Elsevier

The Lancet

Volume 383, Issue 9918, 22–28 February 2014, Pages 736-747
The Lancet

Seminar
Adult obstructive sleep apnoea

https://doi.org/10.1016/S0140-6736(13)60734-5Get rights and content

Summary

Obstructive sleep apnoea is an increasingly common disorder of repeated upper airway collapse during sleep, leading to oxygen desaturation and disrupted sleep. Features include snoring, witnessed apnoeas, and sleepiness. Pathogenesis varies; predisposing factors include small upper airway lumen, unstable respiratory control, low arousal threshold, small lung volume, and dysfunctional upper airway dilator muscles. Risk factors include obesity, male sex, age, menopause, fluid retention, adenotonsillar hypertrophy, and smoking. Obstructive sleep apnoea causes sleepiness, road traffic accidents, and probably systemic hypertension. It has also been linked to myocardial infarction, congestive heart failure, stroke, and diabetes mellitus though not definitively. Continuous positive airway pressure is the treatment of choice, with adherence of 60–70%. Bi-level positive airway pressure or adaptive servo-ventilation can be used for patients who are intolerant to continuous positive airway pressure. Other treatments include dental devices, surgery, and weight loss.

Introduction

Obstructive sleep apnoea is a common disorder of repetitive pharyngeal collapse during sleep.1 Pharyngeal collapse could be complete (causing apnoea) or partial (causing hypopnoea). Disturbances in gas exchange lead to oxygen desaturation, hypercapnia, and sleep fragmentation, which contribute to the consequences of obstructive sleep apnoea—eg, cardiovascular, metabolic, and neurocognitive effects. Although several treatments exist, they are often either poorly tolerated or only partially alleviate abnormalities. Thus, improvement of patient adherence to existing treatments and development of new treatments (or combinations of treatments) are needed. In view of the obesity pandemic, the propensity for pharyngeal collapse and therefore the number of cases of obstructive sleep apnoea are likely to rise.

The landmark study investigating the prevalence of obstructive sleep apnoea was the 1993 Wisconsin Sleep Cohort Study.2 This study reported that the prevalence of obstructive sleep apnoea—defined as more than five apnoeas or hypopnoeas per h of sleep plus excessive daytime sleepiness—was 4% in middle-aged men and 2% in middle-aged women (age 30–60 years). Subsequent studies suggest that prevalence in high-income countries is higher than previously reported (10% in women and 20% in men),3, 4 perhaps a result of worsening obesity and improving technology over time.5 Obstructive sleep apnoea is a global health problem; Brazil and several Asian countries have the same, if not higher, prevalence as the USA and Europe, despite less overall obesity.6, 7

Section snippets

Diagnosis and definitions

Patients with obstructive sleep apnoea report snoring, witnessed apnoeas, waking up with a choking sensation, and excessive sleepiness.1 Other common symptoms are non-restorative sleep, difficulty initiating or maintaining sleep, fatigue or tiredness, and morning headache.8 Indicators include a family history of the disease or physical attributes suggestive of obstructive sleep apnoea—eg, a small oropharyngeal airway or markers of obesity (eg, large neck circumference).9

The best test for

Pathophysiology and risk factors

Traditionally, obstructive sleep apnoea was considered to be primarily a problem of upper airway anatomy, where craniofacial structure or body fat decreased the size of the pharyngeal airway lumen, leading to an increased likelihood of pharyngeal collapse.21 During wakefulness, the airway is held open by the high activity of the numerous upper airway dilator muscles, but after the onset of sleep, when muscle activity is reduced, the airway collapses.22, 23 Although this sequence probably occurs

Consequences

Randomised trials have shown that obstructive sleep apnoea causes sleepiness based on significant improvements in symptoms with continuous positive airway pressure compared with controls.63 People with obstructive sleep apnoea are more likely to have motor vehicle accidents (perhaps up to seven-times as many as those without the disease64). This risk might be mitigated, at least in part, by treatment.65 Obstructive sleep apnoea also affects quality of life and different aspects of health

Management

Nasal continuous positive airway pressure is the treatment of choice for adults with obstructive sleep apnoea.98 It was first reported as an effective means of preventing collapse of the pharyngeal airway in 1981.99 The mechanism of continuous positive airway pressure is debated, but probably involves maintenance of a positive pharyngeal transmural pressure so that the intraluminal pressure exceeds the surrounding pressure.33 Continuous positive airway pressure also increases end-expiratory

Prevention

Although many risk factors for obstructive sleep apnoea are fixed, weight loss (though diet and exercise), and avoidance of cigarettes, alcohol, and other myorelaxant drugs can be beneficial.5, 86 Results of a randomised controlled trial5, 86 show that a 10 kg reduction in bodyweight can yield a reduction in apnoea–hypopnoea index of roughly five events per h. Obstructive sleep apnoea resolved in 63% of patients with mild disease, whereas only 13% of patients with severe obstructive sleep

Future directions

Future treatments for obstructive sleep apnoea are likely to be targeted to the cause of disease since the disease occurs for different reasons in different patients (figure 3). For patients with a low arousal threshold, sedatives or hypnotics might be useful, whereas for patients with unstable ventilatory control, oxygen or acetazolamide might improve obstructive sleep apnoea.28 Palate surgery will probably help patients with anatomical problems at the level of the velopharynx.141 For patients

References (141)

  • SB Montesi et al.

