Snoring by night? Snoring by day? Sounds like sleep apnea

Snoring by night? Snoring by day? Sounds like sleep apnea – includes related article on getting treatment

Harold Hopkins

Snoring by Night? Snoozing by Day?

Sounds Like Sleep Apnea

Sleep, even when accompanied by loud snores and snorts, has always been looked upon–almost without question–as a restorer of health. In fact, sleep was deemed so beneficial that until about 20 years ago medical experts didn’t realize that some sleepers’ snoring might be more a danger sign than a condition to be laughed at or complained about. Similarly , most doctors didn’t stop to speculate that inadvertent snoozing during the day might be part of the same condition that caused troublous nighttime sleep.

These two conditions–daytime dozing and disturbed nighttime sleep–are the principal symptoms of a “new” disease called sleep apnea syndrome. Actually, the condition is not new at all, but was rediscovered 20 years ago in the wake of some genuinely new findings about what happens to humans while they sleep.

Sleep apnea syndrome is a disorder in which the victim, while sleeping away the night, stops breathing dozens or even hundreds of times for intervals lasting at least 10 second and then, during the next day, finds it next to impossible to stay awake.

Full medical recognition of sleep apnea as a serious, even life-threatening disease has been a long time coming. The first more or less complete clinical description of the condition was published in the 1890s, but most doctors at the time were reluctant to recognize a disease that didn’t arise from physical changes or a tumor. Sleeping sickness, then newly discovered in Africa, got far more attention, along with another sleep disorder, narcolepsy, first described in 1880. In fact, some cases which were obviously sleep apnea were mistakenly referred to as narcolepsy–a condition characterized by sudden and uncontrollable attacks of deep sleep. (However, about 1 in 10 narcoleptics also has sleep apnea.) So sleep apnea did a kind of Rip Van Winkle, dropping out of sight until 1966, when it was again described in medical literature.

The rediscovery came in the wake of startling findings about the nature and structure of sleep itself. Researchers were able to tie sleep apnea to a condition then known as pickwickian syndrome, characterized by daytime sleepiness and associated with obseity. The newly described condition not only included daytime sleepiness, but also the nighttime sleep disturbances that had been found to threaten the victim’s health and life.

Until its rediscovery, sleep apnea’s nightly ordeals, which produced thundering snores, violent snorts, And desperate gaspings for breath, generally had been throught to be no more than a nuisance that robbed the household to sleep.

There are perhaps 30 million people of all ages in the United States who snore, according to Guide to Better Sleep, a book published by the American Medical Association. Most people snore lightly and intermittently and have no trouble obtaining the oxygen ghey need to suply body organs and tissues and get rid of carbon dioxide, a waste product. But, this book reports, 2.5 million Americans do experience seriously disturbed breathing at night from sleep apnea. Some other estimates of the total number of sleep apnea victims have ranged considerably higher than that.

The loudest snores come from those who experience seriously disturbed breathing during sleep. Some victims may not breathe at all for three-quarters of their time asleep. Breathing pauses have been recorded for as long as three minutes. Four minutes without oxygen can result in irreversible brain damage. Alcohol, sleeping pills, and tranquilizers can make sleep apnea worse.

The attention directed at last to the condition touched off a flurry of research. Medical experts have conducted scores of studies. Sleep disorders centers have been established in or near major hospitals or medical centers in practically every state. And doctors are now able to precisely evaluate and diagnose sleep apnea and other sleep disorders. These advances offered new hope for wrecked marriages and romances that couldn’t survive the Big Snore, new horizons for those who formerly snoozed away valuable time during work or at public gatherings, household relief from the mighty rumbles of the night, and reduced numbers of auto accidents among those who had been subject to dozing off while tooling down a street or highway.

Ironically, the first person to aptly described some of the symptoms of sleep apnea was an observant novelist, not a doctor. In 1836, Charles Dickens, in The Pickwick Papers, introduced a character called Joe, the red-faced Fat Boy. Fat Joe had constant difficulty performing his chores as a serving boy because of his greed for food and a tendency to fall asleep and snore at the drop of an eyelid.

Dickens’ readers recognized these traits in people they knew. But nobody, not even Dickens, considered the symptoms significant, other than as a subject for humor and ridicule.

Later in the 19th century, doctors dubbed this daytime sleepiness, snoring, and obesty the “pickwickian syndrome” in tribute to Dickens’ wickedly accurate pen. But no connection was made to nighttime sleep disorders.

