Best Superspeciality Clinics

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Kadhiri's Apurupa Urban
Beside Chirec Internationl School
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Pulmonology

Sleep disordered breathing (SDB)

Sleep disordered breathing (SDB) describes a group of disorders characterised by:

  • Abnormal respiratory patterns (e.g. the presence of apnoeas or hypopneas); or
  • Insufficient ventilation during sleep.

An apnoea is when a patient stops breathing for 10 seconds or more, and they wake up just enough to take a breath.

hypopnea is when a patient doesn't stop breathing, but the patient's breathing becomes shallow (i.e., at least a 30% decrease in airflow) for 10 seconds or more, with an associated oxygen desaturation or arousal.

Either way, sleep disordered breathing disrupts the patient's sleep pattern, night after night, which not only makes the patient tired and exhausted the next day, but may also put excessive strain on the their nervous system and major organs.

Common symptoms of sleep disorders

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The symptoms of sleep disorders and sleep-disordered breathing (SDB) are important to recognition in patients.

Some of the most recognizable symptoms of sleep disorders are daytime sleepiness and snoring, even though many patients ignore these signs or fail to recognize these as symptoms.

Other symptoms of sleep-disordered breathing may include: 

  • poor concentration
  • morning headaches
  • depressed mood
  • night sweats
  • weight gain
  • fatigue
  • forgetfulness
  • sexual dysfunction
  • nocturia

If your patient presents with any of the above symptoms, it's important to talk to them about the potential risk of sleep apnoea and recommend a sleep test if you believe this is necessary.

Risk factors for developing OSA

In Australia, obesity is increasing and also may be the most common risk factor in developing OSA

Symptoms of sleep-disordered breathing in children

Obstructive Sleep apnoea affects up to 5.7% of children, with common symptoms including:

  • pathological snoring and habitual snoring (which affects 3.2-12% of children)
  • noisy breathing and increased work of breathing
  • pauses in breathing with noisy resumption of breathing
  • chronic mouth breathing
  • behavioural problems, such as hyperactivity and aggressiveness
  • restless sleep

There are a number of risk factors that could also predispose children to having sleep-disordered breathing, including:

  • Adenotonsillar hypertrophy 
  • Craniofacial malformation
  • Congenital syndromes
  • Obesity

If symptoms of sleep-disordered breathing are observed in a child, it's important to either refer the child to a paediatric sleep physician or recommend a sleep test to determine whether he or she has a breathing disorder.

Types of sleep disordered breathing (SDB)

There are three main types of sleep-disordered breathing which are manifested in sleep apnoea. Discovering the specific differences between them can help you recognise how best to treat your patients.

  • Obstructive sleep apnoea (OSA)
  • Central sleep apnoea (CSA)
  • Complex sleep apnoea

OSA

OSA is a common disorder characterised by repetitive upper airway collapse during sleep resulting in apnoeas (cessation of airflow) and hypoapnoeas (reduced airflow).

The primary indications of upper airway obstruction are:

  • lack of muscle tone during sleep
  • excess tissue in the upper airway
  • the structure of the upper airway and jaw

OSA determined by polysomnography is highly prevalent, affecting 25% of men and 10% of women in the United States although most are asymptomatic.

Central sleep apnoea (CSA)

CSA is clinically defined by a lack of drive to breathe during sleep, resulting in repetitive periods of insufficient ventilation leading to compromised gas exchange, in contrast to OSA where there is an ongoing respiratory effort.3 These nocturnal breathing disturbances can lead to various comorbidities and can increase the risk of cardiovascular events.3 There are several known variations of CSA, including high altitude-induced periodic breathing, idiopathic CSA, narcotic-induced CSA, and Cheyne-Stokes respiration (CSR). While unstable ventilatory control during sleep is an indication of CSA, the pathophysiology and the prevalence of the various forms can vary greatly.

Patients with CSA don't often snore, so the condition sometimes goes unnoticed.

Complex sleep apnoea

Complex sleep apnoea (CompSA) can be clinically defined as a combination of obstructive sleep apnoea with central sleep apnoea or Cheyne-Stokes breathing pattern.4 Patients who have CompSA present with both a reduced upper airway tone, resulting in an obstruction during sleep, and unstable ventilatory control, resulting in a cessation of respiratory effort leading to a central apnoea.

