TGIF folks! It has been a wet wet week indeed! ideal for sleeping in!
An increasing number of our population snore 😴 and its not just men! Whilst up to 50 percent of men snore, about 30 percent of women snore too! Some wives worry that their husbands "experience very restless sleep, then stop breathing "and then they start gasping".... they worry that they may even die in their sleep! Today, I just saw a couple in their 30's with this exact scenario; the husband himself is oblivious to his disordered breathing during sleep, but his wife is so worried.
So why do we snore? is it simple snoring? Or is there some more sinister health risk? Do household remedies really work? Should I try to lose weight? These are some of many questions our patients ask us.
So today, we will look at Snoring and Obstructive Sleep Apnoea (OSA)
From gentle snuffles to loud rasps and snorts, snoring is common. An estimated 45 percent of adults snore occasionally, while 25 percent snore regularly—often disturbing their bed partner’s sleep and possibly their own, too.
You’re more likely to snore if you’re overweight, are a middle-aged or older man, or are a postmenopausal woman. These night noises usually worsen with age.
Why do people snore? Snoring is the sound of obstructed breathing, which can be caused by some basic factors, such as nasal congestion (allergies), poor muscle tone, bulky throat tissue, or a long soft palate or uvula. It may also be a red flag that you have a treatable health condition that is interfering with breathing while you sleep—such as nasal congestion caused by a sinus infection or allergy, nasal polyps (noncancerous growths in the nose) or a deviated nasal septum. Many OSA patients wake up feeling tired and unrefreshed, with a dry or sore throat.
In some cases, snoring may be related to more serious, even life-threatening, health concerns.
Sleep Apnoea
“Snoring—especially loud snoring broken up by pauses in breathing and loud snorts or gasps as the sleeper takes a breath again—can be a sign of obstructive sleep apnoea” says Johns Hopkins sleep expert Alan Schwartz, M.D. “Sleep apnea is a serious risk factor for cardiovascular disease. It should be found and treated as early as possible.”
Obstructive sleep apnoea (OSA) is a condition in which one's breathing stops involuntarily for brief periods of time during sleep. Normally, air flows smoothly from the mouth and nose into the lungs at all times. Periods when breathing stops are called apnoea or apnoeic episodes. In OSA, the normal flow of air is repeatedly stopped throughout the night. The flow of air stops because the airway space in the area of the throat is too narrow. Snoring is characteristic of obstructive sleep apnoea. Snoring is caused by airflow squeezing through the narrowed airway space. Untreated sleep apnoea can cause / aggravate serious health problems such as:
hypertension
heart disease
stroke
diabetes
What happens in OSA?
When you fall asleep, your body's muscle tone relaxes and the tongue and soft tissues tend to fall backwards and block your upper airway. This blockage can happen at many levels eg nasal, soft palate, tonsils, adenoids, tongue, tongue base & hypo-pharynx. Each level contributes to the blockage. If you are overweight, the blockage is further accentuated.
Illustration to show how OSA happens when you fall asleep (from MEDLINE)
What Sleep Apnoea Does to Your Body
Why is sleep apnoea such a major health concern?
Well, if left untreated, it can quickly wreak havoc on your body. OSA affects many different systems in your body, as it can negatively impact your breathing and sleep. Medical experts believe that this is why those with OSA have an increased risk for so many serious health issues. Sleep apnea also disrupts your rest and can cause mental health problems due to sleep deprivation.
Decreased Blood Oxygen Levels
When you stop breathing at night due to OSA, that means you’re not getting as much oxygen as you should. This can lower your blood oxygen SaO2 levels (how much oxygen your red blood cells are carrying). Therefore, your body may not be able to get as much oxygen to your vital organs like your heart and brain, both of which require oxygen to function properly.
Getting too little oxygen because of sleep apnea may also increase your risk for oxidative stress. Oxidative stress is a condition where there are more free radicals in your body than antioxidants. This can damage your cells and may accelerate the ageing process.
Once your body senses that you’re not getting enough oxygen during sleep, your brain will suddenly wake you up to help you breathe. Waking up frequently throughout the night is also called sleep fragmentation, which also comes with some serious health effects.
Sleep Fragmentation and Excessive Daytime Sleepiness
Sleep fragmentation is also another common issue for people with OSA. Sleep fragmentation is where you have frequent short interruptions in sleep. This can make it difficult to reach the deep phases of sleep, which is where your body goes through a healing & recovery process and lets your cardiovascular system rest.
