with specialist post-graduate training. The appliance is like a small upper and lower teeth gum shield and correctly fitted will hold the lower jaw in a forward position which serves to keep the airway open whilst sleeping and prevent snoring whilst in certain cases relieving the blockage which causes apnoea. 

As with CPAP they are only worn at night and ideally to get maximum benefit they must be worn all night, every night. The best appliances are correctly and individually made to fit the teeth and so do not interfere with sleep but may take a few nights to get accustomed to. It is crucial that the appliance can be adjusted by the wearer as its effectiveness is dependent on having the jaw in the correct position. Simple versions (Boil and Bite) of these appliances can be bought over the counter and on the internet. These are not adjustable and are bulky and uncomfortable and although inexpensive are generally not very successful. 

Side effects include excess salivation and joint and muscle pain (soreness) in some cases and these usually disappear within weeks, where they do occur. Once your dentist and sleep consultant are happy with the results you are attaining with your appliance you will usually be checked with your appliance once yearly to ensure that all is well.

A certain number of ‘natural’ teeth are required to anchor this type of device.

2. Tongue-Retaining Devices (TRDs)

This is a suction cup that is gripped between the teeth or lips and which sucks the tongue forward, thus opening the airway behind the tongue. People, who snore only when lying on their back, and whose tongue is the main source of obstruction, sometimes find this device helpful. It is not as effective as a mandibular advancement appliance and is usually reserved for those who are missing most or all of their teeth. 

What can I do about my snoring if I don’t have sleep apnoea? 

Oral appliance therapy (OAT) if correctly used is almost universally effective in eliminating snoring. It has been used for this purpose in the USA for as long as CPAP has been used to treat sleep apnoea.  As their correct use involves specialist training most of the dentists with the experience to provide effective treatment have had post-graduate specialist training in the USA. 

Despite the failure of other home remedies, snorers and their partners and families can rest assured that there is a relatively simple, non-surgical treatment that is tried and tested and does actually work! 

Footnote:  SDSF.ie wish to acknowledge and thank Dr. John O’Brien, Dental Surgeon, BDS, NUI. Cert. OFP. (UCLA) (Orofacial Pain) for his kind assistance in compiling this update on OAT.

Implantable Devices

These devices have been around for about 10/15 years now and in the early stages, their development was plagued by power issues (batteries). Several companies now produce them and they have been clinically cleared for use in Europe (CE Approval), and recently (2016) have received clearance for use in the USA (FDA Approval).

The devices comprise a small box, similar in size and construction to a cardiac pacemaker, with two ‘wires’ that sense breathing patterns (connected to the airway/lung) and delivers mild stimulation (electrical impulse) to maintain multilevel airway patency during sleep (connected to the hypoglossal nerve). Approx. thirty days after being implanted the device is ready for use. Thereafter the device is ‘switched on’ before going to bed and switched off in the morning by way of a remote control unit.

The lifetime of the battery (needed to power the device) is reported as being up to ten years. There are reports that rechargeable batteries are being developed (without the need to remove the device).

These devices are quite expensive (reported at €18,000+ VAT). This does not include the cost of the surgical procedure to implant the device. It may be necessary to have the device ‘implanted’ abroad.

Positional Sleep Apnoea Devices

In cases where Mild or Moderate Apnoea is diagnosed, and its primary cause is the position in which the patient sleeps (supine position/on their backs), it is referred to as Positional Sleep Apnoea. This condition can, in some cases, be adequately treated using a ‘device’ that stops the sufferer sleeping on their backs. This device is strapped to the sufferer’s back by way of a harness. It is like a block of wood or polystyrene and makes it extremely difficult to roll on to the back.

Surgeries

General

Surgery (of any type) where anaesthesia is used, poses a very real danger to people suffering from Sleep Apnoea.  In all cases your surgeon and anaesthetist should be informed (in advance) if you suffer from Sleep Apnoea.  You also need to inform your sleep specialist of any impending surgery, as they may need to send medical data to your surgeon.  If using CPAP, you will probably be advised to bring your CPAP machine to hospital and possibly to the operating theatre.  It may be required during the post-operative recovery period.

