Snore-Gonomics - Snoring

Sleep Apnea

Sleep apnea, a disruption of breathing while asleep, is a particularly tricky sleep disorder - 90% of people who have sleep apnea don’t know that they have it! Although episodes of choking or gasping for air might occur hundreds of times throughout the night, you may not have any recollection of struggling for breath.

Usually it is the bed partner who first notices that the person is struggling to breathe. If left untreated, this common disorder can be life-threatening.

Signs and symptoms of sleep apnea

Warning signs and symptoms of sleep apnea include:

• Frequent cessation of breathing (apnea) during sleep. Your sleep partner may notice repeated silences from your side of the bed.

• Choking or gasping during sleep to get air into the lungs.

• Loud snoring.

• Sudden awakenings to restart breathing.

• Waking up in a sweat during the night.

• Feeling un-refreshed in the morning after a night’s sleep.

• Headaches, sore throat, or dry mouth in the mornings after waking up.

• Daytime sleepiness, including falling asleep at inappropriate times, such as during driving or at work.

Rob’s struggle with Sleep Apnea

Rob’s wife, Eileen was always bothered by his snoring, but she became more troubled when she noticed that throughout the night he would stop breathing periodically, seeming to wake up to restart his breathing and then fall back asleep again. Rob occasionally remembered waking up during the night, but for the most part, he did not remember the gaps in breathing. He did, however, know that he was always tired during the day.

Is snoring the same as sleep apnea?

Snoring and sleep apnea are not the same thing. Snoring is simply a loud sound that you make during breathing while asleep if there is any obstruction in your airway. While it may be unpleasant for your sleep partner, snoring is not in itself a harmful condition. On the other hand, people with sleep apnea are deprived of oxygen due to a complete blockage of airways, which can have a major impact on health.

Snoring does often accompany sleep apnea, but just because you snore does not mean you have sleep apnea.

Types of sleep apnea

There are three types of sleep apnea: obstructive, central, and mixed.

Obstructive Sleep Apnea (OSA)

OSA is the most common type of sleep apnea. It is caused by a breathing obstruction, which stops the air flow in the nose and mouth. The rest of this article discusses, in length, the causes, symptoms and treatments for OSA.

Central Sleep Apnea (CSA)

Central sleep apnea is a far rarer type of sleep apnea, which occurs when the brain signal that instructs the body to breathe is delayed. This central nervous system disorder can be caused by disease or injury involving the brainstem, such as a stroke, a brain tumor, a viral brain infection, or a chronic respiratory disease. People with CSA seldom snore, which makes it even harder to diagnose as they do not fit the “normal” profile of a sleep apnea sufferer. However, while the causes of the breathing cessation are different in CSA and OSA, the symptoms and results are much the same - a deprivation of oxygen and poor sleep due to repeated awakenings at night. The treatments for CSA include specific medications that stimulate the need to breathe and administration of oxygen.

Mixed sleep apnea

Mixed sleep apnea is a combination of the two other types of sleep apnea, Obstructive Sleep Apnea and Central Sleep Apnea. A person with mixed sleep apnea will often snore, but finds that treatments which only help obstructions in the airways do not completely stop apnea episodes. Treatment usually includes a combination of the treatments used for OSA and CSA.

Causes and risk factors of obstructive sleep apnea

When you have obstructive sleep apnea, your throat collapses during sleep, blocking the airway and preventing air from getting to the lungs. Generally, your throat muscles keep the throat and airway open.

Causes and risk factors of sleep apnea:

• Shape of head and neck may create a smaller than normal airway.

• Large tonsils or adenoids or other anatomical differences. (A deviated septum, enlarged tongue, or receding chin can also create difficulties breathing during sleep)

• Being overweight or obese (although almost 50% of people with sleep apnea are not obese)

• Throat muscles and tongue relax more than normal during sleep. (This can be due to alcohol or sedative use before bedtime, but not necessarily)

• Snoring - Snoring can cause the soft palate to lengthen, which in turn can obstruct the airway.

