What is Obstructive Sleep Apnoea

Sleep Apnoea, also known as Obstructive Sleep Apnoea (OSA), is believed to affect at least 100,000 people in Ireland and that 90% of people affected are undiagnosed. In the UK, it is estimated that around 4 in 100 middle-aged men, and 2 in 100 middle-aged women have OSA. Studies have also shown that around 60% of people over 65 years of age have some form of OSA.

A layman’s definition of Sleep Apnoea is ‘the cessation of breathing during sleep’. It is a Respiratory Sleep Disorder, not a disease. It is Respiratory in nature (as we stop breathing), but it only happens when we sleep or nap.

These periods of ‘stopping breathing’ only become clinically significant if the cessation lasts for more than 10 seconds each time and occur more than 5 times every hour.

Obstructive sleep apnoea is caused by the obstruction and/or collapse of the upper airway (back of throat), usually accompanied by a reduction in blood oxygen saturation, and then an awakening (arousal) to activate breathing again. This is called an apnoea event.

When breathing stops the levels of oxygen in the blood begin to drop. After a short time, the lack of oxygen causes a reflex response. This response forces open the airway with a loud snort, maybe gasping breaths and loud snoring. There may also be kicking and flailing of the arms.

There are two types of breathing interruptions which have been defined as follows:

Apnoea – the muscles and soft tissues in the throat relax and collapse sufficiently to cause a total blockage of the airway; it is called an apnoea when the airflow is blocked for 10 seconds or more

Hypopnoea – is a partial blockage of the airway that results in an air flow reduction of greater than 50% for 10 seconds or more. Whilst Hypopnoea doesn’t seem as dangerous as an Apnoea, it does create its own problems and should not be disregarded or ignored.

Episodes of hypopnoea are sometimes referred to as ‘obstructive sleep apnoea-hypopnoea syndrome’. The term ‘obstructive’ distinguishes OSA from rarer forms of sleep apnoea, such as central sleep apnoea, which is caused by the brain ‘forgetting’ to breathe during sleep. Instances of central sleep apnoea are rare.

what-is-sleep-apnoea

Obstructive sleep apnoea is caused by the muscles and soft tissue in the back of your throat collapsing inwards during sleep. These muscles support your tongue, tonsils and soft palate (a muscle at the back of the throat that is used in speech).

Once the muscles relax, the airway in your throat can narrow or become totally blocked. This interrupts the oxygen supply to your body, which triggers your brain to pull you out of deep sleep so that your airway reopens, and you can breathe normally.

There is no definitive cause for sleep apnoea but there are several risk factors, such as:

  • Being overweight is a major risk factor because excessive body fat increases the bulk of soft tissue in the neck, which can place a strain on the throat muscles and can obstruct your breathing. Excess stomach fat can also lead to breathing difficulties, which can make OSA worse.
  • Being male – it is not known why OSA is more common in men than in women, but it may be related to different patterns of body fat distribution.
  • Being 40 years of age or older – although OSA can occur at any age, it is more common in people who are over 40 years old.
  • Having a large neck – a man of average height (1.7m or 5ft 8in) with a collar size that is greater than 45cm (18 inches) is classed as obese and has an increased risk of developing OSA. People with thicker necks might have narrower airways.
  • Taking medicines that have a sedative effect, such a sleeping tablets or tranquillisers.
  • Having an unusual inner-neck structure, such as an unusually narrow airway, unusually large tonsils or tongue, or having a small lower jaw that pushes the tongue backwards.
  • Having excess folds in the inner lining of the mouth (mucous membrane).
  • Alcohol – drinking alcohol can make snoring and sleep apnoea worse.
  • Smoking – you are three times more likely to develop sleep apnoea if you smoke. Smoking can increase the amount of inflammation and fluid retention in the upper airway.
  • Being menopausal – the changes in hormone levels during the menopause may cause the throat muscles to relax.
  • Having a family history of OSA – there may be genes inherited from your parents that can make you more susceptible to OSA.
  • Diabetes – OSA is three times more common in people with diabetes.
  • Nasal congestion – OSA occurs twice as often in people with nasal congestion, which may be due to the airways being narrowed. If you have difficulty breathing through your nose — whether from an anatomical problem or allergies — you’re more likely to develop obstructive sleep apnoea.

Sudden drops in blood oxygen levels that occur during sleep apnoea increase blood pressure and strain the cardiovascular system. Having obstructive sleep apnoea increases your risk of high blood pressure (hypertension).

Obstructive sleep apnoea might also increase your risk of recurrent heart attack, stroke and abnormal heartbeats such as atrial fibrillation. If you have heart disease, multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.

