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Sleep is like an elixir and if people are not sleeping, it can cause havoc,” says Edel Hurley, Director and Clinic Manager of the Beacon Dental Sleep Medicine Clinic
“Obstructive sleep apnoea can cause a lot of disharmony in the home, with partners unable to sleep because of the snoring. If people are not sleeping, they become irascible and this can result in escalating inter-personal difficulties. Invariably, the spouse is the person who is on high alert that there is a problem. Sometimes patients come to us and they are already in a spare bedroom and the relationship might already be a bit fractious, so they do need support. If a spouse is helpful when someone develops any chronic illness, not just sleep apnoea, it does help to manage the problem, of course.
“While everyone who has sleep apnoea snores, not everyone who snores has sleep apnoea,” she continues. “This is important to note because snorers can be just snorers. However, snoring can be the first indication of sleep apnoea.”
The most frequent signs of obstructive sleep apnoea- which affects 20% of Irish people, many undiagnosed- are:
Loud snoring.
Noisy and laboured breathing.
Repeated short periods where breathing is interrupted by gasping or snorting.
Excessive daytime sleepiness.
Not feeling refreshed, when waking in the morning.
“Obstructive sleep apnoea can also run in families and is more common in men. However, it is also common in women, especially around the menopause, due to variations in circulating hormone levels, with a change in subsequent night-time sleep patterns.”
Obesity causing increased incidence
The number of people developing sleep apnoea has risen in the past few years, because of the current universal obesity pandemic.
“We saw an increase in patient contact and attendance at our clinic over and after the COVID pandemic,” she adds. “This is largely because people were at home, contributing to frequent snacking and under-exercising, which invariably led to weight gain.”
Food wise, people who are undiagnosed, are often “dragging themselves” around in the daytime and more likely to eat foods which are highly calorific in an attempt to gain energy, she says. “However, that is simply adding to the problem.”
But how does obesity contribute to the problem?
“We have some fat pads in the oropharynx [the area at the back of the throat that descends into what is the larynx, trachea and down into the lungs] and these pads increase in size as we gain weight,” she responds.
“The airway becomes increasingly narrowed, so breathing may become progressively obstructed.”
This is what happens:
As the person sleeps, the muscles and soft tissues in the throat relax and collapse inward and cause this partial or total blockage of the airway. This blockage is called obstructive sleep apnoea.
People with sleep apnoea don’t get consistent, restorative sleep because of the repeated airway size changes during the night.
The combination of effort of breathing and a circulating high carbon dioxide level (due to reduction and/or cessation of breathing) triggers the brain through the respiratory centre to restart breathing, forcing the patient out of their deep sleep into taking a big breath, so that the airway re-opens and breathing restarts.
“This is commonly described by a bed-partner as ‘witnessing their partner startle or jump, just as they restart breathing,’” she says. “This physical narrowing of the airway causes chronic cycles of interruptions in breathing, which over time, if left untreated, is substantially damaging to health.”
She states that those with sleep apnoea will always restart breathing.
“This is true, however, it is the chronic nature of interrupted breathing and poor overnight oxygenation that causes the chronic health damage.
“Many bed partners worry that the snorer [who stops breathing for whatever period of time] will not restart breathing. In many incidences, the bed partner then takes on a role of some responsibility at night-time, meaning their own sleep is interrupted through noise and ongoing anxiety that their partner may fail to breathe. This then becomes a vicious circle, with both bed partners having poor sleep patterns.”
Fit people can be affected too
While most people may develop sleep apnoea due to weight gain, particularly in the neck area, fit people can be affected too. Sleep apnoea is particularly related to a phenotype i.e. a particular head and neck anatomy, which predisposes people to sleep apnoea. It can also be hereditary, running in families.
One thing you don’t want to do is immediately silence a snorer, because really, you don’t know what you’re silencing.
People with larger neck circumferences tend to be more vulnerable to obstructive sleep apnoea. For men, it’s a collar size of 17 inches or greater and in a woman, it is a collar size of 16 inches or greater.
“We’d see athletes who could have sleep apnoea too, associated with the presentation of their head and neck anatomy, where their tongue may be larger and fall backwards, obstructing their airway while they sleep,” she says.
