loader

Obstructive sleep apnoea

Addbanner

Obstructive sleep apnoea



Introduction 

Obstructive sleep apnoea (OSA) is a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing.

There are two types of breathing interruption characteristic of OSA:


apnoea – where the muscles and soft tissues in the throat relax and collapse sufficiently to cause a total blockage of the airway; it is called an apnoea when the airflow is blocked for 10 seconds or more

hypopnoea – a partial blockage of the airway that results in an airflow reduction of greater than 50% for 10 seconds or more


As many people with OSA experience episodes of both apnoea and hypopnoea, doctors sometimes refer to the condition as obstructive sleep apnoea-hypopnoea syndrome, or OSAHS.

The term "obstructive" distinguishes OSA from rarer forms of sleep apnoea, such as central sleep apnoea, which is caused by the brain not sending signals to the breathing muscles during sleep.

What happens in OSA?

People with OSA may experience repeated episodes of apnoea and hypopnoea throughout the night.

During an episode, the lack of oxygen triggers your brain to pull you out of deep sleep – either to a lighter sleep or to wakefulness – so your airway reopens and you can breathe normally.

After falling back into deep sleep, further episodes of apnoea and hypopnoea can occur. These events may occur around once every one or two minutes throughout the night in severe cases.

Most people with OSA snore loudly. Their breathing may be noisy and laboured, and it is often interrupted by gasping and snorting with each episode of apnoea.

These repeated sleep interruptions can make you feel very tired during the day. You'll usually have no memory of your interrupted breathing, so you may be unaware you have a problem unless a partner, friend or family member notices the symptoms while you sleep.

When to seek medical advice

You should see your GP if you think you might have OSA.

They can check for other possible reasons for your symptoms and can arrange for an assessment of your sleep to be carried out through a local sleep centre.

What causes OSA?

It's normal for the muscles and soft tissues in the throat to relax and collapse to some degree while sleeping.

For most people this doesn't cause breathing problems, but in people with OSA the airway has narrowed as the result of a number of factors, including:


being overweight or obese

having a large neck

taking medicines that have a sedative effect, such as sleeping tablets

having an unusual structure in the neck, such as an narrow airway, large tonsils, adenoids or tongue, or a small lower jaw

smoking or drinking alcohol, particularly before going to sleep


 

Who is affected?

OSA is a relatively common condition that affects more men than women.

Most cases of OSA develop in people aged 30 to 60 years old, although it can affect people of all ages, including children. 

In the UK, it is estimated around 4% of middle-aged men and 2% of middle-aged women have OSA.

As someone with OSA may not notice they have the condition themselves, it is likely that OSA often goes undiagnosed.

How OSA is treated

OSA is a treatable condition, and there are a variety of treatment options that can reduce the symptoms.

Treatment options for OSA include:


lifestyle changes – such as losing excess weight, cutting down on alcohol and sleeping on your side

using a continuous positive airway pressure (CPAP) device – these devices prevent your airway closing while you sleep by delivering a continuous supply of compressed air through a mask

wearing a mandibular advancement device (MAD) – this gum shield-like device fits around your teeth, holding your jaw and tongue forward to increase the space at the back of your throat while you sleep


Surgery may also be an option if OSA is thought to be the result of a physical problem that can be corrected surgically, such as an unusual inner neck structure.

However, for most people surgery is not appropriate and may only be considered as a last resort if other treatments have not helped.

Outlook

The treatments mentioned above can often help control the symptoms of OSA, although treatment will need to be lifelong in most cases.

If OSA is left untreated, it can have a significant impact on your quality of life, causing problems such as poor performance at work and school, and placing a strain on your relationships with others.

Poorly controlled OSA can also increase your risk of developing high blood pressure, having a serious accident caused by tiredness (such as a car crash), having a stroke or heart attack, and developing an irregular heartbeat (such as atrial fibrillation).

 

Can OSA be prevented?

It is not always possible to prevent OSA, but making certain lifestyle changes may reduce your risk of developing the condition. These include:


losing weight if you are overweight or obese

limiting your alcohol consumption and avoiding alcohol during the evening

stopping smoking if you smoke

avoiding the use of sleeping tablets and tranquillisers


Symptoms of obstructive sleep apnoea 

If you have obstructive sleep apnoea (OSA), you may not realise it yourself. The condition is often first spotted by a partner, friend or family member who notices problems while you sleep.

Signs of OSA in someone sleeping can include:


loud snoring

noisy and laboured breathing

repeated short periods where breathing is interrupted by gasping or snorting


Some people with OSA may also experience night sweats and may wake up frequently during the night to urinate.