Surgery for Sleep Apnoea

The goal of surgery is to enlarge the airway and prevent snoring and airway collapse.  Surgery is site specific (to enlarge a specific portion of the airway).  Due to the risks associated with anaesthesia or an operation, surgery should not be considered as a first option.  There is also a risk that surgery may cure snoring, but if the patient has Sleep Apnoea, one of the primary symptoms (snoring) will be removed while the Sleep Apnoea remains and may go undiagnosed while further damage is being done to the respiratory and cardiovascular systems possibly leading to a stroke (which may have been avoided).

We are unable to source reliable figures for success/failure with surgery.  In general, except for a tracheostomy (see below) surgery for ‘curing’ Sleep Apnoea is not successful and is quite painful. There are incidences where there is temporary relief post-surgery, but research indicates that the apnoea will return, anytime up to five years’ post-surgery.  In America, an increasing number of ENT (Ear Nose and Throat) surgeons continue to pioneer this method of treatment and now offer a ‘cocktail’ of surgical procedures over a period of two to four years, (please see section on multi-phase surgery) In some cases ‘success’ has been claimed, however they are usually short lived as symptoms of Sleep Apnoea start to reappear within a short space of time.  There are no ‘quick fixes’ for Sleep Apnoea.

The following is a list of all known surgical procedures currently in use to treat/cure Sleep Apnoea.  There are no reliable figures available for the success or failure of any one procedure.  The best estimates for UPPP surgery is ‘a 50% improvement in 50% of cases’.  Unfortunately for anyone with mild to severe Sleep Apnoea this means that CPAP must still be used after the operation.

SOME OR MANY OF THESE PROCEDURES MAY NOT BE AVAILABLE IN IRELAND.

Nasal Surgery

Septoplasty

The septum is the divider between the two nasal passages. A deviated (crooked) septum may obstruct the nasal airway. A Septoplasty is performed through the nostrils. The cartilage and bone of the septum is straightened. For someone with a ‘blocked nose’ (injury) this type of surgery is ideal to increase airflow and is helpful in becoming compliant with CPAP, at possibly reduced air pressure. It is not successful in ‘curing’ sleep apnoea.

Turbinate Reduction

The turbinates within the nose are made of bone surrounded by soft tissue whose function are to warm and moisten the air as you breathe. There are three turbinates’ in each nostril (lowest, middle and upper). Reduction of the size of an enlarged turbinate can improve the size of the nasal airway. Turbinate reduction may be performed with surgical instruments, lasers. Radio frequency energy or cauterised.

Removal of Polyps

Nasal polyps can obstruct the nasal airway. Removal of polyps can ‘free up’ the airway.

Sinus Surgery

Sinus infections can contribute to nasal obstruction and surgery may be necessary.

 

Upper Airway Surgery

Uvulopalatopharyngoplasty (UPPP) surgery

This surgery removes the uvula, the lower edge of the soft palate trimmed.  If present, the tonsils are generally removed and tissues around the tonsils trimmed.  It can be done separately or in conjunction with other treatments, depending on where in the airway the obstructions occur.  There are the usual surgical risks involved with this surgery.  Notable ones are general anaesthetic (depresses breathing reflex and can be risky in people with breathing problems like sleep apnoea), swelling of the airway, need for pre-and post-operative medications (may depress the breathing reflex), bleeding, and significant pain lasting up to several weeks.

This surgical procedure (introduced around the same time as CPAP) has proven to be ineffective in ‘curing’ sleep apnoea over an extended period. We have been unable to source ‘independent’ research on its success/failure beyond a three/five-year period.

The clear majority of people who have undergone UPPP for the treatment of Obstructive Sleep Apnoea do have to continue using CPAP, or return to CPAP.

Laser-Assisted Uvulopalatopharyngoplasty (LAUP)

LAUP involves laser surgery on the uvula and soft palate that is reported to diminish snoring, but no controlled studies have been done to show that it reduces sleep apnoea.  Because it is less extensive than UPPP, it is unlikely to be any more effective than UPPP in treating obstructive apnoea.  It is usually done in several steps, and is an outpatient procedure.  For that reason, it is less risky than UPPP.

Potential patients should be careful that they don’t see an advertisement in the paper, call the doctor, and rush into an LAUP procedure without research and consideration.

