When Snoring Goes Haywire
UC Berkeley Wellness Letter, March 2008
Anywhere from 30 to 50% of Americans snore at least occasionally. Among older people, there may actually be more snorers than nonsnorers. Snoring is usually a minor affair, though a frequent source of strife between bed partners or roommates. But heavy snoring can be a symptom of a serious disorder called obstructive sleep apnea. Previously thought to be relatively rare, apnea is now estimated to affect as many as 10% of adults (as well as some children), though estimates vary widely. Most people don't know much about it, so it often goes undiagnosed.
A lot of night music
If you have sleep apnea, your bedmate may tell you — not always in the gentlest terms — that you saw logs all night, and that often you stop breathing (for anywhere from 10 seconds to more than a minute), then emit a choking, explosive sound as you struggle to recover — a pattern that may be repeated hundreds of times a night. It's like someone waking you 10 to 30 times an hour, though you may not even be aware of it. Occasionally your bedmate may even wonder if you've stopped breathing altogether.
Sleep apnea is caused by a temporary blockage of the breathing passages. The soft tissues of the mouth vibrate during snoring, but with apnea the tongue and other soft tissues periodically fall back and totally block the airway. Sometimes the airway is only partially blocked, resulting in very shallow breathing (hypopnea). In either case, oxygen levels in the blood fall, and carbon dioxide rises. Your throat muscles contract as you struggle for air, you gasp or snort loudly, then you start breathing again and fall back to sleep, until the cycle starts again.
By robbing you of restorative sleep, apnea leads not only to daytime drowsiness, but also to irritability, faulty memory, inability to concentrate, headaches, and possibly depression and decreased libido. Especially dangerous: people with sleep apnea are at high risk for falling asleep while driving.
Apnea is more common in men than women. Excess weight and age increase the risk, since these can lead to excessive relaxation of muscles at the back of the throat. Having a thick neck, in particular, seems to make it more likely that the airway will collapse during sleep. Though not everyone who snores has apnea, loud snorers are most likely to have it. Heavy drinking and use of sedatives can also promote apnea.
Research Links Snoring to Cardiovascular Problems
The loss of sleep and its daytime consequences — such as drowsiness and slow reaction time when driving — are sufficient reason to seek treatment. But in addition, research has linked apnea to a broad range of cardiovascular problems, including hypertension, strokes, heart attacks, arrhythmias, and heart failure, as well as Type 2 diabetes. Stopping breathing for short periods during the night can cause a temporary rise in blood pressure that may become chronic. Moreover, there are many other ways in which apnea may damage blood vessels and the rest of the cardiovascular system. New research, for instance, has linked apnea to chronic inflammation, which is associated with heart disease. Since many features of sleep apnea overlap with those of the so-called metabolic syndrome (notably obesity, hypertension, and elevated blood sugar), some researchers believe that apnea should be included as part of the syndrome.
Snoring Do's and don'ts
If you aren't sleeping well and snore loudly, or if you are tired all the time despite what seems to be adequate sleep, talk to your doctor about apnea — particularly if you have hypertension and/or are overweight. You may need to see an ear, nose, and throat specialist, who may send you to a sleep clinic at a nearby hospital. Spending the night in such a facility for special testing is the best way to get sleep apnea diagnosed. There is also an FDA-approved home testing device called the Apnea Risk Evaluation System (ARES), which can be attached to your forehead to monitor your snoring, blood oxygen, pulse, head position, and other factors. Available only by prescription, it costs about $300, and the results have to be interpreted by the company that makes it.
If you have been diagnosed with apnea, do-it-yourself therapies such as the following should help, and may even resolve the problem.
These steps can also help with regular snoring.
- If you're overweight, lose weight. Even a 10% loss can help.
- Limit or avoid alcohol, especially in the evening.
- Avoid sedatives (tranquilizers, sleeping pills, and some antihistamines).
- Avoid heavy meals in the evening.
- If you smoke, stop.
- Elevate the head of your bed. But don't use a large pillow that forces your neck to bend.
- Sleep on your side, not on your back. This helps keep your tongue from falling back and obstructing the airway. Attaching a tennis ball to the back of a pajama top is an old trick to help keep you off your back.
- You can try one of the inexpensive nonprescription devices that reposition the lower jaw as you sleep, such as SnorBan. A little like the mouthpieces worn by football players, these "mandibular advancement devices" sell for about $30. They can cause mouth and jaw discomfort, however, and don't work for everyone. Consult your doctor first.
Other measures to help your snoring
Your doctor may prescribe CPAP, which stands for "continuous positive airway pressure" and is pronounced "see pap." This air pump attached to a mask or nasal tube is effective at maintaining a flow of air while you sleep. Besides being expensive, it is cumbersome and noisy, and many people find it causes nasal congestion and claustrophobia, and thus stop using it.
There are also custom-made mandibular advancement devices (made by dentists who specialize in apnea) that pull the tongue and jaw forward while you sleep. They are expensive, insurance may not pay for them, and a recent review found they are not as effective as CPAP.
Surgery should be considered only as a last resort. The standard procedure widens the airway and/or corrects other physical problems contributing to apnea. This is major, painful surgery, can have adverse effects, and doesn't help everyone. There are also less invasive options, notably laser surgery, as well as the Pillar procedure, in which three tiny inserts are implanted into the soft palate in the back of the mouth. But since Pillar is relatively new, there are questions about its long-term safety and effectiveness.