Obstructive sleep apnoea
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3745 (Published 17 June 2014) Cite this as: BMJ 2014;348:g3745
All rapid responses
Dear Sir/Madam
We would like to congratulate the authors on such a comprehensive review article on the diagnosis and management of Obstructive Sleep Apnoea (OSA). From a Urological standpoint we would suggest that another important symptom of OSA is nocturia, in particular nocturnal polyuria (NP). Nocturia is often the primary reason for Urological referral and rated by patients as their most bothersome lower urinary tract (LUT) symptom.
NP is defined as greater than one third of the total daily voided volume being passed between the hours of 12a.m. and 8a.m., whilst nocturia alone indicates waking to void one or more times during sleep. NP is diagnosed following patient self assessment of voiding patterns using a frequency volume chart. Bladder outflow obstruction (incomplete emptying), over active bladder, intravesical pathology, diabetes mellitus and fluid overload should also be considered.
Possible pathophysiological mechanisms include large negative swings in intra-thoracic pressure resulting in a cardiac mediated diuresis.
OSA is undoubtedly associated with nocturia and urinary symptoms, with some studies suggesting up to 80% of patients describing these.1,2 Increasing severity of OSA is also associated with a greater number of nocturia episodes.3 Patients with OSA are also at risk of progression of their LUT symptoms if left untreated.4
We would suggest that health care professionals, principally primary care physicians, consider OSA and sleep patterns in patients presenting with NP and nocturia.
1. Lowenstein L, Kenton K, Brubaker L, Pillar G, Undevia N, Mueller ER, FitzGerald MP. The relationship between obstructive sleep apnoea, nocturia, and daytime overactive bladder syndrome in women. Am J Obstet Gynecol 2008;198:598.e1-598.e5.
2. Kemmer H, Mathes AM, Dilk O, Gröschel A, Grass C, Stöckle M. Obstructive sleep apnoea syndrome is associated with overactive bladder and urgency incontinence in men. Sleep 2009;32(2):271-5
3. Kaynak H, Kaynak D, Oztura I. Does frequency of nocturnal urination reflect the severity of sleep-disordered breathing? J Sleep Res 2004; 13(2):173-6
4. Martin S, Lange K, Haren MT, Taylor AW, Wittert G. Risk factors for progression or improvement of lower urinary tract symptoms in a prospective cohort of men. J Urol 2014; 191(1):130-7
Competing interests: No competing interests
I write as a patient who has suffered from Obstructive Sleep Apnoea and who first sought medical advice for it in 2002. Since then I have received surgery, in Germany, to clear out my nasal passages; being told, politely, that I was overweight with a 'thick-neck' and should lose weight; for a while, successfully used a rubberised plastic 'mouthpiece' that forced me to breathe through my nose; but latterly, and coincidentally, have been able to follow a regular exercise regime of 4 x 1 hr gym sessions a week.
Whilst the mouthpiece was partially successful, the exercise regime has been most effective. I now sleep well and deeply and, if my sleep is still disturbed occasionally, I attribute it to general stress - career transition and a divorce - and have different symptoms: REM and vivid dreams rather than apnoeic 'starts'.
I recognise that one patient's experience is no substitute for systemic study of all available evidence but offer my experience, and what has worked best for me, as a contribution to dealing with a condition that is sometimes laughed-about but destroys the quality of life, not only for the sufferer but also for those who have to live with it.
Competing interests: No competing interests
Reply to: Obstructive sleep apnoea
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3745 (Published 17 June 2014)
Cite this as: BMJ 2014;348:g3745
1. Michael Greenstone, consultant1,
2. Melissa Hack, consultant2
Author Affiliations
1. 1Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, UK
2. 2Royal Gwent Hospital, Newport, Gwent, UK
Dear Sir /Madam
We were pleased to see an overview of Obstructive Sleep Apnoea (OSA) in the BMJ as awareness amongst General Practitioners and Hospital specialists is very poor. We feel much more recognition of the condition should take place as it is estimated that we are only treating about 20% of those with the condition1.
The Department of Health OSA working group lead by Martin Allen of which we are members considered the following as key themes/issues for further consideration but were not emphasised sufficiently or not considered in the review by Greenstone and Hack.
1. A recommendation to replace the Epworth Sleepiness Scale with the STOPBANG questionnaire to support effective referral from primary care and subsequent treatment;
2. Raising awareness of comorbidities e.g. obesity, diabetes, cardiovascular disease and OSA in primary care and the potentially targeting these high risk groups;
3. Promoting the benefits of an MDT approach to management. The main stakeholders are ENT, Respiratory and to a lesser extent anaesthetists and maxillofacial clinicians; From April 2013 there has been a uplift in tariff prices for MDT Clinics
4. There is a lack of consensus regarding the issue of using flexible nasendoscopy on every patient. To our mind it this is the only way to effectively examine the upper airway, the obstruction or narrowing of which can result in OSA. The working group, after lively discussion, included it as a core part of the clinical workup. This procedure will more readily identify those patients with potential surgically correctable causes of OSA.;
