Sleep Disordered Breathing (SDB) – how is it diagnosed?
Sleep disordered breathing continues to be poorly screened, diagnosed and managed – how is it diagnosed?
Sleep Disordered Breathing (SDB)
Sleep disordered breathing encompasses snoring, obstructive sleep apnea (OSA) and UARS which will be described later. Although snoring is considered a joke by some it is far from benign and should be treated that way.
To illustrate the widespread ignorance, those third-party (insurance) carriers who potentially cover treatment of OSA / SDB refuse to cover any snoring management as well as OSA if it doesn’t reach a certain score – despite it’s known risks of increased mortality and morbidity.
How is OSA or SDB measured?
There are likely several tests and questions that you will be asked and undergo if you have symptoms of snoring, obstructive sleep apnea (OSA) and UARS. The first thing is screening.
Just like blood pressure and other screening tools, everyone should be asked at check-ups (doctor or dentist) if they snore or have been seen “breath holding at night”, those are pretty basic questions in the initial screening.
Although not frequently performed, at the doctor’s office, any past experience of cardio-vascular disease (stroke, hear attack, atrial fibrillation) indicates that a screening MUST be done.
In the case of children, ADHD like symptoms is another ‘red flag’ – when adults don’t get enough sleep they compensate but appear tired, when children don’t get adequate sleep they become overly active and show signs of not being able to “fit in” with the situation at that time.
At the dentist’s office, just like a regular cancer and gum disease screening, signs of tooth wear of jaw pain or dysfunction (temporomandibular disorder – TMD), is another ‘red flag’ from which a screening should be made.
Do you have signs of SDB or OSA?
If there are signs or symptoms of OSA / SDB in the screening, the next step is to complete a short questionnaire covering the very basics of indication likelihood.
Such questionnaires are generally not ideal and frankly inadequate in some cases but worth while as false negatives are unusual. Just because there is a low score despite screening showing a likelihood, indicates that the questionnaires may have been inadequate for you. Tests include, STOP-BANG, Epworth Sleepiness Score (ESS), Berlin, etc.
What tests should be done for OSA or SDB?
If after this, there is reason to proceed with testing, there are 4 common tests that might be suggested.
They are called level 1,2,3 and 4. Level 4 testing is commonly performed but limited in value due to the limited information recorded.
Level 3 is considered to be the ideal ‘home test’ it is relatively easy to attach by the patient, can be relatively accurate and can provide adequate information to make a likely diagnosis. Level 2 is rarely done due to potential difficulties to the patient f a sensor comes off as they are at home.
Level 1 testing is performed overnight in a “Sleep Clinic” and requires sensors on the head, neck, chest and ankle. These are usually attached and watched by same-sex sleep technicians.
What do SDB / OSA test results mean?
Primarily the test is to show if, when and how frequently a limitation or cessation of breathing occurs (these are called ‘events’).
Measurement is arbitrarily grouped as mild ( 5-15 events per hour), mild (15-30 events per hour), or severe (30+ events per hour). Snoring can also be registered as this also indicates an obstruction.
Level 1 testing in a sleep clinic can be used to find other sleep disorders too. An indication of body position is very important and usually not available in a level 4 situation, such a sensor may show obstruction only when on your back and management may therefore be completely different.
What is UARS (Upper Airway Resistance Syndrome and Central Sleep Apnea?
As well as obstructive sleep apnea (in which the obstruction is frequently behind the tongue (remember the back of the tongue is the front of the airway, the back of the airway is the spine) there is a disorder called, “central sleep apnea” which is basically when your brain doesn’t give the message to breath.
UARS, or Upper Airway Resistance Syndrome was mentioned earlier. Until about 10 years ago those doctors that knew what SDB was, were unaware of this disorder and vigorously disputed its existence. Why?
Well a few years ago, and alas to most still, people with OSA / SDB are male, overweight, heavy set, unfit and snore. From experience this is not the case at all. Young female, even athletic looking, females who are slim, also get OSA / SDB and while it is thought that the reasons (pathophysiology) is different, the results are pretty much the same.
The problem is that a lot of these sufferers are ignored at screening because, “how could they have obstructive sleep apnea?”
What will happen if I’ve got OSA or SDB?
So, what happens if I have SDB or one of its categories? Well it all depends on how bad it is, what your symptoms are (most people have a problem adhering to advice even if very serious – if they’re not having any symptoms) when you get these events and what the actual sleep disorder is.
(You can have more than one, for instance many people with OSA / SDB also have insomnia, the most common sleep disorder. OSA / SDB is the second most common.) These should be discussed with someone with training in this area.
Unfortunately, in the UK, US and Canada this is not a regulated discipline and consequently it is “buyer beware” – second opinions are useful but being knowledgeable and forearmed is best.
The History of OSA / SDB.
OSA has been termed the Pickwickian syndrome, and clinically known as obesity hypoventilation syndrome (OHS), after Charles Dickens (an astute observer of man) described one of his characters as having it.
Joe from the 1836 Charles Dickens novel, ‘The Pickwick Papers’, had many of the symptoms later described by clinicians when they discovered the condition of OSA such as obesity, lack of energy, snoring, constantly eating and falling almost on his feet.
The term is generally ascribed to William Osler the famous Canadian physician although it was not until Pierre Robin recognised the benefit of moving the lower jaw forwards in children so affected with a deficient lower jaw that the case started to be made for oral appliances.
It was Colin Sullivan who developed the first Continuous Positive Airway Pressure which acted as a “pneumatic stent” to open the airway, as an oral appliance to hold the lower jaw forward may be considered a “mechanical stent” both are examples of OSA and SDB management.
Who can diagnose sleep disorders?
Here’s the rub. Only a physician can diagnose sleep disordered breathing disorders. Many alas either don’t have the time or knowledge to screen , diagnose, treat or manage. Consequently, (in Canada as well as some other countries) the patient is referred to a commercial concern. As such, many are there to sell an approach to management.
DENTISTS CANNOT DIAGNOSE SDB.
They can screen and refer to a sleep physician, they can follow up with management, but they are not allowed by law to diagnose. To do so is a cvil offence, categorised as ‘practicing medicine without a licence’.
Do I have treatment options?
Now you know what to look for, what the problem is and how it’s measured to give a diagnosis, alas, outside in the real world you will often not be provided any information, or worse still only that based on “provider profitability”.
Dr Stephen Bray 2019