Sleep apnoea:Finnish Nationalguidelines for prevention and ... · of hospital days was12803 in...

Vol.97 (2003) 337^365

Sleep apnoea: Finnish National guidelines forprevention and treatment 2002^2012L.A.LAITINEN,*U. ANTTALAINEN

w, A. PIETINALHOz, P.H%M%L%INEN

}, K. KOSKELAz

AND

THE EXPERTADVISORYGROUP LISTED INFOREWORD

*Hospital District of Helsinki and Uusimaa, Finland, wTurku University Central Hospital,Turku, Finland, zFinnish LungHealth Association, Sibeliuksenkatu, Helsinki, Finland, }Ministry of Social A¡airs and Health, Finland

INTRODUCTIONThis national programme of obstructive sleep apnoeadeals with the prevention and treatment of the disease.The term‘‘sleep apnoea’’ is used to refer to an illness thatresults in daytime symptoms because of abnormal cessa-tions of respiration during sleep.There are other formsof sleep disorders but they are referred in this pro-gramme only in connection with di¡erential diagnosis.

According to Finnish population studies, the Health2000 survey by the National Public Health Institute (Ar-omaa et al., 2002) and the register of hospital treatmentperiods (HILMO) of Finnish National Research and De-velopment Centre for Welfare and Health (Stakes), ap-proximately 150 000 Finnish patients su¡er from sleepapnoea.Up to 3% of middle-aged men and 2% of middle-aged women have the illness in Finland. The number ofpatients with sleep apnoea and other sleep disorders isunderestimated by diagnosis and is increasing. The stu-dies on the prevalence of sleep apnoea in other countrieshave ¢gures from 0.8% (Gleadhilletal.,1991) to10% (Bear-parket al.,1995).

Obesity is themost importantrisk factor for sleep ap-noea.The main target of prevention and treatment is toachieve lower weight and weight control. Other treat-mentmethods of sleep apnoea, particularly nasal contin-uous positive air pressure (n-CPAP) treatment, areindividually initiated by specialist care.The main respon-sibility for helping patients in reducing weight and weightcontrol will be in public health care.

The national programme has the following goals: (1) adecrease in the incidence of sleep apnoea; (2) full recov-ery of as many sleep apnoea patients as possible; (3)maintenance of good functional and working ability ofsleep apnoea patients; (4) a decrease in the number ofpatients with severe sleep apnoea; (5) a decrease in thenumber of sleep apnoea patients requiring hospitalisa-tion; and (6) an improvement in the cost^ e¡ect ratio of

Received 8 August 2002, accepted in revised form 8 Aaugusst 2002Correspondence shouldbe addressed to: Dr Anne Pietinalho,MD,PhD,Chief Physician, Finnish Lung Health Association, Sibeliuksenkatu11A,FIN-00250 Helsinki, Finland.Fax.: +358-9-45421210;E-mail: anne.pietinalho@¢lha.¢

sleep apnoea treatment. The most important measurestowards achieving these goals include: (1) stepping upprevention of obesity and promoting weight reductionand weightcontrol; (2) ensuring children’s nasalbreathingand intensifying the removal of obstructive adenoid tis-sue; (3) steeping up treatment of malocclusions and de-viations in maxillomandibular growth in children; (4)increasing key group’s knowledge of risk factors of sleepapnoea and the treatment of the disease; (5) stepping upearly diagnostics and active treatment; (6) initiating earlyindividual rehabilitation as part of the treatment; and (7)emphasising the importance of research.

The implementation of this national programme isvital. Regional direction and training will mainly beorganized by hospital districts and/or provincial govern-ments and local health-care centres. Special attentionmustbe paid on the evaluation of the success of sleep ap-noea prevention and treatment. Both special follow-upstudies by Finnish Lung Health Association and popula-tion studies by the National Public Health Institute aswell as HILMO by Stakes will be used in the evaluationof the programme.

FOREWORDSleep apnoea is a disease a¡ecting approximately150 000Finns. Untreated sleep apnoea not only leads to an in-crease in mortality, the number of accidents, and the in-cidence of cardiovascular diseases, but also reducesworking and functioning capacity, and undermines thequality of life. The signi¢cance of the problem in termsof national health and economy, the increasing patientnumbers, the knowledge of improved possibilities forpreventing and treating the disease, and the need forlarge-scale collaboration create the foundation for a na-tional prevention programme.

After reaching an agreement with the Finnish Ministryof Social A¡airs and Health, the Finnish Lung Health As-sociation appointed a working group to prepare a pro-gramme for the prevention and treatment of sleepapnoea for a10-year period from 2002 to 2012. Professorand Managing Director Lauri A. Laitinen from theHospital District of Helsinki and Uusimaa was elected

338 RESPIRATORYMEDICINE

chairman of the working group. The other memberswere Docent Antti Ahonen from Helsinki UniversityCentral Hospital, Jukka Antila (MD) PhD fromTurku Uni-versity Central Hospital, Jaakko Herrala (MD) PhD fromTampere University Hospital, Docent Raimo Isoahofrom Turku University, Turkka Kirjavainen (MD) PhD,Docent Paula Maasilta and Docent Pertti Mustajokifrom Helsinki University Central Hospital, DocentMarkku Partinen from Haaga Neurological ResearchCentre (NEURO),Professor Olli Polo fromTurku Univer-sity, Docent Tapani Salmi from Helsinki University Cen-tral Hospital, and Kimmo VNhNtalo (Specialist inDentistry) fromTurku University Central Hospital.

At ¢rst, PNivi HNmNlNinen (MD) PhD from the provin-cial government of Western Finland served as the secre-tary of the working group. She was succeeded by UllaAnttalainen (MD) fromTurku University Central Hospi-tal and Anne Pietinalho (MD) PhD from the Finnish LungHealth Association.Professor Kaj Koskela, the SecretaryGeneral of the Finnish Lung Health Association, also par-ticipated in the work of the working group.The expertsconsulted during the process were Kimmo LehtimNkiDSc (Dental Sience) and Docent Heli Vinkka-Puhakkafrom Tampere University Central Hospital and JuhaMarkkula (Specialist in Psychiatry) from the sleep work-ing group of Turku University Central Hospital.

Statements about the programme have been made by—land Central Hospital, South Karelia Central Hospital,the provincial government of Southern Finland, HelsinkiUniversity Central Hospital, the Pulmonary AssociationHELI, Jorvi Hospital, the National Public Health Institute,Kanta-HNme Pulmonary Society, Kuopio UniversityHospital, Lohja Hospital, the provincial government ofWestern Finland, Mikkeli Central Hospital,Oulu Univer-sity Hospital, North Karelia Hospital District, PNijNt-HNme Central Hospital, Satakunta Central Hospital, Sa-vonlinna Central Hospital, SeinNjoki Central Hospital,Stakes, the Finnish Medical Society Duodecim, the Fin-nish Dental Association, the Association of Finnish Pul-monary Physicians, the Finnish Society of ClinicalPhysiology, the Finnish Paediatric Association, the Fin-nish Medical Association, the Finnish Neurological So-ciety, the Association of Finnish Otolaryngologists, theFinnish Sleep Research Society,Tampere University Hos-

TABLE 1. De¢nitions relating to sleep apnoea

Term De¢nition

Apnoea Acomplete interruption iObstructive apnoea Arespiratory interruptioCentral apnoea Arespiratory interruptioMixed apnoea Arespiratory interruptioHypopnoea Decreasedrespiratory ai

pital, the Union of Health and Social Care Professionals,Turku Pulmonary Association, Turku University CentralHospital, Turku University Institute of Clinical Medicineand the Finnish Sleep Federation.

The national programme is a recommendation to beapplied to the prevention and treatment of sleep apnoeathroughout the ¢eld of health care. The programmeshould be revised when necessary as medical knowledgeincreases and the equipment and medical treatments de-velop. The patient and the health-care professional andunit treating him are responsible for the actual treat-ment. The programme is based on numerous study re-sults, reports and practical experience. Detailedreferences to published material are not given in thetext, but examples of key literature have been gatheredin an Appendix.

The Ministry of Social A¡airs and Health hopes thatthe programme will become a practical tool in the pre-vention of sleep apnoea.

Markku LehtoPermanent Secretary

SLEEPAPNOEAASANILLNESS

De¢nitions

Occasional short-term interruptions in breathing occurduring normal sleep. If the episodes are long-term or fre-quent and result in symptoms during waking hours, thecondition can be de¢ned as sleep apnoea. In literature,the terms sleep apnoea syndrome or sleep apnoea illnessare also used. In this programme, the term sleep apnoeais used to refer to an illness with abnormal respiratoryinterruptions during sleep.

Various forms of sleep apnoea and the associatedterms are explained inTable 1.The events of obstructiveapnoea are described in Appendix 1. This programmedeals with the prophylaxis and treatment of obstructivesleep apnoea. Reference to other sleep disorders is onlymade in connection with di¡erential diagnosis.

The de¢nitions of sleep apnoea combine the symp-toms of the patient and the ¢ndings from various testmethods. Table 2 shows the diagnostic criteria of sleepapnoea in adults suitable for clinical work. Special

nrespiratory air £owlastingZ10 snwhereno air £owis detected despite respiratorye¡ortnwithoutrespiratorye¡ortnthat is a combination of obstructive and central sleep apnoear £ow

TABLE 2. Diagnostic criteria of sleep apnoea (mild sleep apnoea A+B+C, moderate-to-severe+D)

(A) Symptomsinclude abnormal daytime fatigue or restless sleep.The patientdoesnot alwaysrecognise the symptoms.(B) Recordedrecurrentrespiratory interruptions during sleep.(C) Othercharacteristic features:1.Snoring, especially intermittent2. Morningheadaches3.Dryness ofmouth onwaking4.In children, paradoxalbreathingduring sleep

(D) More than ¢ve apnoea episodes orone ormore ofthe following ¢ndings recorded in sleep registration:1. Recurrent arousals after apnoea episodes2. Cyclicalvariation inpulse rate3. Decrease in arterial oxygen saturation after apnoea episodes4. Deviating sleep latency in MSLT test

(E) Maybe connected to other illnesses, e.g. large tonsils and adenoids(F) Other sleep disordersmaybe included, e.g. restless legs ornarcolepsy

Source: International Classi¢cation of Sleep Disorders,Diagnostic and Coding Manual,American Academyof Sleep Medicine2001, revised.