Despite some advertising claims that LAUP can be carried out during lunch hour with the patient returning to work, this procedure is extremely painful.

TORS (Trans Orbital Robotic Surgery)

This type of surgical device was originally developed in the US to remove ‘hard to reach’ cancerous tumours in the airway. It is now being used in the US (by some practitioners), using the Da Vinci Robot to carry out what is in effect the Uvulopalatopharyngoplasty (UPPP) surgery.

Early indications are that it is no more effective than the traditional procedure, however it is not in use for long enough to determine its effectiveness. Anecdotal reports indicate that recovery time may be extended through its use.

Somnoplasty (Radio-frequency Tissue Ablation of the Palate)

Deliverance of Radio-frequency waves by a needle electrode to the underside of the soft palate to cause contraction of excessive tissues that cause snoring.  This procedure involves a progressive shrinkage of the soft palate and uvula.  Usually patients require up to four treatment sessions of 15/20 minutes, under local anaesthesia. 

Tonsillectomy and Adenoidectomy

Tonsils are tissues on the sides of the upper throat and if enlarged may narrow the width of the upper airway.  Adenoids are at the back of the nose and can obstruct the nasal airway.  This surgery is most common with children as Adenoids usually shrink with age.

This procedure is ineffective in adults.

Lower Airway Surgery

Genioglossus Advancement

The Genioglossus muscle attaches from the back of the tongue to a spot on the back of the chin.  This surgery attempts to pull the back of the tongue forward to enlarge the air space behind the tongue.  The procedure pulls forward a rectangular or circular segment of chin bone (below the front four teeth) and holds it in place with a plate or screw.  A minimal change in the appearance of the chin results (millimetres).

Hyoid Advancement

The Hyoid bone is just above the Adam’s apple.  The Hyoid bone is moved forward and either attached to the Adam’s apple or jaw bone.  The purpose is to enlarge the air space behind the tongue.

Midline Glossectomy, Lingualplasty, and Lingual Tonsillectomy

Midline Glossectomy involves a reduction in the size of the tongue (if enlarged).  The back of the tongue is reduced in size by excising a V shaped portion of the centre part of the tongue.  Lingualplasty is a more aggressive resection with additional removal of side wedges.  Lingual Tonsillectomy involves the removal of tonsil like tissue on the back part of the tongue, it may also be removed with a laser.  A temporary tracheostomy is usually performed with these procedures to avoid breathing difficulty that might result from temporary swelling. The purpose is to reduce the size of the tongue thereby increasing the air space behind the tongue.

Bimaxillary Advancement (Lafort 1 Maxillary Osteotomy with Bilateral Sagittal Split Mandibular Osteotomy)

The upper and lower jaw bones are moved forward along with all teeth to pull soft tissue structures forward and make more room for the tongue.  Metal plates and screws are used to hold the realigned jaw bones in place.  Orthodontic work prior to or following the procedure may be necessary to maintain proper alignment of the teeth.  Change in facial appearance relates to the extent of the advancement.

Tongue Suspension Suture (Repose)

The tongue is pulled forward by way of a permanent stitch attached to a screw which has been placed through the back of the tongue.  This is to prevent the tongue falling back during sleep and obstructing the airway.

 

Surgical Bypass of the Airway

Tracheostomy

An opening is made at the front of the neck to the windpipe and a plastic or metal pipe is inserted. During sleep the patient breathes through the tube, while during the day the tube is covered to allow normal speech and breathing. There are considerable hygiene problems with this procedure.

This procedure is the only surgery that is guaranteed to ‘cure’ sleep apnoea.

 

Multi-Phase Surgery/Stanford Protocol

A relatively new concept (10/12 years old) is a series of surgical procedures pioneered by surgeons at Stanford, California (hence the name).

The Protocol involves two phases, the first of which involves Uvulopalatopharyngoplasty (UPPP) and one or more of Genioglossus Advancement or Hyoid Suspension. If this is unsuccessful, the second phase of the operation involves maxillomandibular advancement.

