Sleep Apnea and Snoring

Patterns, Causes and Treatment Options 

Although people who snore loudly are the frequent targets of bad jokes and the occasional victims of middle-of-the-night elbow thrusts, snoring is no laughing matter.

Loud snoring can be a signal that something is seriously wrong with your breathing during sleep. Snoring is a sign that the airway is not fully open, and the distinctive sound of snoring comes from efforts to force air through the narrowed passageway.

An estimated 10% to 30% of adults snore: for most of them, snoring has no serious medical consequences. For an estimated 5 in 100 people, however--often overweight middle-aged men--extremely loud habitual snoring is the first indication of a potentially life-threatening disorder: obstructive sleep apnea. Apnea is a Greek word that means "want of breath"

People with sleep apnea don't breathe properly during sleep. They don't get enough oxygen and their sleep is poor. Sleep apnea can lead to daytime sleepiness, and can trigger high blood pressure, heart failure, heart attack and stroke. Snoring loudly every night, in all positions, calls for a visit to a healthcare provider, who may suggest a series of studies at a sleep disorders center.

Fortunately, sleep specialists are now able to detect and diagnose breathing disorders in their earlier, more treatable stages. Proper treatment can prevent or reverse the potentially life-threatening consequences of sleep apnea.

Warning Signs of Sleep Apnea

In adults: Snoring may be so loud that it rivals a jackhammer and can be heard rooms away (or even by neighbors). A particular pattern of snoring interrupted by pauses, then gasps, reveals that the sleeper's breathing stops and restarts. Some people do not breathe at all for three-quarters of their sleep time.

Such seriously disturbed nights can produce extreme sleepiness during the day, interfering with work and personal life. People with sleep apnea may fall asleep at inappropriate time; such as at work or while driving. Sleep apnea sufferers are two to five times more likely to have car accidents than are those who don't suffer from this disorder.

People with sleep apnea may have trouble concentrating, and can become unusually forgetful, irritable, anxious, or depressed. These problems can appear suddenly or emerge gradually over many years. Sometimes the symptoms go unnoticed, or their significance is downplayed. Family members, employers, or coworkers may be first to recognize a pattern of changes in mood or behavior and encourage a visit to a healthcare provider.

Sometimes the sufferer seeks help for trouble sleeping. People with sleep apnea may notice that they are waking up frequently, gasping for air, and thrashing about in their sleep. They may complain about morning headaches and loss of interest in sex. Men may complain of erectile failure.

In children: Sleep apnea has been linked to some cases of sudden infant death syndrome (SIDS), although the exact relationship is still uncertain. Ongoing research is evaluating the role of sleep apnea as a possible factor in SIDS.

Sleep apnea may be present in children who are overweight and those who have enlarged tonsils and adenoids. Children with sleep apnea may snore, squeak, have difficulty breathing, and sleep fitfully. Since it is not normal for a child to snore, parents should report their child's snoring to a healthcare provider.

Older children who have sleep apnea may seem sluggish and may perform poorly in school. Sometimes they are labeled "slow" or "lazy."

What Causes Sleep Apnea?

Muscles relax more during sleep than they do during waking hours, including the muscles used in breathing. This process doesn't cause problems for most people, but in some people, the throat muscles relax to much. This relaxation interferes with breathing and makes sleep a time of increased risk.

In other people, the muscles relax to a normal degree during sleep, but a narrower-than-normal throat passage allows the airway to close. In some cases, the trouble lies in the part of the brain that controls breathing during sleep; the brain appears to forget to send out the necessary instructions to the muscles that control breathing.

Types of Sleep Apnea

Sleep specialists recognize two basic patterns of breathing disturbance:

Obstructive sleep Apnea

This is the most common and severe form of sleep apnea. It is also called upper airway apnea.

The muscles of the soft palate (located at the base of the tongue and uvula--the fleshy tissue that hangs from the center of the soft palate) relax and sag, obstructing the airway and making breathing labored and noisy. Collapse of the airway walls blocks breathing entirely. When breathing periodically stops, a listener hears snoring broken by pauses. As pressure to breathe increases, muscles of the diaphragm and chest work harder. Sleep is then temporarily interrupted, and this interruption activates that throat muscles and "uncorks" the airway. The effort to breathe is similar to slurping a drink through a floppy wet straw. A listener hears deep gasps as breathing starts, and each gasp awakens the sleeper momentarily. Awakenings are generally so brief and incomplete that the sleeper does not remember them in the morning. Someone with obstructive sleep apnea may stop breathing for 10 seconds or longer, dozens--even hundreds--of times each night.

Each time breathing stops, the level of oxygen in the bloodstream falls and the heart must work harder to circulate the blood. Blood pressure rises and may stay elevated after breathing restarts. The heart sometimes beats irregularly and may even pause for several seconds. These irregularities of the heart may account for some deaths during sleep of people who went to bed in apparent good health. Alcohol, sleeping pills, and tranquilizers taken at bedtime further reduce muscle tone and may make the airway more susceptible to collapse.

While most people with obstructive sleep apnea have no obvious physical abnormality that interferes with their breathing during sleep, some physical conditions can play a role. A smaller-than-normal jaw, large tongue, enlarged tonsils, or tissues that partially block the entrance to the airway can be factors. Sometimes several of these conditions are present in the same person.

