The Disorder
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Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) affects up to a billion people globally, causing airway blockages and breathing interruptions during sleep. It raises the risk of car accidents, cardiovascular issues, diabetes, mood disorders, and reduces quality of life. Prevalence can exceed 50% in some areas. Treatments include lifestyle changes, CPAP therapy, oral appliances, and surgery, with early diagnosis being crucial.(1).
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It is characterised by recurring episodes of upper airway obstruction during sleep for at least 10 seconds or longer.
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The upper airway closure is either complete (apnoea) or partial (hypopnea). These episodes, which can occur up to several hundred times during sleep, often lead to micro-arousals which substantially alter the quality of sleep.
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Apnoeas and hypopneas are almost always accompanied by loud snoring and are a cause of major stress on the cardiovascular system and other organs (2-4)
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1.Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MS, Morrell MJ, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. The Lancet Respiratory Medicine. 2019;7(8):687-98. ​
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2. Bjornsdottir E, Keenan BT, Eysteinsdottir B, Arnardottir ES, Janson C, Gislason T, et al. Quality of life among untreated sleep apnea patients compared with the general population and changes after treatment with positive airway pressure. J Sleep Res.2015;24(3):328-38.
3. Bonsignore MR, Baiamonte P, Mazzuca E, Castrogiovanni A, Marrone O. Obstructive sleep apnea and comorbidities: a dangerous liaison. Multidisciplinary respiratory medicine.2019 Dec;14(1):1-2.
4. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine. 2019 Feb15;15(2):335-43.: JCSM : official publication of the American Academy of Sleep Medicine.2019;15(2):301-34.
Symptoms
It is often the partner of the person with OSAHS who notices the pauses in the breathing pattern or who is woken up by his or her partner snoring.
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Other signs are often little-known but indicate OSAHS:
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Excessive daytime sleepiness
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Unexplained fatigue
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Impaired memory
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Choking or gasping during sleep
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Night sweats
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Nocturia (frequently needing to go to the toilet at night)
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Morning headaches
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Depression or irritability
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Reduced libido
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Impaired concentration
Consequences
If left untreated, OSAHS affects all aspects of everyday life.
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Impaired concentration, reduced intellectual performance, mood issues, excessive fatigue, and sleepiness indicate a lack of restorative sleep, disrupting the daily lives of affected patients.
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The consequences of untreated sleep apnoea can go far beyond simple disruptions to daily life:
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​Diagnosed or undiagnosed OSAHS is a major public health concern and a known risk factor for motor vehicle accidents (6).
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OSAHS worsens personal relationships, reduces work productivity, and increases occupational accidents, resulting in significant costs to healthcare organizations when left undiagnosed and untreated. (7).
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OSAHS leads to an increased risk of adverse cardiovascular events (8-10)
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An increased risk of obesity and type 2 diabetes (11,12).
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6. Purtle MW, Renner CH, McCann DA, Mallen JC, Spilman SK, Sahr SM. Driving with undiagnosed obstructive sleep apnea (OSA): High prevalence of OSA risk in drivers who experienced a motor vehicle crash. Traffic injury prevention. 2020 Jan 2;21(1):38-41.
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7. Morsy NE, Farrag NS, Zaki NF, Badawy AY, Abdelhafez SA, El-Gilany AH, El Shafey MM, Pandi-Perumal SR, Spence DW, BaHammam AS. Obstructive sleep apnea: personal, societal, public health, and legal implications. Reviews on environmental health. 2019 Jun 1;34(2):153-69.
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8. Moula et al, Clin. Med. 2022, 11(5), 1242; https://doi.org/10.3390/jcm11051242
Brown et al, 2022 Current Hypertension Reports - https://doi.org/10.1007/s11906-022-01181
9. Javaheri et al 2017, J Am Coll Cardiol. 2017;69:841–858. doi: 10.1016/j.jacc.2016.11.069
10. Yeghiazarians et al 2021, Circulation Volume 144, Issue 3, 20 July 2021; Pages e56-e67 https://doi
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11.Reutrakul and Mokhles 2017, CHEST 2017; 152(5):1070-1086
12. Lopez et al 2008 - Am Surg. 2008 Sep;74(9):834-8. PMID: 18807673.
Risk Factors
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In Europe, approximately 175 million people (44.0%) are estimated to have OSAHS, with about 90 million (22.7%) experiencing moderate to severe cases (AHI ≥ 15) (13).
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Age is a risk factor for OSAHS with nearly one billion adults aged 30–69 years suffering from OSA worldwide (14), although OSAHS can affect any age group (15).
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Finally, some morphologies or lifestyles particularly increase the risk of OSAHS:
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A narrow jaw, prognathism, or a thick tongue
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Being overweight or obese
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Hypertrophy of the tonsils/adenoids in a child
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Alcohol consumption/Some sedative medications
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Use of sleeping pills
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Sleeping position (sleeping on the back increases the risk of sleep apnea)
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13. Malhotra A, Heinzer R, Morrell MJ, Penzel T, Pepin JL, Valentine K, Nunez C, Benjafield A. Late-Breaking Abstract-European prevalence of OSA in adults: Estimation using currently available data.
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14. Thompson C, Legault J, Moullec G, Baltzan M, Cross N, Dang-Vu TT, Martineau-Dussault MÈ, Hanly P, Ayas N, Lorrain D, Einstein G. A portrait of obstructive sleep apnea risk factors in 27,210 middle-aged and older adults in the Canadian Longitudinal Study on Aging. Scientific reports. 2022 Mar 24;12(1):1-1.
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15. Savini S, Ciorba A, Bianchini C, Stomeo F, Corazzi V, Vicini C, Pelucchi S. Assessment of obstructive sleep apnoea (OSA) in children: an update. Acta Otorhinolaryngologica Italica. 2019 Oct;39(5):289.
Screening and Diagnosis
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Polysomnography is the gold standard for diagnosing sleep apnea, conducted in hospitals or at home to assess sleep quality, however there are often long waiting lists for this test.
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It records and analyses various factors related to the patient's sleep and cardio-respiratory activity throughout the night, though in-lab tests often have long wait times.
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Home Sleep Apnea Testing (HSAT) is a viable alternative, recording cardio-respiratory signals for at least six hours during sleep, typically conducted at home.
Treatment
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Treatment by Continuous Positive Airway pressure (CPAP) is currently the most effective treatment of OSAHS, as its benefits largely outweigh the drawbacks.
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CPAP consists of blowing air generated by the device via a hose and mask on the face to keep the airway open and restore normal breathing and sleep patterns during sleep.
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After prescription by a specialist, the NHS Sleep Medicine service provides the CPAP device and offers education and support to ensure user adherence.
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As of the first night of treatment, apnoeas and hypopneas start to reduce disappear, leading to improved quality of sleep and gradually eliminating difficulties in the patient’s daily life.
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Other treatment options:
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A mandibular advancement device (MAD) is an alternative therapy for mild to moderate sleep apnea in patients without severe cardiovascular diseases.
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It is a custom made dental device that holds the lower jaw and tongue forward during sleep.
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Positional therapy is an effective treatment for positional OSA, but long-term compliance is low, particularly in patients with moderate OSA.
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Surgery is typically not recommended but may be needed for nasal abnormalities, rare bone morphology anomalies, or removal of excess tonsillar tissue.
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Other treatments, such as surgery, myofunctional therapy, and hypoglossal nerve stimulation, are options for moderate to severe obstructive sleep apnea, but current evidence regarding their safety and efficacy is limited in quantity and quality.
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