Originally published: September 2018

Key learning points

  • Obstructive sleep apnoea is more common in men, and most patients who present with any combination of snoring and/or excessive sleepiness will be overweight with a large neck circumference
  • The condition is common in people who have heart failure, hypertension, atrial fibrillation and type 2 diabetes mellitus
  • Obstructive sleep apnoea is associated with significant morbidity and mortality related to road traffic accidents and cardiovascular disease
  • Treatment with continuous positive airways pressure, or mandibular repositioning devices, should be accompanied by lifestyle advice

Introduction

Obstructive sleep apnoea (OSA) occurs when the pharyngeal walls collapse intermittently during sleep.1 It has been shown to develop in more than 20% of men and 9% of women,2 and is particularly common in those with obesity, heart failure, hypertension, atrial fibrillation and type 2 diabetes mellitus.1–4 OSA remains largely undiagnosed, although it is associated with significant morbidity and mortality related to road traffic accidents and cardiovascular disease.1,2 Most, but not all, patients present with snoring and/or excessive daytime sleepiness, and are overweight with a large neck circumference.2,3

Case study

Bill, a 55-year-old man, attended the surgery following his wife’s complaint that he stopped breathing for short periods during the night, and snored loudly, with occasional gasping sounds. He was not aware of any sleep disturbance, but admitted to occasional mild daytime sleepiness, which he insisted never occurred while working as a professional LGV driver. He had refractory hypertension and was overweight with a BMI of 36.

An Epworth sleepiness scale score was recorded as 12/24 (normal <10/24).5 A STOP-Bang questionnaire recorded a high probability for OSA with a score of 8/8 (normal <3/8) with points for Snoring, Tiredness, Obstruction witnessed, Hypertension, BMI >35, Age >50, Neck circumference >40cm (16 inches) and Gender male).6 A home overnight sleep study (cardio-respiratory polygraphy) showed an apnoea–hypopnoea index (AHI) of 60 per hour, indicating episodes of cessation or reduced amplitude of breathing for at least 10 seconds.1 Oxygen desaturation index was also 60 per hour, indicating associated falls in oxygen saturation.7

Bill was advised of the diagnosis of obstructive sleep apnoea syndrome and related driving and cardiovascular risks. He was advised that he must cease driving due to his excessive sleepiness and that he must inform the DVLA of his diagnosis.

Assessment tools
These two simple questionnaires only take a few minutes to complete and are useful to assess a patient's level of sleepiness and chance of having OSA.
Epworth sleepiness scaleSTOP-Bang questionnaire
This quesionnaire can be used to measure a patient's daytime sleepiness.5 Patients are asked to answer eight questions about how often they fall asleep in different everyday situations and the score indicates the level of daytime sleepiness they experience:8
  • A score of 11-12 indicates mild excessive daytime sleepiness
  • A score of 13-15 indicates moderate excessive daytime sleepiness
  • A score of 16-24 indicates severe excessive daytime sleepiness
This simple questionnaire can be used to assess the risk of a patient having OSA. The questionnaire includes eight questions that are answered yes/no for Snoring, Tiredness, Obstruction witnessed, high blood Pressure, BMI, Age, Neck circumference >40cm (16 inches), and Gender male; with a resulting score between 0 and 8:6
  • A score ≥3 indicates OSA
  • A score ≥5 indicates moderate/severe OSA

Bill’s outcome

Bill was given lifestyle advice to lose weight by diet and exercise. A trial of treatment for OSA with continuous positive airways pressure (CPAP) was given using an electric compressor and nasal mask to act as a pneumatic splint and maintain airway patency during sleep. He felt much more alert after two nights of treatment and his wife was pleased that his pauses in breathing and snoring had resolved.

At six-week review, remote monitoring via CPAP modem showed satisfactory CPAP effectiveness and compliance of more than four hours per night. Bill felt much more alert, and his wife was pleased that he no longer fell asleep on the sofa, and was more involved in family life. The DVLA allowed him to resume driving, subject to annual review.

Discussion

Patients with OSA are not always symptomatic, such that prospective screening is appropriate in high-risk groups with obesity, cardiovascular disease, type 2 diabetes mellitus, and in preoperative assessment of those with a BMI >35.6

Treatment is appropriate in symptomatic patients or those with cardiovascular co-morbidity. Treatment options that aim to reduce night-time episodes of apnoea include CPAP or mandibular repositioning devices according to tolerance and patient preference, combined with lifestyle measures.1

Treatment options1,9
Lifestyle measures: advise patients to lose weight, stop smoking and/or reduce alcohol intake
Dental devices: worn at night to keep the upper airway open and may be effective for mild/moderate OSA. Although not as effective as CPAP, these may be useful for patients who cannot tolerate a CPAP device
Surgery: not generally offered due to a lack of evidence of its effectiveness
CPAP: recommended for patients with moderate/severe OSA and for those with mild OSA if symptoms affect their quality of life or if lifestyle measures and other treatment options prove unsuccessful. A mask is worn when sleeping, which is connected to a CPAP device that produces airflow, and the positive pressure this creates maintains the patiency of the upper airway. CPAP devices have been demonstrated to significantly reduce daytime sleepiness compared with placebo or usual care. However, not all patients will be able to tolerate them. Humidication devices may be used with CPAP devices to prevent side effects, such as nasal dryness and an irritated throat

Treatment relieves sleep disturbance and sleepiness, and reduces the risks of road and industrial accidents, heart failure, atrial fibrillation and stroke. CPAP is cost-effective in patients with moderate (AHI >15) or severe (AHI >30) OSA.1

Summary

OSA is a common condition associated with significant morbidity and mortality. It is amenable to simple screening questionnaires and home-based diagnostics in high-risk groups. Treatment improves morbidity and mortality as well as quality of life.

Dr John O’Reilly is a consultant in respiratory and sleep medicine in Liverpool

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