Snoring: It May Be More Serious Than It Sounds
Do you snore loudly? Or dream about getting a good night's sleep? Wake up and read on—help is available for what may ail you. Your problems may be caused by sleep apnea , a very common problem that affects millions of Americans each year.
If your bed partner is ready to wear earplugs due to your loud snoring, you're not alone: an estimated 30 million Americans ring the air with their nighttime snoring. But of these 30 million, it is estimated that 12-18 million actually suffer from sleep apnea, a potentially life-threatening condition in which breathing is disrupted during sleep. Sleep apnea has been associated with high blood pressure , cardiovascular disease, pulmonary hypertension, memory problems, weight gain, impotency , bedwetting in adults, and headaches. Because apnea occurs during sleep, though, it is often unrecognized as a cause or aggravating factor of these problems
Apnea occurs in men and women of all age groups, but is currently thought to be about two to three times more common in men. According to the National Sleep Foundation, "People most likely to have or develop sleep apnea include those who snore loudly and are also overweight, or have high blood pressure, or have some physical abnormality in the nose, throat, or other parts of the upper airway. Sleep apnea seems to run in some families, suggesting a possible genetic basis."
While sleep apnea has been thought to be more common in middle-aged and older patients, a recent study sponsored by the National Institutes of Health at the Milton Hershey Medical Center in Pennsylvania concluded that the most severe cases of apnea occur in young people under age 45. The study recommended that people be treated more aggressively once a diagnosis has been made to reduce hypertension and cardiovascular problems.
What Is It, Exactly?
By far the most common type of sleep apnea is obstructive sleep apnea . This occurs when the soft tissue of the throat collapses and blocks or closes the victim's airway causing cessation of breathing followed by snoring or snorting and gasping. This results in repeated awakenings—perhaps hundreds per night—when the brain signals the sufferer to arouse and resume breathing. People with sleep apnea are not usually aware of the awakenings but do experience extreme daytime sleepiness. "The pathological sleepiness caused by sleep apnea can have serious medical, legal, and economic consequences," says Dr. Richard Waldhorn, President of the American Sleep Apnea Association and Medical Director of the Georgetown University Sleep Disorders Center.
The other type of sleep apnea is called central sleep apnea . This type results from a defect in the central nervous system (brain) that interrupts the normal flow of information controlling breathing during sleep. This type is quite rare.
Daytime Sleepiness & Other Dangers
It is common but misguided to view daytime sleepiness as a necessary cost of a hard-working, hard-playing, or fast-lane lifestyle. Daytime sleepiness may actually be a sign of a sleep disorder or of sleep deprivation. Although sufficient restorative sleep is necessary for good health, many people view sleepiness as a testament to the fullness of their lives. Therefore, it's rarely mentioned in any discussion of personal health.
Daytime sleepiness is dangerous—not just to the sufferer but to those around him as well. Anyone can be sleep deprived. Exhausted people drive on our highways, operate machinery, fill our prescriptions, work in emergency rooms, care for our children, and patrol our neighborhoods. Sleepiness sufferers themselves are often unlikely to be aware that they have a problem. After experiencing daytime sleepiness for extended periods, people tend to forget how good it feels to be fully awake and alert. They no longer recognize their sleepiness as being out of the ordinary.
Those with untreated obstructive sleep apnea are not only putting others at risk; they are risking great personal danger as well. "In recurring apnea, your oxygen level drops and blood vessels in the lungs constrict, resulting in pulmonary hypertension. Then the right side of the heart fails to pump properly," says Waldhorn. "Apnea can predispose people to heart arrhythmia and other problems." In fact, a study by US and German researchers, published in Stroke , a journal of the American Heart Association, found that patients with obstructive apneas and hypopneas (heavy snoring) are at increased risk of stroke . Scientists believe this to be a result of negative thoracic (chest) pressure created by the cessation of breathing, which then causes a reduction in blood flow in the middle cerebral artery, leading to stroke.