 

Screening and diagnosis for sleep disordered breathing

If you suspect a patient may have sleep disordered breathing (SDB), this three step screening process for SDB can get your patient on the path to getting diagnosed.

  • Assess - Can you identify the patient as having a high risk of OSA?
  • Screen - To aid in the screening process, evaluate your patient by asking a few key questions:

    • Is the patient overweight?
    • Does the patient complain of daytime sleepiness?
    • Does the patient snore?
    • Does the patient have hypertension?
  • Investigate

 Sleep apnoea treatment options

Treatment of OSA requires a multi-faceted approach that encompasses patient education and may include medical, surgical and behavioural options. 

Positive airway pressure (PAP) therapy

Positive airway pressure therapy is widely regarded as the most effective way to treat OSA. It works by creating a "pneumatic splint" for the upper airway, preventing the soft tissues of the upper airway from narrowing and collapsing. Pressurised air is sent from a therapy device through air tubing and a mask that patients wear over their nose or mouth, through to the upper airway.

As a result of positive airway pressure therapy, a patient with severe sleep apnoea may experience a return to a normal sleep pattern once his or her sleep debt resolves.

ResMed's AirSense and AirCurve series of devices have helped patients sleep through the four hour compliance threshold. AirSense and AirCurve devices are stylish and quiet, and provide a variety of unique features that are designed to deliver a more comfortable sleeping experience for your patients.

CPAP, APAP and bilevel therapy

Positive airway pressure therapy can be delivered in a number of modes:

  • Continuous positive airway pressure (CPAP) - which delivers pressurised air at one fixed pressure.
  • Automatic positive airway pressure (APAP) therapy - which automatically adjusts pressure levels based on a patient's breathing patterns. This may be particularly suited to patients with REM-related sleep apnoea, positional apnoea or those who are non-compliant with standard CPAP therapy.
  • Bilevel therapy - which provides higher inspiratory pressure (IPAP) and lower expiratory pressure (EPAP) - can also be effective for certain patients who are non-compliant, and used to treat a wide-range of respiratory disorders.

Oral appliance therapy

An oral appliance, often called a mandibular repositioning device (MRD), can be a second line therapy option and can be considered for patients with mild to moderate sleep apnoea. It is a custom-made, adjustable oral appliance available from a dentist that holds the lower jaw in a forward position during sleep. This mechanical protrusion expands the space behind the tongue, puts tension on the pharyngeal walls to reduce collapse of the airway and diminishes palate vibration.

Alternative treatment options

Surgery is also an option for treating sleep apnoea, but as with all surgeries there are associated risks.

Uvulopalatopharyngoplastry (UPPP) has been widely used to treat snoring or OSA, but is not recommended as the first choice treatment option. This surgical procedure involves the removal of the tonsils, soft palate/uvula and closure of the tonsillar pillars and certain risks are involved.

Patient outcomes and comorbidities

Helping your patients start and continue with the most effective sleep apnoea treatment can help them take back control of their lives. Effective treatment can help reverse the effects of daytime vigilance, cognitive dysfunction and mood disorders. It is a source of lost productivity in the workplace and increases motor vehicle accident risk.

Epidemiology studies have also shown OSA to be independently associated with an increased risk of diabetes and cardiovascular disease, although no causal links.

Patient adherence and replenishment

Patient adherence to therapy can be the biggest challenge for treating respiratory and sleep conditions.

Research indicates that patients and their families feel more supported when they receive:

  • proper equipment and training
  • an adequate number of caregivers
  • a support system of experienced healthcare professionals

Research indicates that patient education on CPAP use and compliance is directly related to:

  • Education
  • Equipment: Correct size/type
  • Comfort: Fit and interface
  • Support and Follow up

At ResMed, we agree that the best way to improve patient compliance is by using a multi-faceted approach, which includes:

Comfortable, easy-to-use and reliable equipment

ResMed's therapy devices, masks and humidification technology give patients every opportunity for successful therapy.  

Effective patient education and consistent follow-up

Recent Empirical studies show there is some evidence that educational interventions and cognitive behavioural therapy do improve CPAP usage.

Equipment replacement and compliance

Timely equipment replacement helps patients stay more comfortable and therefore can increase compliance during therapy.

Take the time to educate your patients on knowing when and how to replace components of their products, and how this relates to comfort and therapy effectiveness.

Let them know that manufacturers recommend regular parts replacement, and remind them of their potential private health insurance benefits.