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During sleep we all lose muscle tone and our airway narrows as a result. This sometimes causes us to stop breathing momentarily which is quite normal. But when somebody stops breathing for more than 10 seconds several times during the night there is cause for concern.
The table above lists the major symptoms of a disease known as Sleep Apnoea (SA) or Obstructive Sleep Apnoea (OSA). Typically it affects middle aged males who are overweight, smoke and often drink excessive amounts of alcohol. There can also be familial components to sleep apnoea which are linked to craniofacial or pharyngeal morphology.
Sleep apnoea is defined as a cessation of airflow at the nose and mouth for 10 seconds or more during sleep. Obstructive Sleep Apnoea occurs when the upper airway collapses intermittently and repeatedly during sleep. This collapse can be complete with no respiratory airflow (apnoea) or partial, which creates a reduction in airflow (hypopnoea) and consequent reduction in blood oxygen levels (hypoxaemia). The Apnoea-Hypopnoea Index (AHI, the average number of apnoeas plus hypopnoeas per hour of sleep) is used to determine the severity of sleep apnoea.
OSA can be sub divided in varying degrees of severity depending on the AHI
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Sleep apnoea is a condition that 'creeps up on you' and is often undiagnosed because the snorer has not recognised that their symptoms have become worse over a period of many years. It is thought that sleep apnoea affects 1-2% of men who are aged between 35 and 60. The prevalence of sleep apnoea in women is less well documented but it is thought to be about half that of males.
Snoring and excess weight are by far the most important predictors of this condition and we all know that being overweight is associated with many health problems such as high blood pressure and heart disease. There is substantial evidence that these health problems become worse if you have sleep apnoea. It has been predicted that a 10% weight gain will increase AHI by 32%, whereas a 10% loss in weight will decrease AHI by 26%.
There is now increasing evidence that the sleep fragmentation and daytime sleepiness that sleep apnoea causes have an adverse effect on blood pressure both at night and during the day. More than 50% of patients with OSA have hypertension, whereas only 25% of patients with hypertension have OSA. One study suggested that both sleep apnoea and snoring are associated with hypertension in men and women. Occasional snoring increases the risk of hypertension by 29% while regular snoring increased the risk by 55%. The risk of stroke is also greatly enhanced for those with sleep apnoea and hypertension.
There are many other known adverse effects of sleep apnoea. For example, sleep apnoea affects catecholamine levels, insulin resistance, leptin levels, clotting factors and several potential cardiovascular risk factors.
The usual route for a clinical diagnosis is a sleep study following a referral from your GP. This will be an overnight stay in hospital where your sleep and other physiological parameters will be monitored. Polysomnography (PSG) is considered the most comprehensive of tests in diagnosing sleep apnoea and will record your sleep and breathing patterns (snoring, breathing pauses or cessations), oxygen saturation, thoracic and abdominal movements, brain activity and sleep staging. However, a PSG is extremely costly and not all hospitals have facilities to carry out this procedure. Some hospitals will have limited facilities, and the patient will be monitored overnight at home with a machine known as an oximeter. This will not perform the full function of a PSG but has proven to be perfectly adequate to make a diagnosis.
Clinical diagnosis can sometimes be misleading as patients' symptoms vary widely. For example, some patients who fit the clinical criteria for a diagnosis do not suffer many or any of the recognised symptoms. Conversely, some patients suffer severely with the symptoms of sleep apnoea but do not meet the clinical diagnosis. This means that counting events and setting thresholds becomes unhelpful and can severely affect the treatment outcome. Many sleep clinics now adopt a more pragmatic approach to the management of sleep apnoea and use the sleep study merely to identify breathing abnormalities from heavy snoring through to severe OSA that might explain the patient's symptoms. The patient's symptoms are the most important part of the diagnosis as symptom resolution determines the success of the treatment. Regrettably the waiting time for a sleep study can be quite lengthy and according to the Hospital Episode Statistics data for snoring, the average waiting time for treatment is 141 days.
If you have been diagnosed with sleep apnoea you will most likely be prescribed Continuous Positive Airways Pressure (CPAP) to reduce your symptoms. CPAP is a well established and effective treatment for OSA. It acts as a 'mechanical splint' to prevent the airway from obstructing. Traditionally, a sleep technician will set, or titrate, the pressure (measured in cm H2O) of the CPAP during an overnight stay in hospital until most of the apnoeas have disappeared. The pressure is then 'fixed' and the patient will take the machine home to use every night. However, overnight titration is time consuming and labour intensive. In recent years autotitrating machines have become available that automatically adjust the pressure according to inspiratory flow limitation, snoring & apnoeas.
A recent study compared fixed pressure, autotitration and an algorithm based method of titration to determine if there were any differences in the control of OSA. The algorithm method (which was based on neck circumference/body mass index and oxygen desaturation/AHI) was used to predict the pressure required. Results demonstrated no significant difference in outcome measures. It was also noted that all subjects reported improvements in their symptoms with a relatively low average pressure of 10cmH2O. It was concluded that the algorithm method represents an effective and economic option of initiating CPAP treatment as there is no need for patients to attend an overnight titration.
What if you haven't been diagnosed with sleep apnoea but experience some or all of the symptoms? Or perhaps you have been diagnosed but your health authority cannot provide you with a CPAP machine. Maybe you have tried everything to stop snoring but without success. Of course, you are anxious to obtain a suitable treatment. You may be pleased to know that you can purchase a CPAP machine yourself providing you first obtain a private prescription from your GP (download from our web site).
The ultra-quiet GoodKnight range of CPAP is in our opinion, the most efficient and easy to use system. The machine is so small it fits in your hand and weighs just 760g. The complete kit including carry case weighs only 1.4Kg. The GoodKnight 420G is the smallest and lightest fixed pressure machine available. If you are looking for an autotitration machine, the GoodKnight 420E will adjust the pressure for you throughout the night, and will adapt with night to night variability to your needs. It senses snoring sounds, apnoeas and hypopnoeas and automatically increases the pressure to counteract them. A small number of patients find that CPAP can cause upper airway dryness. This can be easily remedied as the GoodKnight range now includes the GoodKnight H2O, a heated humidifier to counteract these symptoms. A humidifier will ensure a consistent temperature difference between the water and the ambient air which will minimize condensation in the tubing and keep humidification levels constant throughout the night. The GoodKnight H2O offers a space-saving design that fits neatly with any GoodKnight device and adds only 7.62cm (3") to the length of your CPAP machine. More information and details of how to order can be found at www.britishsnoring.co.uk
Whilst CPAP remains the Gold Standard method of managing sleep apnoea, there is a comparable alternative for those who suffer snoring and mild to moderate sleep apnoea. Mandibular advancement therapy has been proven to be highly effective in reducing the symptoms of snoring and sleep apnoea and it may be a good alternative if you decide that CPAP is not the treatment for you. The revolutionary new SomnoGuard AP is designed for easier adjustment and a better fit than ever before. Unlike the original SomnoGuard, this new MAD is a 2-piece design with a screw adjuster. You can mould each tray separately for better fitting and there is no limit on how many times each tray can be moulded. More information and how to order can be found at www.britishsnoring.co.uk