Irish Sleep Apnoea Trust ISAT

• What is Sleep Apnoea
  

• How severe must it be to require treatment
  

• How do I know if I have Sleep Apnoea
  

• What should I do
  

• I snore, do I have Sleep Apnoea
  

• What can I do about snoring

TOP ^

• Is Obstructive Sleep Apnoea dangerous
  

• What treatments are available
  

• Is there anything I can do myself
  

• Is CPAP uncomfortable
  

• What are Nasal Pillows/Adams Circuit
  

• Which CPAP machine is best

What is Sleep Apnoea?

• There are three different types of sleep apnoea:

  • obstructive
    
  • central
    
  • mixed

Obstructive Sleep Apnoea (OSA) is the most common;
Central Sleep Apnoea and Mixed Apnoea are rare.

Obstructive Sleep Apnoea

Obstructive sleep apnea is caused by the obstruction and/or collapse of the upper airway (back of throat), usually accompanied by a reduction in blood oxygen saturation, and then an awakening (arousal) to activate breathing again.  This is called an apnoea event.

Why?

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/obstructions at the base of the tongue, turbinate problems or nasal blockages.

A decrease in the tone of the muscles holding the airway open.

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 - though the symptoms are very similar.

Mixed Apnoea

Mixed Sleep Apnoea, as the name suggests, is a combination of Obstructive and Central Sleep Apnoeas’.

How Severe Must Apnoea Be To Require Treatment?

For any type of apnoea to be considered important it 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.

How do I know if I have it?

One of the best people to help you answer this question is your spouse/partner.  People with sleep Apnoea generally have the following symptoms: -

• Loud, frequent and irregular snoring:  The pattern of snoring is associated with episodes of silence that may last from 10 seconds to as long as a minute or more.  The end of an apnoea episode is often associated with loud snores, gasps, moans, and mumblings.  Not everyone who snores has apnoea, by any means, and not everyone with apnoea necessarily snores (though most do).  This is probably the best and most obvious indicator.

• Your spouse/partner indicates that you periodically stop breathing or appear to be choking during your sleep, or gasp for breath (witnessed apnoeas).
  
  

• Excessive daytime sleepiness:  Falling asleep when you don't intend to.  This could be almost anytime you are sitting down, such as during a lecture, while watching TV, while sitting at a desk, and even while driving a vehicle.  You may have sleep apnoea or another sleep disorder.  Even if you don't literally fall asleep, excessive fatigue/tiredness could be a positive indicator.

• Body movements often accompany the awakenings at the end of each apnoea episode, and this, together with the loud snoring, will disrupt the spouse/partner’s sleep and often cause her/him to move to a separate bed or room.
  
  

• Forgetfulness, that is, effecting the short term memory, also a difficulty in concentrating, focusing and completing repetitive tasks.  Bouts of irritability and depression are common.  If working, a dis-improvement in performance over a period of time.

Would I not be aware of all these symptoms myself ?

Probably not.  Most people with sleep apnea 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 or REM sleep, and awaken feeling sleepy.  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!

What should I do if I think I may have sleep apnoea?

As with most medical questions, if you have any doubt, the best thing to do is see your doctor.  Unfortunately, many 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 Obstructive Sleep Apnoea is to spend a night in a sleep lab undergoing a "polysomnogram."  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 before sleeping, while awaiting treatment, as they can aggravate the symptoms of Sleep Apnoea. 

YouTube - Introduction To The Sleep Lab: Sleep Apnoea ...

Your doctor should refer you to a sleep disorders expert.  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.

I snore!  Do I have apnoea?

It's possible, but not definite.  Some people snore who 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?
if I don’t have apnoea

• There are thousands of "cures" for snoring.  Most of them are old wife’s tales that vary from ridiculous to dangerous or both.  Few of them are effective.  Be aware that there doesn't appear to be any guaranteed, safe "quick fix".  However, if you've been through a PSG (in a Sleep Disorders Laboratory) and have been diagnosed as not having sleep apnoea, there are a few things you can try:
  
  

• If you're overweight, lose weight.  Excess weight on the throat can contribute to snoring (and, of course, is unhealthy in general)
  
  

• Quit smoking.  Again, this is a good idea in general, needless to say, but the decreased lung capacity could possibly have an effect on snoring, too.
  
  

• If you sleep on your back, try sleeping on your stomach.
  
  

• The new procedure Laser-assisted Uvulopalatopharyngoplasty (LAUP) could be helpful under some circumstances.  Be sure to read the section below concerning LAUP.

Is Obstructive Sleep Apnoea dangerous?
What are the effects?

Absolutely!  In rare cases, apnoea can be fatal.  Think about it!  It is something that makes you 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 time'.

This is not something to ignore or trifle with.  While it isn't usually immediately dangerous, don't take it lightly.  If you think it will go away by itself - don't - It won't.

Dental Devices

Tongue-Restraining Devices (TRDs)
This is a suction cup that is gripped with the teeth 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.

