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Sleep Apnoea

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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. •There are three different types of 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.

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, and then an awakening (arousal) to activate breathing again. This is called an apnoea event.

Why? (OSA)

There are a number of factors:

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

Excess weight/fat around the jaw and throat area.

A decrease in the tone of the muscles holding the airway open, can cause the airway to constrict.

The facial skeletal structure (mainly a receeding jawline) points towards a hereditary nature. Many Sleep Apnoea patients report that one or both of their parents MAY have suffered from the condition.

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 – though the symptoms are very similar.

Mixed Apnoea

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

How Severe Must Sleep Apnoea Be To Require Treatment?

Each Apnoea event must last at least 10 seconds in duration or longer. Clinicians usually consider an average of up to 5 such events per hour to be normal. Anything above an average of 5 events per hour should require investigation and treatment. However, another important factor is whether the person is symptomatic (excessively tired during the day, unexplained hypertension, morning headaches, cognitive impairments, short term memory impairment or mood swings). These are just some of the more common symptoms.

How do I know if I have it?

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 apnoea, by any means, 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 apnoea’s).

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

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, and awaken feeling sleepy. 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!

What should I do if I think I may have sleep apnoea?

As with most medical questions, if you have any doubt, the best thing to do is see your doctor. Unfortunately, many doctors are not very knowledgeable about sleep disorders. Our website contains a list of recognised sleep centres where proper treatment is available. A referral from your doctor will be required. If you think that you have a sleep disorder (are aware of a number of symptoms) do not be afraid to tell your doctor that you want a referral to a sleep clinic.

The only definite way to diagnose Obstructive Sleep Apnoea is to spend a night in a sleep lab undergoing a “polysomnogram.” This is probably what your sleep specialist (consultant) will recommend. You may also be advised to lose some weight (if overweight) and limit or abstain from alcohol before sleeping, while awaiting treatment, as they can aggravate the symptoms of Sleep Apnoea.

Your doctor should refer you to a sleep disorders expert. On rare occasions, a doctor may not take apnoea seriously enough. It has been reported that some people have to actively prod their doctors a bit. If your doctor seems inclined to pass the potential of apnoea off as relatively unimportant, you may want to consider getting a second opinion.

I snore! Do I have apnoea?

It’s possible, but not definite. Some people snore who do not have OSA. It’s even possible, though extremely rare, for someone who has OSA not to snore. (However, if the person has excessive daytime sleepiness, he/she may have another type of sleep disordered breathing, such as upper airway resistance syndrome, or a different type of sleep disorder). Pay attention to the sound and pattern of snoring: is it a steady, regular snoring, or is it loud, frequent, and occurring in periodic bursts punctuated by periods of silence, normal breathing, and/or gasping for air? The latter is a very good indicator of OSA.

Is Obstructive Sleep Apnoea dangerous?

Absolutely! In rare cases, apnoea can be fatal. Think about it! Is something that makes you stop breathing something you consider not to be dangerous? It has also been linked to high blood pressure and to increased chances of heart disease, stroke, and irregular heart rhythms (arrhythmias). Unfortunately, not all of the long-term effects of untreated sleep apnoea are known, but specialists generally agree that the effects are harmful. If nothing else, the continual lack of quality sleep can affect your life in many ways including depression, irritability, loss of memory, lack of energy, a high risk of auto and workplace accidents, and many other problems. Medical Research indicates that people with untreated Sleep Apnoea are more likely to die ‘before their time’.

This is not something to ignore or trifle with. While it isn’t usually immediately dangerous, don’t take it lightly. If you think it will go away by itself – don’t – It won’t.

What treatments are available?

There are only a few effective treatments for OSA. They fall into several categories: weight loss/lifestyle change, surgery, dental appliances, and an airway splint device. The most popular and most effective is the latter one, the use of a device which delivers air under slight pressure to the airway by way of a nasal mask. There are several types of positive airway pressure devices including, CPAP, Bi-level positive airway pressure, and responsive and ‘smart’ airway pressure devices. They are all variations on Continuous Positive Airway Pressure, or CPAP.

