Jane Scullion describes the symptoms, causes, and appropriate recognition of obstructive sleep apnoea (OSA); discusses how to manage the condition in primary care; and covers relevant guidance from NICE, SIGN, and the DVLA.
Obstructive sleep apnoea (OSA) is a relatively common condition and is estimated to affect 1.5 million adults in the UK; however, up to 85% of those affected are undiagnosed and untreated, despite treatment being relatively straightforward.1–3 The disorder is characterised by relaxation and narrowing of the walls of the throat during sleep, causing temporary breathing cessation or marked decreases in airflow. This results in a reduction in oxygen saturation levels and an increase in carbon dioxide levels, leading to increased inspiratory effort due to the struggle to breathe and interruptions in sleep with temporary arousals that are often not noticed by the sufferer. In severe cases, narrowing of the airway can happen every 1–2 minutes. OSA interrupts sleep on a regular basis and can have a detrimental impact on the quality of life in the long-term. Prevalence of the condition is compounded by the growing obesity crisis facing us and lack of recognition of the problem—case finding and early intervention is essential in primary care to address this. The following article discuss the recognition, diagnosis, and management of obstructive sleep apnoea.
The most recognisable symptoms of OSA are loud snoring, nocturnal snorting or gasping, and witnessed apnoeas, although in women fatigue and lack of energy are more frequently reported.4 Often OSA is recognised by a bed partner and can include nocturnal and daytime symptoms (see Table 1, below) and it is thought that perhaps men are diagnosed more frequently than women as women have a lower tolerance for being disturbed by their partner.5 Recognition of the problem may therefore be less frequent for those that sleep alone.
|Nocturnal symptoms||Daytime symptoms|
Waking up tired
Noisy and laboured breathing
Daytime fatigue /tiredness
Repeated short periods where breathing is interrupted by gasping or snorting
Dry or sore throat
Excessive daytime sleepiness
Cognitive impairment (poor short term memory and inability to concentrate)
Personality and mood changes including depression and anxiety
In OSA there are several reasons for the airway narrowing with the most obvious one being obesity (see Table 2, below). It is estimated that over 70% of people with OSA are obese, and the prevalence of OSA among obese people may be as high as 45%.6 With a growing population the incidence is likely to continue to rise.
Increases the soft tissue bulk in the neck
Excess stomach fat can restrict breathing and worsen OSA
Possibly due to body fat distribution
Age >40 years
Although it can occur at any age
>17 inches in men and >15 inches in women
Use of sedatives
These relax the airways making narrowing more likely
Alcohol prior to sleeping
This relaxes the airways and makes snoring and OSA more likely
Linked with a higher incidence of OSA
Changes in hormone levels can cause the throat muscles to relax more
Family history of OSA
Due to inherited genes predisposing OSA
Nasal congestion or polyps
Can narrow the airways
Unusual inner neck structure
Includes narrow airways, enlarged tonsils, adenoids or tongue or a smaller lower jaw
Sleeping on your back
Recognition and diagnosis
The first step in recognising and diagnosing OSA is to think about the people we see in practice. This should include a consideration of lifestyle choices, collar size, obesity, smoking, and alcohol use. We can then ask specifically about symptoms (see Table 1, above).
Questionnaires can help in the assessment of OSA, specifically the Epworth sleepiness scale and the STOP-Bang questionnaire (see Box 1 and Table 3, below).7,8 An online version of the Epworth Sleepiness Scale can be found on the British Lung Foundation (BLF) website (www.blf.org.uk/support-for-you/obstructive-sleep-apnoea-osa/diagnosis/epworth-sleepiness-scale) and a score of more than 10 should generate a referral.
In our assessment, we should also look at the upper airway for any physical causes for obstruction of the airway including the nostrils and the mouth.
|Box 1: The STOP-Bang questionnaire8|
S—snoring: do you snore loudly?
T—tired: do you feel tired, sleepy during daytime?
O—observed: has anyone observed you stop breathing during sleep?
P—blood pressure: are you being treated or have you been treated for hypertension?
B—BMI: body mass index >35
A—age: age over 50 years
N—neck: neck circumference greater than 40 cm
G—gender: male gender
|Risk level for OSA||Scoring of Yes answers|
Nocturnal polysomnography is a first-line diagnostic test to confirm a diagnosis of OSA.9,10 It can pick up periods of apnoea and falls in oxygen saturation necessary for accurate diagnosis. Nocturnal oximetry may also be done. These will need referral to a specialist centre to be undertaken.
