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A layman’s definition of Sleep Apnoea is ‘the cessation of breathing during sleep’. When breathing stops the levels of oxygen in the blood begin to drop. After a short time the lack of oxygen causes a reflex response. This response forces open the airway with a loud snort, maybe gasping breaths and loud snoring. There may also be kicking and flailing of the arms.
Obstructive Sleep Apnoea (OSA) is the most
Obstructive Sleep Apnoea
Obstructive sleep apnoea is caused by the obstruction and/or collapse of the upper airway (back of throat), usually accompanied by a reduction in blood oxygen saturation, often a ‘cardiac’ event and then an awakening (arousal) to activate breathing again. This is called an apnoea event.
There are a number of factors:
Extra or loose tissue in the back of the throat, such as large tonsils, large uvula, large tongue or long/floppy soft palate. There may also be an obstruction at the base of the tongue, turbinate problems or nasal blockages.
A decrease in the tone of the muscles holding the airway open.
There is growing evidence that the condition may be hereditary (receding jawline etc).
Central Sleep Apnoea
Central Sleep Apnoea is defined as a neurological condition where there is a cessation of all respiratory effort during sleep (the brain forgets to instruct the body to breathe), usually with decreases in blood oxygen saturation levels. The person is aroused from sleep by an automatic breathing reflex, so may end up getting very little sleep at all. Note that Central Sleep Apnoea, which is a neurological disorder, is very different in cause than OSA, which is a physical blockage/constriction - though the symptoms are very similar.
Mixed Sleep Apnoea, as the name suggests,
is a combination of Obstructive and Central Sleep Apnoeas’.
For any type of apnoea to be considered important, each event
must last at least 10 seconds in duration or longer. Clinicians
usually consider 5 or more of such apnoeas per hour to be of
possible clinical significance (less than 5 per hour is normal).
However, another important factor is whether the person is
excessively tired during the day and/or exhibiting other
One of the best people to help you answer this question is your spouse/partner. People with sleep Apnoea generally have the following symptoms: -
Would I not be aware of all these symptoms myself ?
Probably not. Most people with sleep apnoea do not realize that they are awakening to breathe many times during the night. The arousal is slight, and people become accustomed to this, but it is enough to disrupt the pattern of sleep so that they get very little deep sleep (Stage N3) or REM sleep, and awaken feeling sleepy or even groggy. A great many apnoea sufferers go through a large part (or ALL) of their lives unaware of their condition.
Likewise regarding daytime sleepiness: people with sleep apnoea
often are not aware of feeling tired or unusually sleepy.
The disorder develops over a number of years, and they are not
aware of the increasing symptoms and believe they feel "normal".
Only after treatment do they realize how much more alert and
energetic "normal" feels!
As with most medical questions, if you have any doubt, the best thing to do is see your doctor. Unfortunately, some doctors are not very knowledgeable about sleep disorders. Our website contains a list of recognised sleep centres where proper treatment is available. A referral from your doctor will be required. If you think that you have a sleep disorder (are aware of a number of symptoms) do not be afraid to tell your doctor that you want a referral to a sleep clinic.
The only definite way to diagnose Sleep Apnoea is by having a "Polysomnogram"(overnight sleep study). This is probably what your sleep specialist (consultant) will recommend. You may also be advised to lose some weight (if overweight) and limit or abstain from alcohol and caffeine before sleeping, as they can aggravate the symptoms of Sleep Apnoea.
Your doctor should refer you to a sleep disorders expert (usually a respiratory sleep consultant). On rare occasions, a doctor may not take apnoea seriously enough. It has been reported that some people have to actively prod their doctors a bit. If your doctor seems inclined to pass the potential of apnoea off as relatively unimportant, you may want to consider getting a second opinion.
It's possible, but not definite. Some people snore and do
not have OSA. It's even possible, though extremely rare,
for someone who has OSA not to snore. (However, if the
person has excessive daytime sleepiness, he/she may have another
type of sleep disordered breathing, such as upper airway
resistance syndrome, or a different type of sleep disorder).
