Symptoms, Diagnosis and Treatment of Sleep Apnoea

The sufferer can experience excessive daytime sleepiness, lack of concentration, snoring, unrefreshing sleep, choking episodes during sleep, depression, irritability and a decrease in sex-drive.

The spouse or partner also often recognises recurrent breathing pauses in the sufferer as their throat closes off completely but this is a symptom which the sufferer themselves is often completely unaware of.

Patients with sleep apnoea also have an increased frequency of hypertension (high blood pressure) and this may lead potentially to an increased risk of heart attacks and strokes in later life.

Drowsiness while driving

Drivers falling asleep at the wheel cause about 30% of all major road accidents in Britain and these accidents often result in death or serious injury as they occur at high speed without any evidence of avoiding action.

It is important to realise that the DVLA can withdraw driving licenses from sufferers of untreated apnoea but they usually allow those who are being treated and whose apnoea is controlled successfully to continue to drive normally. More details about driving, insurance and Sleep Apnoea can be found on our News and Events Page

Diagnosis of Sleep Apnoea

Sleep apnoea can be diagnosed easily and treated effectively in the vast majority of sufferers. It is often the sufferer’s partner who first realises that something is wrong, usually because of very heavy snoring and noticeable pauses in breathing during sleep.

If you are a heavy, loud snorer and if you experience recurring episodes of restless and unrefreshing sleep with daytime drowsiness you may well be suffering from sleep apnoea and should consider seeing a sleep specialist.

The presence of significant sleep apnoea may be strongly suspected from the history. Often the patient’s partner has read an article about sleep apnoea and recognises that this must be what their partner has.

Once sleep apnoea is suspected then a sleep study is done to confirm the diagnosis.

A variety of signals can be measured during sleep, without having to use any painful needles or devices.

Your GP will ask you a few simple questions about your sleeping pattern and will often ask you to complete a simple questionnaire about daytime sleepiness called an Epworth Sleepiness Scale and if there is a suspicion of sleep apnoea you can then be referred on to your nearest sleep centre (there are sleep clinics in many of the large hospitals).

The  Epworth Sleepiness Scale provides a way for physicians to identify those patients who may need an overnight sleep study.     Try the online version here: Epworth Sleepiness Scale

Your nearest sleep centre can then diagnose whether or not you have sleep apnoea. This will involve studying your breathing pattern whilst you sleep with a simple piece of equipment which can usually be given to you so that the recording can take place at home in your own bed. The recording is painless and easy to perform. It usually involves measuring your oxygen level and pulse rate with a little finger probe and may also include a recording of your breathing pattern, chest movement of level of snoring if a more complicated piece of equipment is used. Occasionally an overnight stay in a hospital sleep clinic is necessary to allow the diagnosis to be confirmed but this is not always necessary.

Treatment of Sleep Apnoea

When sleep apnoea (and snoring) are not severe then simple approaches can help. Losing some weight, not drinking alcohol after 6.00pm (alcohol relaxes the upper airway muscles even more), keeping the nose as clear as possible, and sleeping on one’s side or semi propped up can all help.

There are now simple dental devices worn at night, some of which are like sports type gum shields, that can greatly reduce snoring.

The only really effective treatment currently used for bad sleep apnoea is continuous positive airway pressure (CPAP). Because the throat is collapsing it can be held open by slightly pressurised air. To deliver this air a mask is worn during sleep just over the nose and connected to a little quiet pump beside the bed. Breathing is then able to return to normal during sleep with the air gently blowing through the nose, holding open the throat. The response is usually dramatic with greatly improved sleep and disappearance of the daytime sleepiness.