 

Sleep Apnoea and Driving (Commercial, Truck and Bus) + -

EU Directive – COMMISSION DIRECTIVE 2014/85/EU of 1 July 2014 amending Directive 2006/126/EC of the European Parliament and of the Council on driving licences, has made new and far reaching changes to driving licensing for ordinary drivers, but especially for all types of professional drivers. All countries in the EU have now adopted these regulations. The regulations especially affect sleep apnoea suffers, but also any person suffering from daytime sleepiness.

The regulations now require that a driver should advise the National Driving Licence Service (NDLS) of any long-term or permanent injury or illness that may affect their safe driving ability (see NDLS )

Driving licence applications must be accompanied by a Medical Report Form (D501) if you:

Are applying for a driving licence in respect of a truck or bus, licence categories C, C1, CE, C1E, D, D1, DE or D1E (unless you have previously provided a medical report which is still valid)

Suffer from any of the disabilities or diseases specified in the diseases and disabilities list

Have ever suffered from alcoholism or epilepsy

Are a regular user of drugs or medication that would be likely to make your driving unsafe

The medical report must be completed by a registered medical practitioner and you must also sign the declaration in his/her presence.

Specified diseases and disabilities which need to be reported on application for, or renewal of, a driving licence are contained in Medical guidelines Sláinte agus Tiomáint: Medical Fitness to Drive Guidelines (Group 1&2). For Group 1 licence categories AM, A, A1,The guidelines set out clear minimum medical requirements and all applicants presenting themselves for medical examination should be assessed on the basis of the minimum standards outlined.

As in the past Group 2 guidelines require a higher standard of physical and mental fitness on the part of these drivers in light of the duration of time they spend behind the wheel and the greater size and weight of their vehicles. The updated Group 2 guidelines have been drafted following a public consultation process, including associations representing Group 2 drivers.

SLEEP APNOEA IS NOW INCLUDED ON THE LIST OF SPECIFIED DISEASES AND ILLNESSES TO BE REPORTED TO THE NDLS

 Appeals

An appeals mechanism is available for drivers who have been refused a licence on medical grounds. The NDLS will inform drivers of the appeals process when informing them of the licensing decision.

 

Sleep Apnoea and Driving (Private) + -

EU Directive – COMMISSION DIRECTIVE 2014/85/EU of 1 July 2014 amending Directive 2006/126/EC of the European Parliament and of the Council on driving licences, has made new and far reaching changes to driving licensing for ordinary drivers, but especially for all types of professional drivers. All countries in the EU have now adopted these regulations. The regulations especially affect sleep apnoea suffers, but also any person suffering from daytime sleepiness.

The regulations now require that a driver should advise the National Driving Licence Service (NDLS) of any long-term or permanent injury or illness that may affect their safe driving ability (see NDLS )

Driving licence applications must be accompanied by a Medical Report Form (D501) if you:

Are applying for a driving licence in respect of a truck or bus, licence categories C, C1, CE, C1E, D, D1, DE or D1E (unless you have previously provided a medical report which is still valid)

Will be 70 years of age or more on the first day of the period for which the licence for any licence category is being granted

Suffer from any of the disabilities or diseases specified in the diseases and disabilities list

Have ever suffered from alcoholism or epilepsy

Are a regular user of drugs or medication that would be likely to make your driving unsafe

The medical report must be completed by a registered medical practitioner and you must also sign the declaration in his/her presence.

Specified diseases and disabilities which need to be reported on application for, or renewal of, a driving licence are contained in Medical guidelines Sláinte agus Tiomáint: Medical Fitness to Drive Guidelines (Group 1&2). For Group 1 licence categories AM, A, A1,The guidelines set out clear minimum medical requirements and all applicants presenting themselves for medical examination should be assessed on the basis of the minimum standards outlined.

SLEEP APNOEA IS NOW INCLUDED ON THE LIST OF SPECIFIED DISEASES AND ILLNESSES TO BE REPORTED TO THE NDLS

Appeals

An appeals mechanism is available for drivers who have been refused a licence on medical grounds. The NDLS will inform drivers of the appeals process when informing them of the licensing decision.

Financing my treatment + -

In Ireland, there are three methods of financing your CPAP equipment.