Pay attention to the sound and pattern of snoring: is it a
steady, regular snoring, or is it loud, frequent, and occurring
in periodic bursts punctuated by periods of silence, normal
breathing, and/or gasping for air? The latter is a very
good indicator of OSA.
What can I do about my snoring?
In rare cases, sleep apnoea can be fatal. Think about it!
Is something that forces you to stop breathing, something you
consider not to be dangerous? It has also been
linked to high blood pressure and to increased chances of heart
disease, stroke, and irregular heart rhythms (arrhythmias).
Unfortunately, not all of the long-term effects of untreated
sleep apnoea are known, but specialists generally agree that
the effects are harmful. If nothing else, the
continual lack of quality sleep can affect your life in many
ways including depression, irritability, loss of memory, lack of
energy, a high risk of auto and workplace accidents, and many
other problems. Medical Research indicates that people with
untreated Sleep Apnoea are more likely to die ‘before their
There are only a few effective treatments for OSA. They
fall into several categories: weight loss, surgery, dental
appliances, implantable devices and an air splint device.
The most popular and most effective is the latter one, a device
which delivers air under slight pressure to the airway by way of
a nasal mask. This is a type of ‘air splint’ that keeps the
airway open. There are basically two types of positive airway
pressure devices; CPAP (Continuous Positive Airway
Pressure) and APAP (Auto Adjusting Positive Airway Pressure). In a small number
of cases Bi-level
positive airway pressure may be used. This is a type of
Non-Invasive Ventilation that may be required to treat the
condition where other respiratory conditions are present.
More recently, Adaptive Servo Ventilators (ASV) are being used to treat Central Sleep Apnoea and other difficult cases.
There is no guaranteed, permanent,
device-free "cure" for apnoea!
Oral Appliances also referred to as Dental devices have been in use for almost as long as Continuous Positive Airway Pressure (CPAP).
Oral Appliance use in Ireland has been, until recently, uncommon, although their use in the USA is commonplace for over twenty years now.
Oral Appliances have been referred to as ‘second line’ treatment
(after CPAP), but advances in technology and the skills of
certain dentists have improved their results in treating certain
types of Apnoea. Typically, they have proven successful in
treating mild and moderate apnoea, in the main.
FOR SUCCESSFUL TREATMENT WITH AN ORAL APPLIANCE, THE TRAINING,
SKILL AND EXPERIENCE OF THE DENTIST IS PARAMOUNT.
There are two distinct groups of OAT:
1. Mandibular Advancement Devices (MADs), sometimes referred to as Mandibular Splints
These are the more successful type of appliance and are the most
commonly used. These specialised dental devices should be
provided by a dentist with suitable training and understanding
of this treatment. As most dental schools worldwide do not
routinely provide this training for dentists, it is often
provided by dentists with specialist post-graduate training. The
appliance is similar to a small upper and lower teeth gum shield
and correctly fitted will hold the lower jaw in a forward
position which serves to keep the airway open whilst sleeping
and prevent snoring whilst in certain cases relieving the
blockage which causes apnoea.
A certain number of ‘natural’ teeth are required to anchor this
type of device.
2. Tongue-Retaining Devices (TRDs)
This is a suction cup that is gripped between the teeth or lips
and which sucks the tongue forward, thus opening the airway
behind the tongue. People, who snore only when lying on their
back, and whose tongue is the main source of obstruction,
sometimes find this device helpful. It is not as effective as a
mandibular advancement appliance and is usually reserved for
those who are missing most or all of their teeth.
ISAT wish to acknowledge and thank Dr.
John O'Brien, Dental Surgeon, BDS, NUI. Cert. OFP.(UCLA)
(Orofacial Pain) for his kind assistance in compiling this
update on ISAT FAQ's webpage regarding Dental Devices.