Mask based treatment

Once the diagnosis of sleep apnoea is confirmed some general advice about treatment is given such as weight reduction if necessary, avoiding excessive amounts of alcohol consumption late in the evening and avoiding sedatives or sleeping tablets as they can produce marked relaxation of the throat muscles leading to worsening of the apnoeic episodes. Any additional treatment varies from persons to person, depending on the severity of their condition. Such additional treatment options usually involve either a mask based treatment called continuous positive airways pressure (CPAP) or a jawsplint (mandibular advancement device – MAD / or mandibular repositioning splint – MRS). Whichever treatment option is chosen it has to continue long term and be used each night as there is no effective cure for sleep apnoea in most people – all that can be achieved is that the condition is controlled and the symptoms improved.

manmask

ladymask

airways

Surgery, either by operation or laser, does not have a role in the treatment of this condition and is no longer recommended. Indeed it can make effective treatment with CPAP more difficult to tolerate. Similarly there are no effective drug treatments for sleep apnoea at present.  Nasal continuous airway pressure (CPAP) is the most effective therapy for sufferers from sleep apnoea.

Continuous positive airway pressure therapy (CPAP)

During sleep, the patient wears a mask over the nose which allows a gentle stream of air, from a portable and quiet blower unit, to flow into the throat thus preventing airway collapse. The pressure generated from the blower is adjusted to the individuals requirements to ensure that the stream of air is just sufficient to produce benefit but not too intense to cause discomfort. Approximately 80% of those people started on CPAP therapy find it helpful and comfortable to wear.

CPAP therapy has been shown to reduce daytime sleepiness and improve concentration, intelligence, driving performance, general quality of life and mood. There is some also increasing evidence that it also reduces blood pressure and therefore may reduce the risk of a future heart attack or stroke in a person with sleep apnoea although more research is needed to confirm this finding.

Although these devices are cumbersome to wear, and hardly improve one’s appearance, the benefits far outweigh the disadvantages with the vast majority of patients deciding to use their machines every night at home after a one night trial in hospital.In some patients, particularly those with simple snoring or mild sleep apnoea, a device worn in the mouth, similar to an athletic gum-shield, can be useful in controlling symptoms. This is described as a mandibular (Jaw) repositioning splint.

Jaw Splints

The splint holds the lower jaw forward during sleep and tends to widen the throat a little thus reducing snoring (vibration) and the tendency towards breathing pauses. It has proved to be effective in reducing snoring but it has yet to be proved very effective against anything other than very mild sleep apnoea. It does not appear to be useful at all in more severe degrees of sleep apnoea and is not as effective as CPAP therapy if CPAP can be tolerated. The splint devices tend to make the wearer salivate more than normal and can cause discomfort in the jaw joints as well as potentially damaging the teeth so although they may seem to be a very attractive first option compared to CPAP they are not always ideal.

teeth

Oral Appliances to Treat Snoring and Obstructive Sleep Apnea

What are oral appliances?
Oral appliances are one of the options that you can use to treat mild or moderate obstructive sleep apnea, as well as snoring.They are also called Mandibular Advancement Splints (MAS) or Mandibular Advancement Devices (MAD) or Mandibular Repositioning Appliances (MRA). They look a bit like a mouth guard. At night, before you go to bed, you put it in your mouth. There is no need to wear it during the day.

How do they work?

They push your lower jaw forwards. Your airway will open up more and there will be less of a risk that it will vibrate (snore) or obstruct.

How well do they work?

As with all treatments, some people respond better than others. The oral appliance will work best if you have mild to moderate sleep apnea, if your sleep apnoea is a lot better when you lie on your side than when you lie on your back and if you are not overweight. If you have central sleep apnea (less common than obstructive sleep apnoea), then oral appliances will probably not help. But until you have tried it, no one can say for sure how well it will work for you.

How well do they work compared to CPAP?

CPAP (Continuous Positive Airway Pressure) will stop sleep apnea straight away in almost all people who use it. An oral appliance will usually improve your sleep apnea, but it may not completely stop it. So if you have moderate or severe sleep apnoea, CPAP may be a better option.

Does it have any side effects?