• Smoking or exposure to secondhand smoke

• Nasal congestion, nasal blockages, and nasal irritants

• Family history of sleep apnea - No specific genetic marker for sleep apnea has been discovered, but obstructive sleep apnea seems to run in families. This may be a result of anatomic abnormalities that run in the family

• Other disorders and syndromes - Hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post-polio syndrome, neuromuscular disorders, Marfan’s syndrome, and Down Syndrome

• Other physical conditions, such as immune system abnormalities, severe heartburn or acid reflux and high blood pressure. It isn’t clear whether the conditions are the cause or the result of sleep apnea

Effects of sleep apnea on health

What happens when you stop breathing during sleep?

If you have sleep apnea, you stop breathing during sleep, and the balance of oxygen and carbon dioxide in the blood is upset. This imbalance stimulates the brain to restart the breathing process. The brain signals you to wake up so that the muscles of the tongue and throat can increase the size of the airway. Then, carbon dioxide can escape, and oxygen can enter the airway. These waking episodes are necessary to restart breathing (and to save your life), but because of them, you become sleep-deprived.

Sleep apnea has serious health consequences and can even be life-threatening. The main effects of sleep apnea are sleep deprivation and oxygen deprivation.

Sleep deprivation

Both the person with sleep apnea and the bed partner suffer from sleep deprivation. A bed partner may lose an hour or more of sleep each night from sleeping next to a person with sleep apnea. Along with the apnea episodes, the person afflicted with sleep apnea may have additional trouble sleeping caused by side effects of the condition, including a frequent need to get up and urinate during the night, and excessive nighttime sweating.

Some trickle-down effects of sleep deprivation are a compromised immune system, poor mental and emotional health, irritability, and slower reaction time, among other problems.

Oxygen deprivation

When you stop breathing, your brain does not get enough oxygen. Drastic problems can result from the oxygen deprivation of sleep apnea, including heart disease, high blood pressure, sexual disfunction, and learning/memory problems.

Depression and sleep apnea

Approximately one in five people who suffer from depression also suffer from sleep apnea, and people with sleep apnea are five times more likely to become depressed. Existing depression may also be worsened by sleep apnea. While it is not clear whether the apnea causes the depression or vice-versa, studies show that by treating sleep apnea symptoms, depression may be alleviated in some people.

Diagnosing sleep apnea

Before you visit a doctor for a possible diagnosis of sleep apnea, ask your spouse or sleeping partner to keep a sleep diary for you. For a few nights, a willing sleep partner can record if you are snoring and how loud your snoring is, how well you are sleeping, whether you are having trouble breathing (that is, choking or gasping), and any other troubling symptoms.

If you don’t have someone to record your sleep patterns, try taping yourself. You can use a sound-activated audio recorder or a software program that turns your computer into a recorder. If you don’t have access to recording equipment, it may be worthwhile to ask a friend or loved one to monitor your sleep pattern for a few nights, or visit a sleep center for observation.

With your sleep record in hand, consult a knowledgeable doctor or a sleep specialist. To diagnose for sleep apnea, the doctor or specialist will examine your mouth and nose to look for obstructions and possibly perform other tests such as an endoscopy of your nose and throat, x-rays, or a CT scan of the head and neck.

If your doctor suspects sleep apnea, he or she will likely recommend an overnight sleep study in a sleep clinic (also known as a sleep lab or sleep center). Sleep tests in a sleep clinic help to diagnose sleep apnea by measuring how frequently you stop breathing.

Self-help Treatment for sleep apnea

Minor sleep apnea is responsive to self-help remedies, or “behavioral treatments.” Some of the following self-help treatments for sleep apnea may work for you.

• Lose weight. Overweight individuals who lose even 10% of their weight can reduce sleep apnea during the night and dramatically improve the quality of their sleep.

• Eliminate the use of alcohol, tobacco, and sedatives such as sleeping pills. Avoiding the use of alcohol, tobacco, and sleeping pills can reduce the likelihood of airway closure during the night.