These devices have been around for about 10/15 years now and in the early stages, their development was plagued by power issues (batteries). A number of companies now produce them and they have been clinically cleared for use in Europe, however they are still (as at 2014) in trial stage in the US.
The devices comprise a small box, similar in size and construction to a cardiac pacemaker, with two ‘wires’ that sense breathing patterns (connected to the airway/lung) and delivers mild stimulation (electrical impulse)to maintain multilevel airway patency during sleep (connected to the hypoglossal nerve).
The lifetime of the battery (needed to power the device) is reported as being anything from 6 to 10 years. There are reports that rechargeable batteries are being developed (without the need to remove the device).
These devices are quite expensive (reported at €20,000+), which
includes the cost of the surgical procedure to implant the
device. While sales material indicates that the device can be
implanted in an ‘out patient’ setting, we have been informed
independently that ‘in patient’ is probably best.
Positional Sleep Apnoea Devices
In cases where Mild or Moderate Apnoea is diagnosed, and its
primary cause is the position in which the patient sleeps
(supine position/on their backs), it is referred to as
Positional Sleep Apnoea. This condition can, in some cases, be
adequately treated by the use of a ‘device’ that stops the
sufferer sleeping on their backs. This device is strapped to the
sufferer’s back by way of a harness. It is similar to a block of
wood or polystyrene and makes it extremely difficult to roll on
to the back.
Surgery for Sleep Apnoea
The goal of surgery is to enlarge the airway and prevent snoring and airway collapse. Surgery is site specific (to enlarge a specific portion of the airway). Due to the risks associated with anaesthesia or an operation, surgery should not be considered as a first option. There is also a risk that surgery may cure snoring, but if the patient has Sleep Apnoea, one of the primary symptoms (snoring) will be removed while the Sleep Apnoea remains and may go undiagnosed while further damage is being done to the respiratory and cardiovascular systems possibly leading to a stroke (which may have been avoided).
We are unable to source reliable figures for success/failure with surgery. In general, with the exception of a tracheostomy (see below) surgery for ‘curing’ Sleep Apnoea is not successful and is quite painful. There are incidences where there is temporary relief post-surgery, but research indicates that the apnoea will return, anytime up to five years post-surgery. In America an increasing number of ENT (Ear Nose and Throat) surgeons continue to pioneer this method of treatment and now offer a ‘cocktail’ of surgical procedures over a period of two to four years, (please see section on multi-phase surgery) In some cases ‘success’ has been claimed, however they are usually short lived as symptoms of Sleep Apnoea start to reappear within a short space of time. There are no ‘quick fixes’ for Sleep Apnoea.
The following is a list of all known surgical procedures
currently in use to treat/cure Sleep Apnoea. There are no
reliable figures available for the success or failure of any one
procedure. The best estimates for UPPP surgery is ‘a 50%
improvement in 50% of cases’. Unfortunately for anyone
with mild to severe Sleep Apnoea this means that CPAP must still
be used after the operation.
SOME OR MANY OF THESE PROCEDURES MAY NOT BE AVAILABLE IN IRELAND .
Types of surgery
Removal of Polyps
Upper Airway Surgery
Uvulopalatopharyngoplasty (UPPP) surgery
This surgical procedure (introduced around the same time as CPAP) has proven to be ineffective in ‘curing’ sleep apnoea over an extended period. We have been unable to source ‘independent’ research on its success/failure beyond a three/five year period.
The vast majority of people who have undergone UPPP for the
treatment of Obstructive Sleep Apnoea do have to continue using
CPAP, or return to CPAP.
Potential patients should be careful that they don't see an
advertisement in the paper, call the doctor, and rush into an
LAUP procedure without research and consideration.
TORS (Trans Orbital Robotic Surgery)
This type of surgical device was originally developed in the US to remove ‘hard to reach’ cancerous tumours in the airway. It is now being used in the US (by some practitioners) to carry out what is in effect the Uvulopalatopharyngoplasty (UPPP) surgery.
