All about Sleep Apnoea

University College London Hospitals Biomedical Research Centre (UCLH) have reported that sleep apnoea rates have almost doubled at the same time as obesity rates have more than tripled over the last 20 years in the UK.

It is estimated that up to 13% of adult men (age 20 to 70) and 6% of adult women (age 20 to 70) in the UK suffer from Obstructive Sleep Apnoea (OSA).

Research conducted by the Office of Health Economics for Asthma + Lung UK has revealed that investing more in awareness, diagnosis and treatment of obstructive sleep apnoea (OSA) could save the NHS up to £28m and prevent up to 40,000 road traffic accidents a year.

What is sleep apnoea?

Sleep apnoea is a type of sleep-related breathing disorder, a group of sleep disorders characterised by abnormal breathing patterns during sleep. It is a common sleep disorder that causes frequent and repeated pauses in breathing for brief periods during sleep.

Although these lapses can cause a person to awaken periodically and reduce sleep quality, sleepers may not fully wake up and many remain unaware that their night-time breathing is abnormal.

Some people with severe obstructive sleep apnoea are likely to be classified as having a disability and are covered by the Equality Act 2010 if their condition has had a substantial adverse impact on normal day-to-day activities for over 12 months or is likely to do so.

Some 2,217 people across the UK claim personal independence payments (PIP) for sleep apnoea and other respiratory tract conditions, Department for Work and Pensions (DWP) figures show.

To be eligible for PIP you must have a health condition or disability where you:

• Have had difficulties with daily living or getting around or both for 3 months.
• Expect these difficulties to continue for at least 9 months.

You usually need to have lived in the UK for at least two of the last three years and be in the country when you apply.

Types of sleep apnoea

The two main types of sleep apnoea are obstructive sleep apnoea (OSA) and central sleep apnoea (CSA).

Obstructive sleep apnoea (OSA) occurs when the airway at the back of the throat becomes constricted or blocked during sleep, which may cause snoring as air is prevented from passing through normally.

In response to the airway obstruction, a person usually wakes up, engages the muscles in their throat, and takes several gasps or deep breaths, often accompanied by sounds like snorting or choking. Obstructive sleep apnoea is the most common type of sleep apnoea, affecting an estimated 1.5 million adults in the UK, and yet up to 85% of people are undiagnosed, therefore untreated. Around 667,000 (45%) of the 1.5 million people estimated to be living with OSA in the UK have the moderate to severe forms of the disorder.

Central sleep apnoea (CSA) involves disruption in the communication between the brain and the muscles that control breathing. As a result, breathing may become shallower and have temporary pauses. The prevalence of central sleep apnoea is low compared to obstructive sleep apnoea.

Mixed Sleep Apnoea is a combination of OSA and CSA.

What causes sleep apnoea?

In obstructive sleep apnoea, a person makes a notable effort to breathe, but the airway is blocked. The blockage often leads to snoring and sleep fragmentation.

Various factors can contribute to the blocking or collapse of the airway; they include:

• Lax muscles and other tissues in the mouth and throat.
• Nasal congestion.
• Thickened tissues and additional fat stores around the airway.
• An underlying neurological problem.

These can result from:

• Genetic factors.
• Colds and allergies.
• Obesity.
• Thyroid problems.
• Heart or kidney failure.
• Large or swollen tonsils.

In central sleep apnoea, the problem is not a blocked airway. Instead, pauses in breathing occur because the brain and the muscles that control breathing do not function properly. As a result, a person with CSA repeatedly stops trying to breathe as they sleep.

Central sleep apnoea can be due to medication or substance use. In this type of CSA, the use of certain medications or substances diminishes the brain’s ability to properly initiate and regulate breathing. Opioids such as methadone are most frequently the cause.

People with an underlying medical condition can also develop CSA; this form of CSA is typically caused by damage to the brain stem through injury or disease and is considered to be rare. CSA is also often found in people with heart conditions.

Central sleep apnoea can also be caused by high altitude. This form of CSA can occur shortly after a healthy person has ascended in altitude, such as above 8,000 feet, where the air has a lower concentration of oxygen. In response, a person’s breathing becomes faster and deeper and can pause during sleep.

Who does sleep apnoea affect?

Sleep apnoea can affect anyone, adults and children.

However, you are more likely to have sleep apnoea if:

• You are a man and are middle-aged.
• You are a woman past menopause.
• You are a woman in the later stages of pregnancy – OSA symptoms often improve or disappear after your baby is born.
• You are overweight or obese.
• You have a large neck size of 17 inches (43 cm) or more.
• You have a small airway, a set-back lower jaw or a small lower jaw, large tonsils, a large tongue or nasal blockage.
• You have a medical condition that makes some of these factors more likely, such as Down’s syndrome.
• You have type 2 diabetes.
• You have hypertension (high blood pressure).
• You have a chronic heart disease.

Sleep apnoea can also be made worse by drinking alcohol, using sleeping pills and smoking.

Symptoms of sleep apnoea

Signs and symptoms of sleep apnoea can be identified when sleeping and whilst awake.

