03.12.2015

New Directions in the Treatment of Obstructive Sleep Apnoea in Adults

Due to the fast pace of life,  sleep disorders are more and more acknowledged as health disorders. Snoring is not only part of sleep, occurring in many middle-aged and old people, but a symptom that requires medical care, indicating the possible occurrence of sleep apnoea.

 

Obstructive Sleep Apnoea

Obstructive sleep apnoea affects 2-4% of the population. This is a disease in the case of which the upper airways are partially or completely closed, the direct consequence of which is disrupted sleep, hypoxemia, repeated changes in pressure inside the thorax, and activating sympathetic nervous system, increased blood pressure, and sleep-related heart rate variability. The chronic course of the disease favours the development of hypertension, disposes patients to heart attack, and thus increases/favours cardiovascular illnesses and mortality. OSA is directly linked with insulin metabolism, diabetes, and the development of metabolic syndrome. A patient with untreated OSA is dangerous on the road due to excess daytime sleepiness and/or fatigue.
Despite the cardiovascular, metabolic, and neurocognitive consequences of OSA and the worsening of the patient’s quality of life, more frequent chronic diseases, and thus increased costs of health care, OSA has been under-diagnosed and under-treated.

The patient might not consider the fatigue and sleepiness symptoms as pathological, but as the norm. Snoring is a sound disturbing sleep in many families, but not a symptom of a disease.

 

Why is sleep apnoea not recognised?

Excess daytime sleepiness and fatigue is presumably considered to be part of a fast paced life, accompanying insufficient night sleep and bad sleep health (inconsistent bedtimes and waking up, noise, and incorrect lighting, or mattress choice in the bedroom, etc.). However, sleepiness and fatigue are the main factors that decrease efficiency and they should not be treated in passing. In addition to advice on improving sleep health, the grounds for patient’s sleepiness and fatigue need to be specified.

 

Symptoms of Sleep Apnoea

Sleep apnoea is caused and characterised by these night symptoms: apnoea, snoring, or gasping for air seen by the fellow sleeper, sleep does not allow to rest, thirst at night, the need to urinate at night, bed wetting (also in adults), sweating at night, nasal congestion, excess salivation, gastroesophageal reflux, impotency. In case of sleep apnoea, the daytime symptoms are: excess daytime sleepiness, dry mouth in the morning, morning headaches, trouble concentrating, excessive irritableness, mood disorders, depression.

 

Treatment Team

An OSA sufferer requires an evaluation from several specialists, due to which the best treatment outcome is achieved in cooperation with a team, consisting of: a general practitioner, a sleep doctor, an otorhinolaryngologist, a pulmonologist, a cardiologist, a psychiatrist, a neurologist, an orthodontist, a nutrition specialist, a physiotherapist, and a sleep technologist.

 

Tests for Assessing the Occurrence of Sleep Disorders

The primary recommendation for a general practitioner to screen sleep apnoea is to use surveys.
The following surveys are accessible on the website of the Estonian Sleep Medicine Association: Epworth sleepiness scale (sleepiness test) and STOPBANG survey (sleep apnoea test).

 

PAP Treatment

A positive airway pressure treatment (PAP) is the most common and efficient treatment method for OSA. The treatment success of PAP is ensured with good co-operation between the sleep centre and the patient. PAP equipment is being constantly developed in order to increase the factors that determine its ease of use. Configuring a next generation PAP device, for instance, can be done from the sleep centre over the Internet, without the patient having to come to the sleep centre. In the case of PAP treatment, the patient’s long-term compliance with the treatment needs to be assessed because some patients cannot tolerate PAP treatment, but treatment with a PAP device is for life in the case of sleep apnoea.

 

Orthodontic Treatment

A less common, but efficient treatment method for snoring and mild to moderate OSA is extending the pharynx of upper airways by using an intra-oral device, the effect of which is based on two methods: 1. Device 2 for stabilising lower jaw position or intruding it. Device for stabilising tongue position or intruding it. The application of these treatment methods is preceded by assessing the severity level of the sleep-related breathing disorder by a sleep doctor as well as a consultation with an orthodontist, dentist, or prosthetics doctor who has experience with an intra-oral device. An intra-oral device is efficient in treating OSA because pushing the lower jaw forward or stabilising the position of the tongue and soft palate increases the capacity of airways. Similarly to PAP treatment, an intra-oral device is efficient only if the patient’s treatment compliance is good, as the device must be used every night. The comfort of the device is thus very important and regular visits by the patient to the doctor who prescribed the treatment device are required in order to assess the condition of the denture, jawbones and jaw joints.

 

Surgical Treatment

The surgical treatment of OSA has undergone significant changes in the last twenty years, being initially a promising method for solving OSA. Unfortunately, the operation method used 15-20 years ago did not bring the hoped for success. Today, surgical treatment has again found its place in the treatment of OSA, but requires specifying tests (polysomnographic procedure, three-dimensional upper airways reconstruction, and endoscopical airways procedure while sleeping to find and assess the location and type of closure/closures) by a surgeon who has undergone special training in sleep medicine. The most common surgery methods used in the case of OSA are restoring nasal breathing (septo or rhino septoplastics) and radio frequency ablations of soft palate and tongue root. Restoring nasal breathing is vital for a successful PAP treatment because the use of a mask is recommended in the case of PAP treatment, requiring that the patient then breathe through the nose. In some cases, changing the position of the tongue bone is also used, musculus genioglossus is shifted forward, and the lower and/or upper jaw is moved forward.

 

New Directions in Surgical Treatment

The n. hypoglossus stimulation treatment is a new surgical treatment method, the objective of which is to keep the tongue from falling into the pharynx during sleep. During the surgery, a stimulator shall be placed under a “pocket” formed under the collar-bone, connected with two guide-wires. One guide-wire is connected to a nerve under the tongue, the other guide-wire is installed between chest muscles and it brings breathing impulses to the stimulator – from here the impulse is guided to the n. hypoglossus which moves the tongue forward. The patient shall control the device with a remote, switching the stimulator on for bedtime. The determining factors when using stimulator treatment are type of sleep apnoea, patient’s bodyweight, anatomical peculiarities of the neck and airways, and the cost of stimulator treatment, which currently complicates accessibility to the treatment.

The author of this article is Dr. Heisl Vaher

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