If you have OSA, you may have no memory of your interrupted breathing during the night. However, when you wake up you are likely to feel as though you have not had a good night's sleep.

Signs of OSA while you are awake can include:


not feeling refreshed after waking up

feeling very sleepy during the day

poor memory and concentration

headaches, particularly in the morning

irritability and mood swings

depression

lack of interest in sex (loss of libido)

in men, erectile dysfunction


 

When to seek medical advice

You should see your GP if you think you might have OSA, as treatment can help reduce the potential impact of the condition on your quality of life.

It can also reduce your risk of potentially serious problems, such as high blood pressure, serious accidents caused by tiredness (such as a car crash), strokes, heart attacks and an irregular heartbeat (such as atrial fibrillation).

Your GP can check for other possible reasons for your symptoms, and can arrange for an assessment of your sleep to be carried out through a local sleep centre.

 

Causes of obstructive sleep apnoea 

Obstructive sleep apnoea (OSA) is caused by the muscles and soft tissue in the back of your throat collapsing inwards during sleep.

These muscles support your tongue, tonsils and soft palate (the tissue at the back of the throat used in speech, swallowing and breathing).

Some loss of stability in these muscles and tissues is normal while you sleep, but in most people this doesn't cause any breathing problems.

In cases of OSA, the relaxation of these muscles and soft tissues causes the airway in your throat to narrow or become totally blocked.

This interrupts the oxygen supply to your body, which triggers your brain to pull you out of deep sleep so your airway reopens and you can breathe normally.

Increased risk

There are a number of things that can increase your risk of developing OSA, including:


being overweight – excessive body fat increases the bulk of soft tissue in the neck, which can place a strain on the throat muscles; excess stomach fat can also lead to breathing difficulties, which can make OSA worse

being male – it is not known why OSA is more common in men than in women, but it may be related to different patterns of body fat distribution

being 40 years of age or more – although OSA can occur at any age, it is more common in people who are over 40

having a large neck – men with a collar size greater than around 43cm (17 inches) have an increased risk of developing OSA

taking medicines with a sedative effect – such as sleeping tablets or tranquillisers

having an unusual inner neck structure – such as a narrow airway, large tonsils, adenoids or tongue, or a small lower jaw

alcohol – drinking alcohol, particularly before going to sleep, can make snoring and sleep apnoea worse

smoking – you are more likely to develop sleep apnoea if you smoke

the menopause (in women) – the changes in hormone levels during the menopause may cause the throat muscles to relax more than usual

having a family history of OSA – there may be genes inherited from your parents that can make you more susceptible to OSA

nasal congestion – OSA occurs more often in people with nasal congestion, such as a deviated septum (where the tissue in the nose that divides the two nostrils is bent to one side) or nasal polyps, which may be a result of the airways being narrowed


 

Diagnosing obstructive sleep apnoea 

Obstructive sleep apnoea (OSA) can usually be diagnosed after you've been observed sleeping at a sleep clinic, or by using a testing device worn overnight at home.

If you think you have OSA, it's important to visit your GP in case you need to be referred to a sleep specialist for further tests and treatment.

Before seeing your GP, it may be helpful to ask a partner, friend or relative to observe you while you are asleep if possible. If you have OSA, they may be able to spot episodes of breathlessness.

It may also help to fill out an Epworth Sleepiness Scale questionnaire. This asks how likely you'll be to doze off in a number of different situations, such as watching TV or sitting in a meeting. The final score will help your doctor determine whether you may have a sleep disorder.

An online version of the Epworth Sleepiness Scale can be found on the British Lung Foundation website.

Seeing your GP

When you see your GP, they will usually ask you a number of questions about your symptoms, such as whether you regularly fall asleep during the day against your will.

Your GP will also carry out a physical examination and some tests, including a blood pressure test. A blood test is also likely to be arranged. These will help rule out other conditions that could explain your tiredness, such as hypothyroidism (an underactive thyroid gland).

The next step is to observe you while you are asleep. To do this, your GP will need to refer you to a local sleep centre. These are specialist clinics or hospital departments that help treat people with sleep disorders. The Sleep Apnoea Trust Association has a list of  sleep clinics in the UK.

Observing your sleep

The sleep specialists at the sleep centre may first ask you about your symptoms and medical history, and they may also carry out a physical examination.

This may include measuring your height and weight to work out your body mass index (BMI), as well as measuring your neck circumference. This is because being overweight and having a large neck can increase your risk of OSA.

