SNORING: Cosmetic Nuisance or Potential Killer?
Edward M. Zimmerman, M.D. FAAFP
Snoring affects million of Americans, especially men, and its incidence increases with age. Poor muscle tone in the tissues of the throat, exacerbated by obesity, bulky tonsils, adenoids, floppy soft palate and uvula as well as nasal obstructions caused by infection and allergy can all cause snoring. Fatigue, drugs, smoking and alcohol worsen these symptoms.
Obstructive sleep apnea syndrome (OSAS) is a condition in which breathing is blocked by closure or collapse of the tissue of the upper breathing passages so that no air flows through the sleepers nose or mouth despite their efforts to breathe. Severe, loud or obnoxious snoring usually precedes the development of OSAS. Both snoring and OSAS often progressively worsen, causing sleep fragmentation and deprivation which may lead to daytime hypersomnolence, depression, memory loss and irritability.
Approximately 3,000 people die in their sleep every year from heart attacks, strokes, and respiratory failure directly related to obstructive sleep apnea and the oxygen deprivation it causes to the heart and brain. Two-thirds of people with OSAS have high blood pressure. The second most common cause of driving fatalities after alcohol is excessive sleepiness. The risk of daytime hypersomnia is especially high in patients who suffer from OSAS. Sleep related disorders produce an estimated $70 billion loss to business each year from accidents, medical bills and lost productivity.
While many people snore, current data suggest only 25% of male and 9% of female snores suffer from progressive obstructive sleep apnea. It is estimated to effect 1 to 4% of the US population - about the same as diabetes - and yet it is a relatively undiagnosed condition. Patients with severe sleep apnea of many years duration may be unaware of their difficulties. At night they may have excessive loud snoring, cessation of breathing, choking, and sonorous gasping or snorting on resumption of breathing. While awake these patients may experience increasing headaches, impotence in males and progressively abnormal functioning of memory and personality disorders. Many of these symptoms may be misperceived as irrevocable changes of aging.
More rare, but also dangerous, is central apnea where their is an absence of both air flow and respiratory effort and mixed apnea which has components of both central and obstructive apnea, usually in that order.
While asleep, OSAS patients have repeated episodes of 10 seconds to as long as 5 minutes when ventilation is stopped by occlusion of their airway. The patients' chest and even abdominal muscles continue to move in a vain attempt to draw air past the obstruction. Meanwhile the normal bodily reactions to asphyxia are occurring - the pulse races and then falls and may progress to a lethal cardiac arrhythmia, oxygen flow to the brain decreases which predisposes patients to strokes, and respiratory failure and pulmonary and systemic hypertension progressively develop as the heart tries mightily to pump blood through the immobile tissue of the lungs. Finally the survival centers at the base of the brain sends out the signal to breathe or die and the body is briefly roused to a lighter stage of sleep which restores the muscle tone and airway patency to the back of the throat with a mighty gasping or choking. This scenario recurs many times a night, witnessed only by the often exhausted spouse who lies awake listening to the intermittent loud snoring or waiting for their spouse to once again take a breath after an agonizingly long wait. The patient awakens oblivious and unfreshed after a night of fitful, fragmented sleep.
Often, the diagnosis of obstructive sleep apnea is suspected when the patient or other household members mention the symptoms to their doctor in passing. About 50% of OSAS is identified by history. Conversely 70% of patients without OSAS were appropriately excluded from further testing by history alone. Physical examination includes careful assessment of the head and neck. If both history and the physical point to the possibility of sleep apnea after other treatable causes are eliminated, then an overnight sleep study may be ordered.
Sleep studies are usually in a sleep lab. The patient goes their for one or two nights and is monitored through a series of wires, bands, and tubes that are attached to their body as well as direct observation. Obstructive, central and mixed apneas are recorded along with body position and level of sleep when apneas occur. There are limitations to the sensitivity of any sleep study because a patient may not sleep "well" wired and under observation in an unfamiliar place. Recently, portable devices that monitor many of the same parameters as a sleep lab have become available. They claim to be very sensitive and specific for OSAS. Home studies cost less and are more convenient. They may be more accurate because the patient sleeps in their own home. Retesting should be done to assess effectiveness of the therapy.
We know that treatment of severe apnea improves quality of life and longevity. Since this is a progressive problem, it makes sense to treat OSAS in it's early stages before the sequelae become permanent. Generally, people snore less if they are sleeping on their side. This can be prompted by sewing a tennis ball into the back of their pajamas. Avoidance of alcohol, sedatives and narcotic painkillers before bedtime may decrease snoring. Weight loss and smoking cessation help some patients eliminate snoring and OSAS. Recurrent sinus and tonsil infections should be definitely treated. Assessment and treatment of deviated septums, nasal polyps, hypothyroidism and gastroesophageal reflux are useful too.
Nasal continuous positive airway pressure (CPAP) is the current first line therapy for documented OSAS. Patients wear a small face mask that blows oxygen under enough pressure to keep the back of the throat open through the night. Careful education is necessary prior to initiating CPAP to improve comfort and compliance. A number of variations of the device are available. Some patients experience excessive dreaming initially as normal sleep architecture is restored. Nasal and even transtracheal oxygen have been used too.
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