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Snoring and Sleep Apnea: The Basics
by Richard W. Clark, M.D.
Increasingly, people are seeking the advice of physicians for snoring and the
related problem of sleep apnea. Television and radio commercials advertise
various treatments and articles in newspapers and magazines are commonplace.
This article is a basic introduction to snoring, sleep apnea and the currently
available options for treatment.Snoring is best defined as a partial obstruction of breathing during sleep. If you purposely make a snoring sound and then compare it with a normal breath, you will easily see that less air enters your lungs when you snore. After air passes through the mouth or nose it is directed downward into the windpipes through a passage that is best thought of as a "tube" of muscle. This “tube” includes the soft fleshy part of the roof of the mouth and the back part of the tongue. We refer to this "tube" of muscle as the collapsible airway. The only thing that keeps this airway open is a constant contraction of the muscles of this "tube". During sleep, the muscles relax and become floppy and sag inward, like wet soda straw paper. If there is enough sagging, then air passing by these floppy tissues during breathing causes them to flutter and vibrate, producing the often obnoxious sound of snoring. Therefore, the narrower the airway is, or the more relaxed or floppy the muscle walls are, the more likely that snoring can occur and the louder it can be.
Anything that adds to the narrowing of the airway passage at the back of the throat makes snoring more likely. The main causes of snoring in children are large tonsils and adenoid tissue. Excessively large tonsils project into the airway making it smaller. Adenoid tissue is present in most children in the upper part of the throat behind the nasal passage. As with enlarged tonsils, excessive adenoid tissue can also narrow the air passage increasing the likelihood of snoring.
In adults, the air passage may be small for no reason other than that we are all built differently. Many of us have small collapsible airways just as some of us have smaller feet or are taller or shorter than average. Age is also a factor for reasons that are not entirely clear. One theory states that as we age, we lose muscle tone. This loss in tone adds to the sagging of the collapsible airway muscles during sleep.
We also know that there are many medications that cause throat muscles to relax. Individuals who take certain antihistamines or tranquilizers are more likely to snore. Alcohol is a relaxant, and it is well known that in some individuals the use of alcohol alone can make the difference between a night of loud snoring and a night of peace.
Our modern society with its fast convenience foods, super size servings and sedentary ways is a society that is becoming increasingly overweight. Obesity is a major contributor to snoring, when excessive fatty tissues in the neck add to inward sagging of the throat muscles in much the same way as snow on the roof of a tent will cause it to sag.
Snoring is aggravated by a blockage of the nose in about 15 percent of people who snore. Some individuals snore only during allergy season or when suffering from a cold, mainly due to the effects these conditions have on breathing. The first thing that occurs with taking a breath is an increase in the size of the chest cavity. This occurs when the bottom of this cavity, a big muscle called the diaphragm, descends. This creates a negative pressure in the lungs causing air to be sucked in from the outside. Most of us prefer to breathe through the nose, and our bodies must work harder to create a greater negative pressure to get air through a nose that is congested or blocked. If you take a breath through your nose, then take a second breath with the tip of your nose slightly pinched between your fingers, you can easily experience this. This larger negative pressure adds to the collapse or sagging of the throat muscles, increasing the likelihood of snoring.
About ten percent of people who snore have a condition called obstructive sleep apnea or OSA. I previously described snoring as a partial obstruction of breathing during sleep. OSA is a complete obstruction of breathing during sleep. Recall that during snoring, the muscles at that back of the throat between the nose and windpipe relax and sag inward, partially blocking breathing. In OSA, these same muscles sag inward to the point where breathing is completely shut off. Such a blockage cannot last long or the individual will suffocate. Many people are surprised at just how long these periods of “no breathing” or apnea can last, and in the OSA sufferer, the blockage occurs repeatedly during certain periods of the night.
Most of us are aware that sleep does not always have the same “quality”. The terms “light sleep” and “deep sleep” are commonly used to describe different types of sleep. During sleep, the brain puts us through different stages that vary in the amount of muscle relaxation that occurs. We need to spend a minimum amount of time in the deeper stages in order for adequate restoration to take place, which is the reason why we need to sleep. Consider the following simplification as to what occurs during sleep apnea: John Doe, who has sleep apnea, falls asleep. As the muscles begin to relax and sag they start to vibrate causing snoring. At some point during the night, the brain automatically puts John into the deeper stages needed for him to feel rested in the morning. But as he goes into these stages, the muscles relax even more to the point where they collapse inward and he becomes completely obstructed – no air is reaching his lungs. The snoring stops, but not for long. If this obstruction continues, John will suffocate. At this time, body alarms go off (increasing carbon dioxide levels in the blood is one such alarm) which tell John, “You’d better wake up a little, or you'll die!” John most likely does not wake up completely. Instead, he goes up into a lighter stage where the muscles are relaxed, and although he is snoring again, at least he is breathing. This jump from a deep stage to a lighter one is called an arousal. Since our brains are programmed to try to get the deep, restful sleep we need, John goes back down to the deeper stages only to obstruct once again. Like a broken record that keeps repeating the same few bars, the sequence of passing into a relaxed stage followed by obstruction and arousal back to a lighter stage goes on over and over throughout substantial portions of the night.
