Sleep disordered breathing (SDB) is an umbrella term for a group of conditions, such as sleep apnoea and upper airways resistance, that are characterised by an abnormal respiratory pattern during sleep. The lack of oxygen your body receives can have long-term negative consequences for health including high blood pressure, heart disease, stroke, pre-diabetes and diabetes, depression and increased mortality. Symptoms include loud snoring, pauses in breathing and disturbed sleep. Although most people with SDB do snore, not every snorer has SDB.
Sleep disordered breathing is known to be widely prevalent in the general population and contributes to a range of problems including poor work productivity, heart disease and road traffic accidents to name a few. Due to the negative impact on daytime alertness, concentration and increased healthcare utilisation, SDB is thought to have a significant economic burden.
There are many people with SDB who have not been diagnosed or received treatment. It is likely that whatever field of OT you are working in; you will encounter people with SDB. As OTs we have a key role to play in identifying patients who may be suffering from SDB, guiding them to seek formal assessment, and supporting them with their treatment.
- Increased neck circumference (17 inches or more)
- Craniofacial abnormalities (small airway, a set-back or small lower jaw, large tonsils, a large tongue, an abnormal face shape or nasal blockage)
- Male and middle aged
- Female and post menopausal
Types of Sleep Disordered Breathing:
Obstructive sleep apnoea (OSA)
Obstructive sleep apnoea is by far the most common breathing disorder of sleep. It is caused by partial or complete obstruction of the airway due to the muscles in the throat relaxing during sleep, narrowing the airway and reducing airflow. The upper airway in patients with OSA is often smaller than normal, possibly due to fat deposits in obese individuals or other structural factors, such as position of the jaw, airway length, enlarged tonsils or size of the tongue.
OSA is characterised by repetitive pauses in breathing of at least 10 seconds (termed an apnoea) or shallow breathing (termed a hypopnoea) during sleep, despite the effort to breathe. Not surprisingly apnoeas and hypopnoeas are often associated with oxygen desaturation and arousals as the brain prompts the body to start breathing again. Some people will wake up briefly, while others are not aware of what is happening. In cases of severe OSA, a person may repeat this cycle hundreds of times a night. These frequent arousals disrupt sleep, interrupt essential bodily processes that occur during normal sleep and often result in daytime somnolence (sleepiness).
Central sleep apnoea (CSA)
Central sleep apnoea, a less common form of sleep apnoea, is also characterised by apnoeas but these take place in the absence of any effort to breathe, usually due to the brain failing to transmit signals to breathing muscles.
Upper airway resistance syndrome (UARS)
Upper airway resistance syndrome is characterised by snoring with abnormal airway resistance in the upper airway. This does not lead to apnoeas or hypopnoeas, but instead results in arousals during sleep, secondary to the increased effort of breathing. As with sleep apnoea, repeated and multiple arousals (of which the person is usually unaware) result in abnormal sleep architecture and daytime somnolence.
Sleep disordered breathing is considered a chronic condition requiring long term treatment. Although treatment often involves Continuous Positive Airway Pressure, there are changes the individual can make to reduce the severity and sometimes alleviate the problem.
- Eliminate alcohol, caffeine, nicotine or sedatives for several hours before going to bed. This will improve the sleep quality and reduce inflammation that contributes to SDB
- Lose weight if you are overweight or obese
- Sleep on your side, rather than on your back (OSA is often worse when an individual is sleeping on their back)
Continuous Positive Airway Pressure (CPAP)
A CPAP device delivers pressurised air to the upper airway, via a mask, splinting the airway open to increase its size. CPAP is effective at improving sleep quality and reducing daytime sleepiness. Long term treatment with CPAP reduces mortality and the acute blood pressure elevation that occurs with SBD. Effectiveness is however dependent on nightly use of the CPAP and the duration of use in a night.
Oral appliances and surgery
Some individuals with OSA may be considered for an oral appliance instead of CPAP or even surgery, if their condition is severe and cannot be treated with CPAP. Some people prefer an oral appliance to CPAP however these are typically difficult to tolerate, due to fixing the jaw in an unnatural position during sleep. Long term use of over the counter oral appliances is not recommended firstly due to lack of evidence for their effectiveness in treating OSA and secondly due to likely negative impact on the jaw structure and integrity of the teeth.