Mandibular Advancement Devices (MADs)
These are specialized dental devices (must be fitted by a dental surgeon) which clamp on your teeth and jaw joint to ‘pull forward’ the jaw to allow more space for breathing.  They are only worn at night (removable) and initial research show a certain amount of success, however side effects include excess salivation and joint pain (soreness) in some cases.  They must be worn all night, every night.  While a relatively new way of managing Sleep Apnoea, further design modifications are continually coming on stream making dental procedure worth considering.

Surgeries

General
Surgery (of any type) where anaesthesia is used, poses a very real danger to people suffering from Sleep Apnoea.  In all cases your surgeon and anaesthetist should be informed (in advance) if you suffer from Sleep Apnoea.  You also need to inform your sleep specialist of any impending surgery, as they may need to send medical data to your surgeon.  If using CPAP you will probably be advised to bring your CPAP machine to hospital and possibly to the operating theatre.  It may be required during the post operative recovery period.

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 anesthesia 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.  In Europe surgery is seldom used to treat/cure Sleep Apnoea.  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.  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.

Types of surgery

Nasal Surgery

Septoplasty
The septum is the divider between the two nasal passages. A deviated (crooked) septum may obstruct the nasal airway. A Septoplasty is performed through the nostrils. The cartilage and bone of the septum is straightened.

Turbinate Reduction
The turbinates within the nose are made of bone surrounded by soft tissue whose function are to warm and moisten the air as you breath. There are three turbinates in each nostril (lowest, middle and upper). Reduction of the size of an enlarged turbinate can improve the size of the nasal airway. Turbinate reduction may be performed with surgical instruments, lasers. radio frequency energy or cauterised.

Removal of Polyps
Nasal polyps can obstruct the nasal airway. Removal of polyps can ‘free up’ the airway.

Sinus Surgery
Sinus infections can contribute to nasal obstruction and surgery may be necessary.

Upper Airway Surgery

Uvulopalatopharyngoplasty (UPPP) surgery
This surgery removes the uvula, the lower edge of the soft palate trimmed.  If present, the tonsils are generally removed and tissues around the tonsils trimmed.  It can be done separately or in conjunction with other treatments, depending on where in the airway the obstructions occur.  There are the usual surgical risks involved with this surgery.  Notable ones are general anaesthetic (depresses breathing reflex and can be risky in people with breathing problems like sleep apnoea), swelling of the airway, need for pre-and post-operative medications (may depress the breathing reflex), bleeding, and significant pain lasting up to several weeks.

Is it effective?
Will it free me from having to wear a CPAP machine for life?
This surgery seems to have a history of being about 50% effective in about 50% of patients who have it.  In other words, many of the people who have UPPP will end up having to use CPAP anyway.  It is almost never a "cure-all."  The risks and side effects of the surgery are usually not worth it.  This is a decision that each person has to make, but you should give it a great deal of thought beforehand.  Surgery is not something to be undergone on a whim, and certainly not for the sole reason of ridding yourself of the need for CPAP.  The vast majority of people who have undergone UPPP for the treatment of Obstructive Sleep Apnoea do have to continue using CPAP.

UPPP is seldom, if ever, used for treating OSAS in Ireland or England.

Laser-Assisted Uvulopalatopharyngoplasty (LAUP)
LAUP is a relatively new laser surgery on the uvula and soft palate that is reported to diminish snoring, but no controlled studies have been done to show that it reduces sleep apnoea.  Because it is less extensive than UPPP, it is unlikely to be any more effective than UPPP in treating obstructive apnoea.  It is usually done in several steps, and is an outpatient procedure.  For that reason it is less risky than UPPP.

While the procedure may sometimes be effective in helping people who snore but do not have apnoea, the main danger from LAUP is that people may eliminate their snoring and assume that their problems are solved, when in fact they may still have untreated sleep apnoea which may continue to get worse but be ignored because its primary alarm signal (snoring) has been silenced.  Potential patients should be careful that they don't see an ad in the paper, call the doctor, and rush into an LAUP procedure without research and consideration.

Somnoplasty (Radio-frequency Tissue Ablation of the Palate)
Deliverance of Radio-frequency waves by a needle electrode to the underside of the soft palate to cause contraction of excessive tissues that cause snoring.  This procedure involves a progressive shrinkage of the soft palate and uvula.  Usually patients require up to four treatment sessions of 15/20 minutes, under local anesthesia.  The procedure is relatively painless.

Tonsillectomy and Adenoidectomy
Tonsils are tissues on the sides of the upper throat and if enlarged may narrow the width of the upper airway.  Adenoids are at the back of the nose and can obstruct the nasal airway.  This surgery is most common with children as Adenoids usually shrink with age.