When sleeping these include:

• Loud snoring.
• Stopping breathing or struggling to breathe.
• Feeling of choking or gasping.
• Tossing and turning.
• Sudden jerky body movements.
• Waking up a lot during the night.
• Snorting while you sleep.

If you sleep alone, you may not be aware of some of the symptoms; if you sleep with a partner, they may notice your snoring and pauses in your breathing when you are asleep.

If you have concerns that you may have sleep apnoea, you could ask them to record (using a mobile phone or another recording device) your breathing at night, or to note down any of the symptoms you are experiencing.

Signs and symptoms of sleep apnoea when awake include:

• Waking up sleepy and unrefreshed.
• Headache when you wake up.
• Difficulty concentrating and feeling groggy.
• Poor memory.
• Feeling depressed, irritable or other changes in mood.
• Poor coordination.
• Loss of sex drive.

Signs and symptoms of sleep apnoea in children when sleeping include:

• Snoring, often with pauses, snorts or gasps.
• Heavy breathing while sleeping.
• Very restless sleep and sleeping in unusual positions.
• Bedwetting, especially if a child had usually stayed dry at night.
• Sleepwalking or night terrors.

Signs and symptoms of sleep apnoea in children when awake include:

• Having a hard time waking up in the morning.
• Daytime sleepiness.
• Being tired during the day.
• Behaviour / learning problems.
• Having trouble paying attention or being hyperactive.

Not everyone who has these symptoms will necessarily have sleep apnoea. We possibly all suffer from these symptoms from time to time, but people with sleep apnoea demonstrate some or all of these symptoms all the time.

Effects of sleep apnoea

Some of the effects that are linked to sleep apnoea include:

• You experience thinking problems such as impaired memory and concentration.
• Your judgement and vision are affected.
• You may have mood disturbances including irritability and a higher risk of depression.
• Sleep apnoea reduces sleep quality, and the effects of poor sleep are compounded by how sleep apnoea affects oxygen levels in the body – it can leave you drowsy and tired during the day.
• You are less alert and react more slowly.

Is sleep apnoea dangerous?

Having sleep apnoea raises your risk for other health issues such as high blood pressure and diabetes. If you already have high blood pressure sleep apnoea can make it worse.

When you wake up often during the night, your body gets stressed. That makes your hormone systems go into overdrive, which boosts your blood pressure levels. Also, the level of oxygen in your blood drops when you can’t breathe well, which may add to the problem.

People with sleep apnoea are more likely to have heart attacks. The cause may be low oxygen. Strokes and atrial fibrillation – that is a fast, fluttering heartbeat – are also linked with the condition. Sleep apnoea disrupts how your body takes in oxygen, which makes it hard for your brain to control how blood flows in your arteries and the brain itself.

If you have sleep apnoea, you could also get what is called pulmonary hypertension or right-sided heart failure (RHF). This happens when your right ventricle is too weak to pump enough blood to your lungs, so the blood builds up in your veins, and fluid is pushed back into tissue, causing swelling. One symptom of right-sided heart failure is swelling in your feet, ankles and legs. RHF can lead to congestive heart failure.

Because sleep apnoea can reduce the blood flow to your brain, it puts you at an increased risk for what is called an ischaemic stroke. This happens when a blood vessel to the brain is blocked. Possible reasons for this include reduced blood flow to the brain and the body not getting enough oxygen. People are up to 25% more likely to have these types of strokes while sleeping, because they happen very early in the morning, during REM sleep.

Driving with sleep apnoea can be very dangerous. If you hold a current driving licence of any type you must tell the Driver and Vehicle Licensing Agency (DVLA) (or Driver and Vehicle Agency in Northern Ireland) if you are diagnosed with a condition that causes sleepiness such as sleep apnoea. You can tell the DVLA online but would need to ring the DVA. You can be fined up to £1,000 if you do not tell the agencies about a medical condition that affects your driving.

How is sleep apnoea diagnosed?

If you are displaying signs and symptoms of sleep apnoea, you should talk to your GP about your symptoms and concerns. Your GP will ask about your symptoms, your health, your medical history, and about how sleepy you are when awake. Your GP might give you lifestyle advice about the best ways to get a good night’s sleep, lose weight and stop smoking.

Your GP may refer you to a sleep clinic. Once you have been referred, you will be assessed at the clinic, either in person or virtually through a remote session. Clinics assess people in different ways. Some arrange for you to have an overnight sleep study at home before you visit, while others will talk with you first before deciding if you need an overnight study.

You will be asked questions about your medical history; this involves talking about your symptoms and quality of life. If you have a partner, bring them with you, so they can explain what happens when you are asleep. A good clinical history helps the doctor to reach a diagnosis.

It may include questions about:

• How long you sleep and the quality of your sleep.
• Shift working (patterns and timings).
• Your symptoms and how long you have had them.
• Your smoking history.
• Family history of sleep disorders, such as OSA or narcolepsy.
• Your mental health.
• Any medication you use or have used.
• How sleepy you are and when you might fall asleep.
• The effect on your work and ability to concentrate.