• Sleep on your side. People who experience sleep apnea only when they sleep on their backs can benefit from special pillows or folk remedies that encourage side-sleeping, such as the “tennis ball trick” (putting a tennis ball under you to make back-sleeping uncomfortable).

• Regularize your sleep hours. Irregular sleep hours can throw off your sleep cycles and lead to breathing problems during the most important sleep stages. Stabilizing bedtime hours and eliminating disturbances to your sleep can reduce sleep apnea.

Treatment for sleep apnea

Continuous Positive Airway Pressure (CPAP)

Positive airway pressure, the most widely recommended treatment for moderate to severe obstructive sleep apnea, entails wearing a mask-like device while you sleep that supplies pressurized air, which helps prevent the airway from collapsing. The most common of these devices is called CPAP (Continuous Positive Airway Pressure), which provides constant air pressure regardless of whether you are breathing in or out.

While CPAP works very well in preventing apnea symptoms, many people find the apparatus uncomfortable and difficult to use. Luckily, recent advancements to CPAP technology have made these once cumbersome devices much lighter and quieter. Newer styles provide options, so that users can find one that works best for them. Recent refinements include options such as “bilevel PAP”, which switches from higher to lower air pressure during the exhalation, making breathing easier for some, and “AutoPAP”, which uses an internal regulator that adjusts pressure rather than remaining at one fixed setting.

CPAP can be cost-prohibitive - the devices can cost up to $1000 or more - but they are usually effective when used correctly. Unfortunately, many people don’t receive proper coaching and guidance for using these breathing devices, and give up on them quickly.

The following tips may help you use CPAP more comfortably and successfully:

• Don’t “self-medicate” with CPAP. Your doctor should help you in obtaining the device, and will probably suggest a night at a sleep lab where experts can adjust air pressure for your individual needs. The mask needs to fit correctly and be used in specific ways, and your doctor can help achieve optimal results.

• Irritation can be soothed. Some find that the mask irritates the skin or nose. There are special skin moisturizers for CPAP users, and nasal pillows can be worn in the nostrils to relieve pressure on the nose.

• Find out if you’re a mouth breather. For those who breathe through the mouth rather than the nose at night, a full-face mask will work better that the normal CPAP, which just covers the nose.

• Take your time. Adjusting to the CPAP takes time. Try wearing it for just a few hours per night, and increase the time incrementally every night. Talk to your doctor about specific issues, as most problems can be addressed. For example, some find the constant air pressure makes it difficult to breathe. Rather than giving up on CPAP, you doctor can switch you to a bilevel device, which lowers air pressure when you exhale. This treatment is effective enough to give it your best shot - keep trying until you adjust to wearing the device.

Dental appliances, oral devices, and lower jaw adjustment devices

Most dental devices are acrylic and fit inside your mouth, much like an athletic mouth guard or orthodontic appliance. Some others fit around your head and chin to adjust the position of your lower jaw. Two common oral devices are the Mandibular Repositioning Device and the Tongue Retaining Device. These devices open your airway by bringing your lower jaw or your tongue forward during sleep.

While oral devices are less cumbersome than CPAP and relatively simple to use, they are only effective for mild to moderate sleep apnea. There are also a number of troubling side effects from using this type of treatment - soreness; damage to/permanent change in position of the jaw, teeth, and mouth; saliva build-up; and nausea. It is vitally important to get fitted for these devices by a dentist that specializes in sleep apnea, and continue to see the dentist on a regular basis to monitor for any dental problems that may occur.

Surgery as treatment

Certain types of surgery can increases the size of your airway by surgically removing tissues. The surgeon may remove tonsils, adenoids, or excess tissue at the back of the throat or inside the nose. Or, the surgeon may reconstruct the jaw to enlarge the upper airway.

Surgery may be an effective option for some, and can even provide permanent relief from symptoms. However, any surgery carries risks of surgical complications and infections, and in some rare cases, symptoms have worsened after surgery. If you have exhausted other apnea treatment options, or find the non-surgical treatments intolerable, you may want to discuss surgical options with your doctor or sleep specialist.