Obstructive Sleep apnoea –

relevance to the general

physician

Dr Sophie West

Newcastle Regional Sleep Service

Sophie.west@nuth.nhs.uk

Obstructive sleep apnoea

• Common in the general population

- 4% men, 2% women

>70 year olds = 15-20%

Men with Type 2 diabetes = 23%

Diabetic macular oedema = 50%

Bariatric surgery waiting list = 70%

Bipolar disorders = 21% -51%

Marfan’s Syndrome =33%

AAA= 41%

Fat distribution is important

Visceral

obesitySubcutaneous

obesity

OSA

DM

Met synd

Overnight oxygen saturation levels in OSA: >400 dips/apnoeas in total

Beginning

of night

1st hr

2nd

hr

8th hr

End of

night

60 minutes

3rd hr

Red = SaO2, Blue = pulse rate

Episodic rise in pulse rate with each arousal from sleep (even if the

cortex is not ‘woken’ as well).

Arterial blood pressure during OSA

Rise with every

arousalRecurrent dips with every

obstructed breath

Kohler M, Stradling JR. Nature Rev Cardiol 2010

Symptoms of OSACommon (>60%)• Loud snoring• Excessive daytime sleepiness• Choking or shortness of breath sensations during sleep• Restless sleep• Unrefreshing sleep• Changes in personality• NocturiaLess common (10-60%)• Morning headaches Enuresis• Reduced libido Nocturnal sweating• Spouse worried by apnoeic episodesRare (<10%)• Recurrent arousals/insomnia • Nocturnal cough• Symptomatic oesophageal reflux

OSA in the medical clinic

• Snoring? Loud, nightly

• Witnessed apnoeas

• Unrefreshing sleep and daytime sleepiness

• Driving? Job? Shifts?

• Especially if associated other condition or difficult to control

Ask GP / Refer to Local

Sleep Service if suspicion

- we will do sleep study

Treatment of OSA

1. Weight loss (+bariatric surgery)

2. Sleep hygiene

– Avoidance of sedatives/alcohol

– Stop smoking

– Positional changes

3. Mandibular advancement device

(4. ENT Surgery)

5. CPAP

Nasal continuous positive airway pressure, CPAP

Newcastle > 5000 CPAP patients

c.£300

c.£100

c.£100

CPAP

Sullivan C et al. Lancet 1981

CPAP• Adjustment period – support from trained staff

• Side effects not severe – dry mouth/nose, red marks on face, air leak, noise

• Benefit generally proportional to OSA severity

• Generally well tolerated

Retrospective cohort analysis, n=640

• Average use 6.2 hours/night AIM 4 HRS

• 81% adherence at 5 years, 70% at 10 years

• Severity of OSA on sleep study determines long term adherence

Kohler M et al. Thorax 2010

CPAP

Could it be used to treat more than OSA?

Resolution of

intermittent hypoxia

Decreased sympathetic drive

Improved sleep architecture

Improved energy and activity

Decreased cellular inflammation

CPAP and other conditions

Robust RCT data:

• CPAP reduces BP – greatest if severe OSA,

high CPAP use, hypertension

Bazzano LA. Hypertension 2007

• CPAP reduces ESS in minimally symptomatic

people with OSA – cost effective

Craig S et al. Thorax 2012

• CPAP improves some measures of vascular

functionSchwarz EI et al. Respirology 2015

CPAP and other conditions

• CPAP probably improves cardiovascular risk

- But not yet demonstrated in RCT

- International trial ongoing

Marin JM et al. Lancet 2005

CPAP and diabetes

• Many RCTs show CPAP doesn’t improve glycaemic

control or insulin resistance

• – but one recent study 8 hrs CPAP /night for 2 weeks in

sleep lab N=39 “pre-diabetes” Insulin sensitivity improved,

p=0.04 Pamidi S. 2015;192:96-105.

• CPAP improved vision in patients with diabetic

macular oedema - small pilot study Mason RH et al. Respiration 2011

70 year old female

�Type 2 Diabetes Mellitus

�Blood Pressure 128/78mmHg

�HbA1c 55mmol/mol

ESS 5, ODI 57

….But, macular oedema

• Prevalent – especially if you see patients with

raised BMI, visceral obesity

• Relevant to general physician – association with

other conditions, may make them worse

• Treating OSA is straightforward, inexpensive, cost

effective

• Falls in sleepiness, better driving, Q of L

• Improved BP, ?CV disease

Refer to local sleep service to investigate

Obstructive Sleep apnoea