The result of these changes in sleep stages means that John does not get a good night’s rest. Every time he drops into a really deep sleep he obstructs and has to arouse himself to a lighter level. He wakes up the next day and finds himself tired. He is not aware of all the turmoil that has occurred and only knows that he spent a good 6 or 7 hours asleep. But it is the quality of his sleep that is lacking. The person who suffers from sleep apnea may be falling asleep every night, but he is in fact sleep deprived. People with sleep deprivation are constantly tired which produces many complications for their overall well being, their ability to function well, and the safety of themselves and others. For many OSA sufferers, it feels like they are getting only 2 or 3 hours of sleep a night.
But sleep deprivation and the chronic daytime sleepiness that results are not the only problems with sleep apnea. During the arousal that causes John to go from the deep stage where he is obstructed to a lighter stage where he can get air, there is a rise in heart rate and blood pressure. Although only lasting for a few moments, this increase in blood pressure occurs repeatedly every night. Over time, the blood pressure becomes elevated all night and all day, leading to hypertension (high blood pressure), making the individual more susceptible to coronary artery disease, stroke, and kidney failure.
The bottom line is that sleep apnea can have important consequences. Snoring alone may be an embarrassment or a social problem, but the person with sleep apnea has a serious medical condition. The good news is that once recognized, sleep apnea can be treated.
The typical person suffering from OSA is not usually aware that he has sleep apnea. Often he seeks medical advice regarding snoring. Occasionally his sleeping partner provides the motivation or he may seek help from his doctor because of excessive fatigue. But virtually all with sleep apnea have one thing in common – they snore.
The doctor will ask about any medications or other substances that might add to the relaxation of the throat muscles and will inquire about symptoms of daytime sleepiness. To further quantify sleepiness, a questionnaire such as the Epworth Scale is commonly administered. Questions about high blood pressure and any heart illnesses or symptoms are important. A careful examination of the head and neck is necessary to assess the size of the collapsible airway and to note any obstruction, such as a large tongue or tonsils. Commonly, a calculation of your Body Mass Index (BMI) is made to determine if and by how much you are overweight. Following the office evaluation, it is likely that you will be scheduled for a sleep study.
The main purpose of a sleep study is to determine if you have sleep apnea and it's severity if present. Sleep studies can take place in either a special facility or in your home. In the sleep lab, you are attached to several monitors that measure your breathing, depth of sleep, heart rate and the oxygen content in your blood. These measurements all take place while you sleep in a room similar to a motel. Home studies can also be performed, but the measurements are less extensive. There are several different types of home monitors available, usually the size of a notebook computer, which your doctor will provide for you. The unit is simple to set up at your beside and to use. Information about your sleep is recorded for your doctor who will analyze the data when the unit is returned. Even though a sleep study in a laboratory provides more data, home studies can be valuable to individuals who snore but whose office evaluation indicates a low risk of sleep apnea. Most insurance carriers cover both types of sleep studies and we recommended checking with them first to find out what kind of coverage they provide.
Sleep apnea can be successfully treated. Our philosophy is that all patients with sleep apnea should initially be treated with Continuous Positive Airway Pressure (CPAP). With CPAP, a small electric powered unit is set up next to your bedside. A small mask attached to the unit blows a preset amount of air gently into your nose as you sleep. This air acts as a splint or support and prevents the airway from collapsing. CPAP is advantageous since it is about 100% effective in controlling sleep apnea as well as stopping snoring. Because there is no risk, this method is tried first. The CPAP units can be rented and most insurance carriers will cover the costs.
Not everyone can tolerate CPAP, and for some individuals, the mask is too uncomfortable or they may be unwilling to use the device every night. Since CPAP is so effective, we encourage individuals to stick with it before giving up. There are a variety of different CPAP units available and adjustments to the masks or the use of different types of masks can make a difference. In some cases, nasal blockage makes the use of a CPAP mask difficult. These people are often able to use CPAP after the blockage is corrected.
For those who try but cannot use CPAP, there are several surgeries that can be performed. Depending on the severity of the apnea and other factors, the results of surgical treatments are not nearly as effective as those obtained with CPAP. Your doctor can discuss this at length, but you should be aware that most of the advertised office procedures for the treatment of snoring are not effective for even moderate cases of sleep apnea. These procedures may help with snoring, but do little to correct the obstructing of the airway that causes sleep apnea.
There are common sense steps that both the snorer and the snorer with sleep apnea should take. Weight reduction, sensible exercise, and avoiding excessive alcohol in the evening are the most important of these.
There are several options available for the snorer who does not have sleep apnea. First, the points already mentioned (weight control, exercise, and avoidance of alcohol or sedative medications) apply to the snorer as well. If these alone do not help, then you should ask your doctor about doing something to stiffen the floppy tissues at the back of the throat. There are several ways to accomplish this. Surgery can be used to remove some of these tissues, but this requires going into an operating room, and is perhaps overkill for simple snoring. A laser can be used in the office to remove tissue, however this can be a painful experience. There is a procedure called Somnoplasty®, where a small needle is placed into these tissues and radio wave heat energy is applied to cause scarring and stiffening over time. Somnoplasty® can also be used at the back of the tongue in addition to the roof of the mouth. Another similar procedure is called Injection Snoreplasty. Instead of radio wave energy, a chemical is injected into the tissues. The net effect is the same: scarring produces stiffening that prevents the loud noise of snoring.
There are other options as well, including the use of a dental device to hold the tongue forward. There are several throat sprays available as well that may have some benefit. Finally, any treatment that will relieve nighttime nasal congestion may help snoring.
Many of these treatments are summarized in a table provided on the next page. You should be aware that most insurance carriers do not cover the cost of snoring treatment unless you have associated sleep apnea.
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