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The Sleep Apnoea Trust

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Guidelines for GPs and other Doctors                            

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The recent recognition of obstructive sleep apnoea as a cause of considerable morbidity and mortality has produced much interest in upper airway function during sleep. Our understanding of sleep apnoea and snoring has increased enormously in the last ten years so that often much can be done to help both these conditions. As a result there has been an extraordinary rise in the number of referrals for these conditions. The purpose of this information is to explain what the ENT, the sleep clinic and dentists can do (and thus which patients are the most appropriate for which service) and what managements can be tried in general practice first, prior to referral.

Background

During sleep the pharyngeal airway narrows in everyone, due to a reduction in dilator muscle tone. Snoring is simply vibratory noise generated from the pharynx and soft palate when this phenomenon goes beyond a certain point. Further narrowing produces not only louder snoring, but also laboured inspiration. Finally, yet further narrowing can cause complete obstruction, so called sleep apnoea. There comes a point where the increased inspiratory effort is sensed by the sleeping brain and a transient arousal provoked. A few od these arousals do not matter, but when there are many (sometimes hundreds) then sleep is seriously fragmented with consequent daytime symptoms of excessive sleepiness. Thus snoring and sleep apnoea are part of a spectrum extending from "benign" or "simple" snoring with no sleep disturbance, through to obstructive sleep apnoea with severe daytime symptoms and the physiological consequences of recurrent asphyxia.

Is treatment really necessary?

Both ends of the spectrum deserve treatment. "Benign" snoring can be far from benign. The social consequences can be extremely distressing: banishment from the bedroom, marital disharmony, no holidays because of the enforced sleep disruption when sharing a hotel room, fear of travelling, falling asleep during long journeys on public transport and the consequent ridicule and embarrassment. Many of the stories we hear are very sad and not worthy of the music hall approach to snoring.

Obstructive sleep apnoea, through the gross sleep disruption, produces greatly impaired performance at work, at home, and on the road. Car accidents are much more common in this group. The response to therapy is extraordinarily dramatic with a return to a state of alertness and vitality often not previously experienced for years or even decades. There is no doubt in our minds that treatment is essential for sleep apnoea and extremely appropriate for some snorers.

Initial Assessment

First of all decide if the problem is likely to be just snoring or whether there may be some evidence of sleep apnoea. (Table 1)

Is the problem severe snoring only?

  • If so then referral to ENT (or a dentist for a mandibular advancement device) may be appropriate.

Are any of these features of sleep apnoea present?

  • Daytime sleepiness (not tiredness) eg: nodding off during less stimulating activities: reading, watching TV, meetings etc, best assessed with the Epworth Sleepiness Scale.
  • Spouse has noticed episodes of stopping breathing (although any snorer will have occasional such events, especially supine).
  • Patient experiences waking with choking / obstructed episodes (although he will only recognise a tiny proportion of the number actually occurring).
  • Regularly waking unrefreshed in the morning.
  • Neck circumference over 17.5 inches (thus usually, but not always, overweight).
  • Small pharynx on visual inspection.
  • If there are, then referral to a Sleep Clinic may be appropriate.

 Why is it present? The commonest causes of snoring (and indeed sleep apnoea) are shown below. (Table 2).

One or more of these are usually present and may be amenable to simple therapy. Sometimes none of these are present and the reason for snoring is not clear. One catch here is that sometimes the complaint of snoring by the spouse is used as an excuse to leave the marital bed and may actually be trivial or absent. Suggesting the couple bring along a cassette recording of the offending noise can be quite useful in assessing this point and their motivation. Operations for snoring should not be done unless there is good evidence of a significant problem.

The following approaches can be tried in practice before considering a referral. (Table 3)

What has the dentist to offer snorers?

There is now good evidence that intra-oral devices worn in the mouth at night can greatly help snoring by holding the lower jaw forward and closed during sleep. Simple mandibular advancement devices consist of two sports type gum shields, one for the top teeth and one for the bottom teeth, welded together so that when worn the lower jaw is protruded to about 75% of maximum. Newer devices, some adjustable, are now available. Significant forces are imposed on the teeth and t-m joints so the dentist has to be satisfied that these structures are sound.

 What has surgery to offer for snorers?

When these approaches have failed, then the ENT department may well be able to help. For example, nasal stuffiness can be helped by septal straightening, polypectomy, or turbinate reduction. Sometimes it is worth removing residual tonsils, although in adults this is not a trivial operation. When all else has failed, including trying a mandibular advancement device, and the snorer is desperate for help (and a sleep study has been performed to confirm snoring and exclude significant sleep apnoea) then an operation on the pharynx (uvulopalatopharyngo-plasty, or UPPP) may be appropriate. This operation removes part of the soft palate, any residual tonsils, and tightens the pharyngeal walls: it is very painful postoperatively and may produce temporary difficulty swallowing (and rarely some subtle changes in the voice). Other surgical operations on the palate, such as laser scarring, are only experimental and do not appear to be very successful.

Sleep Apnoea in Children

Sleep apnoea with snoring and sleep disturbance is quite common in children aged 2 - 7, particularly at times of upper respiratory tract infection when the tonsils enlarge. This sleep disruption produces a variety of daytime consequences including sleepiness, hyperactivity, poor attention span and bad behaviour. Sometimes the tonsils are big enough to produce this problem every night, even in the absence of current infection. If the history is very convincing, and suggests every night sleep apnoea, then referral directly to ENT for consideration of tonsillectomy is warranted. However, if there is some doubt, then a Sleep Unit would be happy to monitor such children overnight and try and decide if the benefits of tonsillectomy are likely to outweigh the traumas to a young child of hospital admission and an operation.

 Summary

When presented with a snorer (without symptoms of sleep apnoea) requesting help, then consider the causes above in Table 2. Then try appropriate therapies as listed in Table 3. If these do not work then consider referral to the ENT department or dentist as appropriate.

If sleep apnoea is suspected because of symptoms (Table 1) then consider referral to a sleep clinic, usually part of the respiratory service.