Obstructive sleep apnoea

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Do you have an interrupted sleeping pattern? Do you wake up in the morning with a bad headache? Do you feel sleepy during the day? If the answer to all three questions is ‘yes’, you could be suffering from obstructive sleep apnoea syndrome (OSAS). Although these signs may not strike you as a serious problem, you need to know that OSAS could possibly kill you. As per an observational study that was recently conducted at Sir Ganga Ram Hospital, ~97% of study participants (suffering from various cardiac problems) had significant sleep apnoea and ~58% of them could be classified into the severe category of sleep apnoea. People with a high body mass index (BMI) are widely believed to be more prone to sleep apnoea; however, this study demonstrated no correlation between sleep apnoea and BMI. This indicates that even patients who had a low BMI were at risk and had a significant prevalence of the disease.

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Types

Based on the obstructive breathing events that you face, obstructive sleep apnoea is of the following types.


  • Apnoea occurs when there is a complete or near-complete pause in your breathing for at least 10 s

  • Hypopnoea- There is a decrease in your airflow for a duration of at least 10 s.

  • Respiratory effort-related arousal (RERA) - RERA does not meet the criteria of apnoea or hypopnea. In RERA, there is a limitation in your breathing, which results in an increased effort by you to carry on your respiration. Because of increased effort, you will be awakened or aroused from your sleep.


Based on severity, it is of the following types. In this classification, obstructive sleep apnoea is divided as per the apnoea-hypopnea index (AHI), which is the measurement of how many pauses you take per hour during your sleeping time.

  • Mild obstructive sleep apnoea - when your AHI is between 5 and 15

  • Moderate obstructive sleep apnoea - when your AHI is between 15 and 30

  • Severe obstructive sleep apnoea - when your AHI is >30

Symptoms

A person who suffers from sleep apnoea feels very sleepy during the daytime, often wakes up during the night, lacks focus and may experience general fatigue. The effects of the disease are not restricted to just these signs. Other signs and symptoms of obstructive sleep apnoea are listed below.


  • Snoring

  • Frequent nighttime awakenings

  • Restlessness while sleeping

  • Abrupt awakenings from sleep with a feeling of being choked or out of breath

  • Dry mouth

  • Depression, anxiety or other mood disturbances

  • Night sweats

  • Frequent urination at night

  • Headaches

  • Sexual dysfunction


The following symptoms may be observed in children.

  • Decreased performance in school

  • Sluggishness in the classroom

  • Mouth breathing during the daytime
    Difficulty in swallowing

  • Excessive nighttime sweats

  • Behavioural and learning disorders such as attention deficit and hyperactivity

  • Bedwetting

Causes And Risk Factors

Causes


Obstructive sleep apnoea syndrome (OSAS) is a condition characterized by erratic breathing while sleeping. Because of interrupted breathing, the oxygen levels in the blood significantly drop. Usually, obstructive sleep apnoea occurs when the soft tissue in the back of your throat collapses when you sleep, thus blocking your airway.

Risk Factors


There are certain factors that increase the risk of OSAS:

  • Obesity

  • Neck circumference of >1 in or 40 cm

  • Family history of OSAS

  • Alcohol consumption

  • Use of sleeping pills

  • Sleep deprivation

  • Smoking

  • Sleeping on your back

  • Nasal congestion

  • Certain hormonal abnormalities such as hypothyroidism, which is an underactive thyroid gland and acromegaly. Note that excessive production of growth hormone will result in the swelling of airway tissues.


OSAS seems to have a gender bias. Males are about three to nine times more likely to have OSAS than women, whereas risk factors for women include obesity and menopause.

Prevention

Making certain healthy lifestyle changes can help in preventing obstructive sleep apnoea.


  • Eating a heart-healthy diet

  • Maintaining an optimum weight

  • Quitting smoking

  • Reducing your alcohol intake

  • Substitute sleeping on your back with sleeping on your side.

  • Sleeping for the recommended amount of time as prescribed by your doctor

Diagnosis

OSAS is diagnosed based on monitoring, recording and analysis of physiological parameters of the person via a sleep study or polysomnography undertaken by a trained professional. Polysomnography is an easy test that helps to differentiate sleep apnoea from other sleep disorders. In adults, a home sleep test (HST) may be performed, which is a modified sleep study performed at home. Although OSAS was identified more than three decades ago, physicians do not have any sort of formal training in identifying and treating the condition to date. Other than polysomnography, other tests, which can help your doctor identify the location of your obstruction in obstructive sleep apnoea, are listed below:


  • Nasopharyngoscopy - In this procedure, a flexible scope is inserted into your nose and throat to identify any obstruction in your throat that is causing obstructive sleep apnoea.

  • Sleep endoscopy - This is similar to nasopharyngoscopy; however, it requires mild sedation. This test simulates the sleeping state of the patient to help identify the cause of obstruction.

  • In case surgeries planned to treat the obstruction are identified, imaging methods such as computerized tomography (CT) scans are used. Sleep and awake magnetic resonance imaging (MRI) may be advised by your doctor.

Treatment

In certain cases, if the symptoms are mild, conservative treatment will be sufficient to treat obstructive sleep apnoea.

Conservative treatment such as losing weight if you are overweight, avoiding alcohol and sleeping pills, sleeping on your side rather than your back, treating nasal congestion or sinus problems with breathing strips or nasal sprays and getting adequate sleep can help treat mild obstructive sleep apnoea.