Weight Loss/Lifestyle Change

It is recommended that people with Sleep Apnoea, who are overweight or obese, should make efforts to lose weight. This advice is also given to people with other illness, conditions or disease. While losing weight is not guarantted to ‘cure’ Sleep Apnoea, it does help the patient, in conjunction with other treatment therapies to minimise the effects of the condition.

A number of clinical studies indicate that if weight gain is the sole cause of a Patient’s Sleep Apnoea, then sufficient weight loss should treat the condition. A primary problem with this is that some people can lose weight, but find it very difficult to keeo the weight off. Another problem is that as long as Sleep Apnoea remains untreated, it will continue to deteriorate in severity.

Airway Splint Devices

Continuous Positive Airway Pressure (CPAP) “Nasal CPAP” is the treatment of choice for most people with obstructive and mixed apnoea. It is the most reliable and effective treatment in most cases. Hundreds of thousands 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 devices blows air into your nasal passages to splint your airway open, prevent it from collapsing or becoming obstructed. It isn’t as unpleasant as it sounds – most people get used to the sensation fairly 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.

Bi-Level Positive Airway Pressure

Bi-level positive airway pressure is a type of Non Invasive Ventillation. Instead of providing air at a constant, fixed pressure all night, the machine provides pressure at two different pressures; one for inhalation and a lower pressure to facilitate exhalation. On inspiration, a higher pressure is needed to prevent Apnoea’s, Hypopneas, or Snoring. But on expiration the patient typically requires several centimetres less of 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.

Responsive and “smart” airway pressure devices

These devices are an advanced form of CPAP. They incorporate flow and pressure sensors and automatic regulation systems. They are designed to afford the patient a higher level of comfort by automatically adjusting the pressure required to treat individual apnoea events. These devices are usually referred to as Auto Adjusting Positive Airway Devices (APAP)

Compared to CPAP, APAP devices offer greater patient comfort insofar as the overall pressure is reduced, providing that the changes in pressure reduce or eliminate apnea, snoring, and also provided that the changing pressures are tolerated by the patient. They may be used for patients whose pressure requirements may vary during the course of a night, from night-to-night, and over longer periods of time.

APAP Devices can also be set to deliver a set pressure (like CPAP). As a result of this they are the most commonly prescribed device on the market.

Oral Appliances

Tongue-Restraining Devices (TRDs)

This is a suction cup that is gripped with the teeth 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. They are also fitted to patients who do not have enough natural rear teeth to anchor a Mandibular Advancement Device.

Mandibular Advancement Devices (MADs)

These are specialized dental devices (must be fitted by a specially qualified dentist), which clamp on your rear teeth and to ‘pull forward’ the jaw to allow more space for breathing. They are only worn at night (removable) and research shows good success for certain types of Apnoea (mild/moderate). For some people, side effects may include excess salivation and joint pain (soreness) in some cases. They must be worn all night. Fitted by an experienced dentist, these devices are proving to be quite successful in treating Obstructive Sleep Apnoea.

Surgery

There are a number of surgical procedures available. They range nasal and upper airway procedures to lower airway and base of tongue procedures to maxillofacial surgery and ‘combination type’ (combination of a number of procedures over a period of time) surgeries. In all cases, surgery is quite painful.

There doesn’t appear to be any independent clinical studies indicating long term success of surgery as a ‘cure’ for Sleep Apnoea.

Implantable Devices

This device is similar to a cardiac pacemaker in appearance and is surgically inserted into the chest cavity. It is linked to the Geniglossal Muscle/Nerve and the Lungs. Before going to sleep the device is switched on, which allows it to electrically stimulate the Geniglossal Muscle and also build up an algorithim of the patient’s breathing patterns. The device is turned off during the day.

Clinical trials indicate good success for certain types of patient. In the past, battery life caused certain problems but the manufacturers now claim that the bettery should last about 10 years.

Figures recently released (2016) indicate that the device costs in the region of €18,000 plus VAT. In addition to this there is the cost of surgically implanting the device.