Recognizing and Treating Sleep Apnea
Expert tips on how to tell common snoring from sleep apnea -- and advice on seeking treatment.
If you think sleeping next to an industrial-grade snorer is bad, consider the world of sleep apnea.
You're sleeping quietly beside your partner when all of a sudden, his chest stops its comforting rise and fall. The silence is broken with an explosive gasp or snort, he becomes restless, and then normal breathing -- or more likely, snoring -- resumes.
"My wife couldn't sleep in the same room with me," says Jim DeCastro, the sheriff of Bristol County, Rhode Island, who suffers from sleep apnea. "My tenants on the second floor complained. No one could take it anymore."
Sleep apnea is more than just loud snoring. A person literally stops breathing while asleep. The tongue or other soft tissues fall back and completely collapse the airway. At other times, the airway is only partially obstructed and breathing is very shallow. Either way, oxygen levels drop. Throat muscles contract as the person struggles to breathe. He gasps or lets out a snort as air rushes down the now-open throat. Oxygen levels return to normal and the person falls back asleep.
This cycle can be repeated dozens of times each hour. Snorting and snoring become such a routine, most people have no memory of their spasmic breathing cycle. Others may remember a restless night or a sudden awakening.
Most people with obstructive sleep apnea stop breathing for 10 to 40 seconds. Some stop breathing repeatedly, as many as 500 times a night. Martin Scharf, Ph.D., director of the Tri-State Sleep Disorders Center in Cincinnati, has treated a man who stopped breathing 144 times every hour throughout the night.
Who is at Risk?
If you sleep alone, you probably won't know you have apnea until symptoms develop, which can take a while. If someone has complained that your snoring sounds like a jackhammer, suspect apnea. Not all snorers have sleep apnea, but more than half of all heavy snorers do.
James Kiley, M.D., director of the National Center on Sleep Disorders Research at the National Institutes of Health, says women usually recognize the problem. "Often it doesn't happen in the reverse," he says, "because women may not snore as intensely as men so their male bed partner doesn't wake up."
Symptoms may be vague and subtle. You may feel tired and sleepy during the day even after a full night's sleep. Before he became a sheriff's deputy, Jim DeCastro was a mechanic and would fall asleep on the cars he was supposed to be fixing, despite getting 12 hours of sleep.
Apneics may wake up with a headache. They feel irritable, experience memory difficulties, and have problems concentrating. Many sufferers report depression, impotence, or loss of sex drive. Marlene Greene, a computer specialist in New York City, was being treated for depression until a sleep lab determined she really had obstructive sleep apnea. Some people are so exhausted, they fall asleep at the wheel. Patients with sleep apnea are three to seven times more likely to have a car crash, says Allan Pack, M.D., director of the Penn Center for Sleep Disorders.
Jim once fell asleep outside the drive-through window at a bank, was suspected of drunk driving, and then couldn't recall how to sign his name.
Collar size counts. Obstructive sleep apnea is most common in middle age and more likely to strike men than women. "In men 30 to 60 years old, it's as common as asthma and diabetes," says Richard Millman, M.D., director of the Sleep Disorders Center at Rhode Island Hospital.
One big risk factor appears to be body fat. Sixty percent of people with sleep apnea are overweight. But specifically, it's not the poundage, but the neck size that counts. Men with a neck circumference of 17 inches or larger (16 inches for women) are more likely to have their airway collapse while sleeping. So is someone with a double chin or a lot of fat at the waist.
Apnea usually worsens with age because the tissues in the throat become floppier and people gain weight. Men are more susceptible because they often have beefier throat tissues and gather fat in their abdomen, neck, and shoulders -- all factors for a narrower airway.
It's unclear whether apnea is caused by obesity, oversized tissues in the throat, a thick neck, basic jaw structure, or a combination, says Rafael Pelayo, M.D., of the Stanford Sleep Clinic. There may be a genetic link as well. Snoring does run in families, and relatives of those affected with apnea tend to be more likely to have apnea and have shallow breathing.
The heart connection. When you stop breathing, your body experiences a fight-or-flight response: adrenaline is released and blood pressure shoots up. After repeated bursts of nighttime high blood pressure, hypertension may persist during the day. With each apneic episode, the heart has to work harder. That's because there's less oxygen flowing to the heart. The worry is that apnea may increase the risk of heart attack, stroke, and heart rhythm disturbances.
Dr. Millman found that men with sleep apnea were more likely to be obese, have high blood pressure and poor blood sugar regulation -- all risks for heart disease -- though not when the researchers controlled for age and weight. Dr. Millman believes sleep apnea doesn't cause heart disease but it may make underlying heart disease worse.
"If someone has severe apnea and coronary artery disease, the stress of apnea could be equivalent to shoveling heavy snow," says Dr. Millman. That's because an apneic's low oxygen levels compound the problem of reduced blood supply to the heart. A non-obese person with apnea who doesn't have heart disease wouldn't have an increased heart disease risk as long as he didn't have high blood pressure.
Sleep Apnea Diagnosis and Treatment
Until recently, most family doctors would rarely diagnose apnea or were unfamiliar with how to treat it. Sleep apnea was only officially defined in 1965.
"If you tell a doctor that you're fatigued, tired, and sleepy during the day, he'll laugh because he's sleep-deprived himself," Dr. Millman says. "It's not going to send off bells and whistles like chest pain."
