Sleep Service

Snoring is caused by a narrowing of the airway in the throat during sleep. Many of the body’s muscles relax during sleep but relaxation of the throat muscles can cause the breathing passages at the back of the tongue to narrow. 

This narrowing means the air struggles to find a way into the lungs and the flow of air causes vibration of the tissues in the throat, producing the snoring noise. With simple snoring, you will be perfectly fit and well, but obviously the noise can be a nuisance to others. This can put a strain on relationships. 

Some snorers describe a sore or dry throat in the morning but they will not normally have any other symptoms.

What is it?

Obstructive Sleep Apnoea (OSA) or Hypopnoea Syndrome (OSAHS) is a common condition in which there is repeated blockage of the airway in the throat. This causes repeated interruptions to the normal breathing pattern. If the tube between the lungs and the outside is blocked, breathing stops temporarily. If breathing stops for 10 seconds or more it is called an 'apnoea'. If breathing reduces but does not stop for 10 seconds or more it is called a ‘hypopnoea’.  

Fortunately, the brain has mechanisms to monitor the breathing pattern. If breathing stops, the brain responds by increasing muscle tone in the throat and the airway opens up again. Breathing is therefore safely restored, often with a loud snort as the airway pops open.

However, each episode of brain activation can disturb sleep and so repeated episodes of stopping breathing can seriously disrupt refreshing sleep and cause sleepiness the following day.  

What symptoms does OSA cause?

The characteristic symptoms of OSA are severe snoring and excessive daytime sleepiness. Bed-partners may notice the episodes of stopping breathing and notice how restless sleep becomes. They may notice a change in the person’s mood or personality. The person with OSA will notice sleepiness and poor concentration during the day and will not feel refreshed by sleep, regardless of how long they sleep. They may have morning headaches and occasionally may be aware of waking up in the night with difficulty breathing. 

Sometimes people complain of the need to pass urine frequently during the night. Most alarmingly, people with OSA can fall asleep in inappropriate circumstances, resulting in car accidents and accidents at work. Falling asleep and underperformance at work can cause problems with fellow workers and managers.  

In the longer term, there does seem to be an association between untreated OSA and heart disease and strokes, in the same way that high blood pressure and high cholesterol increases the risk of heart disease and strokes.

How common is OSA?

NICE (National Institute for Health and Clinical Excellence) estimates that OSA is present in about 2% of men between 18 and 34 years old, 4% of men over 34 years, 1% of women between 18 and 34 years and 2% of women over 34 years.  

This means that about 6,400 people will have OSA in the Wakefield area and about 7,200 people in the Kirklees area and about 4,400 people in Barnsley area.  

Obstructive sleep apnoea (OSA) is a common condition that can cause severe daytime sleepiness, increase the risk of accidents and cause relationship and employment problems. Even simple snoring can put a strain on a relationship. There is an effective treatment for OSA available on the NHS which is usually highly effective in reducing OSA symptoms. The treatment is called Continuous Positive Airway Pressure (CPAP).  

Read more about CPAP here 

If you have moderate or severe sleep apnoea, you will be offered a trial of CPAP therapy.  If you have mild sleep apnoea, CPAP may still be appropriate but alternative treatments including a dental appliance may be discussed.  

If you have simple snoring, a dental appliance may be discussed as potential treatments although you may choose to put up with the symptoms. Surgery is generally ineffective.  Losing weight can help.

PAP therapy

CPAP stands for Continuous Positive Airway Pressure. The idea is to apply pressure to the airway in the throat in order to keep it from collapsing. The patient wears a CPAP mask over the nose.

The mask is attached to a machine that blows air gently into their air passages, increasing the pressure in the airway, and stopping the collapse of the tube. CPAP is a very effective treatment and is usually successful in stopping the snoring, the irregular breathing and the daytime sleepiness associated with OSA. Most patients with OSA find the treatment effective and use their CPAP machine every night. Sometimes the benefits can be quite striking:

“I feel like a new man” – Alan, Barnsley

“Thank you for giving me my husband back” – Jane, Featherstone

“I wish I had done this years ago” – Judith, Ossett

CPAP is the only treatment proven to work for moderate or severe OSA and is recommended by NICE.

Mandibular advancement appliances

These dental appliances are like gum shields or mouth guards that sportsmen wear to protect their teeth. However, the top and bottom guards are joined together in such a way that when the device is in place, the lower jaw is pulled forward slightly. This pulls the tongue forward, and creates space behind the tongue.

The structures at the back of the throat are tightened a little and snoring and mild OSA usually improve. The appliances can be obtained over the counter, from some Dentists or via the Orthodontic service at the hospital. In general, the purpose-built appliances are more effective.

We provide a Sleep Service for the residents of Wakefield, Kirklees and Barnsley. Our main role is to assess people who have symptoms of Obstructive Sleep Apnoea (OSA), make an accurate diagnosis and advise on the treatments available. 

As well as OSA, we also deal with patients with other sleep conditions.
We provide a full range of sleep diagnostic tests for all types of sleep disorders

The Sleep service provides clinics at Dewsbury and District Hospital and Pontefract Hospital, with the more complex investigations and treatments carried out on the Pontefract site.  

We see about 1000 new referrals each year and have about 6,000 patients on CPAP therapy – the treatment of choice for moderate to severe OSA.