TABLE 3. Degrees of severityin sleep apnoea

� Mild sleep apnoea a: AHI 5^15/h, mild symptoms� Moderate sleep apnoea: AHI16^30/h, moderate symptoms� Severe sleep apnoea: AHI4 30/h, severe symptoms

aIn children agedunder12months, theresults are deviatingif AHIZ1/h.In adults agedover 70 years, theresults are deviatingif AHI415/h.

Possible sleep apnoea

Snoring

Respiratory interruptions(AHI>5)

Daytime fatiguePartialupper airways

obstructionof

Sleep anpnoea

FIG. 1. Relationship of respiratory interruptions, daytime fati-gue and snoring to sleep apnoea.

SLEEPAPNOEA 339

features of sleep apnoea in children are discussedin the chapter ‘‘Special features of sleep apnoea in chil-dren’’.

Degrees of severity

The degree of severity is de¢ned on thebasis of the num-ber of respiratory disruptions [apnoea-hypopnoea indexAHI] and the severity of daytime symptoms. The AHIshows how many episodes of apnoea and hypopnoeahave been detected during 1h of sleep. In practice, theevaluation of the severity of sleep apnoea (Table 3) iscomplicated by the fact that the number of respiratorydisruptions and the decrease in oxygen saturation mea-sured by pulse oxymeter are not always directly propor-tional to the patient’s symptoms.

Symptoms

The primary symptoms of sleep apnoea are respi-ratory interruptions. Primary symptoms also includeabnormal daytime fatigue, which may be manifested as atendency to doze o¡, a lack of concentration, or animpairment of memory function. Snoring may be the

¢rst sign of incipient obstruction of the airways.Snoring associated with sleep apnoea is generallyhabitual snoring, i.e. regular snoring occurringalmost every night. The relationship of the symptomsto sleep apnoea is presented in Fig. 1 and the symp-toms of sleep apnoea inTable 4.The evaluation of the se-verity of the symptoms is explained in Appendix 2. Thespecial features of sleep apnoea in children are discussedin the chapter ‘‘Special features of sleep apnoea in chil-dren’’.

TABLE 4. Symptoms of sleep apnoea

Symptomswhile awake� Daytime fatigue� Morningheadaches� Tendency to doze o¡� Impairedmemory function� Impaired concentration� Mood changes, shorttemper, irritability� Impotence, impaired libido� Heartburn

Symptoms while asleep� Loud snoring� Respiratory interruptions reported by the sleeping

partner� Restless sleep� Night-time perspiration� Increasedneed to urinate during the night� Heartburn

Severe 15,000 High costs

Moderate 50,000 Moderate costs

Mild 85,000Low costs

FIG 2. An estimate of the number of patients with sleep ap-noea and the related costs based onthe incidence ¢gures in Fin-land.

0

1,000

20001990 1991 1992 1993 1994 1995 1996 1997 1998 1999

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Sleep apnoea

Snoring

FIG. 3. Number of patients diagnosed with sleep apnoea orsnoringadmitted for treatmentper annum (Stakes,HILMO).


Prevalence

Sleep apnoea is a common illness occurring in up to 3% ofmiddle-aged men and 2% of middle-aged women in Fin-land. It is feared that the incidence of the illness will con-tinue to rise with the increasing obesity of thepopulation. A typical patient with sleep apnoea is a manover 35 years of age or a postmenopausal woman. Atleast 0.3% of all adult men below retirement age su¡erfrom moderate-to-severe sleep apnoea. The illness alsooccurs in women. The incidence of sleep apnoea peaksamong men aged 50^59 years (Appendix 3).

Respiratory disruptions during sleep are common inthe elderly even though they do not snore as often asthe middle aged. Of people aged over 65 years, one infour has an apnoea index of more than10. However, thenumber of thosewith symptomatic sleep apnoea is loweramong the elderly than among middle-aged men, esti-mated at 0.5^1%.

In the extensive Health 2000 survey, carried out on10 000 subjects aged over18 years by the National PublicHealth Institute, approx. 7% of the Finns (approx.13% ofmen and approx. 3% of women) reported having experi-enced weekly sleep disruptions, and approx.1% (approx.2% of men and under 0.5% of women) reported havingbeen diagnosed with sleep apnoea.

The incidence of sleep apnoea in 5-year-old children inFinland is estimated to be approx. 2%.The evaluation ofthe incidence of sleep apnoea in children is complicatedby the fact that, in children, the illness is partly relatedto the amount of adenoid tissue in the throat, and theincidence of the illness may £uctuate at di¡erent ages.Studies conducted outside Finland indicate that, amongchildren aged 4^6 years, 7^10% snore, and among chil-dren aged 0.5^6 years, 2^3% su¡er from sleep apnoea.

No di¡erence in the incidence of sleep apnoea with re-gard to sex has been found among children, even thoughboys snore slightly more than girls.

Figure 2 shows an estimate of the sleep apnoea statusin Finland. According to the HILMO register of Stakes,6645 patients were diagnosed with sleep apnoea; thenumber of treatment periods was 8993; and the numberof hospital days was 12 803 in 2000. Treatment durationaveraged 1.4 days. In 2000, 2908 patients were hospita-lised for snoring, and the number of treatment days was3582 (Figure 3). The halt in the rise in patient numbersand treatment days was not caused by a reduction inthe incidence or alleviation of the illness, but rather bythe fact that sleep registration follow-ups requiringmany hospital days have been reduced by increasing out-patient activity.

The number of continuous positive airway pressure(CPAP) devices used for the treatment of sleep apnoeahas been rising steadily in the 1990s. The number con-tinues to rise. In 2000, there were approx. 150 users ofCPAP devices per 100 000 inhabitants in Finland. These¢gures re£ect the number of diagnosed cases of moder-ate-to-severe sleep apnoea. Figure 4 shows the regionaldi¡erences in 2000 for the hospital districts (68^598/100 000).

Apart from sleep apnoea, partial upper airways ob-struction also involving increased respiratory resistance

6005004003002001000

Hospitals district of Helsinki and UusimaaVarsinais-Suomi

SatakuntaKanta-Häme

PirkanmaaPäijät-Häme

KymenlaaksoSouth Karelia

South SavolaxEast Savolax

North KareliaNorth Savolax

Central FinlandSouth Ostrobothnia

VaasaCentral Ostrobothnia

North OstrobothniaKainuu

West OstrobothniaLapland

Åland

FIG. 4. Number of CPAP-treated patients per100 000 inhabi-tants perhospital district in 2000.

TABLE 5. Anatomical factors predisposing to sleep ap-noea

1.Nose� Oedema ofthe nasalmucosa� Deviatednasal septum� Nasalpolyps� Large adenoids

2.Pharynx� Anatomicallynarrowpharynx� Increased adipose tissue ofthe upper respiratory tract� Large tongue� Large tonsils� Enlarged soft palate

3.Jaw and face� Micrognathia� Jawlocated farther backwithrespectto the skull thannormal

� Narrowupper jaw� Long face, longlower face

4.Body� Central obesity, thickness of neck

SLEEPAPNOEA 341

but no clear respiratory interruptions should be consid-ered. Its precise incidence is still not known.

CAUSESANDRISKFACTORSThe development of upper airways obstruction causingsleep apnoea is in£uencedby the physiologyof sleep (Ap-pendix1), and factors relating to anatomy and physiology(Tables 5 and 6).

CONSEQUENTEFFECTSThe qualityof life, the alertness, and the functional abilityof a patient su¡ering from sleep apnoea are impaired byfatigue, concentration di⁄culties, mood changes and im-paired libido. Cardiovascular symptoms in sleep apnoeapatientsrelate to hypoxia andincreasedblood CO2 levelsduring sleep, an increase in nocturnal respiratory e¡ort,and an increase in sympathetic nervous activity (Table 7).Sleep apnoea causes vasoconstriction and elevates bothsystemic and pulmonary blood pressure.

SPECIALFEATURESOF SLEEPAPNOEAINCHILDRENThe most important risk factors of sleep apnoea in chil-dren are enlarged adenoids and tonsils. Moreover, sleepapnoea is more common in children su¡ering from var-ious syndromes or mental retardation than in childrenin general. However, sleep apnoea is rare during infancy,except in children with an apparent life-threateningevent (ALTE), up to 50% of whom su¡er from sleep ap-noea. Mental retardation and the various syndromes inchildren are associated with an increased disposition tosleep apnoea. Removal of hyperplastic adenoid massmay cure sleep apnoea in a child. If surgical interventions

are unsuccessful,CPAP treatment is an option to be con-sidered.Obesity and thickness of neck in a child increasethe occurrence of sleep apnoea.

Sleep apnoea in children may also result from mandib-ular deviation and malocclusion in childhood. About 20^25% of children and adolescents have malocclusionswhere the anterior growth of the mandible is not paral-lel with the growth of the other facial parts. Nasal con-gestion, large adenoid tissue mass and oral breathinghave an unfavourable e¡ect on facial bone growth. Chil-dren su¡ering from these problems develop a facialstructure where the growth of the mandible is directeddown rather than frontally. The face does not grow indepth, and the airways do not gain enough space. Ade-noid tissue surgery and orthodontics are used to guidemaxillomandibular growth and occlusion developmentto the right direction.

Daytime fatigue or obesity are not typical symptomsin paediatric sleep apnoea, except in a very severe condi-tion. In children, sleep apnoea causes restless sleep, snor-ing, sweating, recurrent upper respiratory tractinfections, hyperactivity, impaired concentration, learn-ing di⁄culties, and oral breathing. In severe sleep ap-noea, serious cardiovascular complications, for example,have been reported.

GOALSANDMEANSOF THEPROGRAMMEThe goals for the prevention, treatment and rehabilita-tion of sleep apnoea for 2002^2012 are presented in Table

TABLE 6. Physiological factors impairing sleep apnoea

1.Nose andpharynx� Temporaryoedema ofthe nasalmucosa� Decreasedmuscle tone inthe pharyngealregion� Snoring� Infections ofthe upper respiratory tract

2.Respiration-related factors� Diminishedrespiratoryresponse to a decrease in blood oxygen saturation� Diminishedrespiratoryresponse to an increase in blood CO2 levels� Otherdisturbances in respiratoryregulation� Diminishedrespiratoryoutput� Poormobilityof the bony thorax� Impaired function of respiratorymuscles

3.Factors decreasingmuscle tension and depressing CNS function� Alcohol� CNS depressants� Sleep deprivation

TABLE 7. Long-termconsequente¡ects of sleep apnoea

� Impaired functional andworkingability, impaired qualityof life

� Accidents intra⁄c and attheworkplace� Aggravation of cardiovasculardiseases� Increasedriskof cerebral ischaemic attacks� Aggravation ofmentalproblems� Increasedmortality

TABLE 8. The goals for the prevention, treatment andrehabilitation of sleep apnoea

1.Decrease in the incidence of sleep apnoea2.Full recoveryof asmany sleep apnoea patients aspossible

3.Maintenance of good functional andworkingabilityofsleep apnoea patients

4.Decrease inthe numberof patientswith severe sleepapnoea

5.Decrease in thenumberof sleep apnoea patients requir-inghospitalisation

6.Improvement in the cost^e¡ect ratio of sleepapnoea treatment


8 and discussed in more detail later. Table 9 shows themeans of achieving these goals.