The sleep specialists will then arrange for your sleep to be assessed overnight, either by spending the night at the clinic or taking some monitoring equipment home with you and bringing it back the next day for them to analyse.

Testing at home

In many cases, the sleep centre will teach you how to use portable recording equipment while you sleep at home.

The equipment you are given may include:


a breathing sensor

sensors to monitor your heart rate

bands that are placed around your chest

oxygen sensors that are put on your finger


The equipment records oxygen levels, breathing movements, heart rate and snoring through the night.

If more information about sleep quality is required by the sleep centre, a more detailed investigation called polysomnography will be required, which will be carried out at the sleep centre.

Testing at a sleep centre

The main test carried out to analyse your sleep at a sleep centre is known as polysomnography.

During the night, several different parts of your body will be carefully monitored while you sleep.

Electrodes (small metallic discs) and bands will be placed on the surface of your skin and different parts of your body. Sensors will also be placed on your legs, and an oxygen sensor will be attached to your finger.

A number of different tests will be carried out during polysomnography, including:


electroencephalography (EEG) – this monitors brain waves

electromyography (EMG) – this monitors muscle tone

recordings of movements in your chest and abdomen

recordings of airflow through your mouth and nose

pulse oximetry – this measures your heart rate and blood oxygen levels

electrocardiography (ECG) – this monitors your heart


Sound recording and video equipment may also be used.

If OSA is diagnosed during the early part of the night, you may be given continuous positive airway pressure (CPAP) treatment. CPAP involves using a mask that delivers constant compressed air to the airway and stops it closing, which prevents OSA.

Once the tests have been completed, staff at the sleep centre should have a good idea about whether or not you have OSA. If you do, they can determine how much it is interrupting your sleep and recommend appropriate treatment.

Determining the severity of OSA

The severity of OSA is determined by how often your breathing is affected over the course of an hour. These episodes are measured using the apnoea-hypopnoea index (AHI).

Severity is measured using the following criteria:


mild – an AHI reading of 5 to 14 episodes an hour

moderate – an AHI reading of 15 to 30 episodes an hour

severe – an AHI reading of more than 30 episodes an hour


Current evidence suggests treatment is most likely to be beneficial in people with moderate or severe OSA, although some research has suggested treatment may also help some people with mild OSA.

Treating obstructive sleep apnoea 

Common treatments for obstructive sleep apnoea (OSA) include making lifestyle changes and using breathing apparatus while you sleep.

OSA is a long-term condition and many cases will require lifelong treatment.

Lifestyle changes

In most cases of OSA, you will be advised to make healthy lifestyle changes, such as:


losing weight if you are overweight or obese

stopping smokingif you smoke

limiting your alcohol consumption, particularly before going to bed – men should not regularly drink more than three to four units a day and women should not regularly drink more than two to three units a day

avoiding sedative medications and sleeping tablets


Losing weight, reducing the amount of alcohol you drink and avoiding sedatives have all been shown to help improve the symptoms of OSA. 

Although it's less clear whether stopping smoking can improve the condition, you'll probably be advised to stop for general health reasons.

Sleeping on your side, rather than on your back, may also help relieve the symptoms of OSA if you have been diagnosed with the condition.

Continuous positive airway pressure (CPAP)

As well as the lifestyle changes mentioned above, people with moderate to severe OSA will usually need to use a continuous positive airway pressure (CPAP) device.

This is a small pump that delivers a continuous supply of compressed air to you through a mask that either covers your nose or your nose and mouth. The compressed air prevents your throat closing.

CPAP can feel peculiar to start with and you may be tempted to stop using it. But people who persevere usually soon get used to it and their symptoms improve significantly.

CPAP is available on the  and is the most effective therapy for treating severe cases of OSA. As well as reducing symptoms such assnoring and tiredness, it can also reduce the risk of complications of OSA, such as high blood pressure.

Possible side effects of using a CPAP device can include:


mask discomfort

nasal congestion, runny nose or irritation

difficulty breathing through your nose

headaches and ear pain

stomach pain and flatulence (wind)


Earlier versions of CPAP also often caused problems such as nasal dryness and a sore throat. However, modern versions tend to include humidifiers (a device that increases moisture), which helps to reduce these side effects.

If CPAP causes you discomfort, inform your treatment staff as the device can be modified to make it more comfortable. For example, you can try using a CPAP machine that starts with a low air pressure and gradually builds up to a higher air pressure as you fall asleep.

