Managing Sleep Apnoea 101

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Did you get a good sleep last night? Many of us didn’t, which may not surprise you- but you might be surprised by the reasons why. A very common one is obstructive sleep apnoea. According to sleep studies, 9-38% of adults in Australia have sleep apnoea, while 4-6% of the population also report feeling far too sleepy during the day. Males and older people are even more likely to suffer this curse- while the rest of us are more likely to suffer from the sound of their snoring!

Key points: 

  1. CPAP is the most common form of treatment. It seems able to produce good results- although further long term research on it is required, and among people with different health statuses
  2. Despite its apparent value, a significant number of people report having problems sticking to CPAP. A number of available modifications may provide a solution for you. 
  3. Weight loss through healthy eating and exercise is recommended for the large proportion of sleep apnoea patients who are also overweight or obese.
  4. There are a number of other potential management tools, such as respiratory muscle training, exercise with ventilation, mandibular advancement splints, hypoglossal nerve stimulation and airway surgery. There is science and art to finding what’s best for you. 

Why we can’t just hit snooze on concern

There are different forms of sleep apnoea: obstructive, central (where the brain does not regulate respiratory muscles appropriately) and mixed. In this article we will simply use the term ‘sleep apnoea’ to refer to the obstructive variety. 

In sleep apnea, your upper airway collapses repeatedly, causing you to be aroused from sleep. Unsurprisingly, this increases daytime sleepiness and reduces quality of life. 

If that ain’t enough of a concern, perhaps its association with increased risk of car accidents, diabetes (by impairing insulin sensitivity), high blood pressure and coronary artery disease, stroke, atrial fibrillation, congestive heart failure, frequent nighttime urination, sexual dysfunction and mortality will be. Although studies differ, it’s also been linked to impaired cognitive abilities, particularly executive function (used to control and coordinate other cognitive behaviours) and vigilance. 

The root cause of some of these, such as diabetes and cardiovascular diseases, may be difficult to determine, because often people with sleep apnoea are also overweight or obese.

Risk factors for sleep apnoea

Weight gain is the major risk factor. However, sleep apnoea also seems to increase the pace of weight gain, placing people in a pickle. It is common for people to reflect that they gained weight rapidly in the year prior to being diagnosed. This is often also associated with increased snoring and symptoms such as tiredness.

There are exceptions to this though. For example, my brother is a lean, muscular maniac who spends several hours a day exercising, but he still suffers, like other men in my family.  

Other risk factors include: increasing age, male gender, perimenopausal or postmenopausal status in women and craniofacial abnormalities (eg retrognathic jaw). It seems that race can also alter risk, with individuals of African American, Asian, or Hispanic descent being most prone. 

How can you treat/manage sleep apnoea?

CPAP (and other PAP’s)

The most common sleep apnoea therapy is CPAP (continuous positive airway pressure). You’ve probably seen people wearing masks, hooked up to a CPAP machine while they sleep. These generate positive airway pressure that splints the airway open. It’s safe, it stops snoring and available reports suggest it often reduces the severity of apnoea, daytime sleepiness, depression, blood pressure, motor vehicle accidents- while improving alertness, neurocognitive function and quality of life. 

Diving a little deeper into the topic of blood pressure: studies suggest CPAP has a modest effect. i.e. a smaller effect than medication- but this may be greater among people whose blood pressure is higher to begin with. We need more information regarding whether the severity of the sleep apnoea alters the BP lowering effects of CPAP. We also need larger, longer term studies (>1 year) to examine the effect on hypertension and related outcomes- eg, chronic kidney disease, congestive heart failure, and stroke.  At this stage it is thought that combining medication and CPAP may be a way to go. 

We know about some limitations to CPAP. For example, the research shows it doesn’t lead to spontaneous increases in physical activity, despite it helping people be less fatigued. It’s hardly surprising that it is not a magic bullet, when you consider that many of us are not sufficiently active for a whole range of psychosociocultural reasons- regardless of physical capacities. It also seems that CPAP doesn’t improve other cardiometabolic risks such as glycaemic control, blood cholesterol or inflammatory status.  However, according to a 2019 review, we need more robust short-term and long-term studies to make definitive calls regarding its efficacy against most symptoms. 

But overall I’m convinced that there’s more benefits than drawbacks- which may explain why CPAP stores have been popping up over the suburbs almost as quickly as vape shops (hang on, wait, what am I saying?…). The real rub is that approximately 50% of people find using it so intolerable that they don’t/can’t continue to do so in the long term.

Having trouble with CPAP?

