Obstructive sleep apnoea
- Obstructive Sleep Apnoea (OSA) involves repeated episodes of airway obstruction during sleep, due to relaxation of the tongue and airway-muscles. OSA is commonly associated with snoring
- Common symptoms of OSA are snoring, waking unrefreshed, daytime tiredness, and waking during the night choking or gasping for air. However, many patients are unaware that they have the condition, or do not realise that it is severe
- Patients with OSA have about a 7-fold higher risk of death and heart disease, regardless of the severity of the disease, age or history of heart problems. This risk is eliminated by correct treatment
- Risk factors for having OSA include having a narrow airway or a large tongue, obesity and consuming alcohol at night (especially if the amount is large)
- OSA treatment depends on the individual and the severity of the condition. For moderate and severe OSA, the best treatment is usually CPAP – Continuous Positive Airway Pressure. For milder forms of the condition, more conservative treatment interventions may be appropriate
- OSA is diagnosed by having a full, overnight diagnostic sleep study (click here to read more about sleep-studies). This allows a Specialist in Sleep Medicine to recommend the most appropriate treatment.
Patients with OSA experience repetitive episodes of partial or complete occlusion of the upper-airway during sleep. This is caused by abnormal relaxation of the pharyngeal muscles during sleep. OSA sufferers usually snore, and may wake up gasping or choking. However, many people with OSA are unaware of any disturbance of their sleep. OSA is a common cause of excessive daytime tiredness, fatigue and poor concentration.
Obstructive sleep apnoea has detrimental effects on sleep-quality and health, and increases the risk of obesity, high blood pressure, stroke, heart attack, type-2 diabetes, depression, impotence, mood disorders, and motor vehicle and industrial accidents. If you suspect that you have OSA or you have symptoms of OSA, you should see your General Practitioner. You may then be referred for a sleep-study so that you can be investigated for OSA and other sleep-disorders, so that suitable treatment can be implemented if necessary.
Some of the known risk factors for obstructive sleep apnoea include:
- Obesity (especially obesity around the abdomen and neck) – but remember, OSA can also occur in people who are not overweight or obese
- Large neck circumference (>43cm for men and >40cm for women)
- Age over 65 years (although OSA affects individuals of all ages, including children and adolescents)
- Family history of OSA or sleep-disordered breathing
- Certain facial abnormalities, including a high, narrow, elongated, soft palate, a small chin, an abnormal bite and a small jaw
- Cigarette smoking and excessive alcohol consumption
- Medications, especially sedatives at night.
Signs and Symptoms
The signs and symptoms of OSA are wide and varied. Some OSA sufferers do not exhibit all of the symptoms, however they will usually experience one or more of the following:
- Episodes of gasping, snorting or choking during sleep
- Excessive daytime sleepiness, fatigue or lethargy
- Lack of energy and endurance
- Falling asleep or needing to have a nap during the day
- Disturbed or restless sleep (OSA sometimes causes insomnia)
- Poor memory and concentration
- Morning headaches
- Dry mouth or sore throat upon waking
- Irritability, depression, anxiety, mood and behaviour changes (including ADHD in children)
- Increased frequency of urination during the night
- Rapid weight gain or difficulty in losing weight
It is difficult to specify exactly how many Australians suffer from OSA. It is generally thought however that around 9% of women and 25% of men in Australia have clinically significant OSA and that 4% of men and women have symptomatic OSA. The prevalence of obstructive sleep apnoea in Australia is probably increasing due to the 'obesity epidemic'. Despite this, a large proportion of Australians with OSA remain undiagnosed and untreated.
OSA is more common in males than females, and becomes more common with age. Research studies show that mortality rate (death rate) increases according to the severity of sleep apnoea - even mild OSA results in a 2.5 increase in mortality rate. Treating OSA correctly eliminates this risk. OSA is a known cause of sudden death at night time.
The financial burden of OSA (including healthcare costs, lost productivity, road accidents and work-related accidents) in Australia is in the range $2-8 billion per year. Patients with sleep apnoea are 4 to 9 times more likely to be involved in a motor vehicle accident.
