Snoring and Sleep Apnea
- General Facts
- What is Snoring / Obstructive Sleep Apnea (OSA)
- Health Consequences of Obstructive Sleep Apnea (OSA)
- Health Consequences of Snoring
- Risk Factors of Having OSA
- Symptoms of Snoring / OSA
- Diagnosis of OSA
- Treatment / Management of OSA/Snoring
General Facts :
- Approximately 18 million Americans suffer from OSA making it as prevalent as asthma and diabetes.
- Approximately 40 % of adults over 40 snore.
- More than 4% of men and 2% of women have signs and symptoms of OSA.
- Most OSA sufferers remain undiagnosed and untreated.
- Most chronic snorers exhibit apnea tendencies.
- Approximately 50 % of OSA patients exhibit high blood pressure during wakefulness.
What is Snoring / Sleep Apnea?:
NORMAL BREATHING : In people who do not snore or have apnea
- The airway remains open during sleep.
- Air flows freely through the nose past the flexible structures in the throat and into the lungs.
SNORING : During snoring
- Muscles relax in the back of the throat narrowing the airway to a smaller opening.
- During breathing, air is forced through this smaller opening causing vibrations known as snoring.
- Although snoring may be harmless (benign snoring), it can also be a sign of a more serious medical condition which progresses from Upper Airway Resistance Syndrome (UARS) to Obstructive Sleep Apnea (OSA). See Health Consequences of Snoring.
OBSTRUCTIVE SLEEP APNEA (OSA) : During an apnea event
- The muscles in the throat relax and the tongue is sucked against the throat blocking the airway.
- The entire upper airway is blocked causing air flow to stop.
- Air (and oxygen) cannot flow into the lungs.
- When the oxygen level in the brain becomes low enough, the sleeper partially awakens, the obstruction in the throat clears, and the flow of air starts again – usually with a loud gasp or snort.
- People with untreated apnea are generally not aware of the awakenings but only of being sleepy during the day.
- Loud snoring, mixed with periods of silence (apnea), is typical but is not always present, especially in children.
- Obstructive sleep apnea is a life threatening and life altering condition that causes a person to stop breathing repeatedly during sleep. The oxygen deprivation that results can trigger severe health problems. The restless sleep that also results from OSA affects the quality of life of individuals. The bed partner’s sleep can also be disrupted by his or her partner’s snoring, pauses in breathing and restless sleep..
Health Consequences of Obstructive Sleep Apnea (OSA):
What happens if OSA is not treated?
People with OSA have disrupted sleep resulting in low oxygen levels. Both awakenings and oxygen deprivation can trigger severe health problems and decrease quality of life due to OSA’s links with:
- Chronic sleepiness (Excessive Daytime Sleepiness-EDS)
- Increased Motor Vehicle Accidents (People with OSA have three times a higher automobile accident or work-related accident than those in the general public)
- Increased work-related accidents
- Poor job performance
- Family discord (Loud snoring also disrupts the bed partner’s sleep causing frustration and anger in their relationship)
- Decreased quality of life
- High blood pressure
- Decreased sex drive
- Nocturia (a need to use bathroom frequently at night)
- Morning headache
- Systemic Hypertension
- Cardiac Arythmia’s
- Myocardial Ischemia
- Cerebrovascular Disease
- Pulmonary Hypertension
Health Consequences of Snoring:
If your bed partner snores, take the Sleep Observer Scale Quiz
If you snore, you are not alone. Statistics indicate that approximately 40% of adults over 40 snore at least some of the time. Snoring interrupts the restful quiet sleep which is so important to our and our bed partner’s good health. It can lead to daytime sleepiness and fatigue which can impact many aspects of an individual’s life. It can also have many health consequences.
Snoring is associated with increased risk of hypertension as well as an increased risk of both cardiovascular and cerebrovascular disease. Snoring, even without apnea, can lead to numerous arousal’s. Arousal’s have been linked to sympathetic nervous system activation which may provide a causal link between snoring and hypertension.
Risk Factors of Having OSA:
- Anatomy and physiology of the airway
- Malformation of the orofacial area (misaligned teeth, jaw and palate)
- Being overweight – obesity is a major risk factor, although thin people may develop severe sleep apnea as well
- Nasal congestion or obstruction – sinus trouble or allergies
- Large tonsils and/or adenoids, having a “crowded throat”, a large tongue or small jaw
- Lung disease, atrial fibrillation and heart failure
- Scoliosis or muscle weakness
- Sedating medicines and alcohol
- Hypothyroidism and certain other endocrine (hormonal) disorders
- Increasing age
- Family history
- Bruxism (teeth grinding)
- Polycystic Ovarian Syndrome (PCOS)
- Progesterone/Estrogen deficiency
- Male gender
- Neck size >17 inches in men, and >15 inches in women
- A decrease in tone of muscles holding airway open
Symptoms of Snoring / OSA:
Symptoms of OSA: Below are listed several common symptoms of apnea. However, it is important to note that symptoms of sleep apnea vary greatly in their intensity and that some individuals who have sleep apnea have very few symptoms.
