• obstructive sleep apnoea hypopnoea/syndrome
• diagnosis

We very much enjoyed the first paper in the review series on sleep and admired Stradling and Davies’s honest appraisal of the current difficulties in defining disease and the lack of a relationship between symptoms and the results of investigations.¹ One of the problems of truly determining the size of the health burden associated with the obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is that much of the burden may occur before the diagnosis is made. Others have shown how use of hospital resources and use of cardiovascular medication is high in those with undiagnosed obstructive sleep apnoea.^2,3 We administered a questionnaire to 166 consecutive patients with diagnosed OSAHS on continuous positive airway pressure treatment and asked them to identify how long they could recall having symptoms at the time of diagnosis. In 155 cases (93.4%) someone had previously complained of the patient’s loud snoring and first mention of this had been made a median of 12 years (range 2–52) before diagnosis of OSAHS. In 84.3% of respondents excessive daytime sleepiness had been present for a median of 8 years (range 0.5–62) and 133 patients (80.1%) reported that their bed partner had witnessed apnoeas a median of 8 years (range 1–49) before diagnosis. We also found that, of the 119 (71.7%) who were drivers, 26 (21.8%) reported at least one or more automobile crashes in the previous 5 years, with seven respondents having had two and one having had four.

These results suggest a lack of awareness of sleep related breathing disorders among the general population and probably among health professionals. The delay in diagnosis is likely to have significant effects on morbidity, and in recent preliminary work it has been shown that those with OSASHS have structural changes in brain morphology compared with healthy controls.⁴ In addition to the health and quality of life benefits to the individual to be gained by prompt diagnosis, there are also economic aspects in favour of prompt diagnosis and treatment^5,6 and early benefits in terms of driving performance.⁷