Having sleep apnoea increases your risk of developing insulin resistance and type 2 diabetes. It also increases the risk of developing Metabolic syndrome, a disorder which includes high blood pressure, abnormal cholesterol levels, high blood sugar and an increased waist circumference. Metabolic syndrome is linked to a higher risk of heart disease.

Obstructive sleep apnoea is also a concern with certain medications and general anaesthesia. People with sleep apnoea might be more likely to have complications after major surgery because they’re prone to breathing problems, especially when sedated and lying on their backs. If you have been diagnosed with sleep apnoea and require surgery, tell your doctor about your condition and how it’s being treated before the operation.

People with sleep apnoea are more likely to have abnormal results on liver function tests, and their livers are more likely to show signs of scarring (non-alcoholic fatty liver disease).

Loud snoring can keep anyone who sleeps near you from getting good rest. It’s not uncommon for a partner to have to go to another room, or even to another floor of the house, to be able to sleep.

As someone with sleep apnoea can suffer a lack of refreshing sleep, they run an increased risk of being involved in a life-threatening accident, such as a car crash. Their risk of having a work-related accident also increases significantly. Research has shown that someone who has been deprived of sleep due to OSA has the same impaired judgement and reaction time as someone who is over the drink-drive limit, in fact Drivers with OSA are three times more likely to have a road traffic crash than the general population.

If you have OSA, it could affect your ability to drive. It is important that you inform your doctor and the Road Safety Authority (RSA) about a condition which could impact on your driving ability. The RSA have clear guidelines in regards to driving with OSA and the full details can be found here.

Group 1 drivers : Driving a car, motor cycle or tractor

  • You must not drive until your symptoms are under control and can be kept under control with ongoing treatment. This must be confirmed by a medical professional. Also, you will need to have regular medical reviews.
  • You must also notify the NDLS.
  • After that, a 1-3 year licence may be granted.

Group 2 drivers: driving a bus or truck

  • You must not drive until your symptoms are under control and can be kept under control with ongoing treatment. This must be confirmed by a medical professional.
  • You must also notify the NDLS.
  • You will have your licence reviewed regularly – usually every year.

If you continue to drive against advice, and evidence is found of this, it will affect your insurance. Also, the NDLS and the Gardaí will act to revoke (cancel) your licence and a charge may be brought against you even if you don’t have an incident, but, if you cause harm to a person or property, the charge will be more serious.

If you have symptoms of excessive daytime sleepiness, such as feeling drowsy, a lack of energy and poor memory, ask a partner, friend or relative to observe you while you are asleep. They may be able to spot episodes of breathlessness that could help to confirm a diagnosis of obstructive sleep apnoea (OSA).

Physical examination and tests

Visit your GP. They will ask you a number of questions about your symptoms, such as whether you regularly fall asleep during the day against your will.

Your GP will also carry out a physical examination and some tests, including a blood pressure test. A blood test is also likely to be arranged. The physical examination and tests are carried out to rule out other conditions that could explain your tiredness, such as hypothyroidism (an underactive thyroid gland).

The next step is to observe you while you are asleep. To do this, you may be asked to spend a night at a sleep centre so that any events that indicate OSA can be monitored.

Alternatively, you may be given a monitoring device to wear at night while you sleep at home (a home sleep study). The device is returned to the sleep centre the following day so that the recorded information can be downloaded by staff.

For more detailed information on diagnosing sleep apnoea and the locations of sleep centres, click here

Do I Have Sleep Apnoea?

People with sleep apnoea may complain of excessive daytime sleepiness often with irritability or restlessness. But it is normally the bed partner, family or friends who notice the symptoms first.

Most people with sleep apnoea snore loudly. Their breathing may be noisy and laboured, and it is often interrupted by gasping and snorting with each episode of apnoea.

If you have sleep apnoea, you may have no memory of your interrupted breathing during the night. However, when you wake up you are likely to feel as though you have not had a good night’s sleep.

Common Symptoms of sleep apnoea include:

  • Extremely loud heavy snoring, often interrupted by pauses and gasps
  • Excessive daytime sleepiness, e.g., falling asleep at work, whilst driving, during conversation or when watching TV. (This should not be confused with excessive tiredness with which we all suffer from time to time)
  • Waking up with a sore or dry throat
  • Forgetfulness, poor memory and concentration
  • Headaches (particularly in the morning)
  • Irritability and a short temper
  • Anxiety
  • Depression
  • Lack of interest in sex
  • Impotence in men (inability to get or maintain an erection)
  • Some people with OSA may also wake up frequently during the night to urinate.