A physical examination might include measuring and assessing:

• Your weight and height to find your body mass index (BMI).
• Your blood pressure.
• Your neck circumference (size).
• Your jaw size and position.
• Your face and jaw appearance and symmetry.
• The airflow in your nose.
• Your upper airway to see if it’s obstructed.
• Your teeth and having a look at the size of your tongue.
• The inside of your mouth.

Tests for sleep apnoea may include:

• Oximetry – This measures the oxygen level in your blood. It’s usually done at home. You wear a small device with a sensor called a pulse oximeter. This measures your blood oxygen level and your pulse. You will have a clip on your finger or earlobe and a device on your wrist.
• Respiratory limited sleep study – This is an overnight test that can be done in hospital or at home. It measures your airflow, how your chest moves as you breathe, your heart rate and the oxygen level in your blood. Some devices register snoring sounds, body position and leg movements. Equipment will be attached to you with tape, wires and straps as you sleep.
• Polysomnography, or PSG – This is an overnight study, done in a hospital room. It is used when the results of other tests are not clear and in more complex cases. It assesses sleep and wakefulness by measuring your brain waves, eye movements and muscle movements. It also assesses your heart and lung function, by measuring your airflow, the movement of your chest, your oxygen levels and the activity of your heart. It films you while you sleep.

You will be diagnosed with sleep apnoea if the results of your assessment are clear. If they are not, you may be asked to do more tests or to try a treatment called continuous positive airway pressure (CPAP). If CPAP helps, sleep apnoea is the most likely cause of your symptoms.

How is sleep apnoea treated?

Sleep apnoea is a long-term condition, and you may need ongoing treatment to control the symptoms.

Treatment for OSA focuses on reducing the number of breathing pauses you have when you are asleep. You should feel less sleepy during the day, have a better quality of life, and reduce your risk of getting health complications and having accidents.

Treatments include:

• Mandibular advancement devices (MADs) – These are devices that you wear in your mouth as you sleep. They are a dental appliance, and look similar to a gum shield. They are also called intra-oral devices, mandibular repositioning devices, mandibular advancement splints, mouth guards, oral appliances or dental devices. A trained healthcare professional will make impressions of your upper and lower teeth to make a MAD for you. MADs are designed to keep your airway open as you sleep. There are many different devices available but it is best to have one made for you by a trained healthcare professional. If you live in an area that prescribes these devices on the NHS, you will be referred to a specialist to make your device. If not, you may have to buy your own. MADs bring your lower jaw forward to help keep your upper airway open. They are effective if you have mild or moderate OSA.
• Continuous positive airway pressure (CPAP) – This is a simple machine that blows air through a mask you wear at night. It is designed to hold your airway open while you are asleep. It sends air at pressure into your upper airway to stop it collapsing or narrowing. Your sleep clinic or the machine itself will set the pressure for you.
• Positional modifier – If you have mild or moderate OSA and cannot tolerate CPAP or MADs, you might be given treatment in the form of a positional modifier. This is an intervention used to encourage people to not sleep on their backs. There are different devices available, such as tennis ball technique, lumbar or abdominal binders, and full-length pillows. This type of treatment is more likely to be effective if you have a particular type of OSA that is affected by your sleep position. People with positional OSA experience more severe symptoms when sleeping on their back, as opposed to on their side. Positional modifiers are unlikely to be effective in people with severe OSA.
• Surgery may sometimes be an option for the treatment of OSA. Surgery might be an option if you have OSA, large tonsils and a BMI of less than 35 kg/m2. Surgery on the soft tissues at the back of the mouth and top of the airway is used less and less as it is not usually effective. If you are severely obese, i.e. you have a BMI over 40, an operation to help you lose weight, called bariatric surgery, can be very effective.

For people without severe complications of CSA, treating the underlying cause may be enough to resolve abnormal breathing patterns. If CSA continues or is likely to continue after treating the cause, doctors may use additional treatments such as those detailed above targeting night-time breathing.

Final thoughts

There are many practical steps that you can take to help cope with living with sleep apnoea; these include:

• Avoid high-risk activities – People with sleep apnoea should be aware of the risks of daytime sleepiness. Especially for people with untreated sleep apnoea, activities like driving or operating heavy machinery should be avoided when drowsy.
• Consider changing sleeping position – Although they have not been rigorously studied, special products to avoid back sleeping may help some people reduce their symptoms from obstructive sleep apnoea.
• Minimise alcohol consumption – Reducing alcohol intake can be a component of the treatment plan for sleep apnoea. In people with untreated sleep apnoea, even daytime alcohol consumption may exacerbate breathing problems at night.
• Maintaining a healthy weight and having good bedtime habits can all make a big difference.
• Quitting smoking – Research has suggested that smoking can damage your airways and make them more likely to collapse while you are asleep. Stopping smoking is one of the best things you can do for your lungs, and for your overall health.

Anyone who is suffering from sleep apnoea or who knows someone who is a sufferer may want to access additional help and support:

• Hope2Sleep support for people living with OSA 0300 102 9711.
• Sleep Apnoea Trust info@sleep-apnoea-trust.org.
• British Snoring and Sleep Apnoea Association 01284 717688.
• If you suspect your child has sleep apnoea, the Great Ormond Street Hospital for Children (GOSH) has excellent information for parents 020 7405 9200.