PREVENTIONOFSLEEPAPNOEAANDITSCONSEQUENCES

Possibilities of prevention

The risk of developing sleep apnoea may be reduced byin£uencing the behaviour of the individual concerned,by facilitating good treatment of the predisposing ill-nesses (primary prevention) and also by improving theearly detection of sleep apnoea and the motivation ofthe patient with regard to his own treatment (secondaryprevention).Good treatment of sleep apnoea, rehabilita-tion and therapy of concomitant illnesses may help re-duce the individual handicap caused by the illness(tertiary prevention).

The basis for the prevention comprises both individual(risk groups) and national interventions (Tables10^12).

The improvements in the standard of living haveresulted in changes in the society and in lifestyles thatpredispose to obesity. Nationwide prevention of obesity

requires interventions at di¡erent levels of society tofurther reduce the dietary intake of fat and to increasethe physical activity of the population.

This means limiting the energy content of food, devel-opment of school and workplace canteen food, nutritionand exercise guidance, development of light tra⁄c, ex-tensive education and cooperation as well as research.

Persistent upper respiratory tract infections andother factors complicating nasal breathing, such as largeadenoids and tonsils, allergyor irritation due to poor am-bient air, predispose to the development of sleep apnoeaas early as in childhood. In£uenza, haemophilus andpneumococcal vaccines are used to counteract infec-tions. At national level, reminding people aboutthe importance of hand washing can reduce the conta-giousness of respiratory infections.Good hygiene in day-care centres has also been found to reduce infections inchildren.

TABLE 9. Means of achieving the goals of the sleep apnoea programme

1.Steppingup prevention of obesity andpromotingweightreduction andweightcontrol2.Ensuringchildren’s nasal breathingand intensifying the removal of obstructive adenoid tissue3.Steppinguptreatmentofmalocclusions and deviations inmaxillomandibular growth in children4.Increasingkeygroupknowledge ofthe risk factors of sleep apnoea and the treatmentofthe disease5.Steppingup earlydiagnostics and active treatment6.Initiating individualrehabilitation earlyon as partofthe treatment7.Emphasising the importance of research

TABLE 10. Preventing the development of sleepapnoea (primaryprevention)

� Maintainingnormalweight� Ensuringnasal andrespiratory tract function� Removingenlarged adenoid tissue� Initiatingearly treatmentofmalocclusions� Abstaining from smokingandreducing the use ofalcohol

� Reducing the use of CNS depressants

TABLE 11. Earlydetectionandtreatmentof sleepapnoea(secondaryprevention)

� Weightreduction andweightcontrol� Elimination of factors causingnasal congestion� Regularday/night rhythm� Consideringriskgroups inprimaryhealth care� Earlydiagnosis of sleep apnoea� Goodinitial treatment, motivating the patientwithregard to his owntreatment

TABLE 12. Preventing the aggravation of sleep apnoea(tertiaryprevention)

� Weightreduction andweightcontrol� Good treatmentof concomitant illnesses� Rehabilitation

SLEEPAPNOEA 343

Oral breathing guides maxillomandibular growth andocclusion development in an unfavourable direction. Asa result, the anatomy of the upper respiratory tract de-velops to increase the risk of sleep apnoea. Rheumatoidarthritis, particularly juvenile RA or other rare illnessessuch as acromegaly and hypothyroidism in£uence the de-velopment of jaw size and position. Early detection andtreatment of these illnesses is a part of the preventionof sleep apnoea.

Smokers have been found to have more respiratory in-terruptions than non-smokers. The di¡erence is elimi-nated with the cessation of smoking. Giving up smokingreduces the tendency to snore as the incidence of re-spiratory tract infections and mucosal membrane oede-ma of the airways decreases. The elimination of carbonmonoxide from the blood results in more e¡ective noc-turnal oxygenation. The cessation of smoking often re-sults in weight gain and, therefore, concomitant supportwith weight control is needed.The consensus treatmentrecommendation on abstinence from smoking to be is-sued by the Finnish Medical Society Duodecim in 2002will provide tools for guidance and treatment.

Alcohol decreases muscle tone in the nasopharynxand impairs the function of the CNS regulatory mechan-isms. Excessive use of alcohol and heavy drinking are thecommonest promoters of the risk factors of sleep ap-noea. Alcohol also causes weight gain, increases centralobesity and visceral fat. A person with risk factors ofsleep apnoea should be instructed to avoid excessive useof alcohol.

CNS depressants impair sleep apnoea. Decreased useof these agents would reduce the risk of sleep apnoea inthe population. Misuse of CNS depressants should betackled. The history of snoring should be recorded andrisk patients considered when prescribing the medica-tion.

Prevention of sequelae

Once sleep apnoea has been diagnosed, the treatmentshould be directed at the factors causing sleep apnoeain each individual case. Successful treatment of sleep ap-noea removes daytime fatigue and improves the qualityof life.

Eighteen per cent of the fatal road tra⁄c accidents ex-aminedby theroad tra⁄c investigation teams are causedby fatigue or falling asleep at the wheel. It is estimatedthat people with untreated sleep apnoea are at a 6^7-fold risk of having an accident compared to the rest ofthe population. Controlled asymptomatic sleep apnoeadoes not a¡ect driving. The risk in tra⁄c caused by se-


vere sleep apnoea is considered so high that, in caseswhen the treatment is not e¡ective or the patient is re-luctant to undergo treatment, the driving licence autho-rities should be noti¢ed. According to current Finnishlegislation, a written consent from the patient is alwaysneeded for this. When issuing medical certi¢cates fordriving licences, doctors should be able to refer all pa-tients with symptoms or anatomy suggestive of sleep ap-noea to further evaluations. The application of thesleepiness questionnaire in Appendix 2 could be a practi-cal tool. If thepatient’s score is11or higher, specialist con-sultation should be considered. The questionnaire canalso be applied to age group check-ups in occupationalhealth care.

A professional driver with untreated sleep apnoeashould be urgently referred to the initiation of the treat-ment and, if necessary, sick leave should be considereduntil the treatment can be initiated.

The treatmentof sleep apnoea reduces elevatedbloodpressure. If a patient with sleep apnoea su¡ers from hy-pertension and the illness is not properly treated, treat-ment should be organised. On the other hand, whenrefractory hypertension is detected, the potential roleof sleep apnoea should be considered.

Outof sleep apnoea, asthma and COPD, one is not thecause of the other. However, these illnesses are so com-mon that there are patients with concomitant sleep ap-noea and asthma, or sleep apnoea and COPD, or allthree. Untreated asthma or COPD further impair theoxygen uptake in a patient with sleep apnoea. Allergicsymptoms often related to asthma hamper nasal breath-ing. Proper treatment of asthma, allergies and COPD al-leviates the severity of sleep apnoea.

DIAGNOSISOF SLEEPAPNOEA

Diagnosis of sleep apnoea

When sleep apnoea is suspected, the ¢rst thing to do isto establish whether the patient’s symptoms indicatesleep apnoea and whether further evaluation of this diag-nosis is of primary importance. The patient may su¡erfrom another illness causing fatigue or health hazards,the further evaluations of which should be initiated priorto or simultaneously with the evaluation for sleep ap-noea. At the second phase, the objective is to con¢rmor exclude sleep apnoea and evaluate the severity of thediagnosed illness. The phases of sleep apnoea diagnosisare shown in Fig. 5, with more details inTable13 and Ap-pendixes 2, 4^8.

Basic evaluations: establishing sleep apnoeasuspicion and the riskof sleep apnoea

The most important tool in the evaluation is the record-ing of patienthistoryusing a questionnaire on symptoms.

The illness develops slowly, and the patient may considerthe symptoms to be part of his personality without iden-tifying them. A sleepiness questionnaire is used to collectinformation on the severity of the symptoms (e.g. ES-S=Epworth Sleepiness Scale, Appendix 2).Central symp-toms, risks and concomitant illnesses are establishedwhen recording the history and, in connection with aphysical examination, attention is paid to the general ap-pearance, body mass index (BMI) (Appendix 4) and theblood pressure of the patient, as well as nasal, pharyn-geal and facial structure (Table13).

If the symptoms, ¢ndings and risk factors primarilysuggest (1) health problems other than sleep apnoea (de-pression, hypothyroidism, diabetes) or (2) risk factors ofsleep apnoea or, at most, mild sleep apnoea, further eva-luations, symptoms follow-up, health education and pa-tient guidance in accordance with the problem will beimplemented within primary health care. Should the¢ndings suggest moderate or severe sleep apnoea,further evaluations will be performed in specialist care.Appendix 5 shows a checklist for a GP/occupationalhealth physician for referrals to sleep apnoea evaluations.The referral will be directed in accordance with the allo-cated duties to an outpatient unit specialising in sleepevaluation, most often an outpatient department of pul-monary diseases at present.

Specialist evaluations anddiagnosticmethods

If an obese patient has typical indications of sleep ap-noea, the diagnosis is primarilymade on thebasis of sleepregistration.The need for other examinations is de¢nedindividually. As a general rule, sleep apnoea evaluationsare complemented by an ENT specialist consultation.This is necessary in order to ¢nd the patients who wouldbene¢t from surgical treatment.The purpose of the con-sultation is also to assure nasal breathing with regard topotential CPAP treatment. If the structural deviations ofthe face are distinct, evaluations by a maxillofacial sur-geon and a specialist in orthodontics on the deviationsare included. Appendix 6 lists examples of situationswhen consultation with a specialist from outside the spe-cialty concerned should be considered. Diagnostic eva-luations of patients under 15 years of age are arrangedby paediatric units.For patients under 2 years of age, ex-tensive sleep registration is always recommended. Table14 shows the specialist tools for the evaluation of sleepapnoea.