Smoking, drinking alcoholic beverages, and being overweight are all predisposing factors of obstructive apnea. According to Waldhorn, about 70% to 80% of patients with sleep apnea are overweight. "Being 120% to 150% over one's ideal body weight may be enough to predispose someone to apnea," he says. Individuals with sleep apnea should also avoid drinking alcohol within four hours of their bedtime. Other risk factors for apnea include a family history, hypertension, and heart disease , all good reasons to seek diagnosis and treatment if you feel you may have apnea. Men whose bed partners have complained about the nighttime noises, snores, snorts, gasps, etc, should also be evaluated. So should people who just feel tired all the time. "Often the thing that motivates patients to be evaluated is that their sleepiness is interfering with their daytime activities," adds Waldhorn. "They just feel miserable."
Other risk factors include:
Tests and Treatments
If your healthcare provider feels you may have apnea, says Waldhorn, you should be seen at a sleep lab accredited by the American Sleep Disorder Association. (There are now more than 100 such labs throughout the US.) Tests for sleep apnea include:
According to the National Sleep Foundation, this is a test that records different body functions while you sleep, including electrical activity in the brain, eye movement, heart rate, respiratory effort, air flow, and blood oxygen levels. These tests are used both in making a diagnosis of apnea and determining its severity.
The Multiple Sleep Latency Test (MSLT)
This test, says the NSF, measures the speed with which a patient falls asleep by giving him or her several opportunities to fall asleep during the daytime hours. The length of time it takes the patient to fall asleep is measured. Those who fall asleep in less than five minutes are likely to require some treatment for sleep disorders. This test measures the degree of daytime sleepiness and can rule out other types of sleep disorders.
Medication is not generally effective in treating sleep apnea. Behavioral changes such as avoiding alcohol, tobacco, and sleeping pills, weight loss, a change in sleeping position from back to side, or even elevating the head of the bed may cure mild cases. Relieving nasal congestion can also be helpful. If symptoms are unresponsive to these measures, nasal continuous positive airway pressure (CPAP) may be prescribed. CPAP involves the use of a nose mask while asleep. Constant pressure from an air blower attached to the mask forces air through the nasal passages to prevent the soft tissue of the throat from collapsing during sleep. Some patients with mild apneas have also found certain dental appliances to be helpful. Waldhorn is an advocate of CPAP, stating: “For patients with severe sleep apnea, I usually try nasal CPAP first. Patients with severe apnea sometimes see dramatic results in only one or two nights.” While patients may have difficulty tolerating some of the treatments, compliance with doctor's orders can pay off. Many times, cardiovascular problems will begin to reverse when apnea treatment is instituted.
Dental appliances may sometimes be worn to position the tongue and jaws and improve breathing.
Surgery is sometimes performed but, says Waldhorn. "Ironically, surgery works best in mild to moderate cases of apnea. Types of surgery performed for sleep apnea include removal of tissue at the back of the throat (uvulopalatopharyngoplasty, or UPP, which can be performed via laser), radiofrequency ablation of tissue at the back of the tongue, tonsillectomy , and adenoidectomy . Sleep apnea also occurs in children, even in those under three years of age. Many of these children do benefit from surgery, usually the removal of tonsils and adenoids.
"Apnea is a potentially reversible condition," Waldhorn adds. "People treated for the condition are tremendously relieved to be functioning so much better."
American Sleep Apnea Foundation
National Sleep Foundation
The Sleep Well Center
American Sleep Apnea Association. Wake Up Call: The Wellness Letter for Snoring and Sleep Apnea.
American Sleep Apnea Foundation website. Available at: http://www.sleepapnea.org .
Kotagal S. Childhood obstructive sleep apnoea. BMJ. 2005;330:978-979.
Li KK. Surgical therapy for adult obstructive sleep apnea. Sleep Med Rev. 2005;9:201-209.
Sleep Channel website. Available at: http://www.sleepdisorderchannel.com/osa/ .
Stewart MG, Glaze DG, Friedman EM, Smith EO, Bautista M. Quality of life and sleep study findings after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2005;131:308-314.
Last reviewed May 2007 by Elie Edmond Rebeiz, MD, FACS
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