Information
Sleep disordered breathing encompasses a wide range of breathing abnormalities during sleep including:
- Obstructive sleep apnoea
- Central sleep apnoea
- Sleep-related hypoventilation e.g. obesity hypoventilation
What is sleep apnoea?
Sleep apnoea is a form of sleep disordered breathing where there is cessation of airflow despite continued effort to take a breath. The commonest symptoms are snoring, breathing pauses and choking arousals. Very often, the person with sleep apnoea is unaware of their problem (despite being excessively sleepy during the day) and it is their bedpartner who brings it to medical attention.
How common is sleep apnoea?
Sleep apnoea is extremely common. Anywhere between 2 – 4% of the middle-aged population have sleep apnoea. Sleep disordered breathing becomes more common with age.
However, sleep apnoea can affect anyone at any age, from newborns to the elderly.
What are the diurnal symptoms of sleep apnoea?
If sleep apnoea is moderate to severe, over ninety percent of people experience excessive daytime somnolence which means that they are abnormally sleepy. This can lead to driving impairment, intellectual impairment, personality changes, mood disturbances, reduced libido/erectile dysfunction, marital disharmony and overall, reduced quality of life. Untreated, moderate to severe sleep apnoea is associated with an increased risk of cardiometabolic and cerebrovascular disease.
What are the nocturnal signs of possible sleep apnoea?
These are usually reported to the person with sleep apnoea by a bed partner or co-sleepers; occasionally the person is aware of the events themselves. Snoring is the most common event and occurs in 90-95% of all cases. The other signs are witnessed breathing pauses (75%), a dry mouth in the morning (75%), excessive sweating (50%), choking attacks (25%) and urination at night (25%).
An absence of snoring does NOT exclude sleep apnoea.
What are the risk factors for the development of sleep apnoea?
Being male, middle-aged and obese confers the greatest risk of developing sleep apnoea. Menopause in females is associated with a risk on par with males of sleep apnoea. However, there are many other risk factors for developing sleep apnoea including mild abnormalities of the jaw and facial structure, such as an overbite or a backset jaw. The structure of the face, especially the midface, and the shape of the hard palate, nasal blockage and problems with breathing through the nose as well as large tonsils, adenoids and a large tongue can all lead to snoring and sleep apnoea. Central obesity with a high waist:hip ratio, is a greater risk for the development of sleep apnoea. That means ‘apples’ are generally at greater risk than ‘pears’ for developing sleep apnoea.
Between 30 and 50% of people with sleep apnoea will not be obese.
What makes sleep apnoea worse?
Alcohol can worsen sleep apnoea by reducing the activity of the upper airway dilating muscles that prevent the airway from closing over during sleep. Sedative medications have a similar effect and also have the potential of reducing respiratory drive. Sleep deprivation and supine sleep can also worsen the symptoms. Sometimes, nasal congestion can also worsen sleep apnoea.
What other types of sleep disordered breathing are there?
Central sleep apnoea is found in severe and /or poorly treated heart failure but can also occur spontaneously or in association with diseases that affect the breathing centres in the brain such as strokes as well as in the context of large doses of opiates.
Urgent referral to cardiology is warranted in the context of heart failure if the patient is adherent to medications.
In the case of opiates, these need to be reduced and stopped where appropriate.
Nocturnal hypoventilation can occur in the context of other diseases, including muscular disorders, severe obesity and pulmonary pathology. If this is suspected, urgent referral to a respiratory physician in the first instance is warranted.
Who can refer:
Any medical practitioner
Who to refer:
Any patient with a history consistent with obstructive sleep apnoea based on symptoms that occur regularly i.e. nightly basis and who have diurnal impairment (ie day time symptoms – see above):
- Epworth sleepiness score of >/+ 11/24 OR any of the following:
- Impaired ability to function at work
- Sleepiness whilst driving
- Impairment in mood, memory and cognition
- Significant disruption to sleep
- Severe co-morbidities potentially worsened by sleep apnoea e.g. ischaemic heart disease, stroke, diabetes mellitus
Essential criteria for referral:
ALL patients must have the following undertaken and addressed, if necessary, prior to referral:
Full blood count
U’s & E’s
Liver function tests
Thyroid function tests
Full iron studies (ferritin must be greater than 100mcg/l)
Folate
B12
Vit D levels
HbA1C
Patients must be following reasonable sleep hygiene principles and regular sleep and wake times.
Patients must have other conditions contributing to sleepiness addressed and managed appropriately: see section on excessive daytime somnolence.
URGENT REFERRAL
Anyone whose work performance and safety are compromised e.g. HGV and professional driving licences; driving and operating heavy machinery; pilots; people caring for vulnerable children and adults
Sleepy drivers
Pregnant women
Pre-operative assessment
Unstable cardiovascular disease e.g. poorly controlled arrhythmia, nocturnal angina, treatment resistant hypertension, atrial flutter history, recent stroke
Arteritic ischaemic optic neuropathy/idiopathic intracranial hypertension
People aged 25 years and under (the brain is still developing)
Who not to refer:
People with snoring only
People with some symptoms of sleep apnoea but no impairment in daytime function or co-morbidities
People who have not had any of the above investigations performed or addressed
People who have presented solely on account of a partner’s intervention.
People who are claustrophobic and unable to tolerate a mask on the face.
How to refer:
SCI gateway :
RIE > Respiratory Sleep > LI Sleep Referral
Or by headed letter to
Department of Sleep Medicine
Royal Infirmary of Edinburgh
51 Little France Crescent
Old Dalkeith Road
Edinburgh
EH16 4SA
All people who are overweight/obese should be counselled or referred to a weight management programme. See Weight Management Service Adult – RefHelp
Lifestyle issues such as alcohol intake, diet and smoking should be addressed
Depression, anxiety must be addressed – these are frequently overlooked
Medications contributing to sleep disordered breathing should be assessed e.g. opiates, regular use of Z-drugs, other benzodiazepines
Management of Snoring
Snoring is defined as a type of breathing during sleep accompanied by harsh or hoarse sounds caused by the vibration of the soft palate. Breathing occurs through the open mouth and nose. Snoring is a subjective experience on the part of the person forced to listen to it.
Snoring occurs in 90% or more of people with sleep apnoea but they are not the same condition.
What can be done about snoring?
Lifestyle factors contribute to snoring and modification of these can sometimes improve the degree and intensity at which someone snores. These include weight loss, avoiding supine sleep, avoidance of alcohol before bedtime, cessation of smoking and treating nasal congestion. It is important that any anatomical abnormalities which can contribute to snoring or worsen it, including adenoids, large tonsils, jaw problems and nasal blockages are addressed.
Probably the best devices we have currently for treating snoring are mandibular advancement splints/mandibular repositioning devices. There is very good evidence to show that they work if constructed properly by a qualified professional. Mouth-guards bought over the counter are generally useless.
The mandibular advancement splints can be made by an orthodontist (not on the NHS).
If a partner is disturbed by snoring, ear plugs (industrial grade) or sleeping in another room can be useful strategies. Sometimes going to bed before the snoring partner can help.
In extreme cases of very disruptive snoring, continuous positive airways pressure can be useful.