Medical Card Holders:

Those patients who hold a Medical Card merely give their Medical Card details to the CPAP/Homecare supplier, along with their prescription. In most cases the prerscription will have been forwarded directly to a Service Provider who has a Service Contract with the Health Service Executive (HSE). The CPAP/Homecare supplier will then handle all the necessary paper work and submit the relative forms to the HSE to ensure payment. Payment for replacement masks is handled similarly. All other costs are covered under the Medical Card Scheme.

Outright Purchase:

Patients who opt for this method will normally attempt to negotiate the best possible deal with the CPAP/Homecare supplier and pay them for the machine. At present, Health Insurers, in general, make no contribution towards the purchase of CPAP equipment. Laya Healthcare makes a small annual contribution towards CPAP (€150 per annum). Glo Health contribute €250 per annum. These payments are subject to confirmation from your Medical Consultant. The HSE refuse to make a contribution (although there have been reports of some individual successes). It may be possible to negotiate some form of contribution with some of the smaller Health Insurers (St. Paul’s, ESB etc).

Tax relief is available for all equipment costs. Receipts should be included on the Med 1 Form.

Drugs Payment Scheme:

This scheme covers lease/rental of machines (only) and consumables (masks, headgear etc). It is effectively a ‘co – pay’ scheme whereby the patient pays the first €144 per month of the total cost of all pharmacy, equipment lease/rental and consumables, with the balance refunded by the HSE.

The onus is on the patient to initiate the claim, by sending the relevant claim form and receipts (pharmacy, CPAP Rental and mask/tubing/filter purchases) to the centralised payments office at:

DPS Refunds

PO Box 12012

Finglas

Dublin 11

Call save 1890 252 919

Full details, with downloadable Claim Form are available at:

www.drugspayment.ie

Claim progress can be monitored online.

The ‘co – pay’ element (€144 per month, or portion thereof) may be claimed against income tax using the Med 1 Form.

In the event of a claim being refused, the patient should immediately lodge a formal appeal against the decision. This process should take no more than 3/4 weeks. Traditionally, appeals have been upheld.

We receive a number of complaints that CPAP equipment is too dear, relative to prices in other European Countries and online. In this regard, it should be remembered that motor cars and other products may be cheaper abroad also.

You should also be aware that VAT at 23% is payable on all CPAP equipment in Ireland, which is not the case in certain other EU Countries and online. This alone will add €230 to every €1,000 spent.

If purchasing CPAP equipment online or having it delivered from overseas, you should be aware that the Customs Authorities are obliged to collect any outstanding VAT (and may apply a collection charge). This may be requested by the company delivering the product to you.

The companies providing CPAP services in Ireland have advised us that they WILL NOT provide service/repair/call out or support for CPAP equipment purchased overseas, even if the product is under manufacturers warranty. They cite differences in product configuration and that once repaired or examined they must assume any warranty liability remaining.

Oral Appliance Therapy

We are unaware of any financial support for this type of treatment.

 

Air Travel with Sleep Apnoea + -

INFORMATION FOR SHORTHAUL FLIGHTS (LESS THAN 5 HOURS)

1. It is a good idea to get a ‘Letter of Medical Necessity‘ from your Respiratory Sleep Physician (it states your condition and the pressure setting of your CPAP machine). In the event of loss or breakdown, it will prove invaluable should you need to replace your machine while abroad. Probably best to update it annually.
2. It is good practice to clear your CPAP equipment for air travel as soon as possible after booking your flight. Contact the Airline’s Special Assistance Department. This is to ensure that you are allowed to bring the machine on board, as free additional luggage. You will not be allowed to use your machine on shorthaul flights.
3. Follow any instructions from The Special Assistance Department of your airline.
4. Always pack a suitable plug adaptor and extension cable. Check this site for details.
5. It’s a good opportunity to have your machine serviced and replace any worn parts (hose/filter) and mask.
6. If you are renting/leasing your machine, you should check any insurance issues with your supplier.
7. When you approach the security check area, make sure to tell security staff that you are carrying a medical device. Place it in a separate tray. You MIGHT have to remove it from the bag (unlikely). Follow their instructions.
8. On rare occasions, security staff MAY ask to swab your CPAP machine for explosives. Should this happen, you can ask to have it swabbed privately in a room away from other passengers. This process involves removing the CPAP machine from the carry bag and lightly swabbing a small area of it. It should take no longer than a minute or two. You are entitled to ask security staff to replace their gloves with clean ones.
9. Once on board, try to place your CPAP bag beside a bulkhead in the overhead locker, with your other case beside it (protecting it). If you are unable to place the machine safely in the overhead locker, place it on the floor under the seat in front of you.
REMEMBER, problems or difficulties travelling with CPAP are more the exception than the rule.

