Obstructive sleep apnoea is an under-diagnosed and under-treated condition. Stephanie Fsadni wakes up to learn about the sleeping disorder that causes people to stop breathing during the night, leading to debilitating lethargy by day.
When you share your sleep time with a snoring person, it may be annoying to say the least... But some excessively loud snoring may not just be irritating – it may be a symptom of a sleeping disorder known as obstructive sleep apnoea (OSA).
OSA is a condition in which breathing stops several times every hour during sleep. These repetitive pauses are called ‘apnoeas’, and can last from 20 to 40 seconds.
“When one is asleep, the muscles of the back of the throat relax and the airway narrows or closes as you breathe in, reducing the level of oxygen in the blood,” explains respiratory physiologist Chris Deguara.
“But since the body is a perfect machine, it realises that there’s this lack of oxygen in its system and the brain briefly rouses you from sleep to reopen your airway.”
These reflex actions are called mini-arousals: you actually wake up very briefly but are not conscious of it, and you take a deep breath that is characterised by a loud gasp or grunting sound.
They may wake up in the morning already feeling tired, are very sleepy during the day and tend to dose off immediately when quiet and seated
People suffering from this disorder do not usually realise they have a sleeping problem, but their behaviour is often witnessed by spouses and relatives.
As these people do not get enough sleep, they tend to be very lethargic throughout the day.
“The symptoms are very debilitating as they occur on a daily basis,” points out respiratory consultant Josef Micallef.
“They may wake up in the morning already feeling tired, are very sleepy during the day and tend to dose off immediately when quiet and seated, such as when watching TV, sitting on a sofa, during meetings, at the cinema, or worse still, while driving. Other issues include difficulty in concentrating and completing tasks, as well as memory issues.”
These problems are accompanied by restless sleep, turning around in bed and waking up to pass urine. The individual also tends to be very irritable, at times angry and depressed, deeply affecting relationships.
Sleep apnoea is also associated with earlier onset of diabetes, hypertension, heart attacks and strokes.
The most at-risk individuals are obese people, “predominantly males with a collar size of more than 17 inches”, according to Dr Micallef. “However, it can also affect individuals with anatomical problems of the throat, jaw or tongue.”
To find out whether a person is suffering from OSA, tests can be carried out to monitor the breathing and oxygen level while a person is sleeping and to determine if there is a stoppage of breathing.
“Snoring on its own does not mean anything,” says Mr Deguara.
The main treatment of choice involves sleeping with an oxygen mask tied to a CPAP (continuous positive airway pressure) machine that provides a continuous level of airway pressure.
Another similar mode of ventilation is BiPAP (bilevel positive airway pressure) for very obese patients, who tend to hyperventilate and accumulate toxic gases like carbon dioxide at night.
However, there are various lifestyle modifications that can help.
“The top priority is weight reduction, which improves symptoms but does not necessarily reverse sleep apnoea. One should avoid sedative medications as well as alcohol close to bedtime, and it’s better to sleep on the side or prone, rather than in the supine position,” claims Dr Micallef.
Mandibular advancement splints (like a tight brace) created by the dentist can be worn at night, but these are only indicated in mild sleep apnoea. Other invasive surgical treatments include uvulopalatoplasty, which is a major surgical procedure, with refashioning of the pharynx usually done by an ENT specialist.
This is associated with significant morbidity and long-term effects, which might not be acceptable to patients, according to Dr Micallef.
A more invasive procedure in very difficult cases, and usually resorted to as a very last measure, is a tracheostomy, where an opening is carried out surgically through the neck into the windpipe. Supplemental oxygen can also be used at night to try and reverse the low oxygen levels.
International studies quote a nine per cent incidence of OSA in males and four per cent in females. It is rare in children, where it may be associated with enlarged tonsils or adenoids, but increases significantly after the age of 65, where the female and male incidence tends to level out.
There are currently no local studies on the prevalence of this condition, but Dr Micallef and his team are about to embark on research at Mater Dei Hospital.
“We shall be going to all outpatients at Mater Dei, interviewing patients and relatives who are waiting for an appointment. We will personally request consent for a short interview on the symptoms of this condition, which will be followed by a diagnostic sleep study, if we suspect the patient has the condition.
“Hopefully, we will have some local epi-demiological data on this disease, which remains under-diagnosed and under-treated.”
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