There are three types of sleep apnea syndrome: central apnea; obstructive, or upper airway, apnea; and mixed apnea, which is a combination of the first two.

In central apnea, the victim undergoes episodes of “forgetting” to breathe during the night until the oxygen-starved brain sends out distress signals to activate the diaphragm and lungs. Central apnea is considered extremely rare. One pioneer doctor in the field says he has seen only three of four cases among the 2,000-odd sleep apnea victims he has treated.

In obstructive, or upper airway, apnea, the muscles of the sleeper’s soft palate (the area at the rear of the tongue) and the uvula (the small, conical, fleshy tissue suspended from the center of the soft palate) become so flaccid from loss of muscle tone and so relaxed from sleep that the suction of indrawn air causes them to flop together and block the air from reaching the lungs. This is the predominant type of sleep apnea.

In mixed apnea, the victim experiences an episode of central apnea, promptly followed by another of obstructive apnea.

The onset of central apnea tends to come later in life than obstructive apnea, and it affects men and women in equal numbers. Of those with obstructive apnea, men outnumbered premonopausal women 30 to 1; the frequency among women increases as they get older. Some patients may suffer from all three types of apnea in a single night.

Sleep apnea may occur in infancy or childhood. It’s more common in overweight children, and more boys than girls are victims. Some children with sleep apnea complain of morning headaches, and some are sluggish and function poorly in school. Enlarged tonsils or adenodids may interfere with breathing during sleep, and surgical removal may be necessary. Autopsies suggest that sudden infant death syndrome may be caused by repeated periods of iniadequate oxygen intake brought on by respiratory abnormalities such as sleep apnea, though other factors may also be involved.

An episode of obstructive apnea is normally preceded by loud snoring. this labored breathing is then interrupted when the airway is constricted and blocks the inflow of air. The episode ends when the muscles of the diaphgram and the chest, continuing to try to function, build up sufficient pressure to force the airway open again. The sleeper then partly awakens with a strangled snorting noise caused by gasping for air, then slips back into a slumber until the obstruction again develops and the cycle is repeated.

Arousal is so brief, so incomplete, that sleep is resumed immediately without full awakening, and there is no memory of the episode. Hypopneas also may occur; these are partial or incomplete blockages that reduce the amount of oxygen delivered to the lungs and thence to other body systems.

The loud snoring so characteristic of obstructive apnea results when indrawn or expelled air produces vibration of the muscles of the upper airway which have become flabby from one or more causes. The reduction in the muscle tone of the victim’s palate, pharynx, and uvula can result from aging, but also may be caused by abnormalities of the part of the brain that sends signals to these muscles. The airway also is constricted by the reclining position of the body at night. In some cases, the tongue muscle may relax so that this organ falls back and obstructs air flow.

Obesity and a short, thick neck are physical attributes that contribute to breathing difficulty during sleep, although the exact way this works is not known. The upper airway also can be narrowed by enlarged tonsils or adenoids, a deviated nasal septum, nasal polyps, abnormal growths, and congenital or other defects.

Most researchers believe that daytime sleepiness results from the frequent sleep interruptions of the previous night and the aggregate sleep-time lost. But this daytime sleepiness could be to some extent a symptom of more ominous developments that result from inadequate oxygen in the system.

The entire pickwickian syndrome, obesity-sleepiness-snoring, occurs only in about 1 in 20 victims of obstructive sleep apnea. Thin and normal-weight persons have sleep apnea too. Some of these do have the short, thick neck associated with severe cases of sleep apnea.

In central apnea, the diaphragm and chest muscles simply stop functioning, and partial or full awakening occurs before breathing resumes. The SOS signal that wakens the victim is belived to be set off when the blood’s oxygen drops to a critical level, triggering a chemical wearning mechanism in the brain. A victim who is fully awakened often enough may complain to a physician about insomnia. Unless the condition is correctly diagnosed, a sedative or tranquilizer may be prescribed inappropriately, with potentially disastrous, even fatal, results since these can impede the sleeper’s awakening responses to the apnea episodes.

Severe sleep apnea can result in continuing or prolonged oxygen starvation in the brain and other parts of the body, which in turn causes general body deterioration. Death during sleep can result from failure to resume breathing or from heart arrhythmias during an episode. Some researchers believe sleep apnea may be implicated in many unexplained deaths that occur during sleep. This could someday cause new thinking among those who believe that dyring in one’s sleep, when the time comes, is the most beautiful way to go, especially if that time otherwise might have been postponed a matter of years.