 

Remember, not everyone who has these symptoms will necessarily have sleep apnoea. Most people will suffer from these symptoms from time to time but people with sleep apnoea demonstrate some or all of these symptoms all the time.

Episodes of hypopnoea are sometimes referred to as ‘obstructive sleep apnoea-hypopnoea syndrome’. The term ‘obstructive’ distinguishes OSA from rarer forms of sleep apnoea, such as central sleep apnoea, which is caused by the brain ‘forgetting’ to breathe during sleep. Instances of central sleep apnoea are rare.

The Epworth Sleepiness Scale

This is a simple test you can do at home and is the standard method of assessment in the world of sleep medicine. In the questionnaire, you are asked questions regarding your likelihood of falling asleep during eight normal, low activity situations. You rate your likelihood of dozing off on a scale of 0-3, with 0 being “no chance of dozing” and 3 being “high chance of dozing.”

Likelihood of having a sleep disorder is ranked on a scale of 0-24 after all questions have been answered, and the total points of “chances of dozing” are added to produce a single number.

  • 0-7: Unlikely that patient is abnormally sleepy
  • 8-9: Patient has an average amount of daytime sleepiness
  • 10-15: Patient may be excessively sleepy depending on the situation. Patient may want to consider seeking medical treatment
  • 16-24: Patient is excessively sleepy and should consider seeking medical attention.

 

The reason the ESS has become the standard assessment tool for symptoms of sleepiness is because it is a very quick questionnaire to complete and it gives a generalised level of a person’s average sleepiness.

Click here to download the Epworth Sleepiness Scale

Sleep Apnoea Treatment

Mild cases of obstructive sleep apnoea (OSA) can often be treated by making lifestyle changes, such as:

  • losing weight (if you are overweight or obese)
  • stopping smoking (if you smoke)
  • limiting your alcohol consumption
  • Sleeping on your side rather than your back

 

Whilst these may help and possibly cure mild cases of sleep apnoea, often medical assistance is required. There are other treatments available such as surgery and dental implants/ appliances, but the most effective treatment is continuous positive airway pressure or CPAP for short.

CPAP involves using breathing apparatus to assist with your breathing while you are asleep and is used in moderate to severe cases of OSA.

CPAP is used at night when you are asleep. A mask is placed over your nose, which delivers a continuous supply of compressed air. The compressed air prevents the airway in your throat from closing. Earlier versions of CPAP often caused nasal dryness, nose bleeds and a sore throat. However, the latest version includes a humidifier (a device that increases moisture) which helps to reduce these side effects.

As CPAP can feel peculiar to start with, you may be tempted to abandon the treatment. Please don’t, people who persevere with it quickly get used to wearing the mask, and their symptoms improve significantly. Nightly use of CPAP reduces blood pressure and the risk of stroke by 40% and lowers the risk of cardiac (heart) complications by 20%. It literally gives a new lease of life in many cases with extra energy during the day and restful sleep at night.

At Beechfield Healthcare, our nationwide CPAP experts are on hand to make sure your CPAP treatment is as comfortable as possible. If your CPAP causes you discomfort, inform our expert team and we can visit your home and modify the device or mask, to make it more comfortable. It may take several visits to find the right configuration, but we will work with you to ensure you get the best possible solution. For example, we have a range of different masks or we can modify the machine to start with low air pressure and gradually build up to a higher air pressure as you fall asleep.

Polysomnography, also called a sleep study, is a non-invasive, painless test used to diagnose sleep disorders. Polysomnography records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. This investigation will enable sleep specialists to decide what is the best treatment for you. In addition to helping diagnose sleep disorders, polysomnography may be used to help adjust your treatment plan if you’ve already been diagnosed with a sleep disorder.

Polysomnography monitors your sleep stages and cycles to identify if or when your sleep patterns are disrupted and why. During polysomnography, specialist nurses will place a series of electrodes on the surface of your skin (this is painless) and bands on other areas. Electrodes and bands are placed on the following areas:

  • electrodes on your face and scalp
  • electrodes above your lip
  • bands around your chest
  • bands around your abdomen (tummy)
  • Sensors will also be placed on your legs, and an oxygen sensor will be attached to your finger.

 

The tests that are carried out during a polysomnography include:

  • electro-encephalography (EEG) – this monitors your brain waves
  • electromyography (EMG) – this monitors your muscle tone
  • recording thoracoabdominal movements (movements in your chest and abdomen)
  • recording oronasal airflow (the airflow in your mouth and nose)
  • pulse oximetry – this measures your heart rate and blood oxygen levels
  • electrocardiography (ECG) – this monitors your heart
  • sound and video recording to record your breathing and snoring, and your behaviour during the night

 

Polysomnography must be done by experienced technicians in a hospital or sleep centre so you will be required to stay overnight. You may be advised to avoid drinks or food containing alcohol or caffeine during the afternoon and evening before polysomnography. Alcohol and caffeine can change your sleep patterns, and they may make symptoms of some sleep disorders worse. Napping in the afternoon before a sleep study is also discouraged.

