Is It Snoring? Or Is It Sleep Apnea??

Loud snoring isn’t just a nuisance, it can be a significant health issue. About half the time, it predicts the presence of sleep apnea, in which the snorer stops breathing for a short period, many times per hour. As the muscles in the back of the throat relax during the night, they collapse and impede air movement, eventually leading to a decrease in the blood oxygen level. Interruptions in breathing up to 5 times per hour is considered normal, as long as the oxygen level remains adequate.

Sleep apnea used to be a diagnosis we’d look for in obese men with large necks. Although this population does have the highest incidence, we now test more liberally — 9% of middle-aged women and 24% of middle aged men have it, many of whom are not markedly overweight. 

The most common symptoms are snoring or gasping as reported by a bed partner, fatigue despite adequate time in bed, morning headaches, and tendency to fall asleep easily during the day when sitting in a quiet place. A somewhat amusing article recently reported that the best indicator that someone has sleep apnea is the “elbow sign”, i.e. that the snorer is awakened by their partner’s elbow frequently.

Sleep apnea has significant health implications. First off, sleep is important for refreshing your energy, clearing toxins from the brain that otherwise can contribute to dementia, and forming memories related to the previous day’s activities. Apneic episodes make sleep less efficient, so none of these processes go on as they should. The associated sleep deprivation is likely to cause irritability, poor concentration, depression and decreased sex drive.

In addition, sleep apnea contributes to high blood pressure (BP), especially in the early morning hours and contributes to resistant blood pressure which requires many medications for treatment. There can be extremely slow or irregular heartbeats, especially during the night. Sleep apnea has also been associated with an increased incidence of heart disease, strokes and insulin resistance, although it is difficult to tell if these problems are due to the apnea or overweight or both.

Often, though not always, a person with sleep apnea has a ‘crowded pharynx’ – fullness of the soft tissues at the back of the throat, making them more likely to close off the airway during sleep. However, any person with any body habitus can be considered for a sleep apnea evaluation if they have snoring, gasping, fatigue, morning headaches, resistant blood pressure, or nighttime irregular heartbeats. People with palpitations waking them up at night, which can happen with atrial fibrillation, should be tested for sleep apnea.

The usual evaluation involves an overnight stay in a sleep lab, where brain waves and sleep stages, air flow, heart rate, chest and limb movements and oxygen level are monitored. There are many portable devices that allow sleep tests to be done at home. They have only 3 or 4 monitors, and may be adequate in some situations.

Not all people who snore have sleep apnea.  If the sleep test does NOT show sleep apnea, the snoring can be addressed in other ways – sometimes by using nasal saline or nasal steroid inhalers to relieve nasal congestion, or adhesive strips to widen the nasal passages for sleep. Weight loss or sleeping on one’s side may decrease snoring as well.  

If significant apnea IS detected, your physician will likely check the thyroid function and encourage weight loss, if that is appropriate. If treatment is indicated, it will be initiated most often with CPAP (Constant Positive Airway Pressure) by a mask attached to a machine. Air is delivered under pressure to keep the airway open during sleep; this eliminates the snoring that results from air being pulled through a nearly-collapsed airway. The mask can be anything as small as nasal pillows, just covering the openings to the nose, to as large as a mask covering the nose and mouth. There are other treatments available, from disposable one-way valves for the nose, to dental appliances, to surgery, but CPAP is the best studied modality at this time. Whichever one is chosen, especially if it is not CPAP, re-testing is often done to ensure that treatment is optimal.

Since people generally don’t wish to sleep attached to a mask and a hose, compliance with treatment varies. People who note a huge improvement in energy, mood and ability to concentrate are those most likely to use CPAP regularly. Even when symptom improvement is minimal, however, health benefits related to the heart and brain may accrue, especially in more severe sleep apnea.  Often people ask if they can just use oxygen instead of CPAP, but that isn’t helpful and may even make the problem worse by fooling the brain into thinking there is less need to breathe and making the apneic episodes even longer.

Making sure a comfortable mask is chosen and adding humidity to the machine to alleviate dryness of the mucus membranes both improve compliance. The snorer can also feel good about being less disruptive to those around them – others often appreciate the low hum of the CPAP compared to the loud roar of snoring!

If some of the symptoms mentioned sound familiar, ask your doctor if you might benefit from a sleep evaluation.

REFERENCES:
Chirinos, et al. CPAP, Weight Loss, or Both for Obstructive Sleep Apnea. NEJM 2014; 370:2265-75.
Gottlieb, et al. CPAP versus Oxygen in Obstructive Sleep Apnea. NEJM 2014; 370:2276-85.
Basner,R. Cardiovascular Morbidity and Obstructive Sleep Apnea. NEJM 2014; 370:2339.
Kline, L. Clinical presentation and diagnosis of obstructive sleep apnea in adults. UpToDate.com
Tamisier,R et al. Cardiovascular effects of obstructive sleep apnea. UpToDate.com