Limited sleep registration monitors airways patency,respiratory resistance, movements of the chest and legsand changes in oxygen saturation measuredbypulseoxy-meter expressed as ODI (¢gure describing falls in oxygensaturation during sleep). Extensive sleep registration isthe most expensive form of sleep registration. Apart

SUSPECTED SLEEP APNOEA

- The person personally suspects that he has symptoms of sleep apnoea

- Health check reveals history or constitution suggestive of sleep apnoea

- The attending doctor or dentist is alerted by suspicion of sleep apnoea

in connection with other treatment

EVALUATIONS WITHIN PRIMARY AND OCCUPATIONAL HEALTH CARE

- Mapping of symptoms

- Mapping of risk factors

- Establishing the use of alcohol, drugs and smoking

- Physical examination

- Laboratory and x-ray examinations

EVALUATIONS WITHIN SPECIALIST HEALTH CARE

- Complementary history and physical examination by a specialist

- Sleep recording (limited/extensive if needed)

- Complementary laboratory and x-ray examinations

- Consultation of an ENT specialist

- Consultation of an oral and maxillofacial surgeon and an orthodontist

- Other consultations as necessary

- Differential diagnosis

FIG 5. Diagnosis of sleep apnoea.

SLEEPAPNOEA 345

from other changes during sleep, it is used to monitorthe di¡erent phases of sleep with the help of electroen-cephalography (EEG) (Appendix 7). Extensive evaluationis necessary in special cases even though the diagnosiscan normally be con¢rmed by limited sleep registration(Table 15). The unit performing the evaluation gives aclear report on the results, including information aboutthe diagnostic methods as well as the quantitative re-sults. Being able to relate the results from the registra-tion to the symptoms of the patient is necessary.

Di¡erential diagnostics

Daytime fatigue also has causes other than sleep apnoea.With regard to di¡erential diagnosis, the most commoncauses of daytime fatigue are listed inTable16.

Alternatives for the di¡erential diagnosis of sleep ap-noea in children are shown inTable17.

CHAINOF TREATMENTPatients with sleep apnoea are encountered at all levelsof the health-care chain both in primary and occupa-tional health care and in specialist health care (Table18).The prevention, treatment andrehabilitation of sleep ap-noea include many tasks that are implemented outsidethe health centre and hospital system. Patient organisa-tions have a central role, but themunicipal social servicesand exercise departments as well as the private sectorparticipate in o¡ering services suitable for patients withsleep apnoea. The prevention, treatment and follow-upof sleep apnoea are a joint e¡ort of all these sectors.

The tasks of primary health care are the prevention ofsleep apnoea, the treatment of patients with mild-to-moderate sleep apnoea as agreed in cooperation withspecialist health care, and the treatment of concomitantillnesses.The tasks of specialist health care are con¢rm-ing the sleep apnoea diagnosis, drafting a plan for thetreatment and rehabilitation of the illness, initiating

TABLE 13. Tools of primary and occupationalhealth care forcon¢rming sleep apnoea suspicion

Tools Symptoms and ¢ndings indicative of sleep apnoea

1.Historyof symptoms � Symptomswhile awake� Symptomswhile asleep

2.Knowledge of risk factors � Beingmale� Beingmiddle aged orpostmenopausal� Weightgain� Allergic rhinitis� Otherconcomitant illnesses� Snoring

3.Historyof intoxicantuse � Use of alcohol� Use of CNS depressants� Smoking

4.Questionnaire on symptoms � E.g.ESS (Appendix 2)

5.Bodymass index (BMI) � Appendix 4

6.General status � Central obesity and thickness of neck� Signs of other predisposing illnesses, such as� hypothyroidism, arthritis, acromegaly,� kyphoscoliosis

7. Anatomyofthe upper respiratory tract � Anatomicallynarrownose� Polyps� Large tongue� Long soft palate, large uvula

8.Jaw and face � Small jaws, maxillaryormandibular retrusion� Domedpro¢le� Longlower face� Deviatingocclusion

9.X-ray and laboratory tests � Appendix 5


CPAP treatment, implementing other specialist health-care measures and supporting primary health care in im-plementing further treatment and follow-up as agreed.

The instruments designed for the diagnosis and treat-ment of sleep apnoea have become simpler. With sup-port from specialist health care, it is possible to screenthe patients with sleep apnoea primarily within primaryhealth care.Problematic cases shouldbe referred to spe-cialist treatment. A self-regulating CPAP device adjuststhe pressure level automatically to comply with the pa-tient’s needs, rendering admissions to hospital for pres-sure titrations redundant. The device records deviatingrespiratory events and the actual duration of use.

As the number of sleep apnoea patients receivingtreatment increases, the taskofmonitoring sleep apnoeawill be increasingly directed to primary health care withspecialist consultations in problematic cases when neces-

sary. Active treatment chains require (1) agreement be-tween the di¡erent levels of health care, (2) education ofprimary health care and (3) research.

The treatmentchain and the treatment lines shouldbeadjusted regionally due to varying patient numbers, ar-rangements for cooperation and treatment opportu-nities. Appendix 9 shows an example of the treatmentlines within primary health care.

TREATMENT

Goals andmethods

The aim of the treatment of sleep apnoea is to eliminatethe respiratory interruptions. If this succeeds, the treat-ment is curative. Even if the respiratory interruptionsare not entirely eliminated, they can be controlled by

TABLE 14. Tools of specialisedhealth care forcon¢rming sleep apnoea

Basic evaluations in specialisedhealth care� Patienthistory and clinical examination� Consulting other specialties on a case-by-case basis� Sleep registration (limited orextensive, if needed)� Symptomquestionnaires

Furtherevaluations (whenneeded)� Flow volume spirometry� Arterial blood oxygen saturation� Complementary X-ray and laboratory tests� Cephalometric sleep apnoea X-rayevaluation� Nasal function evaluations� Fibroscopyofthe upper respiratory tract

Special tests for evaluating the patient’sworkingand functional ability� Multiple sleep latency test (MSLT)� Maintenance of wakefulness test (MWT)� Driving simulationtest

TABLE 15. Symptoms and ¢ndings a¡ecting the choice of sleep registrationmethods

� Highlyprobable sleep apnoea onthe basis of symptoms and ¢ndings-; limited sleep registration oronenightwith a self-regulating CPAP device and oxymeter

� Snoringpatient lacking other symptoms suggesting sleep apnoea- limited sleep registration (upon consideration)

� Probable sleep apnoea onthe basis of symptoms and ¢ndings- limited sleep registration

� Possiblyother than sleep apnoea, atypical symptoms and ¢ndings- extensive sleep registration

� Results fromextensive sleep registration are unclear, orno treatmentresults are reached despite good treatmentcompliance-extensive sleep registration

SLEEPAPNOEA 347

various treatment methods so that the patient feelscured. It can also be presumed that the risks derivingfrom an untreated illness are avoided.Table19 shows thegoals of the treatment of sleep apnoea. A summary ofthe di¡erent treatment methods is presented in Table20. Central factors in choosing the mode of treatmentare the cause of the respiratory obstruction and the se-verity of the disease.

Conservative treatment

Weight reduction and weight control

Weight reduction as a treatment of sleep apnoea is ofprimary importance for all obese patients with sleep ap-noea. A treatment programme for obesity is initiated ifthe patient is at least signi¢cantly overweight (BMIZ30kg/m2). In the range of slight overweight (BMI 25^29.9 kg/m2), weight reduction is necessary if the patient

su¡ers from central obesity (waist circumference490 cm in women and 4100 cm in men).

The objective of the treatment in adults is permanentweight loss of 5^10%.The target weightdoes not need tobe the normal weight, which is usually an unrealistic ob-jective for severely obese patients.Obese people tend tocontinue gaining weight and, particularly in cases ofslight overweight, arresting the accumulation of weightis already a signi¢cant initial result. The treatment ofobesity is mainly implemented within primary healthcare. Severe, pathological obesity that is associated withsleep apnoea and requires weight reduction can be trea-ted within specialist care.

Weight control after weight reduction requires per-manently lowered energy intake and/or greater energyconsumption than prior to the weight reduction. Thetreatment of obesity includes expert guidance in perma-nent life-style changes. The Medical Society Duodecimhas published a consensus treatment recommendation

TABLE 16. Other conditions thatcan cause daytimefatigue

Sleep disorders� Insu⁄cient sleep� Insomnia� Restless legs� Narcolepsy^cataplexy� Sleep^waking schedule disorders� Chronic fatigue syndrome� Idiopathic hypersomnia� Psychiatric reasons� Otherdisorders

Other illnesses� Depression (Appendix 8)� Hypothyroidism� Anaemia� Diabetes� Epilepsy� Cerebral disorders� Musculardisorders� Dementia� Adverse e¡ects ofmedical treatment� Pulmonaryhypoxia� Chronic infections� Vasculitis

TABLE 17. Alternatives fordi¡erential diagnosis of sleepapnoea in children

� Stenosis of the airways� Laryngomalacia� Asthma� Gastro-oesophagealre£ux� Nocturnal epileptic seizures� Restless legs� Narcolepsy� Central sleep apnoea


for adult obesity in 2002.Table 21shows methods for thetreatment of obesity. Appendix10 describes the contentof basic care and brief guidance.

Position therapy

Most patients snore less when they lie on their side. At-taching a tennis ball to the back of the nightgown mayprevent supine sleeping, or various cushions or supportscan be placed under the back. Position treatment canhelp patients with mild sleep apnoea but motivating pa-tients to adopt this mode of treatment is problematic.

The long-term bene¢ts of this treatment have not beenestablished.

Medicines

Several di¡erent medicines have been used in the treat-mentof sleep apnoea but, in repeated controlled studies,none of them has proved more e⁄cient than placebo.Progesterone derivatives have yielded the best results.New medicines are being developed, but their introduc-tion to the market may take years. Sleep apnoea may beassociated with depression, which must be treated ap-propriately using modern antidepressants. If sleepapnoea is associated with severe obesity, pharmacother-apy may be considered. There are two medicines, orlis-tate and sibutramide, for this. If the patient su¡ers frommoderate-to-severe sleep apnoea, his BMI is 432 kg/m2

and a loss of weight of at least 4 kg has been reachedprior to the initiation of pharmacotherapy in an 8-weekdieting programme, the Social Insurance Institution cangrant basic reimbursability for an anorexigenic medicineon the basis of Medical Statement B.

Devices in£uencing the position ofthe mandible and thetongue, and orthodontic treatment

There are various devices in£uencing the position of thetongue and the mandible. Devices preventing the retrac-tion of the tongue or devices that protrude the mandiblecan be placed in the mouth. These devices help preventsnoring in particular. The device may present a solutionfor patients with problematic snoring without elevatedapnoea indices, and for patients with mild sleep apnoea.The bene¢ts of the device are evaluated by sleep regis-tration.

