Snoring and Sleep Apnea
Snoring
About half of the men and a quarter of all women snore regularly. Both men and women are more likely to snore as they age and are more common in people who are overweight. The tissue in the back of the throat becomes looser and the greater amount of fat in the back of the throat narrows the airway and vibrates as they sleep. If you cannot breathe through your nose due to nasal obstructions you are more likely to snore.
In the early stages the person snoring suffers no consequences in many cases except the elbow in the ribs from their spouse who cannot sleep. Often sleeping on your side will help as when you are on your back the weight of you jaw and tongue fall back narrowing your airway causing you to labor to breathe resulting in snoring. Sleeping on your side the jaw and tongue fall with gravity away from your airway and you can breathe easier decreasing snoring. Sewing tennis balls into the back of your pajamas to prevent you from rolling onto your back is another home aid. Some people benefit from snore strips on their nose if they have nasal obstructions. Loosing weight will help open up the airway and decrease snoring. Alcohol consumption and drugs to help us sleep also increase snoring. Dental oral appliances much like a sports night guard or a retainer worn at night can hold the lower jaw forward and thus open the airway to allow a person to breathe easier and reduce snoring.
Sometimes, at some point the spouse must leave the room to sleep and they end up in separate bedrooms which can lead to relationship and marriage problems. Now the snorer is affected and must make a decision if they want to address the issue or continue to ignore it. No solution is perfect for all people and may take an adaptation period. But what people do not often realize is snoring is a warning noise produced by the force of air through a narrowed upper airway caused by the collapse of the soft tissue in the back of the throat. It is an indication that there is a problem with normal breathing. Anytime we cannot get enough oxygen into our system we have a problem. As the problem progress the snoring gets louder and eventually the snoring is interrupted by pauses in breathing and then a gasping noise for breath. We must breath and as our oxygen levels go down a feedback mechanism in our body takes us out of a deep sleep to a lighter level of sleep so we can gasp for air. The snorer is never awake enough to remember or be aware of these episodes. This can happen a few times per night to several hundred times per night. The result is the snorer cannot get into a deep sleep where we feel rejuvenated in the morning and rested. This is sleep apnea.
Sleep Apnea
Apnea is present when we do not breathe for 10 seconds or longer. This causes our blood oxygen levels to drop which takes us out of deep sleep so we can gasp for breath and get the oxygen levels back up in our blood. This can happen a few times per night or several hundred times per night resulting in no deep sleep and many health problems. There are two types of sleep apnea: central and obstructive. Central sleep apnea is much less common and is a problem in the regulatory function of the brain or heart. This occurs most frequently in people who have chronic congestive heart failure, stroke, prolonged
opioid drug use, heart or kidney disease. Obstructive Sleep Apnea is more common and is caused by the physical blockage of the airway at night by the tissue in the back of the throat collapsing to block the airway. This keep oxygen from getting to the lungs as the muscles and thus tissue relax in the throat as you sleep combined with the force of gravity causing the tongue to fall back and block the airway when you lay down.
Normal Breathing
Obstructive Sleep Apnea
Can Snoring and Sleep Apnea be serious?
Snoring can be serious both medically and socially. Snoring can disrupt marriages and cause sleepless nights for bed partners. Medically snoring can be a precursor of obstructive sleep apnea that has been linked to heart failure, high blood pressure and stroke. Often people with large necks, overweight and large uvula and soft palate or nasal congestion or all of the above can be more likely to die in their sleep as their heart disease advances since the heart is already compromised. These are people who you hear of having a heart attack in their sleep. Snoring is associated with Types II Diabetes and a higher rate of heart disease in its own right. People with untreated Obstructive Sleep Apnea suffer from daytime fatigue, sleepiness and irritability. Additionally they have higher rates of high blood pressure, heart disease, stroke, depression and erectile dysfunction. Often people with severe untreated sleep apnea will fall asleep at a stop light or dose off (micro sleep) for a moment while driving, sometimes causing them to swerve or loose control of their car. The daytime fatigue associated with the lack of quality sleep can affect your job performance, memory loss, affect your ability to concentrate make you irritable and affect your relationships.
Warning Signs
Snoring interrupted by a pause in breathing and then gasping (sudden intake of air)
Daytime Fatigue and falling asleep at inappropriate times
Loud Snoring
Trouble with concentrating, poor memory, depression, irritability, or loss of sex drive
Headaches, frequent nighttime urination, dry mouth, sore throat or nausea in the morning.
Unfortunately you cannot diagnose yourself. As long as you snore you are at risk and until you have a sleep study you do not know as not all people have symptoms.
Diagnosis ( How do you know if you have OSA?)
Taking a simple test below is a starting point but be sure to visit your physician or dentist (if they offer home sleep studies ) if you think you have a problem. This test is for daytime sleepiness not specifically for snoring and apnea.
Epworth Sleepiness Scale
The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to see a sleep specialist. These issues should be discussed with your personal physician.
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze or sleep.