Early indications are that it is no more effective
than the traditional procedure, however it is not in use for
long enough to determine its effectiveness. Anecdotal reports
indicate that recovery time may be extended through its
Lower Airway Surgery
Surgical Bypass of the Airway
An opening is made at the front of the neck to the windpipe and a plastic or metal pipe is inserted. During sleep the patient breathes through the tube, while during the day the tube is covered to allow normal speech and breathing. There are considerable hygiene problems with this procedure.
This procedure is the only surgery that is guaranteed to ‘cure’ sleep apnoea.
Multi-Phase Surgery/Stanford Protocol
A relatively new concept (10/12 years old) is a series of surgical procedures pioneered by surgeons at Stanford, California (hence the name).
The Protocol involves two phases, the first of which involves
Uvulopalatopharyngoplasty (UPPP) and one or more of Genioglossus
Advancement or Hyoid Suspension. If this is unsuccessful, the
second phase of the operation involves maxillomandibular
It is wiser and safer to get professional treatment. You
can use the techniques below, in consultation with your sleep
specialist/doctor, while your treatment progresses. Sleep
Apnoea is a disorder and as such cannot be cured, it can however
be managed effectively. There are several things doctors
suggest you do that can greatly alleviate it:
If you're overweight, loose it! Excess weight contributes to obstructive sleep apnoea in two ways:
Weight loss by itself is very difficult (as many of us know).
Sometimes people are only able to lose their excess weight after
treatment for sleep apnoea has begun, they are able to be more
awake and vigorous, and increase their energy use.
As with the loss of excess weight, this is, of course, just a
good idea in general. However, quitting might also help your
sleep apnoea in addition to its countless other health benefits,
by returning lung capacity to normal.
Eliminate alcohol in the evening. Alcohol depresses your
breathing reflexes and significantly worsens sleep apnoea.
These cause nasal congestion, which narrows the airway and
contributes to apnoea. Consult your physician for medications to
treat these which will not interfere with sleep.
Many common medications interfere with either the breathing
reflex or sleep or both. Some of the most common are "sleeping
pills", tranquilizers, and short-acting beta blockers. Consult
your sleep specialist about seeking alternative medications.
The answer to this varies, but generally there are things you
can do, depending on your individual situation:
This is probably the easiest and most effective thing you can
do: spend time learning how to adjust your headgear and
mask. Many people struggle with it and call it
uncomfortable when they haven't really tried to adjust it
properly. It's especially tough when you’re sleepy and
fumbling with it in the dark.
If you find the incoming air to be too dry, and your sinuses are
drying out, many manufacturers offer a humidifier as an option.
Essentially, this is a (rather expensive, for what it is) piece
of plastic which you fill with water and place in between the
machine and your mask. The air flows over the water and
picks up moisture, just like a regular house humidifier.
Most CPAP machines are quite quiet. Most people don't mind it, and some even find the soft "white noise" of rushing air to be relaxing. Some, however, find the noise of the machine disturbing. The only two things you can do are 1) block the noise somehow, or 2) put the machine further away.
To block the noise, try putting the machine behind something - a
dresser or board, perhaps.
However, DO NOT PLACE ANYTHING OVER THE CPAP UNIT OR
BLOCK THE FLOW OF AIR IN ANY WAY! Remember,
this machine pumps air - if you cut off the air flow, you could
damage it or even start a fire. It must have plenty of
space around it so air can circulate.
Unfortunately, there's really nothing you can do about this.
Even if you bought Gucci or Armani headgear and mask, there's no
hiding the fact that you're wearing headgear and a mask.
If you think your bed partner doesn't like it, ask them if they
find snoring more attractive!
There are several different manufacturers of CPAP machines, each with different models. They all perform the same function; the major differences are in price, size, weight, and options.
The most important piece of equipment is the interface
(mask/nasal pillows), as it is the only part that comes into
direct contact with your face.