Orthodontic treatment plays a role in the preventionof sleep apnoea in children. In adults, orthodontic treat-ment is an essential part of the surgical treatment of themandible.

Continuous positive airway pressure treatment

The principle of CPAP treatment is to create positive air-way pressure, an ‘‘air splint’’, using a nasal mask and anair-blowing device, thereby counteracting the collapseof the airways. It in£uences thewidening of the upper re-spiratory tract also indirectly by increasing the residualvolume of the lungs.

CPAP treatment can be o¡ered to patients with diag-nosed sleep apnoea. CPAP treatment has been found tocorrect respiratory disturbances during sleep. It is theprimary mode of treatment in severe sleep apnoea andin some cases of moderate sleep apnoea, keeping the im-portance of weight control in mind. The indications ofCPAP treatment are shown inTable 22.There are no ac-tual contraindications to CPAP treatment, but not all

TABLE 18. Treatmentchain of a patientwith sleep apnoea

Tasks of primaryhealth care:1.Prevention2.Con¢rmingand treatingproblemsin occlusion andmaxillomandibular position3.Con¢rming suspected sleep apnoea, basicevaluations, andreferring the patientto specialisedhealth care for further examina-tions

4.Treatment and follow-up ofmild-to-moderate sleep apnoea as agreed5.Basic treatmentof obesity and brief instruction (mini-intervention)6.Treatmentof concomitant illnesses7.Providingdevices services in compliancewith provincial collaborationprocedures8.O¡ering guidance inmatters relating to illness and social security9.Organising rehabilitation services

Tasks of units providing specialised health services1.Con¢rming sleep apnoea diagnosis2.Drafting and implementing treatment andrehabilitationplans3.Designing, adapting and initiatingdevice treatment4.Deliveringdevices, o¡ering guidance and organising adaptationtherapy5.Monitoring the status of bothpatient and instruments in collaborationwith primaryhealth care6.Surgicalprocedures7.Treatmentof extreme or severe obesity8.Comprehensive evaluation of workingability, and evaluation ofthe need foroccupationalrehabilitation9.Diagnosis, treatment and follow-up of problematic cases10.Designingprovincial treatmentchains and developing the qualityof services in collaborationwith primaryhealth care

Tasks of other service providers1.Organisingrehabilitation services (SII, associations andrehabilitation institutes)2. Supporting the patient’s social skills, organisinghealth education (associations)3.Supportingweight reduction andweightcontrol (associations, pharmacies)4.Promoting exercise (associations, municipalities)5.Promotinga supportperson system (associations)6.Device development (business life)

TABLE 19. Objectives for the treatmentof sleep apnoea

� Curing sleep apnoea� Maintainingworkingand functional ability� Improving the qualityof life� Preventingand treating concomitant illnesses� Preventing the aggravation of sleep apnoea

SLEEPAPNOEA 349

patients adapt to the treatment. Some conditions causemore problems than usual in connection with CPAPtreatment and can be considered relative contraindica-tions (Table 23).

In order for CPAP treatment to be e¡ective, it shouldbe used at least ¢ve nights a week, 3^4 h/night. Thetreatment does not cure the illness. CPAP treatment isinitiated at a health-care unit with su⁄cient facilities.Once the correct pressure level (usually 5^15 cmH2O)has been attained, sleep is usually normal and there

should no longer be any abnormal arousals. After the in-itiation, the patient takes the device home for a trial of afew weeks, after which the treatment success is evalu-ated.Once the CPAP treatment has been successfully in-itiated and the patient has been instructed in the use ofthe device, the treatment canbe monitored on an annualbasis. Follow-up visits may be arranged as appointmentswith a nurse or a rehabilitation instructor trained forthe follow-up. The treatment device will be inspectedand serviced at the follow-up visits. Should it be foundduring the follow-up visit that the overall situation ofthe patient has changed or the patient has other healthproblems, he will be referred to a doctor. The aim is toarrange the follow-up preferably within primary healthcare.

Over 90% of the sleep apnoea patients using the CPAPdevice feel that they have obtained bene¢t from thetreatment. Most adverse e¡ects of CPAP treatment areminor. Problems arise in 30^50% of the patients, butthey do not usually result in the discontinuation of thetreatment if the patient feels that the symptoms have

TABLE 20. Treatmentmethods of sleep apnoea

Methods for the treatment ofmild sleep apnoea� Weightreduction andweightcontrol� Medical treatment improvingnasal breathing� Surgical treatment improvingnasal breathing� Devices a¡ecting the position ofthe tongue and themandible� Discontinuing smoking� Refraining fromthe use of CNS depressants andparticularly sleepingmedicines� Positiontherapy� Good treatmentof concomitant illnesses

Additionalmethods for the treatment ofmoderate-to-severe sleep apnoea� Hyperbaric breathing throughthe nose (nasal CPAP)� Oral andmaxillofacial surgery� Uvulopalatopharyngoplasty� Treatmentof obesitywithmedicines and operations� Tracheostomy

All patients with sleep apnoea� Adaptationtherapy andrehabilitation

TABLE 21. Methods for the treatmentof obesity

Method When can it be used?

Brief instruction (mini-intervention) As awayofmotivating the patientorwhenbasic treatmentcannot be provided

Basic treatment of obesityGuidance inchanging thewayof life,10^20 visits,usually in groups

Primaryoptionused in connectionwith all othermethods.Suitable for all.

Extremelylow-calorie diet in connection withbasic treatment

Generally when BMIisZ 35 kg/m2.Optionalwhen BMIis30^34.9 kg/m2 Onlyexceptionally when BMIis 25^29.9 kg/m2

and basic treatmenthas failed

Anorexigenic medicines (orlistate, sibutramine) Basic treatmenthas failed and BMIisZ 30 kg/m2

Surgical treatment For selected and treatment-compliant patientswhen BMIisZ40 kg/m2 and other treatmentmethodshave failed


alleviated. The commonest problems are due to irrita-tion of the nasal mucosa. Severe adverse e¡ects relatingto CPAP treatment are quite rare.The problems of CPAPtreatment and the treatments of CPAP-related nasalsymptoms are described inTables 24 and 25.

Poor treatment compliance is predicted byprevious corrective surgery of the pharynx anda mild illness with few symptoms. If the patient does notadapt to CPAP treatment, it is important to make sure

that other forms of treatment and follow-up will con-tinue.

Surgicalmodes of treatment

The objective of surgical treatment of sleep apnoea is towiden the airways by surgery.The surgery can be direc-ted to soft tissue or to bony structures.The airways are

TABLE 22. Indications of CPAP treatment

� Experimental treatment for allpatientswith AHI430 regardless of symptoms a

� If AHIis 5^30, treatment is initiated if the patienthas disturbing symptoms or ¢ndings:* Abnormal daytime fatigue and tendency to doze o¡* Cognitive disorders* Recurrent awakenings* Severe cardiovasculardiseases* Mood changes

aIf the patient is over 70 years of age, treatment is initiated individuallydepending onthe symptoms.

TABLE 23. Possible contraindications to CPAP treatment

� Floppyepiglottis� Chronic or acute in£ammation ofthe upper respiratory tract� Completelyblockednose, problematic nasalpolyposis� Otitis� Air accumulation in the stomach inpatientswith diaphragmatic hernia� Severe alcoholism� Problematic untreatedpsychiatric illness

TABLE 24. Problems of CPAP treatment

� Drying and encrustation of nasal, oral and pharyngealmucosa� Persistent rhinorrhoea andrecurrent sneezing� Nasal congestion� Recurrentepistaxis� Skin irritationunder themask� Irritation oftunica conjunctiva� General discomfortcaused by the treatment� Undetectedpsychiatricdisorder� Poor treatmentcompliance

TABLE 25. Treatmentof CPAP-relatednasal symptoms

Prevention ofthe dryingofnasalmucosacausedbyrecycledair:� Optimalpressure level� Facialmask that ¢ts aswell as possible� Support for the jaw� Nasal^oralmask� Humidi¢er

Symptom-dependent treatment:� Vasoconstrictors (for temporaryuse only)� Humidifying solutions� Local steroids� Ipratropiumbromide

SLEEPAPNOEA 351

widenedby the removal of an isolated obstructive factor,such as large tonsils or nasal polyps.The pharynx can bewidenedby the removal of the surrounding tissues, whichis a secondarymethodwithregard to CPAP treatment, orby changing the relative locations of the tissues by maxil-lomandibular osteotomies. Since scienti¢c evidence ontheusefulness of the surgical treatments is still partly con-tradictory, more studies are needed. Surgical treatmentmethods and their e¡ects are shown inTable 26.

REHABILITATIONANDDEVICES

Rehabilitation

In the rehabilitation of a patient with sleep apnoea, theprimary focus must be on directing the patient toward

self-care and encouraging him to adopt it. Exercise,weight loss, weight control, abstinence from smoking,and prevention of the overuse of alcohol are essentialfeatures of self-rehabilitation. As a general rule, rehabili-tation should be organised as outpatient rehabilitation inconnection with primary health care.

Medical rehabilitation includes o¡ering advice aboutrehabilitation and available rehabilitation services, evalu-ating the patient’s need for rehabilitation and the di¡er-ent rehabilitation options on the basis of the patient’sworking and functioning capacity, occupational rehabili-tation, physiotherapy and other similar therapies,

TABLE 26. Surgicalmodes of treatment

Site ofoperation

Procedure E¡ectof procedure

Nose � Straightening of a deviatednasal septum -Decreases the airwayresistance, causedby the deviated septum

� Reduction ofthe size of nasal concha -Increases the space in the nasalmeatus� Removal of polyps -Increases the space in the nasalmeatus� Correctional surgeryof externalnasal structure

-Decreases the obstruction causedbyexternalnasal structure

-All forms of nasal correctional surgerycan improvethe success of CPAP treatment

Adenoid tissue � Removal of adenoids -Widens the oropharynx� Removal of tonsils -Widens the nasopharynx

Palate � Uvulopalatopharyngoplasty -Removal of obstructive softtissue ofthe pharynxto preventthe collapse ofthe tissue

Mouth and jaw � Genioglossalmuscle advancement(GGA surgeryofthemandible)

-Increases the air space behind the tongue

� Bilateral sagittal splitosteotomy (BSSO) -Advances the tongue andwidens the pharynx� Maxillomandibular advancement (MMA) -Increases the air space (maxillary advancement

enables su⁄cientmandibular advancement)

Trachea �Tracheostomy -Passages obstructing the pharynx are bypassed


adaptation therapy, device services, and rehabilitationguidance. These methods can be used either in outpati-ent care or during institutional rehabilitation periods.

