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When a snooze means problems

Dr. Joseph Yammine. (Photograph by Akil Simmons)

“Sleep,” said the old gentleman, “he’s always asleep. Goes on errands fast asleep, and snores as he waits at tables.”

“How very odd!” said Mr Pickwick, for Joe was constantly hungry, very red in the face and is always falling asleep in the middle of tasks.

Obesity hypoventilation syndrome, a condition closely related to sleep apnoea, was first called Pickwickian Syndrome. It is named after Dickens’s The Pickwick Papers because the novel features a character, Joe, who has all the classic signs of the condition: “The object that presented itself was a boy, a wonderfully fat boy, habited as a serving lad, standing upright on the mat, with his eyes closed as if in sleep.”

In 1956 a poker-playing businessman developed similar symptoms to Joe. People studying his condition named it Pickwickian Syndrome.

Here is a quote from the original study: “… on this crucial occasion, he was dealt a hand of three aces and two kings, a full house. Because he had dropped off to sleep he failed to take advantage of this opportunity. A few days later he entered … hospital.”

So, what is sleep apnoea?

It is a sleep disorder in which the person stops breathing for at least ten seconds each hour during sleep. There are two types of sleep apnoea: obstructive sleep apnoea and central sleep apnoea. In obstructive sleep apnoea, breathing is abnormal because of narrowing or closure of the throat. In central sleep apnoea, it is abnormal because of a neurologic change in the breathing control. This column focuses on the most common type of sleep apnoea in adults, obstructive sleep apnoea (OSA).

The symptoms of OSA are loud snoring, morning headaches, and daytime fatigue or sleepiness. It is evident that the consequence of OSA is an increased risk of car/bike accidents and errors in daily activities. Studies have shown that people with severe OSA are twice as likely to be involved in a motor vehicle accident as people without this condition. A rather sad but satirical quote was coined by the late comedian Bob Monkhouse: “I’d like to die like my old dad, peacefully in his sleep, not screaming like his passengers.”

In addition, people with untreated OSA may have an increased risk of cardiovascular problems such as high blood pressure, heart attack, abnormal rhythms, or stroke.

Approximately 25 per cent of adults are, to some degree, at risk for OSA in their lifetime; men more often than women. Obesity is the major factor for OSA development.

Tonsils enlargement can be an important cause, especially in children. Some patients have genetic predisposition.

The diagnosis of OSA is based upon the person’s medical history, examination, and a sleep study called polysomnogram. OSA is best treated by a sleep medicine specialist. The goal of treatment is to maintain an open airway during sleep. Below are some of the recommendations typically made:

• Continuous positive airway pressure or CPAP is the most effective treatment. It uses air pressure from a mechanical device to keep upper airways open during sleep. A CPAP machine uses an airtight attachment to the nose, typically a mask connected to a tube and a blower.

• Weight loss.

• Avoidance of alcohol and sedatives as they can worsen sleepiness, potentially increasing the risk of accidents or injury.

• An oral device or a “mandibular advancement appliance” can reposition the jaw (mandible), bringing the tongue and soft palate forward. While it is excellent for reducing snoring, its effect on OSA is more limited.

• Surgery is generally reserved for patients who cannot tolerate or do not improve with non-surgical treatments. It is successful in 50-60 per cent of patients only.

Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women’s Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients’ care recognition awards