Have you ever tried to tell someone they, “Snore”! It usually causes a tirade of denial and the fact that the sufferer is asleep and would not even be aware is not appreciated. It’s the partner, if they remain so, friends, if they remain so, and family that push an individual to seek advice.
Snoring is a non-musical sound, produced by air passing along an airway which is narrowed and floppy. During sleep the upper breathing passage in the nose, palate, throat, tongue and windpipe area become lax and collapse inwards on inhalation. This produces a turbulent airflow which manifests as an unpleasant noise, snoring. This sound is louder and more unpleasant the greater the narrowing. The noise may be so loud it can be heard through closed doors, walls and even on adjacent floors. No wonder the partners in many cases sleep in separate rooms leading, inevitably, to disharmony in relationships.
It can be even worse as on occasions the degree of collapse is so much that the airway is actually occluded, and this blockage can continue for several seconds and occasionally a minute or more. During this period there is no movement of air so there is no noise/snoring. However, the individual may be seen to be struggling to breathe with heaving chest movements until finally the brain, due to the reduction in oxygen level, kicks the respiratory centre to open the airway. At this point the suffer gasps and inhales, may even wake up briefly, but then returns to sleep only for the cycle to be repeated.
For the partner this is very distressing; listening to the noisy, unpleasant snoring, viewing the struggle and seeing the gasping and restlessness. In fact some partners are afraid that their loved ones completely stop breathing and so nudge and elbow them into arousal to start rebreathing.
Professor Ram Dhillon and Mr Michael Oko (both Department of Health, UK, advisors on Sleep Apnoea), who run a special “Snoring and Sleep Apnoea” service in the world famous Harley Street, London explain that these periods of silence of 10 seconds or more occur in normal individuals about 5 times per hour of sleep and are termed “apnoea attacks”. The attacks can be measured by using a piece of kit, which can be dispensed by a specialist, and employed overnight to measure the key parameters of the sleeping pattern and in particular identify the levels of snoring, the numbers of apnoeic episodes and the drop in levels of oxygenation. A reading of 5-15 apnoeic episodes per hour of sleep is classified as mild “Sleep Apnoea”; 15-30 episodes as moderate and 30+ episodes as severe apnoea. What is the significance of “sleep apnoea”? Try and imagine what it may be like to be strangled for 30-40 seconds 20, 30 or more times per hour. Not only is the body being poorly oxygenated but it is pouring into the bloodstream chemicals such as adrenaline to counteract the distress. Adrenaline mobilises the movement of sugar into the blood and raises the blood pressure and heart rate.
This sleep deprivation results in individuals paying the overdraft of sleep by falling asleep doing the day, usually when the brain is less active e.g. passenger in a car, watching TV, driving a car on long straight roads, at dinner parties… As sleep is required to reboot the brain, individuals find their concentration is poorer and short term memory may have deteriorated. There is also a significant detrimental effect on sex drive. There is plenty of evidence to associate long periods of untreated Sleep Apnoea with a higher incidence of obesity, poorly controlled diabetes, high blood pressure, heart attacks strokes, memory impairment and lowered sex drive.
It is clear that such sufferers should be identified early and treated. Traditionally, there was a view that this problem occurred in overweight, middle aged men only. This is not the case, although weight and age do play a key role. However, there are many young sufferers, in their mid-20s to early-40s and of ideal weight. It is frequently the particular anatomy of the upper airway and changes in lifestyle that conflate with resulting Sleep Apnoea in such people. Most are men, who areblissfully unaware of their condition and despite being nagged by wives and partners may refuse to seek advice. Usually the picture is of a pushy partner cajoling a reluctant man to see a specialist.
Ideally, an opinion should be sought from someone with expertise and experience in Sleep Apnoea. In the main these are ENT surgeons, some of whom have a special interest in this area and a few dedicated respiratory physicians, who can assist patients but who deal also with other causes of sleep disorders. ENT surgeons are competent in examining the upper airway anatomy to identify any potential surgically curable causes for the Sleep Apnoea, using a very small f lexible endoscope.
It is also possible to predict, with reasonable accuracy, whether Sleep Apnoea is a likely to be present in a snorer by completing a simple questionnaire named the “STOP BANG”. Patients can usually be investigated by having an overnight “Sleep Study”, which in most cases can be done at home but in a few more complicated cases may require hospital admission.
Management and treatment is tailored to the patient. Most children and teenagers will have large adenoids and tonsils and will be cured by surgery. About 7-10% of adults are also identified as having huge tonsils, kissing in the midline, and can have curative surgery.
The remainder of patients are likely to benefit from a CPAP (pronounced C-PAP) and is method of delivering air under the minimum pressure to keep the individual’s airway open, by wearing a face or nasal mask during sleep. For the 75% or so who are able to use CPAP the outcomes are excellent. Not only is the snoring abolished but the daytime energy levels rise significantly, the partner sleeps well and benefits to diabetes, blood pressure and weight reduction may also accrue. A small percentage of patients gain improvement with devices designed to be worn in the mouth called mandibular advancement devices (MAD) and which pull the lower jaw and hence the tongue forward so that the upper airway is opened. Even fewer patients require, or are recommended, surgery (except for children, who might undergo removal of the tonsils and adenoids (and which is curative in a large proportion of cases), very few patients require, or are recommended, surgery. Such surgery is extensive and major and requires fracturing and repositioning of the jaw in order to reduce snoring and abolish apnoea.