NEVER, EVER PLACE YOUR CPAP EQUIPMENT WITH ‘CHECKED’ LUGGAGE (TO GO IN THE HOLD). EVEN IF PROTECTED BY ADDITIONAL PADDING. IT IS UNSAFE TO DO SO.

INFORMATION FOR LONG HAUL FLIGHTS

Please follow points 1 to 9 above.

Should you wish to use your CPAP equipment while on a Long Haul Flight, you should check with the Speacial Assistance Department of your airline in advance (at least 48 hours).

Most airlines insist on battery operated machines.

Check with the Special Assistance Department of the airline. If you don’t have a suitable machine, you should contact your equipment supplier/provider.

 

Sleep Apnoea: What can I expect from my treatment + -

The Gold Standard treatment for Sleep Apnoea is CPAP (Continuous Positive Airway Pressure). This involves an airflow device that delivers slightly pressurised air to splint open the airway by way of a nasal or full face interface (mask) while we sleep.

The dangers of leaving Sleep Apnoea untreated include a high risk of Stroke, Hypertension, Right Ventricular Heart Failure and Diabetes. Also, Short Term Memory Impairment, Reduced Cognitive Function, Nocturia (frequent bathroom visits during the night). There is also an increased risk of having a Road Traffic Accident through Excessive Daytime Sleepiness. In short a greatly increased risk of an early death.

Under current Irish and EU Legislation, Sleep Apnoea must be reported to the National Driving Licence Service (NDLS), who will insist on a satisfactory Medical Report before issuing a licence. Motor Insurers are also demanding confirmation that the condition is under control and that the sufferer is not an increased risk for driving.

From a clinical point of view, the benefits of proper treatment far outweigh any discomfort from using the device. Compliant use of CPAP will reverse or correct many of the negative side effects and symptoms of untreated  Sleep Apnoea, such as sleepiness and snoring, but it also decreases the risks of associated conditions. Studies have shown that CPAP can lower Hypertension (High Blood Pressure), decrease insulin resistance, and lower the risk of heart attack, stroke and epilepsy in people with  Sleep Apnoea.

Sleep Apnoea is a ‘condition’, and as such cannot be ‘cured’. It can however be successfully treated, allowing the sufferer to ‘get their life back’. Treatment must be used during all the time that you sleep. It is not an ‘a la carte’ type treatment.

The nature of the treatment is somewhat ‘mechanical’, rather than ‘medication’. The airflow ‘splints’ the airway open and this in turn allows the individual to breathe normally as the airway remains open. This helps to ensure a normal sleep, during which the individual gets the full benefit of proper/structured sleep which allows them to enjoy a ‘full life’.

Over the years we hear of people who refuse to use CPAP. Excuses vary:

‘it’s too invasive’;

‘I won’t have anything touching my face while sleeping’;

‘I can’t sleep with air being forced down my throat’

‘I’m not wearing that thing in front of my spouse/partner’

‘I can’t afford that device, it’s too expensive’

In some cases, Sleep Apnoea sufferers decide in advance of diagnosis that they will NOT use that device.

IT SHOULD BE NOTED THAT THERE ARE MILLIONS OF PEOPLE, THROUGHOUT THE WORLD, SUCCESSFULLY USING CPAP.

So, the plus side…..

Compliant adherence to CPAP treatment therapy can bring about a complete change in the patients life. More energy, more interest in family and life in general. Improved work performance,  return to normal risk for driving and other activities. From a clinical point of view the risks of developing the health factors quoted above diminish quite considerably.

Successful treatment with Oral Appliances are somewhat similar. This treatment option (if suitable) also involves regular use and regular visits to the dentist who fiited the device. Oral Appliances experience significant abuse through usage at night. It is surprising the amount of pressure they come under as the user moves and grinds their teeth.