FAQ: Snoring and Sleep Apnea

David A. Nye MD (nyeda@uwec.edu)
Midelfort Clinic, Eau Claire, WI

When we sleep, muscles in the throat relax, narrowing the air passages. If this narrowing is enough that the walls touch, the air passing through makes them vibrate together, producing snoring. If the walls collapse further so that no air gets through, obstructive sleep apnea (OSA) results. The spouse hears the loud snoring of a patient with OSA broken by pauses which are followed by a gasp. During the pause, the airway is completely sealed. The inability to breath rouses the patient to lighter levels of sleep whereupon muscle tone increases and the airway opens again. Simplistically, these patients can either sleep or breathe but not both. The result is that they are constantly tired during the day, falling asleep at unwanted times. They have an increased risk of accidental injury and death, particularly when driving, as well as headaches, weight gain, hypertension, heart disease and stroke. OSA is a life-threatening disorder but the patient and sometimes even a sound-sleeping spouse may have no idea that the problem exists.

Snoring without apneas is not associated with daytime sleepiness, has less risk, and is mainly a problem for the snorer's family, particularly the spouse, although the familial disruption can be enough to break up a marriage. Both snoring and sleep apnea are easily treatable. If you have OSA you should consult a sleep disorders specialist without delay. For snoring without apneas, there are some simple things you can try first which may be helpful.

Alcohol is a potent muscle relaxant and is often the sole cause of a patient's OSA or snoring problem. Patients with OSA should probably abstain completely from alcohol, or at least limit themselves to one before-dinner drink. Some medications taken at night can cause similar problems, for example some antidepressants and seizure medications. If you suspect one of these, ask your doctor about taking the medication at a different time.

Weight loss will often cure snoring in the overweight. If the snorer suffers from chronic nasal congestion, perhaps from a deviated septum, nasal polyps, or allergies, treating these problems can sometimes eliminate snoring and apneas (see an otolaryngologist or allergist). If the snorer snores only when lying on his back and you are tired of giving or receiving "elbow therapy," try putting a tennis or whiffle ball in a sock and safety-pinning it to the back of the pajamas so the ball pokes the patient between the shoulder blades if he rolls on his back. There are snore pillows sold which tip the chin up and head backward to better open the airway. The spouse can wear earplugs (this is one of the cheapest and most effective solutions to snoring without apneas).

For OSA, or for snoring if the above measures don't work as they often don't, see a sleep disorders specialist for help. If OSA is suspected, a polysomnogram (overnight recording of your sleep) will be scheduled, measuring brain waves (for sleep stages), breathing patterns, oxygen saturation, muscle activity, and other parameters. If OSA is confirmed, Nasal Continuous Positive Airway Pressure (CPAP) can be administered through a mask over your nose, either that night or on a second night, and the pressure adjusted until the snoring and apneas are gone. If it works, you get a unit to use at home. Breathing against a little pressure keeps the airway from collapsing and eliminates both snoring and obstructive apneas. This works better than anything else in resistant cases of snoring and is standard treatment for obstructive sleep apnea. Recent improvements in the technique have made acceptance very good. BiPAP (Bilevel Positive Airway Pressure) senses when you are breathing out and cuts the pressure, and may be well tolerated when CPAP is not. Plugs placed into the nostrils are an alternative to the CPAP mask and may be preferred by some patients.

A few patients can't tolerate CPAP or aren't controlled even at high pressures. For them, surgery is an option. The oldest and most effective operation for OSA is tracheostomy, but this is rarely done now because of cosmetic and other long-term problems. Laser-assisted uvulopalatoplasty (LAUP) can be done in the doctor's office over several visits. It is less clear that it is helpful for OSA than for snoring, and most insurance companies will not pay for treatment of snoring without obstructive sleep apnea, so if you want a LAUP for snoring you are probably stuck paying for it out of pocket. Personally I'd rather spend about the same amount and get a CPAP machine. There are several other surgical procedures which may be best for certain patients. In general surgery is less effective than CPAP, but sometimes surgery followed by CPAP will work when CPAP alone doesn't. Success has been reported with training patients to pass a tube through their nose into their throat every night to keep the airway open (no thanks).

There are other less invasive treatments that help an occasional patient. If the point of greatest upper airway resistance is in the nose, an adhesive-backed leaf spring applied to the outside of the nose to hold it open at night may help. These can be found in most drug stores. You may have noticed some professional atheletes wearing them during games. A dentist or oral surgeon can make you a mandibular advancement prosthesis, a piece of plastic worn in the mouth which has the impressions for the lower row of teeth forward from the upper row to pull the jaw forward. A tongue-retaining device worn in the mouth at night can sometimes help by holding the tongue forward. I haven't found any of these appliances to work in more than a small percentage of patients with snoring, fewer with true with sleep apnea.

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