- Excessive daytime fatigue/sleepiness (See our How Sleepy Are You Test?)
- Choking or gasping for breath while sleeping
- Difficulty falling or staying asleep
- Memory problems
- Weight change
- Falling asleep while at work, while driving, or other inappropriate times
- Fragmented, non-refreshing sleep
- Additional symptoms may include: morning headaches, difficulty concentrating, decreased sex drive, irritability, and gastro-esophageal reflux
Diagnosis of OSA:
A consultation, including a thorough sleep history and physical exam, is often the first step to diagnosing any sleep disorder including OSA. If it is determined you need a more detailed assessment, your primary care physician may refer you for an overnight sleep study (polysomnogram). This test records the patient’s brainwaves, heartbeat, respiratory effort, airflow, eye movement, blood oxygen levels and breathing during an entire night. Other sleep tests, such as a Multiple Sleep Latency Test (MSLT), may be performed to measure and assess the severity of daytime sleepiness, and to exclude other sleep disorders. In addition to your PCP, pulmonologists, neurologists, or other physicians with specialty training in sleep disorders may be involved in making a definitive diagnosis. Sleep apnea is easily diagnosed and must not be ignored.
Terminology upon testing :
- An apnea event - defined as a cessation of ventilation(breathing) for 10 seconds or longer.
- Apnea diagnosis - occurs when a person experiences 30 or more apnea episodes during a seven hour sleep period.
- Hypopnea - occurs when there is a partial obstruction somewhere in the airflow. It involves a decrease in oxygen levels in the blood (oxygen de-saturation-uptake of greater than 4%).
- RDI (Respiratory Disturbance Index ) / AHI (Apnea-Hypopnea Index) - average number of apneas plus hypopneas combined per hour of sleep.
- UARS (Upper Airway Resistance Syndrome) - this condition lies midway between benign snoring and true OSA. People with UARS suffer many of the symptoms of OSA, but sleep testing results lack evidence demonstrating true apneas or oxygen de-saturation.
Severity of Apnea defined by:
- Length of time of apnea event
- Percentage of oxygen de-saturation
- Complete or partial stoppage of breathing
- 5-15 events per hour = Mild OSA
- 15-30 events per hour=Moderate OSA
- 30+ events per hour=Severe OSA
NOTE: Many different factors contribute to the diagnosis of OSA. The above range is only a general breakdown. Other parameters such as lowest oxygen level obtained and length of apnea episodes during the sleep testing procedure effect the final diagnosis of this disorder.
Treatment/ Management of OSA
The specific therapy selected for an individual with OSA is based on the patient’s medical history, physical examination, and the results of the polysomnography. Multiple treatments are available for OSA including, but not limited to :
- Behavioral modifications (see below)
- Oral appliance therapy
- Pharmacological treatment – currently marginally effective
Behavioral Modification is an important part of all treatment programs, and in mild cases behavioral therapy may be all that is needed.
- Weight loss, if needed
- Regular exercise
- Avoidance of alcohol, sedatives, hypnotics, and tobacco
- Stress management
- Body positioning during sleep
Nasal Continuous Positive Airway Pressure Device (CPAP) – is the most common and effective treatment for sleep apnea and is considered the gold standard of treatment for OSA. It provides positive-pressure air through a nasal mask to keep airway open during sleep. Nasal CPAP is not “site specific” and is the only treatment which is effective regardless of the location of the obstruction and the severity of the disease. Although this treatment has helped many people, most cannot tolerate this method due to the discomfort and many side effects. Even when prescribed, only about 30% of patients will wear the CPAP.
Oral Appliance Therapy (OAT) – is a conservative treatment option using an oral appliance for patients to wear at sleep. These devices change the position of mouth structures to maintain an open, unobstructed airway in the throat. There are many types of oral appliances and selection as to which is to be constructed is based on many patient parameters. Proper design, construction, and follow-up care of these devices requires a trained dentist and in depth knowledge of jaw joints and sleep disorders. This type of treatment is “site specific” in that an OAT will have no effect on obstructions high in the upper airway or low in the airway. Patients usually prefer oral appliances to CPAP, however, CPAP is more effective in reducing number of apnea’s and increasing oxygen levels.
Surgery - except where abnormalities are present (nasal polyps, enlarged tonsils, deviated septum, or jaw malformations) surgery is only 50% effective and many cases which are initially successful fail within five years. The type of surgery that may be required is dependent on site and type of obstruction. Types of surgeries may include but not limited to:
- Uvulopalatopharyngoplasty (UPPP)
- Nasal surgery
- Tonsillectomy / adenoidectomy
- Maxillofacial surgery