Mandibular advancement device (MAD)

A mandibular advancement device (MAD) is a dental appliance, similar to a gum shield, sometimes used to treat mild OSA. They are not generally recommended for more severe OSA, although they may be an option if you are unable to tolerate using a CPAP device.

An MAD is worn over your teeth when you are asleep. It is designed to hold your jaw and tongue forward to increase the space at the back of your throat and reduce the narrowing of your airway that causes snoring.

Off-the-shelf MADs are available from specialist websites, but most experts do not recommend them, as poor-fitting MADs can make symptoms worse. It is recommended you have an MAD made for you by a dentist with training and experience in treating sleep apnoea.

MADs are not always available on the  so you may need to pay for the device privately through a dentist or orthodontist.

An MAD may not be suitable treatment for you if you do not have many (or any) teeth. If you have dental caps, crowns or bridgework, consult your dentist to ensure that they will not be stressed or damaged by an MAD.

Surgery

Surgery to treat OSA is not routinely recommended because evidence shows it is not as effective as CPAP in controlling the symptoms of the condition. It also carries the risk of more serious complications.

Surgery is usually only considered as a last resort when all other treatment options have failed, and if the condition is severely affecting your quality of life.

A range of surgical treatments have been used to treat OSA. These include:


tonsillectomy – where the tonsils are removed if they are enlarged and blocking your airway when you sleep

adenoidectomy– where the adenoids (small lumps of tissue at the back of the throat, above the tonsils) are removed if they are enlarged and are blocking the airway during sleep

tracheostomy  – where a tube is inserted directly into your neck to allow you to breathe freely, even if the airways in your upper throat are blocked

weight loss (bariatric) surgery – where the size of the stomach is reduced if you are severely obese and this is making your sleep apnoea worse


Surgery to remove excess tissue in the throat to widen your airway (uvulopalatopharyngoplasty) used to be a common surgical treatment for OSA, but it is performed less often nowadays.

This is because more effective treatments are available, such as CPAP. This type of surgery can mean you are unable to use a CPAP device properly in the future if you need to.

Soft palate implants

Soft palate implants make the soft palate (part of the roof of the mouth) stiffer and less likely to vibrate and cause an obstruction. The implants are inserted into the soft palate under local anaesthetic.

The National Institute of Health and Care Excellence (NICE) has said soft palate implants are safe, but they are not currently recommended for treating OSA as there is a lack of evidence about their effectiveness.

However, this form of treatment is recommended for treating snoring associated with OSA in exceptional cases.



Many people with OSA will need to use a CPAP device while they sleep 


Support groups

OSA can have a significant impact on the quality of life for someone with the condition, as well as their friends and families.

As well as causing physical problems such as tiredness and headaches, the condition can have a significant emotional impact and affect your relationships with others.

For support and advice about living with OSA, you may find it helpful to contact a support group, such as:


British Lung Foundation

British Snoring & Sleep Apnoea Association

Sleep Apnoea Trust


 

Complications of obstructive sleep apnoea 

Obstructive sleep apnoea (OSA) can sometimes lead to further problems, such as high blood pressure, if it is not treated.

High blood pressure

Evidence suggests OSA can lead to high blood pressure(hypertension).

This may not cause any obvious symptoms in itself, but it can increase your risk of potentially serious problems such as heart attacks and strokes.

Maintaining a healthy weight, exercising regularly and eating a healthy, balanced diet can all help prevent high blood pressure, as can the appropriate treatment of OSA, such as using breathing apparatus while you sleep.

Road traffic accidents

As someone with poorly controlled OSA can experience excessive daytime sleepiness, they have an increased risk of being involved in a life-threatening accident, such as a car crash. Their risk of having a work-related accident also increases.

Research has shown someone who has been deprived of sleep because of OSA may be up to 12 times more likely to be involved in a car accident.

If you are diagnosed with OSA, it may mean your ability to drive is affected. It is your legal obligation to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could have an impact on your driving ability.

Once a diagnosis of OSA has been made, you should not drive until your symptoms are well controlled.

The GOV.UK website has advice about how to tell the DVLA about a medical condition.

Diabetes

OSA has also been linked to an increased risk of developing type 2 diabetes. This is a lifelong condition that causes a person's blood sugar (glucose) level to become too high. It may occur in people with OSA if your body becomes less able to break down glucose properly.

However, it is not clear whether people develop diabetes as a direct result of OSA, or whether it is the result of an underlying cause of the condition, such as obesity.




Obstructive sleep apnoea