In 2023, a survey was conducted among pharmacists in Ireland to investigate their experiences and the management of customer concerns related to sleep. The findings were significant. On average, more than half of the pharmacists surveyed reported that 11 per cent or more of their customers sought their advice regarding sleep issues. Additionally, nearly 60 per cent of pharmacists indicated that 11 per cent or more of their customers purchased sleep aids within a single week.

The statistics match international reports on sleep disorders, with insomnia and obstructive sleep apnoea being notably prevalent. About 30 per cent of adults globally experience insomnia at some point, and nearly 10 per cent suffer from chronic insomnia. Obstructive sleep apnoea affects over 25 million Americans and approximately 936 million people worldwide, making it a significant concern.

Obstructive sleep apnoea (OSA) exerts a complex influence on individuals affected by the condition and also has significant implications for the economy. According to a report by the American Academy of Sleep Medicine, the financial burden of undiagnosed OSA in the United States was estimated at approximately $150 billion in 2015. This cost arises from increased healthcare utilisation, diminished work performance, and the heightened risk of occupational injuries. The economic impact of untreated OSA in Europe is comparable to that observed in the United States.

Pharmacists frequently serve as the initial point of contact for individuals experiencing sleep difficulties. Customers may seek to purchase over-the-counter remedies, such as nasal drops for snoring, nasal strips, or other products that they believe may alleviate snoring and address undiagnosed sleep apnoea. This may also include OTC sleep medications used in the treatment of general sleep difficulties, due to a lack of awareness. Furthermore, pharmacists play a crucial role in educating these potential sleep apnoea patients and providing guidance on the appropriate referral pathways for further evaluation and management of their condition.

An introduction to obstructive sleep apnoea

Definition and classification

• Obstructive sleep apnoea is a sleep-related breathing disorder characterised by repetitive episodes of complete or partial upper airway obstruction during sleep, resulting in:
• Apnoea (complete cessation of air flow); or
• Hypopnoea (partial reduction in air flow).
• The conditions above are typically associated with:
• Oxygen desaturation (drop in the oxygen levels);
• Sleep fragmentation (multiple awakenings); and
• Daytime symptoms such as excessive sleepiness

Epidemiological data

At present, accurate data regarding the prevalence of obstructive sleep apnoea (OSA) within the Irish population is unavailable. However, international studies suggest that approximately 4 per cent of the middle-aged demographic is affected by this condition. This estimation indicates that there may be between 50,000 and 100,000 individuals currently experiencing sleep apnoea in Ireland.

In the UK, the prevalence of obstructive sleep apnoea is estimated to affect 1.5 million adults, and a significant number of individuals with OSA remain undiagnosed.

Pathophysiology and risk factors

Obstructive sleep apnoea is commonly defined as having more than five abnormal breathing disturbances. These breathing disturbances are typically referred to as apnoeas and hypopnoeas. Apnoea is defined as a reduction in oronasal airflow of 90 per cent compared to the pre-event baseline. A hypopnoea is defined as a reduction in the oronasal airflow by at least 30 per cent and associated with either a 3 per cent reduction in the oxygen levels or followed by a micro-arousal in the brain as detected by the EEG. The resultant poor sleep quality from the occurrence of apnoeas and hypopnoeas has daytime consequences, including excessive daytime sleepiness.

Obesity is the main risk factor for the development of OSA. Non-obese individuals may also suffer from OSA, and this is commonly attributed to anatomical changes like retrognathia (a condition in which the lower jaw is positioned further back than normal in relation to the upper jaw). A high BMI, central accumulation of adipose tissue, and increased neck circumference are strong predictors of OSA. The prevalence of OSA is two to three times greater in men than in women and in older individuals compared to middle-aged individuals.

The human airway has multiple functions, including the vital function of acting as a passage for air for breathing. The airway itself is composed of numerous muscles and soft tissues but lacks rigid or bony support. It also has a collapsable portion that extends from the hard palate to the larynx, and this feature provides the opportunity for collapse at inopportune times, such as during sleep. The cross-sectional area of the upper airway is reduced in patients with OSA compared to their non-OSA counterparts. Furthermore, the arrangement of the surrounding soft tissue also appears to be altered in patients with OSA, which places the upper airway at increased risk for collapse. This collapse or narrowing of the upper airway often results in either an apnoea or a hypopnoea, reducing the quantity of air reaching the lungs and their alveoli. This will, in turn, lead to a drop in the oxygen saturation in the blood, which is often termed as oxygen desaturation.