Referrals should be urgent if people are sleepy while driving or working with machinery, or are employed in hazardous occupations, for example, pilot, or bus or lorry driver).9–11 We should always advise the person not to drive until they have been assessed by a specialist. Also, we should refer urgently if there are any signs of respiratory failure or heart failure, and if there are symptoms suggestive of severe OSA and coexistent chronic obstructive pulmonary disease. Any suspicion of a head or neck cancer should be referred urgently (2-week wait) to ear, nose, and throat (ENT).9
We should also be aware that children can also have OSA; the prevalence in this population is estimated to be 0.7–1.8%.12 Referral should be made to a paediatric ENT specialist if there are any clinical features of adenotonsillar hypertrophy, symptoms of persistent snoring, and symptoms of OSA. Many children snore and OSA can be difficult to diagnose clinically unless there are obviously enlarged adenoids or tonsils: in this case, adenotonsillectomy is an effective treatment. Undiagnosed OSA in children can have neurobehavioural consequences and will also negatively affect quality of life due to affected children being constantly tired.12
Education and management in primary care
OSA is a treatable condition and there are a variety of treatment options that can reduce the symptoms. The first treatment option is to advise lifestyle changes: losing excess weight, exercise, smoking cessation, reducing alcohol intake, avoiding sedatives, and promoting sleeping on the sides rather than the back.9 Unfortunately, many people are not committed to making lifestyle changes.
We should assess people for diabetes as the incidence rises with a high BMI and the risk of cardiovascular disease; we should also check the blood pressure for hypertension as both conditions are possible side-effects of OSA.
With regard to driving we need to advise that it is a legal obligation to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could impact on driving ability.11 Once a diagnosis of OSA has been made, people may be advised to stop driving until symptoms are well controlled. The DVLA has just published updates to the Excessive sleepiness—including obstructive sleep apnoea syndrome section of Assessing fitness to drive—a guide for medical professionals.11 The main changes are:
- a change in focus to the main symptom (sleepiness) as opposed to the diagnosis itself
- control of sleepiness, highlighted as the principal factor in terms of road safety
- the rewritten guidelines make it clear that drivers with uncontrolled excessive sleepiness must be advised not to drive
- there are additional requirements for patients awaiting or undergoing assessment for excessive sleepiness
- there is no longer a distinction between OSA and OSA syndrome.
People should also be advised to check their driving insurance as they may no longer be insured to drive under their current insurance policy. We may also find it useful to signpost people to the BLF website (www.blf.org.uk/support-for-you) and the Sleep Apnoea Trust website (http://www.sleep-apnoea-trust.org/sleep-apnoea-information-patients), as these both provide information leaflets on OSA.
What we should consider is that people who depend on driving for their livelihood may be very reluctant to come forward with symptoms as they will be unable to drive until they are being given treatment if it is established they have OSA.
Ongoing management in primary care
Many people with OSA end up using a continuous positive airway pressure (CPAP) device. This works by delivering a continuous supply of compressed air through a mask or via the nostrils, to prevent the airways closing during sleep. CPAP will correct sleep-related breathing disorders: improving daytime symptoms and day time functioning, and reduce mortality, heart rate variability, and blood pressure.13 Some people cannot tolerate CPAP and may use a bi-level device instead. The BiPAP or bi-level machine is very similar to the C-PAP machine. Utilising an identical set-up as a CPAP with tubing and masks, the BiPAP uses a different pressure setting. While CPAP delivers one pressure, BiPAP delivers two pressures.
For mild OSA, wearing a mandibular advancement device (MAD) might be recommended.14 This gum shield-like device fits around the teeth, holding the jaw and tongue forward to increase the space at the back of the throat during sleep. Evidence shows that CPAP is more effective than surgery at controlling the symptoms of the condition; consequently, surgery is not routinely recommended. If all other treatment options have been ineffective and the condition is severely affecting quality of life, surgery may be considered as a last resort.14 If surgery is thought to be necessary, it may involve either uvulopalatopharyngoplasty, craniofacial reconstruction with advancement of the tongue or maxillomandibular bones, or in extreme cases tracheostomy(see www.webmd.com/sleep-disorders/tc/sleep-apnea-surgery for more information).
In primary care, we need to encourage adherence to treatments such as CPAP or intra-oral devices as they help manage symptoms and reduce the risk of long–term complications. Pharmacotherapy is not thought to be very useful in the treatment of OSA although there is occasional use of central nervous system stimulants.15
Complications of OSA
As well as the fact that those with OSA are more likely to be involved in a car accident,16 poorly controlled OSA may increase the risk of other medical conditions: 16–21
- developing hypertension
- having a stroke
- having a myocardial infarction
- developing an irregular heart beat such as atrial fibrillation
- developing congestive heart failure
- developing type 2 diabetes, although this might be linked to obesity.
In primary care, we need to monitor and support people diagnosed with OSA as they make lifestyle changes and adapt to treatments. Ongoing assessment for developing complications will also be important. OSA is clearly a common condition but it is often under recognised and therefore under treated, despite effective treatments being available. What is evident is that OSA is a significant problem and amenable to prompt recognition in primary care where early detection can lead to prompt treatment and improvements in quality of life.
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