5. There is variability in access to mandibular devices through the NHS;
6. It was considered essential to target and identify those at risk of RTAs;
7. There is poor management of the transition between paediatric and adult services;
8. Education in OSA is lacking in both primary care, secondary care and in public health circles.
The fact that OSA is a NICE Technical Assessment 139 was not mentioned- It is legally binding on all commissioners to fund an OSA service in England and wales
In June 2013, The American Academy of Sleep Medicine recommended that all type 2 diabetics and hypertensives should be routinely screened for OSA. Their rational is that seven in 10 people with Type 2 diabetes also have obstructive sleep apnoea, and the severity of the sleep disorder directly impacts diabetes symptoms; the more severe a diabetic’s untreated sleep apnoea, the poorer their glucose control. In addition between 30 and 40 percent of adults with high blood pressure also have sleep apnoea, which is even more prevalent in those with resistant hypertension. Approximately 80 percent of patients that do not respond to hypertensive medications have sleep apnoea.
There is a call from the Sleep Apnoea Trust that all HGV drivers, with suspected OSA, should be fast tracked as part of a good sleep service and about 40% of services offer this facility.
According to The British Thoracic Society (BTS) Impress document, oximetry alone can confirm severe OSAS but has significant rates of both false negatives and false positives, such that Respiratory PSG is now preferred as the primary investigation in many departments
Although PSG (Polysomnography) is thought to be the “Gold Standard” there are problems with it such as the first night effect and the high costs. New technologies are now available to perform an overnight Tier 3 study at home. These provide data on sleep architecture as well as respiratory parameters.
We should be refocusing our primary aim of looking at cerebral effects of hypoxia (hypersomnolence) when we know hypoxia has cardiovascular and metabolic effects on glucose metabolism? Extrapolating the effects of severe cerebral apnoea/hypoxia logically leads to the consideration that at least some patients with dementia maybe the consequence of severe recurrent and profound desaturations? The graphically stunning maps of disease produced by Steier et al( 1) should cause us to pause and think about disease prevalence and inter-relationships between OSA, diabetes ,hypertension, obesity and aging.
Although Mandibular Advancement Devices (MAD) are effective in selected patients they should be fitted properly by a specialist dentist embedded in an OSA service as there are long term risks of teeth moving and temporomandibular joint problems. Even edentulous patients can be fitted by a skilled dentist. We agree that post MAD sleep studies should be undertaken to prove efficacy.
There are several exciting areas of development in OSA. Key ones include its association with glaucoma and dementia.
References
1. Predicted relative prevalence estimates for obstructive sleep apnoea and the associated healthcare provision across the UK
Joerg Steier,1,2 Alistair Martin,3 Judy Harris,3 Ian Jarrold,3 Darien Pugh,4
Adrian Williams1,2
Thorax published online September 23, 2013
doi: 10.1136/thoraxjnl-2013-203887
2. NICE technology appraisal guidance 139 www.nice.org.uk/TA139
3. The estimated undiagnosed disease burden of obstructive sleep apnoea in West London glaucoma patients. Dr. T. E. Yap1, Dr. E. M. Normando2, Prof R Dhillon, Dr M Oko, Prof B Bloom, Prof. M. F. Cordeiro2 The European Glaucoma Society poster presentation 2013
Competing interests: No competing interests
How about Obstructive Sleep Apnoea in Pediatric Patients
When addressing Obstructive Sleep Apnea, we should at least highlight the dramatic difference in clinical scenarios between adult and pediatric patients(1). And for infants, I am afraid that suggestions made by this clinical review is hardly of any use. Children never snore as loudly as some adults do, and sleepiness questionnaires mentioned here are obviously irrelevant to their life.
As explained by this review, a narrow upper airway plays a central role in OSAS. Children especially infants have a disproportionately narrower upper airway than adults do. Their oral cavity is fully occupied by the tongue; the tonsils are often larger; the epiglottis sits much higher and is relatively bigger in size, with its lateral borders curling backward to the posterior wall of the pharynx; mucous is thick and overactive too. Their muscle tone is lower thus airway is more likely to collapse during sleep, causing obstruction. Furthermore, high metabolic needs require an infant to breathe several times as frequently as an adult does. Gastric reflux is very common and the resulting chemoreflex could pose some risk for apnea.
Prevalence of habitual snoring has been reported to increase with age from 6.6% at 1 years old to 13.0% at 4 years old (2). It has been related to health problems such as ADHD. However, it seems that very little information is provided here to help parents and general practitioners recognize and handle this situation.
1.Greenstone M, Hack M. Obstructive sleep apnoea. BMJ. 2014 Jun 17;348:g3745. doi: 10.1136/bmj.g3745. Review. PubMed PMID: 24939874.
2.Kuehni CE, Strippoli MP, Chauliac ES, Silverman M. Snoring in preschool children: prevalence, severity and risk factors. Eur Respir J. 2008 Feb;31(2):326-33. Epub 2007 Nov 21. PubMed PMID: 18032441
Competing interests: No competing interests