    Biomarkers of sleep apnea

    Chest

    (2012)
  • KA Ferguson et al.

    A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea

    Chest

    (1996)
  • CE Sullivan et al.

    Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares

    Lancet

    (1981)
  • T Young et al.

    The occurrence of sleep-disordered breathing among middle-aged adults

    N Engl J Med

    (1993)
  • E Sforza et al.

    Sex differences in obstructive sleep apnoea in an elderly French population

    Eur Respir J

    (2011)
  • PE Peppard et al.

    Increased prevalence of sleep-disordered breathing in adults

    Am J Epidemiol

    (2013)
  • GD Foster et al.

    A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study

    Arch Intern Med

    (2009)
  • SK Sharma et al.

    Epidemiology of adult obstructive sleep apnoea syndrome in India

    Indian J Med Res

    (2010)
  • RJ Davies et al.

    Neck circumference and other clinical features in the diagnosis of the obstructive sleep apnoea syndrome

    Thorax

    (1992)
  • WR Ruehland et al.

    The new AASM criteria for scoring hypopneas: impact on the apnea hypopnea index

    Sleep

    (2009)
  • MH Silber et al.

    The visual scoring of sleep in adults

    J Clin Sleep Med

    (2007)
  • MM Grigg-Damberger

    The AASM scoring manual four years later

    J Clin Sleep Med

    (2012)
  • GE Foster et al.

    Intermittent hypoxia increases arterial blood pressure in humans through a renin-angiotensin system-dependent mechanism

    Hypertension

    (2010)
  • K Stamatakis et al.

    Fasting glycemia in sleep disordered breathing: lowering the threshold on oxyhemoglobin desaturation

    Sleep

    (2008)
  • I Djonlagic et al.

    Increased sleep fragmentation leads to impaired off-line consolidation of motor memories in humans

    PLoS One

    (2012)
  • AT Mulgrew et al.

    Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study

    Ann Intern Med

    (2007)
  • CL Rosen et al.

    A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study

    Sleep

    (2012)
  • ST Kuna et al.

    Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea

    Am J Respir Crit Care Med

    (2011)
  • JF Masa et al.

    Therapeutic decision-making for sleep apnea and hypopnea syndrome using home respiratory polygraphy: a large multicentric study

    Am J Respir Crit Care Med

    (2011)
  • R Schwab et al.

    Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging

    Am J Respir Crit Care Med

    (2003)
  • WS Mezzanotte et al.

    Waking genioglossal EMG in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanisms)

    J Clin Invest

    (1992)
  • JP Saboisky et al.

    Potential therapeutic targets in obstructive sleep apnoea

    Expert Opin Ther Targets

    (2009)
  • A Wellman et al.

    Ventilatory control and airway anatomy in obstructive sleep apnea

    Am J Respir Crit Care Med

    (2004)
  • K Strohl et al.

    Mechanical properties of the upper airway

    Compr Physiol

    (2012)
  • MS Badr et al.

    Pharyngeal narrowing/occlusion during central sleep apnea

    J Appl Physiol

    (1995)
  • BA Edwards et al.

    Acetazolamide improves loop gain but not the other physiological traits causing obstructive sleep apnoea

    J Physiol

    (2012)
  • DJ Eckert et al.

    Eszopiclone increases the respiratory arousal threshold and lowers the apnoea/hypopnoea index in obstructive sleep apnoea patients with a low arousal threshold

    Clin Sci (Lond)

    (2011)
  • JA Dempsey et al.

    Pathophysiology of sleep apnea

    Physiol Rev

    (2010)
  • RC Heinzer et al.

    Trazodone increases arousal threshold in obstructive sleep apnoea

    Eur Respir J

    (2008)
  • RL Begle et al.

    Effect of lung inflation on pulmonary resistance during NREM sleep

    Am Rev Respir Dis

    (1990)
  • RL Owens et al.

    The influence of end-expiratory lung volume on measurements of pharyngeal collapsibility

    J Appl Physiol

    (2010)
  • RC Heinzer et al.

    Lung volume and continuous positive airway pressure requirements in obstructive sleep apnea

    Am J Respir Crit Care Med

    (2005)
  • WB Van de Graaff

    Thoracic influence on upper airway patency

    J Appl Physiol

    (1988)
  • M Younes et al.

    Chemical control stability in patients with obstructive sleep apnea

    Am J Respir Crit Care Med

    (2001)
  • R Ballard et al.

    Influence of sleep on lung volume in asthmatic patients and normal subjects

    J Appl Physiol

    (1990)
  • RL Owens et al.

    Upper airway collapsibility and patterns of flow limitation at constant end-expiratory lung volume

    J Appl Physiol

    (2012)
  • DL Stadler et al.

    Changes in lung volume and diaphragm muscle activity at sleep onset in obese obstructive sleep apnea patients vs. healthy-weight controls

    J Appl Physiol

    (2010)
  • A Malhotra et al.

    Obesity and the lung: 3. Obesity, respiration and intensive care

    Thorax

    (2008)
  • JP Saboisky et al.

    Functional role of neural injury in obstructive sleep apnea

    Front Neurol

    (2012)
  • AS Jordan et al.

    Airway dilator muscle activity and lung volume during stable breathing in obstructive sleep apnea

    Sleep

    (2009)
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