If you have trouble using CPAP or don’t seem to be reaping any benefits, you should see a sleep specialist/clinic. It’s very important to continue using it (many people get used to it over time) or find a solution, especially if you have other risk factors and/or comorbidities. 

Data shows that some of the problems can be overcome with modifications and troubleshooting, or use of educational, behavioral, and telemonitoring interventions. so don’t give up before finding what agrees with you most….

Modifiers to (C)PAP use

While CPAP is the most well known, there are actually different types of PAP machines. For example, in APAP (auto-adjusting PAP), computer algorithms are used to increase pressure in real time when obstructive breathing events are detected… and to periodically reduce the delivered pressure if no events have been detected over a period. There is also BPAP (bilevel PAP), where the pressure is transiently lowered during expiration and increased during inspiration. This is aimed at improving comfort without a loss of openness of the airways.

According to a 2019 review, such modifications provide similar benefits as standard CPAP- at least in the early stages of sleep apnoea management among people with no major comorbidities. It is possible that APAP may be less effective in reducing blood pressure, but this needs to be clarified. Modifications did not even significantly improve adherence. However- one (yes only one) of the studies reviewed suggested that people who have low tolerance to CPAP could possibly do better with modifications. More studies in this vein are warranted. 

In regards to patients with common comorbidities- such as obstructive and restrictive lung disease, CHF, pulmonary hypertension, neuromuscular disease, co-existing central sleep apnea- we don’t have enough studies examining the effect of APAP or BPAP. We need these studies so that we can a) determine what is the best mode of PAP for different clinical populations, and b) refine algorithms- those used for otherwise healthy patients could be very inappropriate.

Mask type could also affect your PAP experience. From systematic reviews, it seems that nasal devices may have greater tolerance/adherence compared to oronasal interfaces… and slightly larger impacts on the severity of the condition. It seems patients more often prefer nasal (or intranasal) devices too, but you should choose whatever works for you. Common reports of side effects for oral interfaces are more oral dryness, excess salivation, lip and gum discomfort. People using nasal interfaces on the other hand more often report air leaks, nasal dryness and strap/mask discomfort.

We also need more studies exploring whether modifications such as APAP, mask type, humidification or modified pressure profiles improve adherence and health in people who are likely to not use the device as recommended.

The use of humidifiers may reduce unwanted side effects such as nasal discharge, congestion, dry nose/mouth/throat, nose bleeds, sinus pain/headache, sore throat, hoarse voice, and unsavoury smell. 

Weight loss: a key for many with sleep apnoea

For many people, weight loss improves the symptoms experienced, health and metabolism and quality of life. However, it has inconsistent effects on the number of times a patient stops breathing during each hour of sleep (more technically known as AHI, Apnoea Hypopnea Index):

  • For those who are overweight and have only mild-moderate sleep apnea, losing approximately 10% of excess weight often produces fewer AHI, but rarely leads to a ‘cure’. While the solution is straighforward- reduce energy intake, increase energy expenditure- it’s certainly not easy. The principles of effective new years resolutions can help you achieve sustainable change, anytime.
  • Those with severe disease get some benefit but usually need to continue CPAP. 

Combining weight loss through PAP and the classics of eating less and moving more is the way to go- it has a synergistic effect on blood pressure, C-reactive protein (an inflammatory marker) and cholesterol. Once again, you can’t beat the good old exercise and healthy eating approach. 

Respiratory muscle training

The evidence is thus far inconsistent. More research is required for definitive answers to safety and efficacy questions… However, building up the fitness of the diaphragm, abdominals and muscles between the ribs (i.e. the muscles that support respiration) may be a useful addition to PAP. Exercises that could accomplish this include oropharyngeal exercises, speech therapy, breathing exercises with or without specially designed devices, and practicing on wind musical instruments. 

While one study into respiratory muscle training found no changes to AHI, there were other meaningful improvements. For example, improved sleep with fewer awakenings and reduced blood pressure. In this study, there was also around a 30% drop in blood norepinephrine levels (a hormone and neurotransmitter that is associated with increased blood pressure and sympathetic nervous system activity). This reduction in norepinephrine is similar to what would be expected from CPAP or 4 months of aerobic training. It is not clear how these changes come about, however.

Exercise combined with respiratory interventions

People who suffer from sleep apnoea and obesity often have a limited exercise capacity due to the clustering of respiratory, muscular, cardiovascular and metabolic problems. Thus programs that combine exercise with non-invasive ventilation may be particularly valuable for them.  

More research is warranted, but in one study, cycling while receiving BPAP was seen to improve exercise tolerance by reducing the work of breathing. This was also seen to reduce cardiometabolic risk (eg: blood pressure and waist circumference) more than a program of cycling followed by respiratory muscle training.

