Chronic Snorer

I liked the title of my last column: “ In search of peaceful sleep”! That, of course, is everybody’s dream! Can we make that dream a reality?

As you may recollect, the last column discussed snoring and obstructive sleep apnea. We learnt that there is a fair amount of uncertainty about this disorder. Today, we will talk about treatment.

It is commonly claimed that obstructive sleep apnea is associated with premature death and illnesses of the lungs and heart. But we know that this has not been proven.

So, one would wonder, is it necessary to seek treatment for this condition? If yes, then what sort of treatment is available?

Treatment of snoring is required if a person snores to the extent that the marital relationship may be threatened. Then the choices are either you snore alone in the basement of your house or few miles away in an isolated barn! Or get help!

Treatment is also required if the sleep disorder affects daytime sleepiness and alters the function of the heart and the lungs.

The goals of treatment are to abolish snoring and eliminate disruption of sleep due to upper-airway obstruction. This will establish adequate oxygen level in the blood and adequate ventilation system.

Treatment strategies are divided into three general categories:

-Behavioural modification
-Medical treatment
-Surgical treatment

Counselling for behavioural changes includes losing weight, avoidance of alcohol and sedatives. Most patients snore sleeping on their back. These patients should be asked to train themselves to sleep exclusively on their side.

Medical management of sleep apnea revolves around positive airway pressure, dental appliance and medications. There is no good medication to help sleep apnea so we won’t discuss that here. Sometimes oxygen therapy helps.

The positive airway pressure (PAP) is delivered through a mask to be worn when a sleep. The machine that creates PAP weighs two kilograms. The cost of the system may run into couple of thousand dollars. PAP keeps the upper airway open during sleep.

Compliance of this method of treatment is not hundred percent. One study demonstrated 46 percent of patients used PAP for more than four hours per night for more than 70 percent of the observed nights. Some people may find system difficult to use. Others have adapted quite nicely. Some studies have shown improved survival in patients who use PAP.

Oral appliance has been promoted as a useful alternative to PAP. There are varieties of appliances. The appliances are worn only during sleep and are generally well tolerated. Not all patients have clinically proven response. It is considered as a second line of treatment compared to PAP.

Surgical treatment for snoring and obstructive sleep apnea has become quite popular recently. Probably due to the inconvenience of PAP and oral appliance. Several surgical procedures are available, each one with advantages and disadvantages. These procedures are done by Otolaryngologists (specialists in ear, nose and throat surgeries).

Not all snorers require major surgery involving the palate. Fixing simple problems in the nose and throat can make a significant difference. Major surgical procedure involving the palate and pharynx is successful in abolishing snoring in about two thirds of selected patients. There is some amount of complications associated with surgical procedures – failure and pain.

There isn’t one solution to the problem of snoring and obstructive sleep apnea. So, Mr. Snorer, and all other snores, if you don’t want to snort with the pigs in the barn then seek help. Some thing may work for you. Besides, you have to help yourself first before anybody can help you!

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Sleep Apnea

Dear Dr. B: I snore and my doctor says I have obstructive sleep apnea. Can you please tell me more about this? Yours, Mr. Snorer.

Dear Mr. Snorer: Normally, breathing is regular. Apnea means cessation of breathing. Sleep apnea is a condition that interrupts breathing during sleep.

Sleep apnea may be central – that is due to instability of the feedback system that regulates breathing. Or sleep apnea may be obstructive – due to recurrent obstruction of the upper airway. Or it can be mixed – central followed by obstructive.

Today, we will confine our discussion to obstructive sleep apnea.

Obstructive sleep apnea affects two percent of women and four percent of men. It is a condition of middle-aged adults.

A typical individual with obstructive sleep apnea starts snoring shortly after going to sleep. The snoring proceeds at a regular pace for a period of time, often becoming louder, but is then interrupted by a long silent period during which no breathing is taking place (apnea). The apnea is then interrupted by a loud snort and gasp and the snoring returns to its regular pace. This behaviour may recur repetitively and frequently throughout the night.

Obstructive sleep apnea causes frequent night awakening, feeling of tiredness in the morning, abnormal daytime sleepiness, headaches, memory loss, poor judgement, personality changes and lethargy. It may also raise the blood pressure.

Who suffers from obstructive sleep apnea?

Obstructive sleep apnea occurs most frequently in obese middle-aged men. Contributing factors may include use of alcohol or sedatives before sleep, anatomically narrowed airways, and massively enlarged tonsils and adenoids. Genetic and environmental factors may also adversely affect airway size. The condition may run in some families.

Diagnosis of sleep apnea is made by sleep studies. One article on this subject says that a sleep study should be strongly considered for two groups of patients: those who habitually snore and report daytime sleepiness, and those who habitually snore and have observed apnea (regardless of daytime symptoms).

Are there any medical or physical side effects to obstructive sleep apnea?

Once upon a time, sleep apnea was thought to imply poor prognosis. It was thought to arise from the diseases of the brain and heart. It is now known that periodic breathing generally occurs during sleep. That it may occur in healthy persons.

During periodic breathing, there is change in the partial pressure of carbon dioxide and oxygen in the blood and this results in the fluctuation of heart rate (with irregular rhythm) and blood pressure and in the autonomic nervous system. Heart failure, heart attack and stroke are other likely complications.

Chronic sleep deprivation caused by sleep apnea increases risk for motor vehicle accidents. The accident rate for such patients has been reported to be seven times that of the general driving population.

Does obstructive sleep apnea really damage our health?

In 1997, a review article in the British Medical Journal evaluated all studies published between 1966 and 1995 on the association between obstructive sleep apnoea and mortality and morbidity, and on the efficacy of nasal continuous positive airways pressure. The authors concluded that there was limited evidence of increased mortality or morbidity in patients with obstructive sleep apnea.

They also concluded that the evidence linking the condition to cardiac irregular rhythm, coronary artery disease, heart failure, high blood pressure, pulmonary hypertension, stroke, and automobile accidents was conflicting and inconclusive. They concluded, that there were insufficient data to determine its effect on quality of life, morbidity, or mortality.

So, is there a need to do anything about snoring and obstructive sleep apnea? Well, Mr. Snorer, stay tuned for an answer next time!

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