Obstructive Sleep Apnoea (OSA) and Your Health
The continuous cycle of breathing cessation and arousal from sleep that occurs in patients with OSA results in poor sleep-quality, excessive daytime tiredness, and contributes to a large number of other health problems, including:
- Obesity - excessive daytime tiredness and metabolic changes that occur in patients with sleep apnoea make it particularly difficult to lose weight, sometimes as a result of secondary tiredness, poor motivation and depression
- Cardiovascular disease - through a variety of complex mechanisms, OSA may contribute to high blood pressure, stroke, heart attack, heart failure, cardiac rhythm disturbances (especially intermittent atrial fibrillation), and night-time angina attacks. These risks can be significantly improved by successful treatment of OSA
- Diabetes and insulin resistance - patients with diabetes and OSA can frequently improve their diabetic control if their OSA is correctly treated. Many patients with OSA (even those without diabetes) have impaired glucose tolerance and increased glucose levels (click here for additional information from International Diabetes Federation)
- Insomnia - patients with OSA experience recurrent awakenings, which can contribute significantly to insomnia (difficulty in initiating and maintaining sleep)
- Cognitive function and quality of life – prolonged periods of poor sleep and sleep-deprivation in OSA sufferers can lead to depression, anxiety, lack of motivation, impaired memory and concentration, mood and behavioural changes. OSA sufferers who are excessively sleepy during the day are also at high risk of motor vehicle accidents. Daytime tiredness can also affect study, work performance and personal relationships
- Penile erectile dysfunction can occur in males with untreated OSA. Reduced sexual drive also occurs in both men and women with this condition.
Overview of Treatment Options for OSA
The most appropriate treatment for OSA varies according to the severity of OSA, age, body-weight, degree of daytime sleepiness, alcohol-consumption, medical history and the anatomy of the upper airway. A Sleep Physician is a doctor who specialises in treating patients with OSA and other sleep-disorders, and who is qualified to help sufferers make an informed decision about which treatment is the most appropriate.
Treatment for OSA should be individualised, and may involve Continuous Positive Airway Pressure (CPAP) treatment, an oral appliance, surgery (in selected patients), or other medical therapies (such as weight loss, change of sleep-position, improved sleep-habits, change in alcohol consumption, cessation of smoking, and measures to improve nasal airflow). Emergeing therapies such as Provent Therapy and the NightShift device can be prescribed alongside adopting different sleep-positions, improving sleep-habits, reducing alcohol-consumption, ceasing smoking and improving nasal air-flow.
Continuous Positive Airway Pressure (CPAP)
The most successful therapeutic intervention for obstructive sleep apnoea is called Continuous Positive Airway Pressure (CPAP – pronounced “see pap”). CPAP treatment involves using a small machine to pump air at a continuous pressure through a mask worn over your mouth, nose or both. This pressure acts as a pneumatic splint to the airway - holding it open and preventing it from closing during sleep - while still allowing for normal breathing.
For additional information on CPAP treatment, click here to visit our comprehensive CPAP information page.
Provent and Theravent Therapy
Provent is a new device for the treatment of obstructive sleep apnoea and snoring. The treatment uses small, disposable, adhesive devices that cover the nostrils. Microvalves control the amount of airflow in and out of the nasal passage, increasing the air-pressure inside the airways (creating an Expiratory Positive Airway Pressure, or EPAP). The EPAP prevents the airway from collapsing. Provent is suitable for patients who do not tolerate CPAP or have mild severity sleep apnoea and snoring.
Theravent is a similar device - the design of the valves is suitable for patients with snoring and minimal degree of airway collapse.
Click here to visit our detailed Provent Therapy page.
Nightshift is a device that is used to reduce the amount of time the wearer spends sleeping on their back (where most patients are more susceptible to snoring). Nightshift provides feedback in the form of vibrations to discourage the patient from rolling over onto their back, keeping them in an exclusively lateral sleep position. The device monitors sleeping-position as well as the decibel-level of snoring. This feedback is initiated only after the patient falls asleep. The frequency and intensity of the vibration feedback adapts to meet the requirements of each user. Nightshift combined with Provent therapy can be a successful conservative treatment for mild-to-moderate OSA.