The Sleep service team is made up of the following staff:

Medical Team

• Dr Akshay Dwarakanath, Consultant
• Dr Sarah Boot Consultant

Physiology Team

• Amanda Peace-Witton, Highly Specialist Respiratory/Sleep Physiologist
• Samantha Pepper, Highly Specialist Respiratory Physiologist
• Sophie Booth, Specialist Physiologist

Sleep Nursing Team

• Lesley Earnshaw, Sleep Nurse
• Cheryl Smith, Sleep Nurse
• Corinne Ledgway, Sleep Nurse
• Beoley Oakley, Sleep Healthcare Assistant

We test your symptoms using different techniques such as:

Overnight oximetry

An oximeter is a simple device which measures oxygen levels in the blood. A probe is placed over the finger, and the pulse rate and oxygen level are displayed on a screen and recorded on a memory chip. We usually ask people to wear the device on their finger overnight. 

We download the information from the memory chip the following day and can see how the oxygen level has changed overnight. A normal result will have an oxygen level that is stable and above 92%. A recording from someone with OSA will show multiple dips in oxygen level with each dip relating to a period of stopping breathing (an apnoea). We accept up to 5 dips per hour as normal, 6 to 15 indicates mild Obstructive Sleep Apnoea (OSA), 16 to 30 indicates moderate OSA and above 30 indicates severe OSA.

A normal result does not mean OSA is impossible, but it does suggest that moderate or severe OSA is unlikely. We use this test often to identify if OSA is present, how severe it is and to monitor progress with treatment. It is usually done at home.

Tosca monitoring

A Tosca device is similar to a standard oximeter in that it measures oxygen levels overnight. The device is much more technologically advanced, however, and can also measure carbon dioxide levels in the body.

The probe usually attaches to the forehead or ear. It gets warm but is completely painless. This test allows us to assess whether the breathing muscles are working well during the night. Problems with the breathing muscles can lead to the person's breathing effort becoming more shallow than normal. This causes the carbon dioxide levels to rise, which the Tosca device will detect.

Overnight sleep study

This test can be done at home or in hospital. As well as measuring oxygen levels, this test involves measuring breathing directly. The patient wears a sensor under their nose that measures the air going in and out of their nose and mouth. They have straps on their chest and abdomen that measure breathing movements. A computer monitors and records the results. 

This test is a more accurate way of diagnosing OSA as it measures the apnoeas (episodes of stopping breathing) directly. We count up the number of apnoeas that occur every hour of sleep. We also count the number of hypopnoeas (episodes of nearly stopping breathing). This allows measurement of the apnoea hypopnoea index (AHI) which is an accurate measure of the severity of OSA. Once again, a normal result does not mean OSA is impossible but it is unlikely.

Polysomnography

This test is usually done for sleep disorders other than sleep apnoea. It is complex and difficult for both the patient and the tester, and the analysis of the results takes several hours. It is only done in hospital. 

As well as the measures for the overnight sleep study, electrodes are placed on the patient’s head which allow us to accurately assess whether the patient is asleep and what stage of sleep they are in.  

Multiple sleep latency test

This test is usually done on the day after a Polysomnography test. It is a test of sleepiness and allows us to see whether the subject will fall asleep when offered a bed during the day. The test takes all day. It helps in the diagnosis of sleep conditions other than OSA, such as narcolepsy.       

Below is an outline of the recommended way that a person who thinks they may have Obstructive Sleep Apnoea (OSA) can get access to the best treatment.

Thinking about the possibility that you may have OSA

The main features of OSA are bad snoring and daytime sleepiness. There is a simple questionnaire – the Epworth Sleepiness Scale – that can help you assess the level of your sleepiness. If you score more than 10 on the questionnaire and you snore heavily, OSA is possible and it would be reasonable to approach your GP for an opinion. 

Before coming to hospital

Your GP will ask you about your symptoms and form an impression as to possible causes of the symptoms. He or she may wish to do some simple blood tests to look for other causes of sleepiness such as anaemia or an underactive thyroid. If your GP thinks that OSA is possible, he or she will refer you to a Sleep service like the one at Mid Yorkshire.    

What will happen after referral to the sleep clinic?

Once we receive the referral, we will organise a test called Overnight oximetry, which records your oxygen level overnight. You will get an appointment to attend the hospital to pick up the device. You will be given information on how to use it and be asked to keep it on your finger overnight while you are asleep. We will also give you two questionnaires that help with our assessment. 

The first questionnaire is the Epworth Sleepiness Scale, and the second is a partner questionnaire which records your bed partner’s view of what happens during the night. This is in case he or she is unable to attend the Outpatient clinic appointment with you.   

The Outpatient appointment

The next step will be the Outpatient appointment itself, when you will be assessed by a sleep clinic Doctor, Sleep Physiologist or a Sleep Nurse. They will take a detailed history of your symptoms and any other medical conditions you may have. They will need a list of your medication so it would be helpful to bring a recent prescription with you. They will carry out a brief physical examination and look at the results of the overnight oximetry test, and the completed partner questionnaire if necessary. At the end of this assessment they should have a good idea whether you have OSA, simple snoring or an alternative explanation for your symptoms. 

Sometimes, further investigations are needed. These might include an Overnight sleep study, Polysomnography or a Multiple sleep latency test. Your symptoms may suggest the need to do other blood tests or other breathing tests.

Epworth Sleepiness Scale questionnaire

These dental appliances are like gum shields or mouth guards that sportsmen wear to protect their teeth. However, the top and bottom guards are joined together in such a way that when the device is in place, the lower jaw is pulled forward slightly. This pulls the tongue forward, and creates space behind the tongue. 

The structures at the back of the throat are tightened a little and snoring and mild OSA usually improve. The appliances can be obtained over the counter, from some Dentists or (if you have sleep apnoea) via the Orthodontic service at the hospital. In general, purpose-built appliances are more effective.

Useful links/support organisations

British Lung foundation  

American Academy of Sleep Medicine

National Institute of Health and Care Excellence (NICE)