“In some people, their lower jaw may be receded slightly, again predisposing the patient to a narrowing of the airway. They may also have a predisposition to sleep apnoea because their airway is anatomically smaller.”
Complex condition
Obstructive sleep apnoea, as described above, is the most common form of sleep apnoea, but there is also central sleep apnoea which is a more serious condition.
Sleep apnoea, in general, however, is a multifactorial, complex condition.
“One thing you don’t want to do is immediately silence a snorer, because really, you don’t know what you’re silencing,” Edel says. “Key steps should be taken to figure out what the presenting patient problem actually is and then work closely in collaboration with a multidisciplinary team of medical practitioners to manage patients optimally.”
Dangerous downside
One of the dangerous downsides of sleep apnoea is “drowsy driving” because of disrupted sleep. Those with undiagnosed and untreated obstructive sleep apnoea are seven times more likely to have traffic accidents, statistics show.
“If a person is driving, operating machinery or is responsible for safe management of any equipment, it is very important that they are appropriately diagnosed and treated if they are suffering from sleep apnoea. Their adherence to prescribed treatment, whether that is a C.P.A.P. [continuous positive airway pressure, mask therapy] machine or a mandibular advancement system device, is very important.”
App to record snoring
There are several apps available that record snoring and bringing a recording with you when seeing a G.P. or medical consultant is very useful.
“The app on your phone records all night, but make sure it’s on your side of the bed,” Edel adds. “We have had cases where both people in the bed discover that they have sleep apnoea.”
Note: 20% of the cost of sleep apnoea devices may be claimed back using Revenue’s Form Med 2 (dental expenses certified by dental practitioner). Some private health insurers may cover some component of the cost, depending on your policy.
Treatment options
The simplicity or the complexity of the problem has to be figured out first. That can involve referral to a dental sleep medicine specialist, a consultant respiratory specialist or an ear, nose and throat specialist.
“When a person presents to us with a snoring condition, we ‘disambiguate the presentation’ i.e. figure out what exactly is the patient’s problem. If they meet specific assessment criteria as a snorer, they can be considered for a mandibular advancement device. These are upper and lower arch intraoral device systems, which connect and are placed in the mouth at night-time. The setting on the device is determined by the clinical presentation and by what are called validation tools [tests], which will tell us what is happening with the patient who is wearing the device.”
This device system may need to be adjusted if, for example, the person gains or loses weight, over time.
“It’s a bespoke device service, not a one-size-fits-all. Individual devices typically last for four to five years.”
Testing may or may not require an overnight hospital stay depending on the patient’s clinical presentation.
C.P.A.P. Machine
In more severe cases, a continuous positive airway pressure (C.P.A.P.) machine is prescribed. This is a device that attaches over the face or nose (or both) and blows pressurised air into the airway during sleep, in order to keep the airway open overnight.
It involves a machine beside the bed that continuously delivers pressurised air through a hose, to a mask worn during sleeping hours. The mask selected for a C.P.A.P. prescription can be facial to include the nose and mouth or nasal only. Individual patient diagnosis, their anatomy and patient preference would be some of the considerations in mask selection.
the impact of ignoring it
Figuring out the simplicity or the complexity of the problem is very important because, from a physiological point of view, snoring is overnight work, Edel states.
“Untreated sleep apnoea can potentially lead to blood pressure problems [because the flow of oxygenated blood is interrupted on a regular basis, damaging the blood vessels over time]. It can also lead to other illnesses including low mood or depressive states and to diabetes also because there is an interruption to oxygenated blood flow throughout the body.”
She highlights the importance of adhering to treatment.
“We encourage people to take ownership and responsibility of their diagnosis. Giving up on the C.P.A.P. machine after a few weeks, for example, is like saying you’re type one diabetic, but you don’t need insulin anymore. Some people may stop using the C.P.A.P. machine for a variety of reasons like mask discomfort, but the problem should be discussed with the patient’s doctor or nurse, not simply abandoned. Some younger people are often frantic to have an alternative to using a machine, because they may be in or forming new relationships and don’t want to reveal these problems to their partner. The mandibular advancement device may provide an alternative for these people.”
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