In obstructive sleep apnoea (OSA), the brain reacts to breathing interruptions by triggering temporary awakenings from sleep, known as arousals. These frequent awakenings can disrupt sleep architecture, leading to daytime drowsiness and other complications associated with OSA.

Clinical presentation and consequences

Individuals with obstructive sleep apnoea usually present with a combination of nocturnal symptoms and daytime symptoms.

The nocturnal symptoms are often reported by a family member and typically include loud and chronic snoring, pauses in breathing, gasping, and restless sleep or multiple awakenings. The daytime symptoms, which are the result of fragmented sleep and oxygen desaturation, are excessive daytime sleepiness, morning headaches, difficulty concentrating, irritability, and dry mouth upon waking.

The immediate consequence of sleep apnoea or poor-quality sleep is fatigue and decreased alertness. This can increase the risk of motor vehicle or occupational accidents.

 

The poor sleep also results in cognitive impairment, leading to increased reaction time and difficulty concentrating.

Obstructive sleep apnoea is also a well-established independent risk factor for hypertension, coronary artery disease, heart failure, type 2 diabetes, dyslipidaemia, and stroke, among other conditions.

Diagnosis

Clinical screening tools

The Epworth sleepiness scale and STOP-BANG questionnaire are easily employable screening tools in a pharmacy setting. There are also sleep disorder symptom questionnaires that are useful to differentiate between different sleep disorder symptoms.

Polysomnography and home sleep tests

The gold standard diagnostic tool for the diagnosis of obstructive sleep apnoea is a polysomnography or an in-lab sleep study. This is performed as an in-patient in the hospital and involves measuring the breathing patterns for the detection of hypopnoeas and apnoeas, respiratory effort, oxygen saturation, sleep staging and arousal detection, electrooculogram, electromyogram, and electrocardiogram.

There are recent developments in sleep testing technologies, but it is the prerogative of a respiratory physician to choose the type of test based on the nature and severity of reported symptoms.

Referral pathway

Management of obstructive sleep apnoea

Continuous positive airway pressure therapy

A continuous positive airway pressure (CPAP) device stands as one of the most prevalent therapies for sleep apnoea. Its primary function is to maintain the upper airway’s openness during sleep, thereby enabling individuals to receive adequate oxygen from the air they inhale. The CPAP device administers air at a predetermined pressure continuously through the mouth and/or nose, gently facilitating the maintenance of airway patency. There are two principal varieties of CPAP machines: the auto CPAP, which self-regulates and employs a range of pressures to keep the airway open as necessary; and the fixed CPAP, which delivers a constant pressure throughout the night. Contrary to widespread misconceptions, these devices are extensively utilised and generally well-accepted by individuals affected by obstructive sleep apnoea.

Oral appliance therapy

Oral appliance therapy is recommended for individuals with retrognathia. When the lower jaw is positioned further back than normal, it reduces pharyngeal space, narrowing the air passage. Using a mandibular advancement device helps pull the lower jaw forward to keep the airway open. This approach is often utilised when individuals meet the criteria for it and are intolerant of CPAP, as determined by a respiratory physician.

Positional therapy

Individuals diagnosed with positional sleep apnoea, experience apnoeic and hypopnoeic events primarily while in a supine sleeping position (lying on their back). Therefore, adopting a non-supine sleeping position is essential for mitigating the respiratory events associated with supine sleeping. Devices designed for positional therapy assist individuals in avoiding the supine position, thereby preventing the occurrence of apnoeas and hypopnoeas associated with that position.

Uvulopalatopharyngoplasty is a surgical intervention that removes tissue (soft palate, tonsils, uvula) within the airway to make it less likely to collapse and interfere with breathing. This option is considered when conventional treatments prove ineffective, or in instances where anatomical abnormalities are present.

Moreover, lifestyle modifications such as weight reduction, abstention from alcohol, cessation of smoking, and the enhancement of exercise regimens are beneficial for individuals with mild sleep apnoea.

The pharmacist’s role in sleep apnoea management

Pharmacists, as the initial point of contact within the healthcare system, occupy a distinctive role in educating and advising patients regarding sleep apnoea while facilitating appropriate referral pathways.

Engaging with patients in your pharmacy who may request items such as OTC sleep aids, nasal drops for snoring, or nasal strips can also help inform patients about sleep apnoea and may prompt them to seek onward referral.

Health promotion and screening measures are important aids in the early detection and management of sleep apnoea and can play a critical role in preventing the onset of metabolic disorders and mitigating the economic burden on patients.

The stratification of patients based on their presenting symptoms and the provision of guidance on referral processes is essential in addressing sleep disturbances and restoring affected individuals’ quality of life.

References available on request.