1. Remember that sufferers often don’t know they have sleep apnoea
Sleep apnoea often goes undiagnosed because the sufferer is mostly unaware of their condition until it is pointed out by someone else that they snore excessively or make loud snorts or gasps in their sleep as they try to resume breathing. Daytime symptoms, such as excessive tiredness, are often attributed to living a busy life and, even if the sufferer visits a GP, sleep apnoea is often initially missed.
2. Shirt collar size in men is a useful guide to risk
Sleep apnoea affects between 2-4% of the UK’s adult population; middle-aged men are particularly affected. Sleep apnoea is frequently seen in obese and overweight patients because of the increased pressure on the airway caused by excess weight around that area – a collar size greater than 17 inches is a risk factor. Other common risk factors include retrognathia, macroglossus and large, obstructing tonsils. Smoking and alcohol are also known to increase the risk and severity of obstructive sleep apnoea.
3. Look for daytime symptoms
Symptoms can be varied. As well as excessive snoring and gasping while sleeping, daytime symptoms include waking tired and feeling unrefreshed, morning headaches, nocturia, nocturnal palpitations, poor memory and lack of concentration, low libido and depression.
4. Remind patients to inform the DVLA of their diagnosis
The law requires sufferers to tell the DVLA when they are diagnosed with sleep apnoea.
Untreated sleep apnoea is a major contributory factor in up to 20% of motorway traffic accidents, and it has been estimated that obstructive sleep apnoea increases the risk of a road traffic accident by up to seven times. Due to associated lifestyle factors, sleep apnoea is common among professional drivers.
5. Assess with the Epworth sleepiness scale
If you suspect that a patient is suffering from sleep apnoea, the easiest thing is to assess them using the Epworth sleepiness scale – click here to access an online version of the scale from our tools and resources section. This is a series of questions to assess how tired someone. Generally, a score above 10 indicates that further investigation and a sleep study are necessary. This can be done in a variety of ways, such as using screening pulse oximetry or by using polysomnography machines, including portable devices that can be taken home, which do the same as hospital-based overnight studies without the video component. Most sleep studies measure oxygen saturation as well as apnoea-hypopnoea index, body position, pulse and loudness of snoring.
6. Don’t leave sleep apnoea untreated
Sleep apnoea can have a serious impact on health – it is linked to hypertension, possibly increased risk of stroke and to type 2 diabetes. It poses a serious economic health burden if left untreated. Sleep apnoea can seriously affect the quality of life of the patient and their immediate family, because of their lack of energy and the effects of the symptoms above.
7. The gold standard treatment is CPAP
The main indicator for treatment is an apnoea-hypopnoea index of greater than 15 per hour and or desaturations of greater than 5% of 15 per hour. Once sleep apnoea is diagnosed, mild-to-moderate cases can be treated with a mandibular advancement device, but for moderate-to-severe sleep apnoea, continuous positive airway pressure (CPAP) should be recommended. I have seen it improve patients’ quality of life dramatically and, with the continued support of the sleep team, the outcomes can be amazing and life changing.
Weight loss can help to reduce the severity of sleep apnoea and resolve symptoms to the point where treatment is no longer required. Considerable weight loss is required to achieve this but being on CPAP will help give the patient sufficient energy to start an exercise programme to lose the weight. If jaw abnormalities or tonsils are contributing to sleep apnoea, weight loss alone may not resolve the condition and CPAP may need to continue.
8. Patients often feel the benefits of treatment overnight
I have seen patients who have been suffering for a long while – not able to function properly during the day and unable to cope in their jobs and relationships – manage their lives for the first time in years. CPAP enables patients to experience a good night’s sleep and the results are sometimes immediate.
9. Advise patients that surgery is not always effective
Each case is unique, so a sleep specialist is the best person to advise on treatment. Aside from CPAP, other approaches include lifestyle advice – stopping smoking and reducing alcohol consumption – and mandibular jaw splints. With the exception of a few cases though, surgery has little place in the treatment of sleep apnoea. It may help in the short term but even tonsillectomy for large obstructing tonsils has very little evidence of success.
10. Be aware that the number of patients with sleep apnoea is rising
Due to rising obesity levels the number of patients with sleep apnoea is increasing, but fewer than 10% of patients with sleep apnoea are thought to be receiving treatment. Sleep apnoea has a similar prevalence to type II diabetes, but treatment levels are far lower, so there is a need to raise awareness of this potentially life-threatening condition.
Dr Robert Koefman is a GP in Binfield, Berkshire, where he runs specialist sleep apnoea clinics
For further information and guidance on spotting sleep apnoea, visit http://www.realsleep.co.uk