Adaptation therapy involves guiding the patient andhis family in postdiagnostic life management. Adaptationtherapy is usually group therapy. In most cases, specia-lised health-care units responsible for the treatment ofsleep apnoea organise survival course-like adaptationtherapy, for which they select the patients. The health-care units plan and organise the courses either by them-selves or in collaboration with other organisations. Hav-ing the patient’s family attend the courses is consideredessential as regards the successful rehabilitation of thepatient. Rehabilitation institutes o¡er adaptation ther-apy courses as well. Patients with a payment agreementfrom specialised or primary health care can be accepted,but patients usually apply for the courses through theSocial Insurance Institution on the basis of the treatingphysician’s statement.

The main task of the Social Insurance Institution is toorganise the rehabilitation of severely handicapped pa-tients. SII also organises other forms of individual rehabi-litation and courses, for which patients are selected onthe basis of the treating physician’s medical statement Bwithin annual resource limits. In 2000, SII funded the re-habilitation of 219 patients with sleep apnoea. Of these,123 were in working life and received a rehabilitation al-lowance from the Social Insurance Institution.

If a patient with sleep apnoea works in tra⁄c or in an-other profession requiring exceptional alertness and

precision, and if the treatment is not successful in elimi-nating all his symptoms, means of occupational rehabili-tation can be considered. The objective is to ¢nd asuitable job for the patient, thus allowing him to partici-pate fully in working life.The services of occupational re-habilitation are vocational guidance, rehabilitationresearch, experiments with work and training, pre-work training, on-the-job training, ¢nancial support, de-vices, and renovations to the workplace. Occupationalrehabilitation also includes training subsidy.The Social In-surance Institution is under an obligation to organise oc-cupational rehabilitation unless it is arranged throughemployment pension legislation or employment initia-tives.

Device services

The positive airway pressure device (CPAP device) usedin the treatment of sleep apnoea is a medical devicewhich falls under the Act and the Decree on Medical Re-habilitation, and the sections on devices in the Act onPublic Health and the Act on Specialised Health Care.Device services include evaluating the patient’s need fordevices, adapting the device for the individual patient anddelivering it for either temporary or permanent use,teaching the patient to use it, monitoring its use, andmaintaining it in working order.

Theunitdelivering the device is responsible forprovid-ing the patient with su⁄cient instructions on its use.The

SLEEPAPNOEA 353

unit is also responsible for keeping it functional andsafe. In practice, the unit either arranges regular mainte-nance of the device, or purchases the service elsewhere.This is possible only when the device register is func-tional.

The Finnish Lung Health Association has colla-borated with two hospital districts over the designof a respiratory device register, which could bedeveloped into a functional system for wider use. Ac-cording to existing legislation, a health care unit cannotleaveresponsibility for devicemaintenance to thepatientalone.

Apart from the actual device, the CPAP treatmentpackage includes a mask, headgear, and tubes. Suppliesfor the use of patients with sleep apnoea are distributedonly by specialised health care, since selecting the sup-plies, training the patients, and monitoring the use ofthe device demand specialised expertise.

In the near future, primary health care may be as-signedgreater responsibility for providing device servicesaccording to a local agreement.The importance of otherorganisations in providing device services may also in-crease in the future.

SOCIALSECURITYThe social security of patients with sleep apnoea is basedon the basic Finnish social security system. Devices forthe treatment of sleep apnoea are lent to the patient(see paragraph ‘‘Medicines’’). The patient can apply tothe Social Insurance Institution, for example, forreimbursement of treatment and medical costs,disability allowance, and care allowance. If the patient isunable to work, he can apply to the Social Insurance In-stitution for sickness allowance, and either to the SocialInsurance Institution or to the patient’s employmentpension institution for disability pension.The patient canapply to the municipal social sector for services de¢nedin the Acton Services for Disabled Persons.There are nospeci¢c decrees concerning this patient group, with theexception of the reimbursability of anorexigenicmedicines on certain conditions (see paragraph ‘‘DeviceServices’’).

COSTSAmerican studies have indicated thatuntreated sleep ap-noea nearly doubled the use of health services comparedto the control population.On the other hand, successfuland motivating treatment of sleep apnoea signi¢cantlydecreased the use of health services compared to the si-tuation prior to treatment.Comparable studies have notbeen conducted in Finland.

There are no exact calculations of the costs of treat-ment for sleep apnoea. The costs can be estimated by

proportioning the number of patients to the knownaverage prices of the services.The price of an individualpatient’s treatment can be estimated on the basis of theprices of di¡erent procedures and treatments suitablefor mostpatients (Appendix11).Realistic treatmentcostsare represented by the calculations made in the Varsi-nais^Suomi hospital district, which indicate that the di-rect annual costs of the diagnosis and the treatment ofsleep apnoea amount to more than 1.68 million euros inthis hospital district alone.

The treatment costs of patients with mild sleep ap-noea can consist of, for example, doctor’s fees and la-boratory tests in primary health care, and participationin weight loss groups and exercise groups.The treatmentof such patients amounts to approx. 151A in the initialphase, and further expenses are approx. 101A per an-num. Patients in the specialised health-care sector areusually patients on CPAP treatment. The CPAP treat-ment of each new sleep apnoea patient costs approx.1682h in the ¢rst year, after which the annual costs ofsuccessful treatment amount to approx. 252h. In prac-tice, 5 years of CPAP treatmentcost approx. 2691h. Afterthe 5-year period, the costs include notonly annual mon-itoring but also the replacement of the device. Recenttrends suggest that if 1000 new patients require treat-ment every year, and if 4000 previously treated patientsare monitored at the same time, as indicated by the sta-tistics from 1998, 2.7 million euros are spent on CPAPtreatment per annum, not counting the costs of devicereplacement. In1998,1000 CPAP devices passed their re-commendedusage age of 5 years, which added 0.5 millioneuros to the expenses. The calculations do not accountfor the treatment of problematic patients requiring spe-cial examinations that also add to the expenses.

Half of the sleep apnoea patients under 65 years of ageon CPAP treatment are inworking life. If thepatientdoesnot su¡er from other illnesses, sleep apnoea alone is nota common cause of incapacity for work.No statistics areavailable for sick leaves or pensions accorded on thebasisof diagnosed sleep apnoea.

IMPLEMENTATIONOF THEPROGRAMME

Information, training and guidance

The implementation of the sleep apnoea programmecalls for the distribution of information, education ofkey groups, and continuous guidance. Key groups includepeople who are at a high risk of developing sleep apnoea,those with sleep apnoea, and those directly involved inthe treatment of sleep apnoea. Key groups also includepeople who can actively help prevent sleep apnoea intheir work (planners, product designers), people who in-form others of issues concerning health and illness(reporters, representatives of organisations, and manu-


facturers of devices), and people who are in a position todecide how public resources are used.

The responsibility for distributing information andeducating key groups can be shared so that organisationssuch as the Finnish Lung Health Association, the Pul-monary Association HELI and the Finnish Sleep ApnoeaAssociation are responsible for informing their ownmembers and, in part, the general public.Together withexperts, the organisations produce material needed inpatient education.To this end, organisations can receivefunding from the Finnish Slot Machine Association, forexample. The Social Insurance Institution distributes in-formation on social security and the ways in which theSII supports the patient’s capacity for work.The authori-ties are responsible for informing experts and trainingthem in collaboration with di¡erent associations and so-cieties.These include the Municipal Doctors Association,the Orthodontic section of the Finnish Dental SocietyApollonia, the Finnish Dental Association, the Associa-tion of Finnish Pulmonary Physicians, the Finnish Societyof Clinical Physiology, the Finnish Societyof Clinical Neu-rology, the Association of Finnish Otolaryngologists, theFinnish Paediatric Association, the Finnish NeurologicalSociety, the Finnish Federation of Nurses, the Finnish In-ternal Medicine Association, the Finnish Sleep ResearchSociety, the Finnish Association for General Practice, theAssociation of Oral and Maxillofacial Surgery, the Unionof Health and Social Care Professionals, the Associationof Health Centre Dentists and the Finnish Sleep Federa-tion. Provincial guidance and education will be the jointresponsibility of hospital districts and provincial govern-ments, whereas health centres will be responsible for lo-cal guidance and education.Themedia have an important

TABLE 27. Information and trainingneeded for the implementa

Information and education

Initial distribution of informationand informingkeygroups

Nationalnegotiations, education and support

National sleep apnoea days

Provincial education

Local education

Informing the generalpublic

opportunity to initiate debate on the programme and tosupport its goals and principles (Table 27).

Special attention must be paid to the training of newhealth-care professionals.The fundamental principles ofthe sleep apnoea programme should be included in thecurriculum of health-care institutes, medical faculties,and specialist training programmes. The possible needto train experts in sleep apnoea, such as respiratorynurses, sleep technicians and weight loss programme lea-ders, for practical work should be considered in the im-plementation of the programme. Hospital districtsshould prepare collaborative programmes for the pre-vention and treatment of sleep apnoea to be applied lo-cally. Hospitals have reported positive experiences ofregular meetings of working groups on sleep attendedby representatives of the appropriate specialisedbranches. The revision of the treatment recommenda-tions canbe accomplishedby preparing a Duodecim con-sensus treatmentrecommendation after theprogrammehas been launched.

Research andmonitoring

Universities, health-care institutes, health-care associa-tions and individualresearchers have conductedresearchinto sleep apnoea in Finland. In Health 2000 survey, acomprehensive studyby the National Public Health Insti-tute, the sleep of the population was one of the subjectsstudied. In future, the study can be used in the monitor-ing of the programme. However, more population stu-dies on the prevalence and signi¢cance of the illness areneeded. Studies on the mechanism of sleep apnoea, the

tion ofthe programme

Theresponsible authority

Finnish Lung Health Association,Pulmonary AssociationHELI,Finnish Sleep Apnoea Association

Finnish Lung Health Association,Finnish Sleep Federationand otherorganisations

Associations ofmedical specialists, di¡erent societies

Hospital districts, provincial governments, provincialoccupationalhealth organisations, societiesHealth centres, occupationalhealth care, societies

Media, societies, experts

TABLE 28. Developmentneeds for the research andmonitoringof the sleep apnoea programme

� Prevalence and incidence of sleep apnoea� Earlydiagnosis and treatment� The signi¢cance of risk factors and concomitant illnesses to the incidence of sleep apnoea� The signi¢cance of childhoodmalocclusions and enlarged tonsils and adenoids to the incidence of sleep apnoea� The e¡ectof treatment andrehabilitation on costs� Creating comprehensive follow-up systems

SLEEPAPNOEA 355

risk factors, the methods of treatment and their cost-ef-fectiveness are also needed. Table 28 lists the develop-ment needs for the research and monitoring of thesleep apnoea programme. Joint meetings/seminars ofsleep apnoea researchers should be arranged annually.