Waking up throughout the night because of sleep apnoea can also make you extremely tired during the day. Daytime fatigue or Excessive Daytime Somnolence is a common sign of sleep apnoea. Now, feeling sleepy may not sound like anything more than annoyance, but it is actually pretty serious. Many people with daytime fatigue because of OSA struggle with work performance, feel irritable, and even have a higher risk for car and work accidents. We oft read of lorry or taxi drivers who fall asleep at the wheel, endangering themselves and other commuters.
Inflammation effects
OSA may increase your risk for chronic inflammation throughout your body. Low blood oxygen levels and a cardiovascular system in overdrive because of a lack of rest can trigger inflammation in your body. Chronic inflammation is a common sign of ageing. Inflammation can also damage healthy cells and increase your risk for health conditions like heart disease and some types of cancer, with increased production of free radicals.
Weight Gain
Now, being overweight can increase your risk for developing sleep apnoea, but OSA may also lead to weight gain. For example, daytime fatigue from OSA can make it hard to get enough exercise. It may also cause you to reach for “easy energy” junk foods with high calories, sugar, and simple carbs, setting up a self-reinforcing negative loop of over-eating.
Also, a lack of sleep can even affect the hunger hormones in your body. Sleep is necessary for keeping hormones in balance, including the ones that regulate appetite. Sleep disruptions throughout the night due to OSA can throw these hormones off balance. This can make you feel hungry when you should be full.
Being overweight also poses other serious health risks, like heart problems, diabetes, and even death.
Q: What should you do if you are concerned about Snoring & OSA?
It is best to seek early consultation with your GP or ENT Specialist to review your medical history, check your BMI, Blood Pressure, perform a Naso-Endoscopy to evaluate the upper aero-digestive tract and finally arrange a Sleep Study or PSG (polysomnography).
For sleep studies, there are various levels of testing, from home based studies to those performed in a sleep laboratory:
Polysomnography. During this sleep study, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep You might be monitored all night, or part of the night in a split-night sleep study. In a split-night sleep study, you'll be monitored during the first half of the night. If you're diagnosed with obstructive sleep apnea, staff may wake you and give you continuous positive airway pressure for the second half of the night. This sleep study can also help look for other sleep disorders that can cause excessive daytime sleepiness but require different treatments, such as leg movements during sleep (periodic limb movements) or sudden bouts of sleep during the day (narcolepsy).
Home sleep apnea testing. Under certain circumstances, your doctor may provide you with an at-home version of polysomnography to diagnose obstructive sleep apnea. This test usually involves measurement of airflow, breathing patterns and blood oxygen levels, and possibly limb movements and snoring intensity.
Sometimes, your ENT specialist may also arrange a DISE (drug induced sleep endoscopy) whereby you are sedated and the naso-endoscopy is performed as you sleep and snore. This gives us a clearer idea of the various levels of possible blockage in your airway. This DISE is done in the hospital under close supervision with an Anaesthetist to ensure your safety.
Q: What are the treatment options for OSA?
There are many options, conservative and surgical, for managing OSA.
Firstly, there are simple life-style changes you can adopt:
Lifestyle changes
For milder cases of obstructive sleep apnea, your doctor might recommend lifestyle changes to start with:
Lose weight if you're overweight. Plan to lose 1/2 kg per month is a reasonable target.
Exercise regularly. This improves your muscle tone and general health.
Drink alcohol moderately, if at all. Don't drink before bedtime.
Quit or reduce smoking.
Use a nasal decongestant or allergy medications, if needed. I recommend my patients to use a nasal douche and nasal spray half an hour prior to their bedtime.
Sleep on your side; Don't sleep on your back. This manouver helps to open up the upper airway as you sleep.
Avoid taking sedative medications such as anti-anxiety drugs or sleeping pills.
Such lifestyle changes can make a BIG difference to improve your Snoring and OSA! So I always encourage my patients to try them out.
Schematic Summary of Treatment Options for OSA (from MedLine)
Therapies:
Continuous positive airway pressure (CPAP) and oral devices
Schematic illustration to show how CPAP is applied via a mask over the nose and mouth; there are many mask configurations available & it is important to select a well-fitting one for good comfort and compliance (from Wikipaedia)
Positive airway pressure:
If you have OSA, you may benefit from positive airway pressure. In this treatment, a machine delivers air pressure through a mask /prongs that fits into your nose or is placed over your nose and mouth while you sleep. Positive airway pressure reduces the number of respiratory events that occur as you sleep, reduces daytime sleepiness and improves your quality of life. The most common type is called continuous positive airway pressure, or CPAP (pronounced as SEE-pap). With this treatment, the pressure of the air breathed is continuous, constant and somewhat greater than that of the surrounding air, which is just enough to keep your upper airway passages open. This air pressure prevents obstructive sleep apnea and snoring.
