Obstructive Sleep Apnoea

Sleep apnoea patients show one or more of the following symptoms:

• Loud snoring
• Episodes of apnoea, i.e., the stoppage of breathing, during sleep (usually reported by another person)
• Gasping for air during sleep
• Insomnia, i.e., difficulty staying asleep
• Waking up with xerostomia, i.e., dry mouth
• Morning headaches
• Irritability and/or difficulty concentrating while awake
• Hypersomnia, i.e., excessive sleepiness during the day

How it happens: Obstructive sleep apnoea is a consequence of the excessive relaxation of the muscles in the back of the throat; while normal muscle relaxation enables proper breathing, excessive relaxation may cause the airways to narrow or close as air is breathed in. This reduces oxygen levels and raises carbon dioxide levels in the blood. As the brain senses this impairment in breathing, it briefly rouses the body during sleep (around 5 to 30 times or more per hour) so that the airway can be reopened. This awakening is so brief that usually, patients do not remember it. Due to these disruptions, deep, restful phases of sleep are disturbed, leading to sleepiness during the waking hours. 

While obstructive sleep apnoea can affect any individual, certain factors are associated with an increased risk for developing this condition:

• Excess weight: Fat deposits surrounding the upper airway can obstruct breathing.
• Older age: The risk of developing this condition increases with ageing (levels off after age 60–70)
• Narrow airway: A naturally narrow airway is a hereditary trait. Moreover, the enlargement of the tonsils or adenoids could also cause airway blockage.
• Hypertension and/or diabetes: Patients with high blood pressure and/or diabetes show higher incidence of sleep apnoea.
• Chronic nasal congestion: The incidence of this condition has been reported to be two times higher in people who have consistent nasal congestion (than in those who do not) at night, regardless of the cause.
• Smoking: Smokers are more likely to have this condition due to increased inflammation and fluid retention in the airway.
• Asthma: Asthma serves as a major risk factor for obstructive sleep apnoea.
• Male sex: Men may be twice or thrice as likely to develop obstructive sleep apnoea as premenopausal women. However, menopause increases the risk of developing this condition in women.
• Family history: Having family members with this condition may be associated with an increased risk.

The diagnosis of sleep apnoea is generally performed by a sleep specialist and involves the following steps: 

• Physical examination: The back of the nose, mouth, and throat of the patient are examined. The patient’s neck and waist circumference and blood pressure may also be measured. Further evaluations are performed by sleep specialists, who can diagnose the condition, ascertain its severity, and accordingly plan the treatment.
• Tests:
  • Polysomnography (sleep study): Devices and sensors that monitor the brain, heart, and lung activities, breathing patterns, blood oxygen levels, and arm and leg movements, are attached to the patients while they sleep. The patients are monitored for the entirety or a specific duration of the night.
  • Home sleep apnoea testing: In certain cases, at-home polysomnography kits may be used to diagnose this condition; however, using these kits, only a limited set of apnoea-related variables can be analysed during sleep.

The following treatments can be used for the management of sleep apnoea: 

• Non-surgical procedures:
  • Mandibular advancement device (or mandibular repositioning device): This device temporarily moves the jaw and tongue forward, widening the airway space and decreasing the degree of throat constriction; thus, it helps prevent sleep apnoea and snoring.
  • Transcutaneous electrical nerve stimulation (TENS): Small devices (TENS units) administer low-voltage electrical currents at or near the nerves; this blocks or alters pain perception, thereby providing pain relief.
  • Positive airway pressure (PAP): During sleep, air pressure is delivered by a machine through a small piece that is either fit into the nose or placed over the nose and mouth. PAP helps reduce the frequency of apnoea episodes during sleep and mitigates daytime sleepiness. The most common method for administering PAP is continuous positive airway pressure (CPAP), which stabilises breathing during sleep by continuously delivering air at a constant pressure; this pressure is slightly higher than the surrounding air pressure (hence, the term positive pressure) and is sufficient to ensure that the upper airway remains open and the intensity of snoring is reduced.
• Surgical procedures:
  • Uvulopalatopharyngoplasty (UPPP): Removal of tissues from the throat) to widen the airways, usually performed under general anaesthesia to induce a sleep-like state.
  • Tonsillectomy and adenoidectomy: Removal of enlarged tonsils/adenoids when these contribute to obstruction.

Patients should seek medical advice if they:

• Snore loudly and persistently
• Experience witnessed pauses in breathing during sleep
• Wake up gasping or choking
• Have excessive daytime sleepiness, morning headaches, or concentration problems
• Have high blood pressure, heart disease, or diabetes along with sleep problems

While not all cases can be prevented, these steps may reduce the risk or severity:

• Maintain a healthy weight
• Avoid alcohol before bedtime
• Quit smoking
• Treat nasal allergies or congestion promptly
• Maintain regular sleep habits

For management of bruxism, consult a:

• Sleep specialist/Pulmonologist: for diagnosis and management
• ENT specialist: for structural airway issues (tonsils, nasal obstruction)
• Dentist (sleep dentistry): for mandibular advancement devices
• Cardiologist / Endocrinologist: if associated with heart disease, hypertension, or diabetes