Creating a well-designed, functional and continuoussystem of quality control and direction is necessary forthe implementation of the programme. Special attentionmust be paid to the monitoring of the success of sleepapnoea prevention and treatment. Existing registers ofrespiratory devices and material withdrawn from useshould be developed for use in the monitoring of treat-ment success and patient £ow.The system of monitoringoverweight people at a high risk of developing sleep ap-noea should be developed so that the treatment of theillness can be initiated early on. The provincial applica-tions of the sleep apnoea programme should include me-chanisms for monitoring the implementation of theprovincial programmes. The Finnish Lung Health Asso-ciation appoints a monitoring group to support and eval-uate the implementation of the sleep apnoeaprogramme. A more comprehensive follow-up reportand evaluation willbe made once the ¢rst-half of the pro-gramme has been completed.

Costs of the programme

The costs of the programme for the prevention andtreatment of sleep apnoea mainly consist of communica-tions, training and programmes for quality control anddirection. These are not additional expenses, but ex-penses relating to the normal functions and developmentof health-care units and associations. The communica-tions, training, production of material and developmentof strategic forms of operation relating to the launch ofthe programme should receive ¢nancial support fromhealth-care development funds (e.g. from the FinnishSlot Machine Association). The additional expenses ofthe launch of the programme (training, communications,guidance, monitoring) amount to under one millioneuros in 2002^2006.

If the programme is implemented and the quality ofthe prevention and treatment of sleep apnoea is im-

proved, sleep apnoea can be treated with the bestpossible cost-e¡ect ratio. If the programme is not imple-mented, the costs caused by sleep apnoea, which hasproved to be a national health problem in Finland, willincrease signi¢cantly.

SUMMARY

(1) After negotiations with the Finnish Ministry of SocialA¡airs and Health, a national programme topromote prevention, treatment and rehabilitation ofsleep apnoea for the years 2002^2012 has beenprepared by the Finnish Lung Health Association onthe basis of extensive collaboration.The programmeneeds to be revised as necessary, because of therapid development in medical knowledge, and inappliance therapy in particular.

(2) Sleep apnoea deteriorates slowly. Its typical featuresare snoring, interruptions of breathing during sleepand daytime tiredness. Sleep apnoea a¡ects roughly3% of middle-agedmen and 2% of women. In Finland,there are approx. 150 000 sleep apnea patients, ofwhich 15 000 patients have a severe disease, 50 000patients are moderate and 85 000 have a mild formof the disease. Children are also a¡ected by sleepapnea. A typical sleep apnea patient is a middle-agedman or a postmenopausal woman.

(3) The obstruction of upper airways is essential in theoccurrence of sleep apnoea.The obstruction can becaused by structural and/or functional factors. Asfor structural factors, there are various methods ofintervention, such as to secure children’s nasalrespiration, to remove redundant soft tissue, aswell as to correct malocclusions. It is possible tohave an e¡ect on the functional factors by treatingwell diseases predisposing to sleep apnoea, byreducing smoking, the consumption of alcohol andthe use of medicines impairing the central nervoussystem. The most important single risk factor forsleep apnoea is obesity.

(4) Untreated sleep apnoea leads to an increase inmorbidity and mortality through heart andcirculatory diseases and through accidents caused


by tiredness. Untreated or undertreated sleepapnoea deteriorates a person’s quality of life andworking capacity.

(5) The goals of the Programme for the prevention andtreatment of sleep apnoea are as follows: (1) todecrease the incidence of sleep apnoea, (2) toensure that as many patients as possible with sleepapnoea recover, (3) to maintain capacity for workand functional capacity of patients with sleepapnoea, (4) to reduce the percentage of patientswith severe sleep apnoea, (5) to decrease thenumber of sleep apnoea patients requiringhospitalisation and (6) to improve cost e¡ectivenessof prevention and treatment of sleep apnoea.

(6) The following means are suggested for achieving thegoals: (1) to promote prevention of obesity, weightloss and weight control; (2) to promote securing ofnasal respiration in child patients and removal ofobstructing redundant soft tissues; (3) to promotethe correction of children’s malocclusions, (4) toenhance knowledge about risk factors andtreatment of sleep apnoea in key groups, (5) topromote early diagnosis and active treatment, (6) tocommence rehabilitation early and individually as apart of treatment and (7) to encourage scienti¢cresearch.

(7) On the national level, the occurrence of sleepapnoea can be prevented, for example, byencouraging weight control. The programmegives examples of such measures and appeals tovarious authorities and voluntary organisations toreinforce their collaboration. Preventive measuresshould be individualised, and based on dueconsideration.

(8) The e⁄cacy of diagnosing sleep apnoea should beincreased. Attention should be paid to thesymptoms of risk group patients at di¡erent units ofthe primary and occupational health care. Even mildforms of the disease shouldbe treated appropriately.Diagnosis and treatment of the disease involvecooperation between the primary and specialisedhealth-care sectors. Methods of treatment are (1)treatment of obesity, (2) positional therapy, (3)reduction of the use of medicines impairing thecentral nervous system, (4) reduction of smokingand the consumption of alcohol, (5) devicesa¡ecting the position of the tongue and lower jaw,(6) treatment with Continuous Positive AirwayPressure (CPAP-treatment), (7) surgical methods oftreatment and 8) rehabilitation.

(9) The hierarchy of referrals in the prevention andtreatment of sleep apnoea should be revised toaccord a greater role to the primary health-caresector. Good exchanges of information andcooperation between the primary health care andspecialised medical-care sectors should be

developed. Hospitals districts in cooperation withprovincial governments and municipalities shouldensure that di¡erent levels of the health-caresystem are capable of ful¢lling the tasks assigned tothem appropriately.

(10) Rehabilitation of sleep apnoea should be goal-orientated and cover all forms of rehabilitation:medical, occupational and social. Rehabilitationshould prevent the e¡ects caused by the disease.Thus, it is possible to support self-care, increasethe patient’s resources and improve quality of life.

(11) Information and training should be directedprimarily towards health-care personnel, patientsand their families. Organisations should producematerials for health and patient education as well asorganising training events.To support the activities,¢nancing will be needed from organisations such asFinland’s Slot Machine Association. The SocialInsurance Institution should disseminateinformation about questions of social security.Regional direction and training will mainly be theresponsibilities of hospital districts, provincialgovernments and local health centres. The mediawill play an important role in the dissemination in-depth information about prevention and treatmentof sleep apnoea.

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S762.

SLEEPAPNOEA 359

APPENDIX1:THEPHYSIOLOGYOFSLEEPANDTHEEVENTSDURINGANOBSTRUCTIVEAPNOEAEPISODE

Sleep is divided into two di¡erent stages, slow-wave andrapid eye movement sleep (REM sleep) based on, for example,EEG.Themuscle tone decreases during sleep.During REM sleep, themuscle tone isparticularly low, and the function ofrespiratory muscles is the most vulnerable to disturbances. Apnoea is most easily caused by an obstruction in theupper respiratory tract during REM sleep, after which the condition deteriorates at all stages of sleep and all sleepingpositions. Stimulated by the cerebral respiratory centre, the patient tries to breathe despite the obstruction in theupper respiratory tract (=obstructive apnoea). Arousal causes an increase in the muscle tone, followed by strongcompensatory breathing. The sleep of the apnoea patient deepens, the muscle tone decreases and causes anotherepisode of apnoea, which is followed by a new arousal, recurrent episodes of apnoea, and disturbed sleep includingonly short periods of deep sleep and REM sleep.The decrease in oxygen saturation (SpO2) as measured by pulse oxy-meter from the ¢nger occurs approx.15 s after the episode of apnoea.

APPENDIX2:SLEEPINESSQUESTIONNAIRE[EPWORTHSLEEPINESSSCALE(ESS)]Abnormal sleepiness is indicated if the ESS score is 410.

(This information must not be visible in the form given to the patient)Instructions: How likely areyou to doze o¡ or fall asleep in the following situations, in contrast to feeling just tired? This

refers toyour usualwayof life inrecent times.Evenif youhavenotdone some of these thingsrecently try toworkouthowthey would have a¡ected you.Use the following scale to choose the most appropriate number for each situation:

Scale (alternative replies):0=no chance of dozing1=slight chance of dozing2=moderate chance of dozing3=high chance of dozing

Estimate of the probability of dozing o¡ (circle the right alternative):How high is the probability that you will doze o¡

10 s

Arousal

Obstruction of upper airways

Respiratory effort

Negative intrathoracic pressure

EEG

Apnoea, interruption of the flow of air

Respiratory motions of the chest continue

Abdominal respiratory motions continue

Decrease in oxygen saturation measured

by pulse oxymeter (SpO )2

The situation No chance of dozing Slight Moderate High

Sittingandreading 0 1 2 3WatchingTV 0 1 2 3Sitting inactive in a public place (e.g. a theatre or ameeting) 0 1 2 3As a passenger in a car for anhourwithout a break 0 1 2 3Lyingdownto rest in the afternoonwhen circumstances permit 0 1 2 3Sittingand talkincg to someone 0 1 2 3Sittingquietly after a lunchwithout alcohol 0 1 2 3In a car, while stopped for a fewminutes in tra⁄c 0 1 2 3

APPENDIX 3: EXAMPLESFROMSTUDIESONTHEPREVALENCEOFSLEEPAPNOEA

APPENDIX4:OBESITYGRADINGONTHEBASISOFBODYMASSINDEX(KG/M2)

APPENDIX5:CHECKLISTOFTHEGENERALPRACTITIONERWHENREFERRINGAPATIENT TOASPECIALISTFORSLEEPEVALUATION

Study Country Testgroup Age (years) Criteria Prevalence (%)

(AHI)

Lavie (1983) Israel Men 421 410 0.9Telakivi et al. (1987) Finland Men 41^50 420 1.4Gislason et al. (1988) Sweden Men 30^69 45 1.4Cirignotta et al. (1989) Italy Men 30^69 45 5.1Stradlingand Crosby (1991) U.K. Men 35^65 45 4.6Gleadhill (1991) Northern Ireland Men 40^64 410 + symptoms 0.8Young et al. (1993) USA Men 30^60 45 + symptoms 4

Women 30^60 45 + symptoms 2Bearparket al. (1995) Australia Men 40^65 410 10 %Marin et al. (1997) Spain Men 418 410 2.2

Women 418 410 0.8 %

BMI Grade

o20 Underweight20.0^24.9 Normal25.0^29.9 Slightoverweight30.0^34.9 Overweight35.0^39.9 Obesity440 Extreme obesity

1.Patient information� weight, height,BMI, waist andneckcircumference� occupation� medication� smoking� use of alcohol

2. Symptoms (yes/no, duration)� snoringeverynightornearlyeverynight� apnoea episodes� daytime fatigue� accidents� impairmentofthe ability towork� Score on ESS410


APPENDIX 6:WHENSHOULDOTHERSPECIALTIESBECONSULTED?

