Recognising sleep apnoea

What is sleep apnoea?

Sleep apnoea is a serious and potentially life-threatening condition where there is cessation of breathing that lasts 10 seconds or more during each session.

Asking about sleep

Most people spend a third of their lives sleeping, and thus, sleep has a major impact on all of us. As sleep is a function and not a structure, it is challenging to treat and prevent its complications. A sleep history should be taken from a patient with sleep apnoea as well as from the bed partner or roommate, and should include questions regarding snoring, witnessed instances of apnoea, gasping/choking episodes, and excessive sleepiness not explained by other factors. The patient’s sleep history should also include an assessment of sleepiness severity by the Epworth Sleepiness Scale,(2) total amount of sleep, nocturia, morning headaches, sleep fragmentation/sleep maintenance insomnia, and decreased concentration and memory. Further relevant questions may include secondary conditions precipitated by obstructive sleep apnoea (OSA), including hypertension, stroke, myocardial infarction, decreased daytime alertness and motor vehicle accidents.

Asking about snoring

Sleep apnoea is not well understood by the public and patients are less likely to bring up its symptoms, such as snoring, in the consultation room. Snoring is often regarded as a personal trait, rather than a medical condition; it may make the snorer an object of ridicule and cause the bed partner or roommate to develop sleepless nights and resentment.(1) Invitation to further elaborate on sleep behaviour and pattern may be necessary before patients voluntarily provide more information on this topic. Many in our local population can observe and describe the end part of each apnoea episode, which they often describe as ‘choking’, before the snoring restarts. It is thus important for the bed partner or roommate of a patient with sleep apnoea to observe any symptoms and to give specific lay descriptions of sleep apnoea at the patient’s follow-up consultations.

A possible symptom of OSA, snoring disturbs the sleep pattern, depriving the snorer of the appropriate rest. Snoring has also been strongly associated with many medical problems such as stroke and cerebrovascular diseases.(3) Snoring occurs in at least 10% of men aged under 30 years, and at least 60% of men aged over 60 years.(1) It also affects men twice as often as women.(1)

Physical examination

When conducting a physical examination, the clinician should document an upper airway assessment and look out for obesity, thick and short neck, receding chin, craniofacial deformities, adenotonsillar hypertrophy, deviated nasal septum, turbinate hypertrophy, crowded oropharynx and a bulky tongue.

Sleep study (polysomnography) and investigations

An overnight sleep study is needed for the evaluation of snoring and OSA. During the study, the patient’s electroencephalographic, electrooculographic, electromyographic and electrocardiographic activities, as well as leg movements, sleep position and respiratory efforts, are monitored via electrodes applied onto the scalp, face, chin, thorax, abdomen and legs. Sleep study can confirm the diagnosis and severity of OSA, but provides limited information on the anatomical levels or degree of upper airway obstruction. Diagnostic sleep study, continuous positive airway pressure titration study, multiple sleep latency test and maintenance wakefulness test are other specialised tests that are conducted in a sleep laboratory.

Sleep apnoea management

OSA is closely linked to the global issue of obesity, as well as problems with soft and skeletal tissues affecting the local upper airway. Thus, the challenge is to tailor each person’s treatment for OSA based on the individual’s situation and needs. Individualised evaluations such as flexible nasopharyngeal endoscopy assessment and videoendoscopic computer-assisted measurement(4,5) of the upper airway enable clinicians to better identify and quantify the sites of obstruction of the upper airway.

Snoring and sleep apnoea are often multifactorial conditions. Therefore, treatment varies from one patient to another, i.e. depending on the severity of their conditions, and their individual circumstances, needs and phases in life. There are many treatment options for OSA, and they are usually offered in a step-wise approach. Patient education and lifestyle changes are a combination of treatments that may sometimes be used (Table I). Wherever relevant, setting realistic targets and timelines with the patient to optimise sleep hygiene, adjust sleep position, reduce alcohol intake and lose weight are also important.

Table I

Lifestyle and nonsurgical management options for sleep apnoea patients.

Many surgical interventions can help to relief upper airway obstruction, depending on the anatomical levels and degree of obstruction. These treatment options are individualised and offered after patient education, lifestyle modifications and nonsurgical management have been explored and rejected, or have failed. As sleep apnoea is often a multifactorial condition, management options that have worked well may not always lead to a permanent cure or an optimised state, as other contributory causes may arise at different phases of the patient’s life, compounded by genetic and hormonal issues, ethnicity and the modern hazards of a fast-paced society.

As some of these management options are offered by different clinical specialities and allied clinical experts, it is thus increasingly relevant and important to form integrated clinical teams to run sleep services or sleep centres. A step-wise management approach can then be seamlessly offered and tried, before tailored surgery is offered to relief physical obstruction or reconstruct the upper airway, depending on the individual’s assessment.