Many people feel trepidation at the thoughts of being watched and they fear they may not sleep and negate the test, but don’t worry as a full night’s sleep isn’t required to obtain accurate polysomnography results.

During the testing process, specialist sleep nurses will monitor the signals. If OSA is diagnosed during the early part of the night, you may be given continuous positive airway pressure (CPAP) treatment. CPAP involves using a mask that delivers constant compressed air to the airway and stops the airway from closing, which prevents OSA.

Once the tests have been completed, staff at the sleep centre should have a good idea about whether you have OSA. If you do, they can determine how much it is interrupting your sleep and recommend appropriate treatment.

The severity of OSA is determined by how many episodes of apnoea and hypopnoea you experience over the course of an hour. These episodes are measured using the apnoea-hypopnoea index (AHI).

The severity of OSA is measured using the following criteria:

  • mild – an AHI reading of 5 to 14 episodes an hour
  • moderate – an AHI reading of 15 to 30 episodes an hour
  • severe – an AHI reading of more than 30 episodes an hour

 

An AHI reading of less than 10 is unlikely to be linked to a clinical problem or sleep disorder and a reading of fewer than 5 events per hour is considered normal.

If more information about sleep quality is required by the sleep centre, a polysomnography will be required, which will be carried out at the sleep centre.

Your doctor might provide you with simplified test called a home sleep study, which can be used at home to diagnose sleep apnoea. These tests usually measure your heart rate, blood oxygen level, airflow and breathing patterns. However, you will still need to visit a specialist sleep centre during the day to learn how to use the home study equipment. A home sleep study kit includes:

  • a breathing sensor
  • sensors to monitor your heart rate
  • oxygen sensors that are put around your finger and bands around your chest

 

The equipment records levels of oxygen, breathing movements, heart rate and snoring.

After you have used this equipment overnight, you will need to take it to the sleep centre, where the information will be downloaded onto a computer and analysed by sleep specialists.

Directory Of Irish Sleep Centres

Cavan General Hospital, Respiratory Department, 2 R212, Lisdaran, Cavan

Website | Phone: 049 4376000

Mid-Western Regional Hospital, Ennis, Gort Rd, Lifford, Ennis, Co. Clare

Website | Phone: 065 6824464

Bon Secours Hospital, College Rd, Cork

Website | Phone: 021 4801715

Mercy University Hospital, Pulmonary Function and Sleep Lab, Cork

Website | Phone: 021 4271971

Cork University Hospital, Wilton, Cork,

Website | Phone: 021 4922000

Mallow General Hospital, Mallow, Co. Cork

Website | Phone: 022 30300

Beacon Hospital, Respiratory Unit, Sandyford, Dublin 18

Website | Phone: 01 2936694

Beaumont Hospital, Respiratory Dept., Dublin 9

Website | Phone: 01 8093166

The Blackrock Clinic, Sleep Laboratory, Rock Road, Blackrock, Co. Dublin.

Website | Phone: 01 2832222

Bon Secours Hospital, Glasnevin, Dublin 9

Website | Phone: 01 8065479

Mater Private Hospital, Sleep Laboratory, Eccles Street, Dublin 7,

Website | Phone: 01 8858164

St. Vincent’s Private Hospital, Respiratory Sleep Disorders Unit, Herbert Avenue, Merrion, Dublin 4

Website | Phone: 01 2638000

St. James’s Hospital, Respiratory Clinic, James’s Street, Dublin 8

Website | Phone: 01 4103763

Our Lady’s Children’s Hospital Crumlin, Cooley Rd, Crumlin, Dublin, Dublin 12

Website | Phone: 01 4096100

Connolly Hospital, Respiratory & Sleep Diagnostics, Mill Rd, Abbotstown, Dublin 15,

Website | Phone: 01 6465000

Hermitage Medical Clinic, Old Lucan Road, Dublin 20

Website | Phone: 01 6459000

Peamount Hospital, Newcastle, County Dublin

Website | Phone: 01 6010300

Tallaght University Hospital, Tallaght, Dublin 24

Website | Phone: 01 4142000

Bon Secours Health System, Renmore, Co. Galway

Website | Phone: 091 381900

Galway Clinic, Doughiska, Galway

Website | Phone: 091 785000

Merlin Park University Hospital, EC5., Old Dublin Rd, Galway

Website | Phone: 091 544544

Naas General Hospital, Pulmonary Function Laboratory, Naas, Co. Kildare

Website | Phone: 045 849500

Aut Even Private Hospital, Freshford Road, Kilkenny, Co. Kilkenny.