3.Concomitant illnesses� asthma� chronic obstructive pulmonarydisease� hypertension� arrhythmias� coronaryheartdisease� diabetes� cerebral ischaemic attacks� restless legs� depression

4.Otolaryngological status (normal/narrow)� nose� soft palate, pharynx� larynx� occlusion� size of tongue and jaw

X-ray and laboratoryresults� Chest X-ray, sinus X-ray� ECG� Blood count,Fs-Cholesterol,Fs-Triglyceride,Fb-Glucose,S-TSH� Flow volume spirometry, if expertevaluation is available� Other results the referringdoctorconsiders important� Cephalometric sleep apnoea X-ray

Dentist�abnormalocclusion andmandibular structure�evaluation and implementation of orthodontic treatment�evaluation andimplementationofmaxillofacial surgery (oralandmaxillofacial surgery)

Pulmonary specialist� exclusion/treatmentof asthma and COPD�exclusion/treatmentof other pulmonarydiseases�implementation of CPAP treatment (inmostunits)

ENTspecialist� evaluation for pharyngeal surgery inpatientswithmild tomoderate sleep apnoea

� nasal congestion� severenasalproblems during CPAP treatment

Paediatrician�exclusion/treatmentof other illnesses if necessary

Neurologist� exclusion of neurological illnesses� abnormalneurological status ¢ndings� diagnosis of other sleep disorders� evaluation of daytime alertness level

SLEEPAPNOEA 361

APPENDIX 7: PARAMETERSUSEDINTHEMEASUREMENTOFLIMITEDANDEXTENSIVESLEEPREGISTRATIONS INTHEDIAGNOSTICSOFSLEEPAPNOEA

� abnormal tiredness of a patient receiving CPAP treatment� estimates of working ordriving ability

Psychiatrist� exclusion/treatmentof psychiatric illnesses, particularlydepression

� problemswithtreatmentcompliance

Specialist inmedicine� treatmentof problematic hypertension� diagnosis and treatmentof cardiacdiseases� treatmentof problematic endocrinological illnesses� exclusion/treatmentof otherdiseases

Measuredparameters Limited sleep registration Extensive sleep registration

Respiratory air £ow + + (+) + + +Intranasalpressure + + (+) + +Respiratorymotion + + + + +Oxygen saturation + + + + + +Position + + + +ECG + + + +Pulse + + +Limbmovement + + +Snoring + + +EEG � + + +EMG � + + +EOG � + + +Usedmainly in researchCO2 of exhaled air � + +Oesophagealpressure � + +OesophagealpH � +Additional EEG channels � +EMGof intercostalmuscle � +CO2 di¡using throughthe skin � +Continuousmeasurement � + +of bloodpressureOther

� + +

+ + + = always included; + + (+) = often included; + + = possibly included; depending on the equipment; + = possiblyincluded; ^ = notusually included.


APPENDIX 8:DEPRESSIONSCREEN (DEPS)When depression is suspected, the DEPS patient questionnaire intended for use within primary health care may be auseful tool. If the score in the test is 499, the patient probably su¡ers from depression. (This information must not bevisible in the form given to the patient.)

Please answer the following questions by ticking the alternative that best describes your situation in thelast month.

SLEEPAPNOEA 363

APPENDIX 9: EXAMPLESOF TREATMENTPRINCIPLES FORSLEEPAPNOEAINPRIMARYHEALTHCARE

1. If the patient su¡ers from socially disturbing snoring but the ¢ndings of sleep registration are normal, support isgiven by o¡ering guidance and, if necessary, by arranging further evaluations within primary health care on thebasis of the patient’s symptoms. Di¡erential diagnosis, e.g. for depression, should be considered if the patientsu¡ers from daytime fatigue.

2. A patient who is not signi¢cantly overweight (BMIo30kg/m2), and whose symptoms indicate mild sleep apnoea, isonlyreferred to specialisedhealth care for an active treatmentevaluationwhen necessary.Guidance, treatment andfollow-up within primary health care.

3. An obese patient (BMI 430^35 kg/m2) su¡ering from partial upper respiratory track obstruction or whosesymptoms indicate mild sleep apnoea is primarily given conservative treatment within primary health care. Theimpact of weight loss is controlled by limited sleep registration. If weight loss does not promote the desiredresults within a set time limit (e.g.1year), the patient is referred to specialised health care for an active treatmentevaluation.

4. A patient, who clearly su¡ers from position-related partial upper respiratory track obstruction or mild sleepapnoea, can be treated by preventing him from sleeping supine.The e¡ect of the treatment should be controlledby sleep registration. If position therapy does not yield the desired result, the patient is referred to specialisedhealth care for an active treatment evaluation.Weight loss as treatment should not be overlooked.

5. A patient su¡ering from moderate-to-severe sleep apnoea should be referred to specialised health care for anactive treatment evaluation regardless of his weight. According to the treatment and rehabilitation plan, cases ofmild and even moderate sleep apnoea can be treated within primary health care in the future if agreed.

6. If the patient’s work requires exceptional alertness (e.g. in tra⁄c) andhis score in the symptoms questionnaire (ESS,Appendix 2) is11or more, referring him to specialised health care for further evaluations should be considered.

7. Children with symptoms indicating sleep apnoea should always be referred to specialised health care forexaminations and an evaluation of the need for surgical treatment.

APPENDIX10: CONTRIBUTORYFACTORSOFLIFEMANAGEMENT, ANDPRINCIPLESOFWEIGHTLOSSANDWEIGHTCONTROL (BRIEF INSTRUCTIONSANDBASICTREATMENTINOBESITY)

During the pastmonth Never Sometimes Quite often Veryoften

Ihave su¡ered frominsomnia 0 1 2 3Ihave beenmelancholy 0 1 2 3Ihave feltthatdoinganythingrequires e¡ort 0 1 2 3Ihave lacked energy 0 1 2 3Ihave felt lonely 0 1 2 3The future has seemedhopeless 0 1 2 3Ihavenotenjoyed life 0 1 2 3Ihave feltthat all joyhas disappeared frommylife 0 1 2 3Ihave feltthat notevenmy family and friends canmakemehappy 0 1 2 3

Source: Salokangas et al. (1994).

Sector Centralpoints

Dietaryenergy � Themost importantthing is to reduce dietary fat.Withregard to health, it is recommended toreduce the amountof animal (saturated) fats


APPENDIX11: REALISTICTREATMENTCOSTSOFDIFFERENTSLEEPAPNOEATREATMENTS

� If the patientwishes to adopt a dietcontaininga restricted amountof energy (e.g. 5.0^7.5MJ = 1200^1800 kcal/day), the diet shouldhave a varied content

� Unbalanced fashion diets are not recommended� Reduction in alcohol consumption

Increased exercise � The importance of exercise is small in actualweight reduction, butgreat inweightcontrol� Themain focus should be on increasingdailyphysical activity (functional exercise, everydayexercise)� Moreover, the patient should be encouraged to exercise inhis free time� The objective is anincrease of 4.2^8.4MJ (1000^2000 kcal) inweeklyenergyconsumption

Control of eating � Bettercontrol of eatingcan be reached byproviding instruction in eatinghabits and foodpurchases� Themost important improvements: regularmeals, carefullyconsidered foodpurchases,

eliminating temptations to eat, concentrating inthemeal, and eatingmore slowly

Beliefs and attitudes(cognitive issues)

� Focus on changing beliefs and impressions that are obstacles to changes� Especiallydealingwithunrealistic expectations and feelings connected to‘‘succumbingto the temptation’’andgivingup

� Diet and exercise diaries, incentives, methods of stress control andproblem solving,and other supportivematerial can be used if necessary

A.Treatment ofa patient withmild sleep apnoea in health centres: the exemplary calculations have been provided bya health centre located in theVarsinais^Suomi district in 2001

h

Doctor’s appointment inprimaryhealth-care 43Basic laboratory tests a35Individualweight loss and other guidance (public nurse) 30Controlvisitto a health-care physician 43Total 151

Furtherannual expensesVisitto a health-care physician 43Twovisits to a public nurse 61Total 104

B. Exemplary calculation ofthe costs of CPAP treatment, which is implemented in specialised health care.The prices used were valid in theVarsinais^Suomi district in 2001Treatment initiationDoctor’s appointment inprimaryhealth care (dg suspicion) 34Visitto a specialistoutpatientdepartment 91Consultation of another specialist (e.g.ENTspecialist) 86Limited sleep registration 252Doctor’s appointmentto learnthe results (outpatientdepartment) 49Initiation of CPAP treatment + device 925Follow-upvisit, patient + device (outpatientdepartment) 27Total 1464

Furtherannual expensesPatient + device once ayear (outpatientdepartment) 91Masks, tubes and ¢lters/year 160Total 251

C. Exemplary calculations: surgical treatment.The prices used were valid in theVarsinais^Suomi district in 2001Doctor’s appointment inprimaryhealth care (dg suspicion) 34

SLEEPAPNOEA 365

Visitto a specialistoutpatientdepartment 86Limited sleep registration 252LateralX-rayof the skull, and cephalometric analysis 52Surgical interventionGGA + hospital fees 1177

Check-upvisit 47Check-up sleep registration 252Total 1900

Other operations Total costsSagittal osteotomy/elongation ofthe lower jaw 1682

(+ orthodontics)Maxillomandibular osteotomy 2943

(+orthodontics)UPPP treatment 622

aThe laboratory tests of the examplewere: blood count,B-ESR,Fs-Cholesterol,Fs-HDLCholesterol,Fs-glucose,ECG,Urinalysis.

Sleep apnoea:Finnish Nationalguidelines for prevention and ... · of hospital days was12803 in...

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