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Obstructive sleep apnoea

Obstructive sleep apnoe ( OSA ) is a sleep related respiratory condition , leading to repeated temporary cessations of breathing because of a narrowing or closure of the upper airways during sleep.Obstructive Sleep Apnoe syndrome ( OSAS ) is OSA + other symptoms most important amongst them is sleepiness.Obstructive sleep apnoea / hypopnoea
 ( OSAH ) is irregular breathing at night but without daytime sleepiness.

The airway can close completely ( apnoea ) or partially ( hypopnoea ) for 10 seconds or more. Apnoea/Hypopnoea index ( AHI ) is number of apnoeas/hypopnoes per hr of sleep. Susceptibility to pharyngeal collapse during sleep resulting in ongoing inspiratory effort is regarded as most relevant mechanism underlying obstructive apnoeas

OSA is a common chronic disorder – most common sleep related breathing disorder Affects large number of middle age ,overweight people Estimated to affect 1.5 million adults in the UK
Up to 85 % of people with OSA are undiagnosed and hence untreated
Estimated prevalence is between 2-14 % Awareness of the condition is low amongst the general population and GPs Men are more likely than women to suffer from OSA

Risk factors- Snoring Intermittently stop breathing when sleeping Male and middle aged Obesity Family h/o OSAS Smoking Alcohol intake before bed Sleeping supine Nasal blockage Increased soft tissue volume eg tonsils , adenoids, tongue Polycystic ovarian syndrome Hypothyroidism ,Post-menopausal women Older age Large neck size
17″ or more in men
16″ in women Small airway Set back or small jaw Large tonsills Down’s syndrome Acromegaly Occupational – commercial drivers , heavy equipment operators

Risk of road traffic accidents – 7 to 12 times ↑↑ risk of RTAs Associated with other health conditions 

♦ hypertension
♦ stroke
♦ atrial fibrillation
♦ congestive heart failure
♦ coronary artery disease

ie OSA is a significant risk factor for 
Cardiovascular disease and mortality

♦ depression
♦ diabetes ( independent risk factor ) Poor quality of life ↑↑ Peri-operative risks/ complications Negative impact on work performance ↑↑ health care utilization.

Excessive sleepiness and loud 
snoring- most common presenting
 complains.Excessive daytime sleepiness Loud snoring Witnessed apnoeas / choking episodes during sleep Tiredness/ Fatigue Feeling unrefreshed on waking Mood disturbance Nocturia Headache in morning.

Sleep history-How many hrs , insomnia Any road traffic accidents or near miss when driving ? Nocturia Early AM headaches Poor conc/ memory/ libido Impact on
○ employment
○ relationship
○ mood
○ social life.

Ask partner / spouse about snoring habits , apnoeas and choking episodes. Exam-Complete head and neck examination
Assess upper airway BMI Neck circumference BP Tonsils Small lower jaw Abnormal craniofacial structures Crowded oropharynx Nasal blockage Signs of COPD , resp failure or cor pulmonale Consider bloods for eg TFT , Iron deficiency

EPSWORTH SLEEP SCALE-measures perception of sleepiness eight questions- scored 0-3 total score > 10 indicated abnormal sleepiness Scale not adjusted for age , sleep deprivation or medication use.

refer-Sleepy while driving or working with machinery Near miss events or incidents Hazardous occupation eg pilot or bus/ lorry driver Presenting with signs of respiratory / heart failure Severe OSAS and coexistent COPD.Epsworth score >=11 Recurrent witnessed episodes Nocturnal choking gasping or dyspnoea Headache in the morning Unrefreshing sleep despite adequate sleep time and continuity Screening before bariatric surgery or upper airway surgery for snoring Otherwise unexplained polycythemia , pulmonary hypertension or ventilatory failure

Treatment- Continuous positive airway pressure machine ( CPAP ) – Rx of choice for moderate to severe COAS. Rx is lifelong Oral appliances Upper airway surgery Lifestyle – eg Weight loss Medication review eg- stop sedatives , caffeine , alcohol.

LINKS AND RESOURCES

The sleep apnoea trust http://www.sleep-apnoea-trust.org/

British Lung Foundation – information on sleep apnoea https://www.blf.org.uk/support-for-you/osa

NHS on sleep apnea https://www.nhs.uk/conditions/sleep-apnoea/

ENT UK printable leaflet on sleep apnoea and snoring https://www.entuk.org/sites/default/files/files/ENT/Snoring%20%26%20Sleep%20Apnoea%206pp%20DL%20(06016)_7_16.pdf

American Thoracic Society printable info on OSA for patients https://www.thoracic.org/patients/patient-resources/resources/obstructive-sleep-apnea-in-adults.pdf#

American Sleep Apnoea Association https://www.sleepapnea.org/

 

Scoring systems

STOP-BANGhttps://www.mdcalc.com/stop-bang-score-obstructive-sleep-apnea

Epsworth https://www.blf.org.uk/support-for-you/obstructive-sleep-apnoea-osa/diagnosis/epworth-sleepiness-scale

DVLA OSA and driving https://www.gov.uk/obstructive-sleep-apnoea-and-driving

Professional resources

British Lung Foundation document on OSA https://www.sleepsociety.org.uk/wp-content/uploads/2015/07/OSA-Toolkit-2015-FINAL.pdf

European respiratory journal- Recommendations for the management of patients with OSA and hypertension https://erj.ersjournals.com/content/41/3/523

An update on the current management of obstructive sleep apnoea from RACGP https://www1.racgp.org.au/ajgp/2019/april/current-management-of-adult-osa

CKS NHS https://www.nhs.uk/conditions/sleep-apnoea/

A review article Spicuzza L, Caruso D, Di Maria G. Obstructive sleep apnoea syndrome and its management. Ther Adv Chronic Dis. 2015;6(5):273–285. doi:10.1177/2040622315590318 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549693/

 

References

  1. Obstructive sleep apnoea BMJ 2014 ; 348 :g3745 https://www.bmj.com/content/348/bmj.g3745
  2. Obstructive Sleep Apnoea ( OSA ) Toolkit for commissioning and planning local NHS services in the UK 2015 British Lung Foundation Service  Specification for Investigation and treatment of Obstructive Sleep Apnoea syndrome Association for Respiratory Technology & Physiology The Sleep Apnoea Trust March 2009 https://www.blf.org.uk/support-for-you/obstructive-sleep-apnoea-osa/health-care-professionals/commissioning-toolkit
  3. CKS NHS Obstructive Sleep Apnoea Syndrome April 2015 https://cks.nice.org.uk/obstructive-sleep-apnoea-syndrome
  4. Sleep apnoea A general practice approach Australian Family Physician Vol 38 , No 5 , May 2009 https://www.racgp.org.au/afp/2009/may/sleep-apnoea/
  5. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Am Fam Physician . 2016 Sep 1;94 (5) :3555-360 https://www.aafp.org/afp/2016/0901/p355.html
  6. Vianello A, Bisogni V, Rinaldo C, Gallan F, Maiolino G, Braccioni F, et al.; Padova Sleep Apnea Study Group Recent advances in the diagnosis and management of obstructive sleep apnea. Minerva Med 2016 December;107(6):437-51.
  7. Obstructive Sleep Apnea – Gudelines for Diagnosis and Treatment Alberta Health Services
  8. Recognition of obstructive sleep apnea and associated excessive sleepiness in primary care Paul Doghramji  2008 Aug;57(8 Suppl):S17-23.
  9. BMJ Best Practice Obstructive Sleep Apnoea in adults https://bestpractice.bmj.com/topics/en-gb/215

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