Other treatments for sleep apnoea

There are various other treatment options, however we don’t yet know how to predict the likelihood of success. All we do know is that morbid obesity (classified as BMI>35) limits their promise. 

  • Mandibular advancement splints may be an alternative to PAP therapy. They may modestly reduce blood pressure
  • Upper airway surgery
  • Stimulation of the hypoglossal nerve, which has a key role in the muscular tone of the airways

What treatment is right for you?

You’ll need to work this out with your sleep specialist, but just know you’ll  need a tailored solution, not a one-size-fits all one. 

Just one factor which could affect your treatment is the form of obstructive sleep apnoea you have. Yes, there are three distinct forms:

  1. Disturbed Sleep.  You are most likely to experience insomnia-related symptoms, eg: difficulty falling asleep, waking too early, restlessness and waking often during the night. From a 2018 Icelandic study, whether people in this group used PAP or not didn’t seem to make a huge difference – but the effects were still greater than in the minimally symptomatic groups. 
  2. Minimally Symptomatic. You have less sleep-related symptoms and are more likely to awaken feeling rested.  In the above mentioned study, use of PAP improved daytime sleepiness and physical fatigue compared to no PAP.
  3. Sleepy. You have a higher risk of sleepiness-related symptoms, such as falling asleep involuntarily and dozing while behind the wheel. In the study PAP had a wide-ranging effect on sleepiness, insomnia-related and apneic symptoms, including significantly less drowsy driving. 

In the future, research could look more closely at how the form of sleep apnoea affects one’s risk to other conditions, and how to target treatments for the specific groups.  Eg:  to discover differences in the potential of PAP, cognitive behavioral therapy for insomnia, oral appliances or hypoglossal nerve stimulation for each group. 

The Verdict

The aim of sleep apnoea treatment is three pronged:

  1. Reduce the frequency of events where the airways close and breathing stops during the night
  2. Reduce the severity of symptoms such as sleepiness, fatigue, mood and cognitive changes and their impact on quality of life and risk of motor vehicle accidents
  3. Reduce the risk of or manage comorbidities. 

CPAP is the mainstay of sleep apnoea management and seems able to produce good results- although further long term research on it is required, and among people of varied health statuses. Modifications are available to deal with problems some people have with using CPAP. Weight loss is valuable in some cases, as excess weight is a major risk factor for sleep apnoea, and there is a crossover in the effects of the two. A range of other management strategies are available. The key is working with your sleep specialist to get a tailored solution. 

If you have sleep apnoea, what has worked best for you?

References

American Sleep Apnea Association. What is Sleep Apnea? https://www.sleepapnea.org/learn/sleep-apnea/ (Accessed February 24, 2020). 

Hamilton, G.S., and Joosten, S.A. (2017). Obstructive sleep apnoea and obesity. Australian Family Physician. 46(7):460-463. Accessed at https://www.racgp.org.au/afp/2017/july/obstructive-sleep-apnoea-and-obesity/

Hsu, B., Emperumal, C.P., Grbach, V.X., Padilla, M., Enciso, R. (2020). Effects of respiratory muscle therapy on obstructive sleep apnea: a systematic review and meta-analysis. Journal of Clinical Sleep Medicine. 16(5). https://doi.org/10.5664/jcsm.8318

Patil, S.P., Ayappa, I.A. Caples, S.M., Kimoff, J., Patel, S.R., and Harrod, C.G. (2019). Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. Journal of Clinical Sleep Medicine. https://doi.org/10.5664/jcsm.7638

Pavwoski, P., and Shelgikar, A. V. (2017). Treatment options for obstructive sleep apnea. Neurology. Clinical practice. 7(1):77–85. https://doi.org/10.1212/CPJ.0000000000000320

Pien, G.W., Ye, L., Keenan, B.T. et al. (2018). Changing Faces of Obstructive Sleep Apnea: Treatment Effects by Cluster Designation in the Icelandic Sleep Apnea Cohort. Sleep. 41(3):zsx201, https://doi.org/10.1093/sleep/zsx201

Vivodtzev, I., Tamisier, R., Croteau, M., et al. (2018). Ventilatory support or respiratory muscle training as adjuncts to exercise in obese CPAP-treated patients with obstructive sleep apnoea: a randomised controlled trial. Thorax. 73:634-643.  DOI: 10.1136/thoraxjnl-2017-211152

Vranish, J.R., and Bailey, E.F. (2016). Inspiratory Muscle Training Improves Sleep and Mitigates Cardiovascular Dysfunction in Obstructive Sleep Apnea. Sleep. 39(6), June: 1179–1185 https://doi.org/10.5665/sleep.5826

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