Although CPAP is the most consistently successful and most commonly used method of treating obstructive sleep apnea, some people find the mask cumbersome, uncomfortable or loud. However, newer machines are smaller and less noisy than older machines and there are a variety of mask designs for individual comfort.
Also, with some practice, most people learn to adapt and adjust the mask to obtain a comfortable and secure fit. You may need to try different types to find a suitable mask. Several options are available, such as nasal masks, nasal pillows or face masks.
If you're having particular difficulties tolerating pressure, some machines have special adaptive pressure functions to improve comfort. You might also benefit from using a humidifier along with your CPAP system.
CPAP may be given at a continuous (fixed) pressure or varied (auto-titrating) pressure (APAP). In fixed CPAP, the pressure stays constant. In auto-titrating CPAP, the levels of pressure are adjusted if the device senses increased airway resistance.
Bilevel positive airway pressure (BPAP), another type of positive airway pressure, delivers a preset amount of pressure when you breathe in and a different amount of pressure when you breathe out.
CPAP is more commonly used because it's been well studied for obstructive sleep apnea and has been shown to effectively treat obstructive sleep apnea. However, for people who have difficulty tolerating fixed CPAP, BPAP or APAP might be worth a try.
Don't stop using your positive airway pressure machine if you have problems. Check with your doctor or sleep therapist to see what adjustments you can make to improve its comfort.
In addition, contact your doctor if you still snore despite treatment, if you begin snoring again, or if your weight goes up or down by 10% or more.
Mouthpiece (oral device):
Though positive airway pressure is often an effective treatment, oral appliances are an alternative for some people with mild or moderate obstructive sleep apnea. It's also used for people with severe sleep apnea who can't use CPAP. These devices may reduce your sleepiness and improve your quality of life.
These devices are designed to keep your throat open. Some devices keep your airway open by bringing your lower jaw forward, which can sometimes relieve snoring and obstructive sleep apnea. Other devices hold your tongue in a different position.
If you and your doctor decide to explore this option, you'll need to see a dentist experienced in dental sleep medicine appliances for the fitting and follow-up therapy. A number of devices are available. Close follow-up is needed to ensure successful treatment and that use of the device doesn't cause changes to your teeth.
Surgical Treatment Options:
Surgery is usually considered only if other therapies have not been effective or appropriate options for you. Surgical options may include:
Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which your doctor removes tissue from the back of your mouth and top of your throat. Your tonsils and adenoids may be removed as well. UPPP usually is performed in a hospital and requires a general anaesthetic.
Upper airway stimulation. This new device is approved for use in people with moderate to severe obstructive sleep apnea who can't tolerate CPAP or BPAP. A small, thin impulse generator (hypoglossal nerve stimulator) is implanted under the skin in the upper chest. The device detects your breathing patterns and, when necessary, stimulates the nerve that controls movement of the tongue. Studies have found that upper airway stimulation leads to significant improvement in obstructive sleep apnea symptoms and improvements in quality of life.
Jaw surgery (maxillomandibular advancement). In this procedure, the upper and lower parts of your jaw are moved forward from the rest of your facial bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. It may also alter your facial appearance.
Surgical opening in the neck (tracheostomy). You may need this form of surgery if other treatments have failed and if you have severe, life-threatening obstructive sleep apnea. During a tracheostomy, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. Air passes in and out of your lungs, bypassing the blocked air passage in your throat. During awake state, the tracheotomy can be plugged so that you can speak, and then unplugged when you are asleep. Nowadays, this a a RARE option for patients with OSA.
Sometimes, other types of surgery may help reduce snoring and sleep apnea by clearing or enlarging air passages, such procedures also help to improve CPAP mask fitting. They include:
Nasal surgery to remove polyps (nasal polypectomy) or straighten a crooked partition (septoplasty) between your nostrils (deviated septum)
Surgery to remove enlarged tonsils or adenoids, this is common in children and young adults who tend to have large obstructing tonsils and/ or adenoids (tonsillectomy / adenoidectomy).
Ultimately, there is no one magic formula for treating snoring and OSA; the treatment has to be designed and tailored to your particular situation and needs, taking into account all the different factors we have discussed above.
So, do make an appointment to see your GP or ENT Specialist to start the discussion.
One thing is clear: untreated OSA is highly detrimental to your health & well being. OSA should be treated so that you can live a LONG & HEALTHY life!
For more information and in-depth reading on snoring & OSA, here are some useful references.
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