If you think you or your partner may have apnea, talk to your doctor. He or she should refer you to a pulmonary specialist or ear, nose, and throat doctor. Make sure the person specializes in sleep disorders and sleep apnea. During the exam, your nose, throat, and jaw will be examined. You and your mate will be asked about snoring history, gasping or snorting, sleep habits, daytime tiredness, or falling asleep in front of the TV. Yosef Krespi, M.D., director of ear, nose, and throat service at New York City's St. Luke's-Roosevelt Hospital, gives his patients and their bed partners an eight-page questionnaire.
The only sure way to make a diagnosis, however, and determine severity is to spend a night or two in a sleep lab for a polysomnography exam. Technicians monitor blood oxygen levels, heart rate, temperature, brain waves, and the number of times breathing stops.
Polysomnography in a lab is expensive (about $2,000), but it's often covered by insurance. There also are home monitoring devices at half the cost, but insurance carriers don't always pay. "Portable unattended tests aren't as sensitive," says Dr. Pelayo. "They pick up obvious apnea but not the milder varieties."
Ways to Silence Snoring
Simple lifestyle changes may help you muffle loud snoring. Avoid alcohol after dinner and stay away from tranquilizers, which relax throat muscle tone, depress breathing, and make apnea more likely. Dr. Millman suggests people with stuffy noses use a decongestant or nasal strips, such as Breathe Right, to open the nasal passage. Some apneics improve by sleeping on their sides and stomachs, rather than their backs. That's because the tongue falls back when a person lies on his back. A classic technique is to stuff a tennis ball into a sock and slip it to the back of your nightshirt so you don't roll onto your back.
If you smoke, quit. Smoking can swell throat tissues, increase mucus formation, and worsen the low oxygen levels that accompany apnea. Losing weight can make apnea disappear in some people. Even a 10 percent weight loss could reduce the frequency of episodes. At this time, there are no pills that can treat sleep apnea.
Continuous positive air pressure (CPAP, pronounced see-pap), according to Dr. Pack, is "the gold standard" for treating sleep apnea. "It can abolish apneic events in anyone, no matter how severe," he says.
Patients wear a mask over their nose that delivers air under pressure to their lungs. The forced air keeps the airway open. As a result, the heart doesn't have to work as hard, and blood pressure may drop to normal.
The first time Jim used his CPAP, he says, he got the first good night's sleep in a long time. "Now, I don't know when I last took a nap," he says. Once Marlene started using a CPAP, she stopped falling asleep at her computer or when visiting friends.
CPAP has to be worn every night for the rest of your life. The mask can be uncomfortable for some patients, and some get eye, nose, or mouth irritations. Others complain it's difficult to breathe out against the high air pressure.
Another alternative: A dentist can fit you with an oral device that repositions your tongue and jaw to hold them forward. It works because when you pull the jaw forward, the tongue moves forward as well.
"These devices are no worse than a retainer and results are similar to CPAP," Dr. Scharf says. The problem is that there are 37 different types which look and operate differently, they can be costly, and your insurance company may not cover the expense.
Surgery -- the final option. Surgery to widen the airway is usually not done unless all other options have failed. Called the uvulopalatopharyngoplasty or UPPP (UP3), it reduces the size of the uvula, soft palate, or both. Only 50 percent of apneics have some success with this technique. It's expensive, there's a painful recovery, and, like all surgery, it carries risks.
"You know you've done something with surgery if patients say they're having wild dreams. With severe apnea, patients don't dream," says Derek Lipman, M.D., an ear, nose, and throat specialist in Portland, Oregon.
The newest surgical procedure involves zapping away excess tissue with a laser, called a laser-assisted uvulopalatoplasty or LAUP. Originally designed to eliminate snoring, LAUP is an office procedure using only local anesthesia. Compared with UP3, it's less costly and less painful with a quicker recovery. On the downside, it may require several treatments. And it is controversial.
"The concern is turning the person into a silent apneic," says Dr. Pack. In other words, the jackhammer sound effects are gone, but the apnea isn't. Success depends on how carefully patients are selected. "In better studies where they are meticulous in selection, the success rate is 80 percent," says Dr. Lipman.
Dr. Krespi, who has treated over 1,200 patients with this procedure, has found that it works for mild apnea if the obstruction is in the palate (and uvula). "People who have moderate or severe apnea, are overweight and can't lose weight, or have uncontrolled high blood pressure aren't good candidates for laser surgery," he says.
One thing experts agree on is that, if you have surgery, you should have a postsurgery sleep study to see how your apnea was affected.
For More Information:
- The American Sleep Apnea Association, 1424 K Street NW, Suite 302 Washington, DC 20005, 202-293-3650.
- The American Academy of Sleep Medicine, 6301 Bandel Road NW, Suite 101, Rochester, MN 55901, 507-287-6006.
- The National Heart, Lung and Blood Institute, Information Center, P.O. Box 30105, Bethesda, MD 20824-0105, 301-251-1222. Ask for "Facts about Sleep Apnea."
Sleep Apnea Quiz
For each question, give yourself 1 point for Never, 2 for Very Infrequently, 3 for Occasionally, 4 for Often, and 5 for Always or Almost Always. If you score a 4 or more on most questions, it's likely you have sleep apnea and should consult your doctor.
1. Does your snoring disturb your bed partner?
2. Do you snore in all sleeping positions?
3. Has someone told you that you stop breathing for a long time between snores?
4. Does your snoring ever wake you suddenly?
5. Are you tired when the alarm goes off?
6. Is it hard for you to get out of bed when you wake up?
7. Are you tired during the day?
8. Do you fall asleep in front of the TV, at the movies, or in church?
9. Have you ever been in a car accident because you fell asleep while driving?
Adapted from Snoring from A to ZZZZ: Proven Cures for the Night's Worst Nuisance by Derek S. Lipman, M.D. (Spencer Press, 1996).