Currently, continuous positive airway pressure (CPAP) is the gold standard for treating OSA. CPAP treats OSA by applying positive airway pressure through a nasal mask (as shown in the image at the extreme right). This positive pressure acts as a pneumatic splint to hold the upper airway open throughout the entire breathing cycle. The level of positive airway pressure requires to be determined during a sleep study. This will vary depending on the patient. The provision of a pneumatic splint ensures that the positive pressure prevents the collapse of your airway and ensures that air flows freely to your lungs. Other types and styles of positive airway pressure devices are listed below:


  • Bi-Level PAP: It uses different pressures during inhalation (breathing in) and exhalation (breathing out). It delivers a different pressure during inhalation and a lower pressure during exhalation.

  • Auto CPAP or Auto Bi-Level PAP: In this type of positive airway pressure device, the machine detects your requirement of pressure and accordingly delivers it.

  • Adaptive Servo-Ventilation (ASV): This is a non-invasive type of ventilation that delivers the required pressure to keep your airways open.

  • Mandibular advancement devices: These devices assist in keeping your airway open while you sleep. They are used for mild to moderate symptoms of obstructive sleep apnoea. Oral mandibular advancement devices advance your lower jaw forward and dental appliances prevent your tongue from blocking your throat.

  • Hypoglossal nerve stimulator: The hypoglossal nerve controls the movement of the tongue. In this device, a stimulator is implanted under your chest skin that is connected via electrodes to your hypoglossal nerve and between your rib muscles. This device is controlled with a remote and is turned on at bedtime. When you breathe, it activates the hypoglossal nerve and your airway is opened by the movement of your tongue forward and out.


Surgery

Surgery is performed when other measures have failed to treat obstructive sleep apnoea. The following surgeries can be performed:

  • Somnoplasty: Reduction of the soft tissue in your upper airway using radiofrequency energy.

  • Tonsillectomy: This is usually performed in children who have obstructive sleep apnoea. In tonsillectomy, the tonsils are removed from the back of your throat to reduce the obstruction.

  • Uvolopalatopharyngoplasty (UPPP): This procedure increases the airway opening in your throat by removing soft tissue at the back of your throat.

  • Mandibular/maxillary advancement surgery: This is usually performed for severe head-face abnormalities contributing to severe obstructive sleep apnoea. It is an invasive procedure. In this procedure, facial abnormalities or throat obstructions are corrected.

  • Nasal surgery: Nasal obstructions such as deviated septum (cartilage present in your nose that separates your nostrils), which contribute to obstructive sleep apnoea, are corrected.

Lifestyle/management

Certain lifestyle changes are important to prevent and ensure obstructive sleep apnoea is at bay:


  • Exercise regularly

  • Lose weight if you are obese by following a healthy diet

  • Make healthy eating choices that are heart-healthy such as reducing your intake of alcohol

  • Developing healthy sleeping habits by getting the recommended hours of sleep as per your age

  • Quitting smoking

Prognosis And Complications

Prognosis


If obstructive sleep apnoea is not treated, it can result in varied health problems because of lack of oxygen and build-up of carbon dioxide, which can result in changes in your heart. Untreated obstructive sleep apnoea can cause stroke, hypertension, abnormal heart rhythms, enlargement of your heart and muscle tissue, heart failure, diabetes, obesity, and heart attacks. Because of complications that involve your heart, it is advised to seek urgent medical assistance to treat your obstructive sleep apnoea.

Complications


If left untreated, it can increase the risk of heart attack, stroke, heart failure, Type II diabetes and hypertension. The relation between sleep apnoea and heart problems such as hypertension, cardiac failure, cardiac rhythm disorders, strokes, dyslipidemias, atherosclerosis and increased platelet activation is quite strong with about three decades of research backup. Other than cardiac complications, cognitive and behavioural disorders such as decreased concentration, attention, motor, and verbal skills may be seen. In children, learning disabilities have been seen with obstructive sleep apnoea. Disorders of the eye such as dry eye or glaucoma (increased pressure in the eye) may be seen. Metabolic disorders such as intolerance to glucose, and type 2 diabetes, leading to chronic kidney disease, may occur. Pregnancy complications such as gestational high blood pressure and gestational diabetes may occur, leading to low birthweight babies.

Alternative Treatments

Other than sleep medication, certain alternatives such as foods, lifestyle changes, herbal medicines, exercise, yoga and meditation can help in inducing sleep.

References

1. Types of Obstructive Sleep Apnoea. Stanford Health Care. Available at: https://stanfordhealthcare.org/medical-conditions/sleep/obstructive-sleep-apnea/types.html. (https://stanfordhealthcare.org/medical-conditions/sleep/obstructive-sleep-apnea/types.html)
2. The dangers of uncontrolled Sleep Apnea. John Hopkins Medicine. Available at: https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-dangers-of-uncontrolled-sleep-apnea. (https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-dangers-of-uncontrolled-sleep-apnea)
3. Sleep Apnea. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/8718-sleep-apnea. (https://my.clevelandclinic.org/health/diseases/8718-sleep-apnea)
4. Sleep Apnea. Sleep Foundation. Available at: https://www.sleepfoundation.org/sleep-apnea. (https://www.sleepfoundation.org/sleep-apnea)
5. Sleep Apnea. NIH. Available at: https://www.nhlbi.nih.gov/health-topics/sleep-apnea. (https://www.nhlbi.nih.gov/health-topics/sleep-apnea)
6. Obstructive Sleep Apnea Diagnosis. Stanford Health Care. Available at: https://stanfordhealthcare.org/medical-conditions/sleep/obstructive-sleep-apnea/diagnosis.html. (https://stanfordhealthcare.org/medical-conditions/sleep/obstructive-sleep-apnea/diagnosis.html)

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