Obstructive sleep apnea most often strikes overweight men. Female hormones and a different throat anatomy may protect women until menopause. In later years, the gap between the sexes narrows although it never disappears entirely.

Central Sleep Apnea

In this form of sleep apnea, the airway may stay open, but the diaphragm and chest muscles stop working. Falling levels of oxygen signal the brain to awaken the sleeper and restart breathing.

Central sleep apnea becomes more common with age, and about one in four people age 60 or older experience disturbed breathing during sleep. For most, the problem is mild. It becomes more frequent and severe in people who have congestive heart failure or neurologic disorders. People with central sleep apnea may be more aware of frequent awakenings than those with obstructive sleep apnea.

What a Healthcare Provider Will Need to Know

A healthcare provider will want to obtain a medical history and may talk with the bed partner or other members of the household about the patient's sleeping and waking behavior. A Provider who suspects sleep apnea will probably refer the patient to a sleep disorders center for further testing. Experts there will evaluate the problem, and the patient may need to spend a night or two in the sleep e3valuation laboratory to monitor various aspects of sleep. A nighttime study will identify sleep apnea if it exists and will help define the best approach to treatment.

On the night of the sleep study, patients are asked to go to the laboratory about one hour before their usual bedtime. Technicians will position dime-sized sensors at various points on the body to continuously record brain waves, muscle activity, leg and arm movements, he3art rhythms, and other body functions during sleep.

Each sleep disorders center has its own system for conducting tests, and several devices may be used to assess the various aspects of a patient's breathing. A light mask that covers the nose and mouth may be used, or temperature-sensitive beads may be taped at the various sites on the body to measure the rate at which air enters and leaves the lungs. These tests help document whether and when apneas occur. Stretch bands with small gauges may be placed around the chest and abdomen to measure the effort needed to breathe, and a device clipped to the earlobe or finger charts the fall in the level of oxygen with each apnea episode.

Sleep maybe studied during the day as well, though a series of naps offered at two-hour intervals. This study, known as the multiple sleep latency test, documents daytime sleepiness, which is often extreme when sleep apnea is severe. The test may also be used to differentiate sleep apnea from other causes of daytime sleepiness, such as narcolepsy, which is a neurologic disorder.

Various types of x-rays and direct examination of the airway with fiberoptics are sometimes used to provide a better picture of the upper airway in people with obstructive sleep apnea.

What Treatment Offers

Most people with sleep apnea can benefit from both general measures and specific treatments.

General Measures

Specific Treatments

Continuos positive airway pressure(CPAP, pronounced SEE-pap): In this highly effective therapy, a light mask is worn over the nose during sleep. Pressure from an air compressor forces air through nasal passages and into the airway. This gentle pressure holds the airway open and allows normal sleep and breathing. CPAP is used primarily to treat obstructive sleep apnea, although recent studies suggest it may also improve the sleep of some patients with central apnea. Approximately 60% to 70% of patients who try CPAP are able to continue its use; the remainder find the apparatus too cumbersome.

Oral appliances: Some Sleep apnea patients are helped by devices that open the airway by bringing the jaw, tongue and soft palate forward.

Surgery: Physical abnormalities that interfere with breathing during sleep can sometimes by corrected surgically. These abnormalities include enlarged tonsils or adenoids (common in children), nasal polyps or other growths, a deviated nasal septum, and malformations of the jaw or soft palate.

Using a technique known as the uvulopalatopharyngoplasty (UPPP), a surgeon removes excess tissue at the back of the throat that may be blocking the airway during sleep. Studies show that UPPP benefits about half of those people who undergo the surgery. Studies are in progress to identify the patients most likely to be helped by this procedure. Some patients have reported negative side-effects of the surgery, such as nasal speech and the regurgitation of liquids into the nose when swallowing.

A tracheostomy may be required to alleviate severe cases of obstructive sleep apnea. This procedure involves creating an opening in the trachea (windpipe). A tube inserted into the opening stays closed during waking hours, allowing normal speech and breathing through the upper airway. The tube is opened for sleep so that air bypasses the obstruction in the throat and flows directly to the lungs.

Oxygen: Supplemental oxygen is rarely needed for treatment of sleep apnea alone. Oxygen may be added to the nasal CPAP system, however, to correct for low oxygen levels dur to existing lung or heart disease.

Medication: Sleep apnea sufferers are likely to derive limited benefit from medication. Certain medications may help mild cases of obstructive sleep apnea and some cases of central apnea.

Good Sleep Habits

These suggestions will help most people, including those with sleep apnea, sleep better:

From the American Sleep Disorders Association

Further Reading on Sleep Apnea and Snoring

The Encyclopedia of sleep and Sleep Disorders, by Jan Yager and Michael J. Thorpy (New York: Facts on File, 1991)

The American Medical Association Guide to Better Sleep, by Lynne Lamberg (New York: Random House, 1984)

Sleep, Dreaming and Sleep Disorders, by William H. Moorecroft (Lanham, MD: University Press of America, 1989)

The Sleepwatchers, by William C. Dement (Stanford, CA: Stanford Alumni Association, 1992)

Snoring and Sleep Apnea, by Ralph A Pascualy, MD and Sally Warren Soest (New York: Raven Press, 1994)

Stop Your Husband from Snoring, by Derek S. Lipman, MD (Emmaus, PA: Rodale Press, 1990)