…And breathe. Obstructive Sleep Apnoea

Maria M. Hadjimarkou, PhD - Lecturer School of Psychology University of Sussex

Previously I wrote about insomnia, a condition where one has trouble falling asleep or wakes up early and is unable to resume sleep. Today, I am writing about a different sleep condition where people go to sleep easily but when they wake up the next day, they don’t feel refreshed, and they indeed feel sleepy throughout the day. The condition that I am referring to is Obstructive Sleep Apnoea or simply Sleep Apnoea (SA).

Apnoea is Greek for lack of air and in this context, lack of breathing during sleep. Obstructive Sleep Apnoea is considered to be the most common respiratory disorder, and if untreated it can have several negative effects, not only on the quality of sleep of the person affected but also on their overall health and wellbeing. SA is caused by blockage of the upper airway by collapsing tissue, resulting in total interruption of breathing or partial reduction of the air that passes through. So, while the person is sleeping, their breathing stops for a few seconds and up to a minute or more. As a result, they need to wake up to resume breathing. These are short awakenings, so people do not become fully aware, and they do not remember the next day that they have woken up.

These awakenings can be so frequent that they add up to severe sleep deprivation. In the long run, SA leads to high blood pressure, and many cardiovascular problems such as stroke, coronary heart disease, type 2 diabetes and obesity. SA also contributes to changes in mood and road accidents, as people fall asleep at the wheel. To put things in perspective, the severity of SA can be assessed by counting the number of times breathing is interrupted in a given hour, what is known as apnoea events per hour. The condition is considered mild if there are up to 14 apnoea events per hour, moderate if there are up to 29 events per hour or severe if there are 30 or more events per hour. One can appreciate the impact of these apnoea events on a single night’s sleep if one considers that in those 7 hours, one may be awakened more than 200 times to breathe!

It is a sneaky condition because the person who suffers from it is unaware that this is happening. Most often, SA is picked up by the partner of the person afflicted. They may report that they notice a prolonged interruption in their partner’s breathing before they resume breathing normally. There are other tell-tale signs, with the most obvious one being excessive sleepiness during the day. There is a tendency to fall asleep while sitting down listening to the radio or while watching TV, in a waiting room, etc. Sleep comes so easily. Once people in the vicinity notice, it becomes obvious that something may be going on.

SA can affect anyone, but it is more frequently observed in those who are overweight or obese. Men are more affected by this condition than women. The overall risk is higher with increases in age but it can happen at any age. Smokers are more likely to suffer from SA than ex-smokers and non-smokers. Alcohol consumption at night may also worsen SA as the muscles relax, making it easier for them to collapse and block breathing.

After a few drinks, the person may snore, and snoring can be another hint that SA may be an issue. According to the UK Asthma and Lung Foundation (previously the British Lung Foundation), 42% of those who snore are not aware that snoring may suggest the presence of SA. In 2015 they launched a toolkit to help raise awareness and encourage people to seek expert advice. The lack of awareness and treatment costs the NHS tens of millions because untreated SA results in more serious and costly health conditions that require treatment. It is estimated that about 4 million people in the UK in the age range of 30-75 years are affected by moderate to severe SA and even more by mild apnoea. However, the vast majority (85%) are undiagnosed because of a lack of awareness. The incidence is increasing as the rates of obesity and life expectancy also increase.

The good news is that effective treatment is available, which is easy and non-invasive, however, it does require compliance and discipline. The gold-standard treatment for SA is the use of a device known as CPAP which stands for Continuous Positive Airway Pressure. CPAP is a mask that pumps air continuously to prevent the collapse of the upper airway and ensures that breathing is not interrupted. The use of CPAP has consistently been found to be effective in restoring sleep and reversing the negative effects of long-term SA. CPAP devices have been available through the NHS since 2008. There are no secrets here, the key to success is compliance despite the mild discomfort.

Other options may be recommended, such as myofunctional exercises, aimed to strengthen the muscles around the mouth, neck and jaw. These exercises may be more appropriate for those with mild and moderate apnoea. Some studies found benefits in those practising double-reed woodwind instruments such as the bassoon and the English horn, but the data are inconsistent. External stimulation of the muscles can also be used. For those with mild symptoms, the simplest measure may be to avoid sleeping in a supine position as it makes the condition worse.

Awareness is the path to prevention and by speaking up you are halfway there.

Key References:

Senaratna CV, et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev. 2017 Aug; 34:70-81. doi: 10.1016/j.smrv.2016.07.002. https://sleep-apnoea-trust.org/research/