Obstructive Sleep Apnoea Sept 2014

What is obstructive sleep apnoea?
People who suffer from Obstructive Sleep Apnoea (OSA) reduce or stop their breathing for short periods
while sleeping. This can happen many times during the night. These breathing stoppages interrupt sleep
which results in poor sleep quality with excessive sleepiness during the day. Because these events
occur during sleep, a person suffering from OSA is usually unaware of them and is often the last one to
know what is happening.
In deep sleep, the muscles of the throat relax and this may reduce the space at the back of the tongue,
through which air must pass to reach the lungs. Normally this doesnt cause any problems with
breathing. In OSA, however, complete relaxation
of the throat muscles may cause blockage of the upper airway so that breathing stops temporarily.
Such an episode is called an apnoea. During an apnoea, people with OSA make constant efforts to
breathe through their obstructed airway. With no passage of air into the lungs, the blood oxygen level
begins to fall. This signals the brain to rouse the person from deep relaxed sleep so that the muscle tone
returns, the upper airway reopens and breathing begins again. Unfortunately, when a person with OSA falls
back into deep sleep, the muscles again relax and the cycle repeats itself again and again overnight.
In OSA, the apnoeas can last for ten or more seconds and the cycle of apnoeas and broken sleep is
repeated hundreds of times per night in severe cases. Most sufferers are unaware of their disrupted sleep
but awaken unrefreshed, feeling tired and needing more sleep.
Who gets OSA?

Whilst OSA is more common in overweight middle-aged men who snore, it can also affect women. Female
hormones and a difference in throat structures may protect women until menopause. Narrowing of the
throat and the upper airway can also contribute
to the risk of getting OSA even in people who are not overweight or middle-aged. In such people, a
blocked nose, small jaw, enlarged tongue, big tonsils or uvula may contribute to blockage of the upper
airway in deep sleep, making OSA more likely.
The use of alcohol, sleeping tablets and tranquillisers prior to sleep tends to worsen OSA by further relaxing
the upper airway muscles. In addition, alcohol can reduce the brains response to apnoea, which may
increase the duration and severity of apnoea events or may cause obstructive sleep apnoea in an individual
who would otherwise only snore.
Most people with OSA snore loudly and breathing during sleep may be laboured and noisy. Sleeping
partners may report multiple apnoeas lasting up to 90 seconds which often end in deep gasping and
loud snorting. Sufferers may report waking for short periods after struggling for breath. OSA is often
worse during deep sleep or when the person sleeps lying on their back.
What are the symptoms of OSA?

Although a person with OSA may not be aware of the many arousals from deep sleep, the sleep disruption
may result in a perception of poor quality sleep despite long periods of time spent in bed. Such people wake
feeling that they havent had a full refreshing nights sleep. They report difficulty maintaining concentration
during the day, have a poor memory, and suffer from excessive daytime sleepiness.
An OSA sufferer may be sleepy only when seated and relaxed, e.g. watching TV, but with more severe
sleep apnoea, sleepiness becomes more pervasive during the day so that car and workplace accidents
may occur.
Other symptoms of OSA include morning headache, depression, short temper, grumpiness, personality
change, loss of interest in sex, and impotence in males.
What other problems can develop from OSA?

OSA can be life-threatening. It is a risk factor for high blood pressure, heart attack, heart failure, and stroke.
All these conditions occur more frequently in people with OSA.
OSA-associated poor concentration and daytime sleepiness have been associated with an increased
risk of accidents in the workplace and on the road. Motorcar accidents have been shown to be two to five
times more common in people with OSA than
in other people.
How is OSA assessed?
In a person suspected of having OSA, their doctor will need to ask questions about waking and sleeping
habits. Reports from the sleeping partner or other household members about any apnoeas are extremely
helpful.
Referral to a sleep disorders specialist and an overnight sleep study will assist with the diagnosis of OSA and
measurement of its severity.
During a sleep study, sleep quality, quantity and breathing are measured by a computer overnight
while the person sleeps. Small coin-sized electrodes are attached to special points on the scalp, face, chest
and legs. There are also chest and stomach bands to detect breathing movements and a sensor placed on
the upper lip to measure airflow. The oxygen level in the blood is assessed by a device placed on the
finger or the ear-lobe. The wires and probes are generally not painful or uncomfortable, but may feel
unfamiliar or restrict movement during the nights sleep. Although patients often worry
that the recording equipment will interfere with sleep, usually the information obtained is sufficient to
make a diagnosis.
Sleep studies can be performed at home or under supervision in a sleep laboratory. More than one
overnight study may be needed. The first is to measure what is going on, and the second is to start
treatment if needed.
How is OSA treated?