 

Lower Airway Surgery

Genioglossus Advancement
The Genioglossus muscle attaches from the back of the tongue to a spot on the back of the chin.  This surgery attempts to pull the back of the tongue forward in an effort to enlarge the air space behind the tongue.  The procedure pulls forward a rectangular or circular segment of chin bone (below the front four teeth) and holds it in place with a plate or screw.  A minimal change in the appearance of the chin results (millimeters).

Hyoid Advancement
The Hyoid bone is just above the Adam’s apple.  The Hyoid bone is moved forward and either attached to the Adam’s apple or jaw bone.  The purpose is to enlarge the air space behind the tongue.

Midline Glossectomy, Lingualplasty, and Lingual Tonsillectomy
Midline Glossectomy involves a reduction in the size of the tongue (if enlarged).  The back of the tongue is reduced in size by excising a V shaped portion of the centre part of the tongue.  Lingualplasty is a more aggressive resection with additional removal of side wedges.  Lingual Tonsillectomy involves the removal of
tonsil like tissue on the back part of the tongue, it may also be removed with a laser.  A temporary tracheostomy is usually performed with these procedures to avoid breathing difficulty that might result from temporary swelling. The purpose is to reduce the size of the tongue thereby increasing the air space behind the tongue.

Bimaxillary Advancement (Lafort 1 Maxillary Osteotomy with Bilateral Sagittal Split Mandibular Osteotomy)
The upper and lower jaw bones are moved forward along with all teeth in an effort to pull soft tissue structures forward and make more room for the tongue.  Metal plates and screws are used to hold the realigned jaw bones in place.  Orthodontic work prior to or following the procedure may be necessary to maintain proper alignment of the teeth.  Change in facial appearance relates to the extent of the advancement.

Tongue Suspension Suture (Repose)
The tongue is pulled forward by way of a permanent stitch attached to a screw which has been placed through the back of the tongue.  This is to prevent the tongue falling back during sleep and obstructing the airway.

 

Surgical Bypass of the Airway

Tracheostomy

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.

 

Is there anything I can do myself?

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 efficiently.  There are several things doctors suggest you do that can greatly alleviate it:

• Weight loss

  If you're overweight, loose it! Excess weight contributes to obstructive sleep apnoea in two ways:

  1. Fat deposits in the neck tissue compress the airway and make it more likely to collapse.
     

  2. Excess weight in the abdomen makes the breathing muscles operate inefficiently, which contributes to breathing difficulty when sleeping.

  Weight loss by itself is very difficult (as many of us know).  Sometimes people are only able, or much better 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.
  Naturally, weight loss is just a generally very healthy thing (if you're overweight - if your weight is normal, don't starve yourself!)
  

• Smoking

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.

• Alcohol

Eliminate alcohol in the evening.  Alcohol depresses your breathing reflexes and significantly worsens sleep apnoea.

Apnoea sufferers should be very careful about excessive drunkenness.  It's possible that if you depress your reflexes enough, you might not wake up at all.  The same thing goes for sleeping pills, drugs, or anything that might affect your breathing.

• Allergies and respiratory infections:

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.

• Medications:

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.

CPAP!  It's uncomfortable.  What can I do?

The answer to this varies, but generally there are things you can do, depending on your individual situation:

• First, read the manual to your CPAP unit
  

• Adjust the headgear

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.

Take some time.  Sit down at the table during the day with the headgear.  Take it apart.  See where all the straps, buckles, and Velcro seams are.  Figure out what each one does.  Generally familiarize yourself with it.  Put it on.  Adjust it so it's the most comfortable, and note what each strap has to be like to achieve this.  Ask someone to help you, if necessary.

A lot of people mistakenly think that the solution to all problems with air leakage is to adjust the straps more tightly.  This frequently increases the leak.  Usually air leakage problems are due to positioning, not pressure.  Naturally, there has to be enough pressure to keep a seal, but make sure you have everything positioned just right before you start tightening the straps.  It’s a very personal thing.  What works for one person may not work for another.

Some people have found that putting a hook in the wall over the bed, and hanging the hose over that helps to keep it from "tugging" on the mask and headgear by removing the weight of the hose.

• Humidifiers

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.

A heated humidifier used with CPAP can make a significant difference in comfort.  The water container sits on a hot plate which ensures that the air you breath is both moist and warm.  This form of humidification is proving very popular.

• Noise

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.

• Appearance

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!

What are  "nasal pillows"  and  "Adam circuits" ?

Nasal pillows ("Adam circuit" is another name for the same thing) refers to a different method of delivering air with a CPAP machine. Basically, these are nose plugs that you use in place of a traditional mask over your nose (you still connect it to the hose to CPAP machine, like a mask).  It is less bulky than a mask, and there aren't as many problems with air leaking out, particularly at low pressure.

Which CPAP machine is the best?

There are several different manufacturers of CPAP machines, each with different models.  They all perform the same function; the major differences are in price, weight, and options.  Some are "bare bones" while some have many options including such things as voltage converters (handy for people who travel to foreign countries) and even remote controls! In particular some machines make less noise than others. 

END.