Medical Therapies: Conservative Treatments
There are a variety of conservative treatment measures that often reduce the severity of obstructive sleep apnoea. In many patients with mild sleep-disordered breathing, conservative treatments may be successful at resolving the problem altogether. These conservative treatments include:
Positional therapy (exclusively lateral sleep): obstructive sleep apnoea and snoring are almost always worse when a patient is sleeping on their back (or particularly, with the head in this position). This is because the back of the tongue and muscles of the pharynx block the airway more easily in this position mainly because our muscles relax during sleep and in the supine head-position, the tongue then sags backwards under the influence of gravity. Sleeping with the head on the side, and by learning to sleep exclusively on the side, many patients with OSA can significantly improve their condition and in patients with strongly positional OSA or snoring, lateral sleep is sometimes the only treatment required (this can be established by performing a proper overnight sleep study such as SNORE Australia provides)
Weight-loss is important for every patient with OSA. In many cases, weight loss will not cure sleep apnoea, but it can significantly reduce its severity (sometimes to such an extent that other treatments are not required). Weight-reduction can also make it possible to reduce the level of pressure needed with CPAP treatment
Cessation of tobacco smoking: in addition to causing cancer and being a major health risk, tobacco smoke causes the walls of airways to retain fluid and swell (this is called oedema). This causes the airway space to become narrow, worsening obstructive sleep apnoea. Smokers are 4 to 5 times more likely than non-smokers to have obstructive sleep apnoea. Nicotine also contributes to insomnia and poor sleep-habits
Alcohol is a sedative that promotes muscle relaxation, including relaxation of the pharyngeal muscles during sleep. This results in snoring and OSA becoming worse. Reducing regular or peak alcohol can reduce the severity of snoring and OSA; an alternative approach in selected patients with a variable alcohol intake (eg, on weekends only) is for specific treatments such as CPAP to be used only on nights when high amounts of alcohol are consumed
Measures to improve nasal airflow may be beneficial in patients prone to nasal allergies or troublesome nasal congestion at night-time. These measures may involve the regular use of nasal sprays (FESS, intra-nasal steroids), other medications such as antihistamines, or other interventions recommended by a Sleep Physician, ENT specialist, Allergist or the patient’s General Practitioner
Sleep hygiene and sleep habits: as patients with OSA already have disrupted sleep, it is important that it is not made any worse. Therefore, it is important for patients with OSA to:
- Have regular bed times and rising times, preferably allowing 8 hours of sleep per night
- Avoid sleep-deprivation (prolonged periods without sleep)
- Avoid consuming excessive stimulant drinks (such as tea, coffee, cola and energy drinks) that may promote insomnia (difficulty initiating and/or maintaining sleep)
- Avoid using sedatives (such as sleeping pills), as these cause pharyngeal muscle-relaxation and worsen OSA severity.
A special type of oral appliance, called a Mandibular Advancement Splint (MAS) is sometimes prescribed for people with mild obstructive sleep apnoea. These fit into your mouth like a mouth-guard, and generally work by holding the lower jaw forward, so as to create extra room in the pharynx for the tongue. These devices are generally not suitable for patients with moderate or severe obstructive sleep apnoea; however some patients experience a reduction in their snoring. The side-effects of oral appliances can include excessive salivation (drooling), temporo-mandibular joint (TMJ) pain and over time, altered bite and dental problems.
There are a variety of tongue-stabilisation devices available for snoring and OSA treatment. These are usually small plastic devices that fit over the tongue and use suction to prevent the tongue falling back and occluding the airway.
Around 10-20 years ago, surgery was considered to be a quick fix for obstructive sleep apnoea; however it is now evident that the long-term success rate of surgery is low, and CPAP is now considered the 'gold standard' treatment for this condition. The goal of surgical intervention for OSA is to increase the size of the airway, either at the nasal passages or at the rear of the throat. Specific ENT interventions are appropropriate for certain patients.
Despite almost 20 years of research in this area, there are still no medications which have proven to be successful in treating OSA. There are some medications which can reduce the severity of OSA, however these are either not available in Australia, and/or they are expensive or have excessive side-effects.