Relevance to Occupational Therapists
A patient with sleep disordered breathing may or may not be aware that they have a problem. They will often present with elevated daytime somnolence (9 or above on the Epworth Sleepiness Scale) and are often aware that they snore, but not always. Frequently it is the bed partner that complains of the individual’s snoring, grunting or breath holding during sleep. Although SDB causes arousals, which disturb sleep quality, it will not necessarily cause awakenings that the individual is aware of. Sleep disordered breathing can have a profound impact on cognitive functioning, daytime sleepiness (to the extent that some individuals may fall asleep unintentionally when queuing in traffic whilst driving), quality of life, health conditions and mortality. There is no doubt that untreated SDB will have an impact on performance of activities of daily living.
The OT role in assessment
As Occupational Therapists sometimes we may be the first to find out about the symptoms of SDB through our functional assessments or our questions about daytime functioning, we then have an important role in screening for and identifying possible cases of SDB..
Questions to ask if you suspect SDB:
- Does this person fit into any of the high risk categories listed above?
- Do they complain of feeling sleepy during the day? Assess sleepiness using the Epworth Sleepiness Scale
- Do they snore?
- Do they have nocturia (urinating two or more times a night)? Sleep apnoea is linked with the production of the hormone atrial natriuretic peptide, which induces frequent need to urinate.
- Do they report waking gasping, choking or snorting?
- Has the bed partner ever observed them to hold their breath?
Please note that not all people with SDB experience all of these symptoms.
There are screening tools available to help identify people who may have SDB (some are described here on our Assessment page).
To be properly diagnosed with sleep disordered breathing, a patient must be evaluated by a polysomnography, which measures multiple physiological parameters during sleep. If you suspect that your patient may be suffering from sleep disordered breathing, please ask them to visit their GP for a referral to a sleep clinic that can assess and treat this condition.
The OT role in treatment
As an OT, we are in an optimal position to support people to deal with their sleep disordered breathing and its consequences i.e. daytime somnolence, poor sleep quality, cognitive impairment.
Adherence to treatment is a frequent problem in the treatment of sleep disordered breathing. For a number of reasons many patients find it hard to lose weight, change their sleeping pattern and/or use CPAP. For some patients, using a CPAP machine is a relief from the first night; their snoring is alleviated (which results in a happier bed partner), their sleep quality improves and they feel like a new person. In contrast, others may find CPAP inconvenient, noisy and even panic inducing. Some patients do not perceive any change or improvement to their sleep quality or how they feel during the day, despite CPAP treating their sleep apnoea effectively (i.e. their apnoea/hypopnoea index is reduced to under 5), for these individuals, adherence to treatment is likely to be low.
As Occupational Therapists, we have an opportunity to educate people about their condition so they can understand its purpose and are aware of the risk to their health if they choose not to do anything. It seems that sometimes, due to the time pressure on services, some new patients come away with a CPAP machine, but have very little understanding of why.
Smoking, drinking and being overweight make people more susceptible to/exacerbate SDB. As OTs we can use our skills in health promotion to support people to make healthy changes to their lifestyle.
Sleep position retraining
Many people have worse SDB when sleeping on their back. Some people with mild OSA overall, will have no sleep apnoea (AHI ≤5) when they sleep on their side. Making an individual aware of this and providing creative ways for them to retrain themselves to sleep on their side (through putting a pair of linked socks in the back of their pants for example) may be enough to prevent apnoeas.
For people whose sleep is being disturbed by arousals due to sleep disordered breathing, good sleep hygiene will ensure they optimise their chances of getting the best sleep they can, despite this. Factors such as a consistent sleep schedule, a sleep inducing environment, avoiding caffeine, alcohol and nicotine in the hours before bed, exercising daily, etc. are all important.
Coping with the day
Many patients with untreated SDB will experience daytime effects which may include low mood, daytime somnolence and difficulties with attention, memory and problem solving. Occupational Therapists can support the individual to find strategies that make coping with these easier. These may include developing an enjoyable daily routine, energy conservation techniques, deliberately scheduling a consistent brief nap time or memory techniques.
Overcoming fears and adjusting to CPAP
Many sleep clinics do not have the time to explore a person’s anxieties around using a CPAP machine and this adversely affects compliance to use it. Some individuals need time to express their concerns and need advice on how to adjust to CPAP. As OTs we are skilled in goal setting and using a graded approach to make activities achievable and motivating. Many of us also have insight into cognitive behavioural techniques such as thought analysis, behavioural experiments and motivational interviewing. We can use these skills to help a person slowly adapt to using CPAP. Establish what the person’s concerns are; is it the mask on the face, the straps around the head or the pressure of the air? Using a graded approach it may be that initially the individual may practice using CPAP during the day, holding the mask on their face for a few minutes, advancing to holding it with the machine turned on. Using the CPAP whilst watching TV can be a good way to learn to relax with it on, progressing on to using it for a daytime nap, and then eventually for night-time sleep.