The chosen form of treatment depends on the severity of OSA and patient factors.
General guidelines
In an overweight person, weight loss is an important part of treatment. Even a small loss of weight can lead
to improvement in symptoms of OSA.
Avoiding alcohol up to two hours before going to sleep and not using any sleeping tablets or
tranquillisers can also help.
Nasal obstruction may respond to nasal decongestant sprays and smoking cessation.
For the patients whose sleep apnoea is worsened by lying on their back, positioning devices such as
special pillows, rubber wedges and tennis balls attached to pyjama backs encourage sleep in other
positions but are of limited value in very severe OSA.
Specific treatments
Continuous positive airway pressure (CPAP)

A CPAP pump is the commonest treatment for OSA and is very effective in many cases. A CPAP pump
delivers air to the upper airways via a plastic tube attached to a soft silicon close-fitting nose mask.
During sleep, the pump provides air at sufficient pressure to keep the upper airway from obstructing.
This form of treatment is ideal for moderate to severe OSA. A small exhalation port built into the mask
allows carbon dioxide to escape. CPAP prevents snoring and disrupted sleep, improves sleep quality and
reduces daytime sleepiness.
Warming the air with special humidification units attached to the CPAP pump may make CPAP more
tolerable. Newer CPAP units that vary their pressure across the night are now available and may help some
patients who have trouble adjusting to standard CPAP therapy. The use of either of these options should
be discussed with your sleep disorder specialist beforehand.
A second overnight study may be needed to determine the correct pressure setting. After this, a CPAP
machine can be rented or purchased. CPAP pumps have a built in memory card which records several
variables and is useful for your doctor to decide how best to manage you. In some states there may be a
subsidy for CPAP treatment, and some health insurance companies may assist with the cost of a
machine.
Other non-surgical treatments

Following assessment by a sleep disorder specialist, individually designed oral appliances or mouth splints
made by dentists may help patients with snoring or apnoea. By holding the jaw forward in relation to
the upper teeth, these mandibular advancement splints can reduce the severity of snoring and
apnoea in selected patients with healthy teeth, when worn during sleep. Tongue retainer devices may
be useful in those who no longer have their own teeth and expansion of the maxilla (the bone to which
the upper teeth are connected) with specially designed mouth plates may help patients who have a
narrow maxilla. A narrow maxilla is thought to predispose to snoring, particularly in the young. In these
cases, close cooperation between a sleep disorder specialist and a dentist is recommended.
Surgery
Weight loss surgery (bariatric surgery) can be useful in alleviating obesity and thereby reducing or
curing some obesity related conditions such as diabetes and sleep apnoea. Although many patients
having this type of surgery will achieve a significant decrease in weight, it may not be enough to stop
them snoring completely.
Surgery to the upper airway may ease some of the structural problems that contribute to airway blockage
during sleep. These operations include:
1. Removal of tonsils and adenoids: this is far more common in children than adults and can have
excellent results.
2. Nasal surgery to improve nasal airflow: this includes removal of nasal polyps, reduction of swollen
turbinates and correction of a deviated nasal septum. Such operations improve nasal airflow and
enable nasal CPAP to work more efficiently.
3. Uvulopalatopharyngoplasty (UPPP): this involves removal of excess tissue at the back of the
throat which may contribute to upper airway obstruction during sleep. A surgical scalpel or
a laser may be used. There is no doubt that
a UPPP helps snoring in some people without OSA. Unfortunately, UPPP rarely cures OSA,
and it is difficult to predict those patients with OSA who will be helped by it as most of the upper
airway obstruction occurs behind the tongue. Thus, in many patients with OSA who have a UPPP,
the snoring might improve, but the sleep disruption, apnoeas and falls in blood oxygen associated
with OSA may be ongoing.
A follow up sleep study is thus essential to measure the results. If UPPP is unsuccessful, this does
not prevent nasal CPAP from being used subsequently.
4. Tracheostomy: this is an operation that has been used in the past to create a hole in the windpipe to
overcome upper airway obstruction. It is rarely performed for OSA these days.
5. Corrective surgery for jaw or hard palate deformity: in a very few patients with OSA, major
surgery to re-align the bony structures
of the lower and mid-face may be helpful.
New pharmacological and device treatments

There is ongoing active research evaluating potential new treatments for OSA using a tablet, spray or
pacemaker to help keep the upper airway open during sleep. To date, no such specific treatments have
been proven effective, safe and reliable, but research continues.
In the meantime, mechanical treatments like nasal CPAP, oral appliances and weight loss remain our most
effective treatments for OSA.
What is it like using a CPAP machine?

Many people with OSA who begin treatment with CPAP report that they havent slept so well for years.
They state that they feel normal again and many are astounded at the improvement in their day-to-day
lives. At first, using a CPAP mask may feel strange. It may feel as though unaccustomed effort is needed to
breathe out. This sensation soon wears off. During the first week, nasal stuffiness and sneezing may occur,
especially in colder weather. It often improves with warming the bedroom at night or using a humidifier
with the CPAP machine.
Occasionally, an air leak from around the nasal mask can irritate the eyes and air leak through the mouth
can cause a dry mouth. Alternative masks or a chin strap may be needed to overcome this problem.
Specialised staff in sleep disorder centres throughout the country can assist when problems occur.
September 2014
This brochure is one in a series produced by Lung Foundation Australia to provide information no lung disease, its treatment and
related issues. The information published by Lung Foundation Australia is designed to be used as a guide only, is not intended or
implied to be a substitute for professional medical treatment and is presented for the sole purpose of disseminating information
to reduce lung disease. Any information relating to medication brand names is correct at the time of printing. Lung Foundation
Australia has no control or responsibility for the availability of medications, which may occasionally be discontinued or
withdrawn. Please consult your family doctor or specialist respiratory physician if you have further questions relating to the
information contained in this leaflet. For details of patient support groups in Australia please call 1800 654 301.

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What is obstructive sleep apnoea?

Who gets OSA?

What are the symptoms of OSA?

What other problems can develop from OSA?

How is OSA treated?

Continuous positive airway pressure (CPAP)

Other non-surgical treatments

New pharmacological and device treatments

What is it like using a CPAP machine?

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