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Occasional Review Obstructive Sleep Apnoea 754 4Thorax 1993;48:754-764 Occasional review Thorax: first published as 10.1136/thx.48.7.754 on 1 July 1993. Downloaded from Obstructive sleep apnoea Steven G McNamara, Ronald R Grunstein, Colin E Sullivan The last 20 years of respiratory medical prac- tion. While an apnoea is agreed upon as a tice have seen many changes. As other sub- cessation of breathing for 10 or more sec- specialties such as oncology, infectious onds,2 there is a wide range in the frequency diseases, allergy/immunology, intensive care, of such events during sleep; how this fre- and occupational medicine increasingly make quency (or "respiratory disturbance index") inroads into the traditional areas of respira- correlates with disease severity and incidence tory practice, new fields requiring the exper- continues to be debated.3 Most researchers tise of the respiratory physician have use a working definition of five apnoeas per developed. Arguably the dominant examples hour to define sleep disordered breathing2 but of these are disorders of breathing in sleep. this is by no means consistent in the litera- Until recently terms such as "REM sleep," ture. This definition was developed at a time "apnoea index," and "nasal CPAP" were for- when OSA was thought to be a rare disorder eign to most people working in respiratory and these arbitrary cut offs allowed medicine. The parallel development of meth- researchers to communicate in a common ods of measuring ventilation and blood gas "language"-an important consideration in levels non-invasively with the standardised reviewing any literature on this subject. As monitoring of sleep has led to a recognition OSA is increasingly recognised as a common that sleep disorders-particularly abnormal disorder such definitions need to be reconsid- breathing during sleep-are both causes and ered. contributors to a broad spectrum of clinical Most clinicians recognise OSA as a dis- morbidity and mortality. order characterised by repetitive apnoeas, http://thorax.bmj.com/ While researchers and clinicans working in loud snoring, and excessive daytime sleepi- the field agree on the importance of accurate ness. However, in OSA the patient is often diagnosis and appropriate treatment for the last to realise the extent of the mental and patients with sleep breathing disorders, there physical effects of the disorder. Recent stud- is considerable disparity in the availability of ies have shown that some forms of OSA may investigation and treatment for such patients occur without the presence of snoring4 or in different countries. In the USA it has been apnoea5 but with obvious clinical effects. estimated that there is more than one sleep Similarly, excessive daytime sleepiness may laboratory per 250 000 people; in Australia not occur but instead the clinical picture may on September 26, 2021 by guest. Protected copyright. there is at least one per 1 000 000, but in the mimic an anxiety state, especially in women.6 UK the ratio is much lower. While these dif- Adult criteria for OSA may also not be appro- ferences in the availability of facilities may priate in children.7 It is important that the reflect a variation in health care expenditure clinical definition of OSA is kept flexible. The or structure, it is likely that they also reflect a individual with one or two apnoeas per hour, divergence in the relative importance with oxygen desaturation to 60-70%, and which health planners and policy makers view impaired arousal reflexes due to autonomic disorders of breathing in sleep. To provide a neuropathy is far more vulnerable to the con- detailed review of recent advances in the sequences of their OSA8 than a healthy, David Read understanding of sleep and breathing dis- asymptomatic 75 year old with 15 apnoeas Laboratory, hour. The or health Department of orders requires a monograph.' The purpose per epidemiologist Medicine, University of this review is to assess some recent devel- administrator may wish for a more rigid defi- ofSydney and Sleep opments in the most common sleep breathing nition of OSA, but until we have a better Disorders Centre, understanding of the exact "dose" of OSA Department of disorder-obstructive sleep apnoea-with Respiratory Medicine, particular emphasis on recent data on diagno- that produces a specific "clinical effect" it is Royal Prince Alfred sis, prevalence, predisposing factors, clinical better to avoid such rigidity. Hospital, and treatment in the adult patient. Camperdown, Sydney sequelae, 2006, Australia EPIDEMIOLOGY S G McNamara Epidemiological studies in OSA fall into three RR Grunstein categories: firstly, studies based solely on C E Sullivan Diagnosis and prevalence questionnaire data about habitual snoring, or Reprint requests to: Dr R Grunstein, WHAT IS OBSTRUCTIVE SLEEP APNOEA? a history of witnessed apnoeas, or both; sec- Department of Clinical One of the key problems in recognising the ondly, studies in which