Some common complications of obstructive sleep apnea, particularly over a prolonged period, are high blood pressure, disrupted heart rhythm and other heart complications, abnormal levels of oxygen and carbon dioxide in the blood, and peripheral edema (swelling of the extremities). All usually worsen unless the sleep apnea is treated.

Some other conditions that may appear as the disorder progresses: sleepwalking; blackouts or automatic (robot-like) behavior; intellectual deterioration–as evidenced by poor concentration, disorientation, senility, and mental retardationf hallucinations when fighting sleep; personality changes such as anxiety, irritability, aggressiveness, jealousy, suspicion, and irrational behavior; loss of interest in sex; morning headaches; and bed-wetting.

Elevating the head at night using two pillows, sleeping in a recliner chair, or setting the bed’s headposts on six-inch to eight-inch blocks is recommended to let gravity help keep the victim’s tongue from falling backward and blocking the upper airway. These practices help make breathing easier.

Some victims are diagnosed as having positional apnea. They experience fewer incidents or none when they sleep in a certain position, such as lying on the side. For them, the doctor may recommend sewing a tennis ball or other bulky object into the back of the sleeping garment to make sleeping on the back so uncomfortable that they turn over.

Obstructive sleep apnea is where most treatment developments have been concentrated. Sleep apnea can be reduced in severely overweight patients by weight loss, and this is encouraged in therapy.

Drugs used experimentally to treat obstructive sleep apnea include some that stimulate breathing and others that reduce REM (rapid eye movement) sleep, the sleep stage when the worst apnea episodes occur. Some drugs under study include theophylline, protriptyline, pemoline, thioridazine, clomipramine, and nicotine.

Surtical treatments include removal of enlarged tonsils or adenoids, nasal polyps or a deviated septum. Gastric bypass surgery–in which a portion of the stomach is closed off–has been performed on grossly obese victims of obstructive sleep apnea. Th is limits the amount of food that can be consumed at one time.

The most drastic surgery is tracheostomy. It is 100 percent effective for obstructive apnea, but is used only in life-threatening cases where less drastic methods are not effective. A T-shaped tube is inserted into the windpipe throgh a small incision just above the notch of the breastbone. The protruding end of the tube above the notch of the breastbone. The protruding end of the tube is closed off in teh daytime, to allow speaking and normal breathing, and opened at night. A tracheostomy can be made temporary or permanent, depending on the severity of the case. There can be complications such as irritations and infections that the patient must take precautions to avoid. Many patients, and their spouses too, are bothered by its appearance.

A surgical tehnique developed in Japan in 1980 and used increasingly in this country is uvulo-palato-pharyngoplasty–called, for obvious reasons, UPPP. Droopy tissues are tightened in the back of the mouth and top of the throat, and excess tissues that block the airway in those areas are trimmed away. UPPP is helpful in 50 percent to 60 percent of the cases of obstructive sleep apnea.

One device, developed in the United States, is a mouthguard worn during sleep that pulls the tongue forward by suction, thus clearing the airway. Another method, developed in Sweden, is the insertion of tubes through the nose and into the windpipe at night. These two methods are not in wide use, one problem being a low level of patient tolerance.

One of the most promising devices, first tested in Australia, employs a system called Continuous Positive Airway Pressure, or CPAP. The device reportedly is completely effective in about 85 percent of sleep apnea cases. It has been embraced enthusiastically by sleep disorder experts everywhere, and a version is manufactured in this country.

At night the patient’s nose (only) is covered by a mask, from which a tube runs to the device, about the size of a small TV set, placed on a bedside table. The bedside mechanism has a fan that forces air through the tube at low pressure, just sufficient to open the patient’s upper airway and permit air to enter the lungs. It is designed not to harm the patient should it malfunction or the power fail. The pressure is set to fit the patient’s own breathing pattern. It can be rented or purhased. It’s portable, and can be bundled along to any place where the patient stays overnight.

The CPAP device is manufactured by Respironics Inc., Monroeville, Pa. Called SleepEasy, the current version sells for close to $1,100. It must be prescribed by a doctor.

Despite all the hurrahs, it has one shortcoming. The motor makes a noise all night somewhat like the sound of a vacuum cleaner or a window air conditioner. But those who praise it figure that the user will be doing what comes unnaturally–sleeping–and will never hear the whir, and that the sleeper’s spouse or others in the household would be more than willing to put up with the new sound in preference to the old.

COPYRIGHT 1986 U.S. Government Printing Office

COPYRIGHT 2004 Gale Group