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
Print out this test, fill in your answers and see where you stand.
| Situation | Chance of Dozing or Sleeping |
Sitting and reading |
____ |
Watching TV |
____ |
Sitting inactive in a public place |
____ |
Being a passenger in a motor vehicle for an hour or more |
____ |
Lying down in the afternoon |
____ |
Sitting and talking to someone |
____ |
Sitting quietly after lunch (no alcohol) |
____ |
Stopped for a few minutes in traffic |
____ |
Total score (add the scores up) |
____ |
Questionnaire for Sleep Apnea Risk
Assess your risk for sleep apnea. The total score for all 5 sections is your Apnea Risk Score. Print out this questionnaire, write in your best answer for each question and see where you stand.
A. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?
1. Never
2. Rarely (less than once a week)
3. Occasionally (1 - 3 times a week)
4. Frequently (More than 3 times a week)
Answer_____
B. How often have you been told that you have "pauses" in breathing or stop breathing during sleep?
1. Never
2. Rarely (less than once a week)
3. Occasionally (1 - 3 times a week)
4. Frequently (More than 3 times a week)
Answer_____
C. How much are you overweight?
1. Not at all
2. Slightly (10 - 20 pounds)
3. Moderately (20 - 40 pounds)
4. Severely (More than 40 pounds)
Answer______
D. What is your Epworth Sleepiness Score?
1. Less than 8
2. 9 -13
3. 14 - 18
4. 19 or greater
Answer ______
E. Does your medical history include:
1. High blood pressure
2. Stroke
3. Heart disease
4. More than 3 awakenings per night (on the average)
5. Excessive fatigue
6. Difficulty concentrating or staying awake during the day
Answer ______
If you answered 3) or 4) for questions A-D, especially if you have one or more of the conditions listed in question E, then you may be at risk for sleep apnea and should discuss this with your physician.
Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.
If your score is high and you consult your physician they will most likely refer you to a sleep specialist or a sleep center to have a polysomniogram done. You will spend the night at a sleep facility hooked up to monitors to record your oxygen saturation level, sleep cycles, snoring, apnea episodes, respiration, etc. A much more comfortable way to have a sleep study done is with a device you wear overnight at home on your head or arm, this is called a home sleep study. Either way you will get a report from which your dianosis and severity can be made.
TREATMENT OPTIONS
Benign snoring can be treated by sleeping on your side, using aids to keep you on your side, raising the head of the bed so it is not flat, weight loss, avoiding alcohol and drugs for sleep aids. If these simply measures do not prove sufficient then Surgical procedures by a ENT specialist who concentrates their practice on airway procedures or an oral appliance by a dentist who has experiences and treats snoring and sleep apnea.
Obstructive Sleep Apnea (OSA) is most commonly treated by CPAP (continous positive air pressure applied through a nasal mask and is considered the “gold standard” in treating OSA . It will treat it 100% of the time and for this reason is always recommended by the medical profession. The problem is multiple research articles have shown CPAP is have as low as a 50% compliance level. Meaning only 50% of the patients use the device because of discomfort and inconvience. OSA suffers who do not use the machine increase their risk of heart failure, high blood pressure, stroke, can be drowsy during the day and can fall asleep while driving, snore, gasp for air and choke loudly.
Severe levels of OSA diagnosed in a sleep study can only be treated effectively with CPAP machines. Mild and Moderate OSA have alternatives if they are CPAP intolerant.
Problems people have with CPAP.
· The mask is uncomfortable
· The mask is taken off at night without knowing it
· The mask is taken off at night to use the bathroom and it’s too much bother to put it back on
· The mask irritates the skin and the nose
· Air in the stomach or sinuses
· The mask leaks air
· The pressure of the CPAP is bothersome
· The CPAP machine is too noisy to allow sleep
· The tubing gets in the way
· You just can’t get used to the mask
· The mask gives you a feeling of claustrophobia
· Your nose can be stuffy because of a cold or allergies
· The air is too hot, too cold or too
Surgery is another option that may help OSA patients by removing tissue from the upper airway to increase the size in the back of the throat or by expansion of the jaw structures that restrict the space for the throat. The success rate varies greatly as the obstructions vary between individuals. In general as the severity of OSA increases so does the invasiveness of the required procedure to achieve a successful result. Some procedures have higher relapse rates than others.
Oral Appliances
Oral appliance therapy, provided by dentists specifically trained in the use of these devices, can be an effective alternative to CPAP. A recent parameters paper published in the journal Sleep by the American Academy of Sleep Medicine stated that oral appliances can be used as first-line therapy in some patients for treating mild-to-moderate obstructive sleep apnea. The guidelines state
“Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change.”
Oral appliances, which resemble sports mouthguards are associated with better compliance than CPAP systems for many patients. Oral appliances can also be used as first-line treatment for primary snoring that is not associated with obstructive sleep apnea.
These appliances should be fitted by dentists specifically trained in oral appliance therapy and those experienced in treatment of temporomandibular joint and dental occlusion. Treatment with oral appliances should be followed on a regular basis and have follow up polysomnography.