questionnaires are Pharmacology, Sahlgrens University Hospital, importance of obstructive sleep apnoea validated by full polysomnographic sleep Gothenburg 41345, Sweden (OSA) is the lack of a clearly agreed defini- studies or nocturnal respiration monitoring in Obstructive sleep apnoea 755 Recent epidemiological studies in obstuctive sleep apnoea Study n Age (y) type Prevalence Comment Reference Gislason, Sweden 3201 30-69 B 0-7-1-9% Men only 9 Cirignotta, Italy 1510 30-69 B 2-7% (RDI >10) RDI >10, men only 10 Thorax: first published as 10.1136/thx.48.7.754 on 1 July 1993. Downloaded from Stradling, UK 893 35-65 C 5% (men) Oximeter dips per hour >5 11 Bearpark, Australia 400 40-65 C 10% men, 7% women MESAM 4 recorder 12 calculated RDI >10 Young, USA 263 30-60 C 7-8% men, 2-3% women RDI >10 on full sleep 13 studies Jennum, Denmark 1504 30-60 B 10-9% men and Inductive plethysmography 14 6-3% women to screen 50% of study had RDI >5 population RDI-respiratory disturbance index (events/hour); study type B-questionnaire with full sleep studies in a subgroup of sleep apnoea positive replies; study type C-overnight screening or sleep studies in entire group. a random or selected subpopulation; finally, ter understanding of the relationship between studies where all or most patients undergo sleep apnoea and clinical effects. Even a con- full sleep studies or nocturnal respiratory servative view of the more recent OSA epi- monitoring. In the past five years studies of demiological studies, however, would suggest the latter two types (some ongoing) have a potentially huge investigative and thera- shown that OSA is a common finding (table) peutic load for health care systems. but there is a wide range (1-9%) in the reported prevalence of OSA.9'4 These differ- SYMPTOMS AND HISTORY TAKING: CAN ences may reflect disparity in methodologies, CLINICAL ASSESSMENT PREDICT SLEEP population differences in obesity and alcohol APNOEA? consumption, or even genetic variability. For If OSA is as common as epidemiological evi- example, the percentage of the population dence suggests, it is important that simple with heavy snoring doubles when the bed methods of diagnosis are available. Obviously partner contributes to the questionnaire (fig the simplest potential method of diagnosis 1)."1 Some questionnaire data also do not would be by history and physical examina- seem to correlate highly with actual respira- tion. The symptoms associated with OSA are tory monitoring. The high prevalence in some many and varied and may include nocturnal studies does not correspond with a high fre- choking attacks, morning headaches, gastro- http://thorax.bmj.com/ quency of such symptoms as hypersomno- oesophageal reflux, nocturia, impotence, poor lence. For example, Jennum and Soul'4 memory and concentration, and alteration in reported that 10-9% of men aged 30-60 years mood.'6 However, those considered to be had OSA (more than five apnoeas/hour) but "key" or "major" symptoms are snoring, only 1-9% complained of hypersomnolence. apnoeas witnessed by bed partners, and In our own epidemiological studies in excessive daytime somnolence.'6 Busselton, a Western Australian rural com- The predictive power of these key symp- munity,'2 10% of men aged 40-65 years had toms has been examined in an Australian on September 26, 2021 by guest. Protected copyright. more than 10 apnoeas per hour. This study study.'7 Apnoeas observed by a bed partner, used a well validated ambulatory monitoring with a lesser contribution from coexisting system (the MESAM 4 recorder)'5 which hypertension, body mass index, and age, pro- measures oxygen saturation, snoring, heart duce a predictive model with high sensitivity rate, and body position. It is important, how- but only moderate specificity. Other workers'8 ever, to confirm whether this high prevalence have found that these "key symptoms" is accompanied by a high prevalence of symp- explained only 36% of the variability in tomatology and clinical consequences. It is apnoea index. The authors suggested that the clear that epidemiological information will presence of key symptoms did not obviate the need to be more sophisticated to allow a bet- need for a properly performed diagnostic sleep study. Additional data provided by such measurements as neck circumference may Figure I Increase in Do you snore or have you been told you help predict OSA, but not to the extent of frequency of "often do? replacing sleep studies."9 snoring" reported ifwife is The nature of these symptoms also empha- actually present at interview wnth subject. sises the importance of obtaining a history Adapted from reference 11 from the spouse, bed partner, and other fam- with permission. ily members in the proper assessment of the patient with OSA. Unless they are told few, if any, patients are aware that they snore or stop breathing during sleep, yet this concerns many bed partners to the point where they initiate the medical review.
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