If fitted correctly, it should be comfortable most of the time. Because it pushes your jaw forward, some people feel discomfort initially, but this tends to get better with prolonged use. Mostly, any discomfort is in the joint at the back of your jaw, just in front of the ear. This should soon go away when you take the appliance out in the morning. Other people find that it causes saliva to build up in the mouth, or makes the teeth feel tender. Again, these symptoms settle quickly with continuing use. Over the long term, there may be tooth movement, changes in your bite or problems with the joint and muscles of the jaw. It is important to have a regular check up with the dentist who supplied the appliance to detect these problems early so they can be dealt with.

How can I get one?
Your GP can refer you to a sleep specialist. They will work out how bad your sleep apnea is and what can be done about it. You will probably have an overnight sleep study. You can do this either at home or in a sleep lab. It takes one night. After the sleep study, you will have another appointment with your sleep specialist to talk about which treatment will be best for you. If you decide on an oral appliance, your sleep specialist will refer you to a dentist who specialises in the treatment of sleep apnea. You will continue to be looked after by both the sleep specialist and the dentist.

Does it need to be specially fitted for me, or is there a one size fits all oral appliance?
Each person has a different mouth and jaw shape, so you should have one made to fit you. Your dentist will take an impression of your teeth and send the mould away for the appliance to be made. This usually takes 2 or 3 weeks. When it is fitted into your mouth, it will be adjusted so that it moves your jaw forward to a position that will be effective but is still comfortable. The device will have a screw adjustment to allow further fine tuning of the position over the next few weeks. Your dentist will help supervise this.
There are some kinds of dental devices that you can buy over the counter. These are cheaper, but they usually do not work. You will be wearing a appliance for a long time, so it is best to have one fitted especially for you. This will make it work better and help avoid any side-effects. After the appliance is fitted, follow-up visits with your dentist or sleep specialist will be needed.

Can it be used to stop snoring?
Yes. If it is fitted properly, it works well for snoring.

How should I look after an oral appliance?
You should brush and floss your teeth before you put it in each night. Plaque can build up on an appliance just like on your teeth, so you need to wash it carefully each day. Make sure you dry it out fully. Also keep it in a place when children and pets can’t get at it.

I am using one, but I think it doesn’t work as well as it used to. What should I do?
Perhaps you have started snoring again, or feel tired during the day. If so, then you need to have it checked out. Your dentist might be able to adjust the appliance further. If it comes out when you are asleep, then you should have it looked at. It might not be fitted right. After a number of years some people using an oral appliance find they need to consider other treatments for their sleep apnea.

Nocturnal Hypoventilation Syndrome


Nocturnal Hypoventilation Syndrome is related to sleep apnoea, but is due to the brain’s respiratory control centre not sending out enough nerve impulses to the breathing muscles. So, rather than the breathing being stopped by obstruction to the upper airways behind the tongue (as with OSA), there simply is not enough breathing and sometimes complete cessation of breathing.

It is less common than OSA, snoring is not a feature of this kind of sleep apnoea, and it usually results from a variety of neuromuscular diseases or chest wall deformities.

The treatment consists of overnight ventilation using a nose or face mask system, very similar to those used in CPAP for the treatment of OSA.

How the information on our site can help you

If you think you may have Sleep Apnoea take a look at our Patient Information Sheet.   You can download and print this document and take it with you to your GP if it helps.

If you are awaiting a Sleep Study to confirm diagnosis of Sleep Apnoea or have been newly diagnosed, the information on these pages will help you understand the diagnostic process and treatment. It does not replace the guidance and advice you should seek from your Medical Professional. The Glossary of Terms may help you understand some of the words that may be used

There is also information on how Sleep Apnoea can affect your ability and eligibility to drive. The authority on driving in the UK is the DVLA whose website should always be consulted for the latest position.

You can view it on their website via this link.

Disclaimer – Information provided here is general in nature and should not be seen as a substitute for professional medical advice.

Ongoing concerns about sleep or other medical conditions should be discussed with your local doctor.

We gratefully acknowledge the use of information from the  http://www.sleephealthfoundation.org.au/