Website | Phone: 056 7775279

Bon Secours Health System, Strand Street, Tralee, Co. Kerry

Website | Phone: 066 714 9800

University Hospital Limerick, St Nessan’s Rd, Dooradoyle, Co. Limerick

Website | Phone: 061 301111

Our Lady of Lourdes Hospital, Drogheda, Co. Louth

Website | Phone: 041 9837601

Roscommon University Hospital, Athlone Rd, Ardsallagh More, Roscommon

Website | Phone: 090 6626200

Kingsbridge Private Hospital, Ray MacSharry Road, Gardenhill, Sligo, Co. Sligo

Website | Phone: 071 9162649

Mid-Western Regional Hospital, Nenagh, Co. Tipperary

Website | Phone: 067 31491

Waterford Regional Hospital, Sleep Clinic, Old School of Nursing, Waterford

Website | Phone: 051 848834

St. Francis Private Hospital, Ballinderry Mullingar Co. Westmeath

Website | Phone: 044 9385300

Grants & Funding

Respiratory diagnostic tests such as sleep clinics are generally covered by most health insurance plans, please check your cover if you have private health insurance.

If you have been diagnosed with sleep apnoea, there are three methods of financing your CPAP equipment in Ireland.

Medical Card Holders:

Patients who hold a Medical Card can supply their Medical Card details to Beechfield Healthcare along with their prescription. We will then handle all the necessary paper work and submit the relative forms to The Health Service Executive to ensure payment. Payment for replacement masks is handled similarly. All other costs are covered under the Medical Card Scheme.

Private Rental:

If you have private healthcare, some companies make an annual contribution towards CPAP equipment, but it depends on the company and the specific policy. Usually these contributions can be found under medical devices or approved medical devices. These payments are also subject to confirmation from your Medical Consultant. It may be possible to negotiate some form of contribution with some of the smaller Health Insurers.

Tax relief is available for all equipment costs. Receipts should be included on the Med 1 Form. For full details of what you can claim, click the following link: http://www.citizensinformation.ie/en/money_and_tax/tax/income_tax_credits_and_reliefs/taxation_and_medical_expenses.html#lf1338

Drugs Payment Scheme:

Under the Drugs Payment Scheme (DPS) an individual or family will pay no more than €124 each calendar month. This scheme covers lease/rental of CPAP machines (only) and consumables (masks, headgear etc).

If you don’t have a medical card and you pay more than €124 a month for any of these, you should apply. Anyone who is ‘ordinarily resident’ in the Republic of Ireland can apply. ‘Ordinarily resident’ means that you are living here and intend to live here for at least one year. There is no means test for a DPS card.

You can apply online on the HSE website here: https://www.mydps.ie/

Alternatively, download the Drugs Payment Scheme application form and post it to:

Client Registration Unit
PO Box 12966
Dublin 11
D11 XFF3

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The good news is…

If you suffer from Sleep Apnoea, CPAP will revolutionise your life once you adjust to the initial change. Getting a good night’s sleep has a myriad of benefits, and if you suffer from sleep apnoea and you may have been depriving yourself of these for some time.

A Tel Aviv University study found that the brain’s ability to regulate emotions seems to switch off when denied sleep – In other words, lack of sleep leads people to lose their sense of proportion. In cases of being sleep deprived, we may experience similar emotional provocations from all events, even neutral ones, and lose our ability to sort out more or less important information. This can lead to biased cognitive processing or in layman’s terms, poor judgment, over reaction and anxiety.

Treating OSA can also lead to weight loss as studies have shown that men with OSA have below-normal levels of the appetite-affecting hormone leptin, which tells your brain your body doesn’t need to eat, and above-normal levels of ghrelin, a hormone that sends signals to the brain that you’re hungry and need to eat. Researchers report that levels of the hormones were shown to regulate just eight weeks after those with OSA began using CPAP therapy nightly.

sleep-apnea-ireland

Regular use of CPAP therapy has a significant impact on mood, reported wellbeing and overall positivity.  Studies indicated

  • 20% improvement in severe depression
  • 66% reduction in severe sleepiness
  • 20% less days lost from work.

 

Nightly CPAP usage will not only halt symptoms like daytime sleepiness, lethargy and headaches, but users report a far higher sense of wellbeing.

Simply put, if you persevere with the initial change that CPAP requires, it will literally change your life for the better.