Snoring and the disturbance it causes used to be regarded as a joke, about which little could be done. However, we now know that snoring can indicate problems with breathing at night, which may harm the snorer. During sleep all the body’s muscles become less active and more floppy. In most parts of the body, this does not matter and indeed helps one to relax and sleep comfortably. When the muscles that help hold open the throat behind the tongue relax, this leads to partial collapse and narrowing in this area.
This increases the resistance to the flow of air when breathing in, but this is usually of no significance. When this narrowing that occurs with sleep is more than normal, then the airway behind the tongue collapses much more. To start with, this causes snoring and then, when the collapse is complete, it causes apnoea, which means “without breath” – actually stopping breathing. Fortunately, the body is able to sense this increased obstruction to breathing (thank goodness it does!) and the sufferer wakes briefly, before suffocation can occur, takes a few deep breaths, followed by a rapid return to sleep.
This obstruction and waking often becomes a continuous cycle, every minute or so, that can go on hundreds of times a night, every night. Usually though, the individual does not remember all these episodes of waking. There are three different types of sleep apnoea: Obstructive (the most common), Central and Mixed, which are rare.
Obstructive Sleep Apnoea is caused by the obstruction and/or collapse of the upper airway (back of throat), usually accompanied by the reduction in blood oxygen saturation, and then awakening (arousal) to activate breathing again. This is called an “apnoea event”. There are a number of factors which give rise to such an “event”. These are: Extra or large tissue at the back of the throat, such as large tonsils, vulva, and tongue or long/floppy soft palate.
There may also be an obstruction/s at the base of the tongue, turbinate problems or nasal blockages. A decrease in the tone of the muscles holding the airway open is another factor.
For any type of apnoea to be considered important the “event” must last at least ten seconds. Clinicians usually consider five or more “events” per hour to be of possible significance. However, another important factor is whether the patient is excessively tired during the day.
One of the best people to help you answer this question is your spouse/partner.
People with apnoea have the following symptoms: Loud, frequent and irregular snoring: The pattern of snoring is associated with episodes of silence that may last from 10 seconds to as long as a minute or more. The end of an apnoea episode is often associated with loud snores, gasps, moans and mumblings. Not everyone who snores has apnoea, by any means, and not everyone with apnoea necessarily snores (though most do). This is probably the best and most obvious indicator.
Witnessed Apnoea: Your spouse/partner indicates that you periodically stop breathing or appear to be choking during your sleep, or gasp for breath.
Excessive daytime sleepiness: Falling asleep when you don’t intend to. This could be almost any time you are sitting down, such as during a lecture, while watching TV, while sitting at a desk, and even when driving a car. You may have sleep apnoea or another sleep disorder. Even if you don’t literally fall asleep, excessive fatigue/tiredness could be a positive indicator.
Body movements often accompany the awakenings at the end of each apnoea episode, and this, together with the loud snoring, will disrupt the spouse/partner’s sleep and often cause them to move to a separate bed or room.
Forgetfulness, that is, affecting the short term memory also a diff
Would I not be aware of all these symptoms myself? Probably not. Most people with sleep apnoea do not realise that they are awakening to breathe many times during the night. The arousal is slight, and people become accustomed to this, but it is enough to disrupt the pattern of sleep so that they get very little deep sleep or REM sleep and awaken feeling sleepy. A great many apnoea sufferers go through a large part (or ALL) of their lives unaware of their condition. Likewise regarding daytime sleepiness, people with apnoea are often not aware of felling tired or unusually sleepy. The disorder develops over a number of years, and they are not aware of the increasing symptoms and believe they feel “normal”. Only after treatment do they realise how much more alert and energetic “normal” feels!
Absolutely. In rare cases Apnoea can be fatal. Think about it: is something that stops you breathing not to be dangerous? It has also being linked to high blood pressure, and to increased chances of heart disease, stroke, and irregular heart rhythms (arrhythmias). Unfortunately, not all the long term effects of untreated sleep Apnoea are known, but specialists agree that the effects are harmful. If nothing else, the continual lack of quality sleep can affect your life in many ways including depression, irritability, loss of memory, lack of energy, a high risk of driving and workplace accidents, and many other problems. Medical Research indicates that people with untreated Apnoea are more likely to die “before their time”.
In a study conducted on a small number of patients Dr. M. J. Morrell of the Sleep and Ventilation Unit at the Royal Brompton Hospital found that:
“The analysis revealed a significantly lower gray matter concentration in the apneic patients within the left hippocampus. No further significant focal gray matter differences were seen in the right hippocampus and in other brain regions. There was no difference in total gray matter volume between apneics and controls. Conclusion. This preliminary report indicates changes in brain morphology in OSA, in the hippocampus, a key area for cognitive processing.”
This is not something to ignore or trifle with. While it isn’t usually immediately dangerous, don’t take it lightly. If you think it will go away by itself – don’t – it won’t.
There are only a few effective treatments for OSA. They fall into several categories: weight loss, surgery, dental appliances, and a breathing assistance device. The most popular and most effective is the latter, the use of a device which delivers air under pressure to the airway by way of a nasal mask. There are several types of positive airway pressure devices, including CPAP, Bi-level positive airway pressure, and responsive and “smart” airway pressure devices. They are all variations on Continuous Positive Airway Pressure, or CPAP.
There is no guaranteed, permanent, device free “cure” for apnoea!
The type of treatment prescribed will depend on the type and location of airway obstruction and on the person’s overall health. Obstructions can occur anywhere from the nose (deviated septum; swollen nasal passages from allergies), the upper pharynx (enlarged adenoids; long soft palate; large uvula; large tonsils), or the lower pharynx (tongue that is large or situated far back; short jaw: short, wide neck with narrow airway). The location of obstructions varies between individuals, and an individual may have more than one obstruction.
Continuous Positive Airway Pressures (CPAP): “Nasal CPAP” is the treatment of choice for most people with obstructive and mixed apnoea. It is the most reliable and effective treatment in most cases. Hundreds of thousands of CPAP devices are now in use treating obstructive apnoea worldwide. An added advantage with this treatment is the elimination of snoring. It involves using a small air blower device connected by a hose to a nose mask you wear while you are asleep – much like a regular oxygen mask, with straps to keep it in place. Essentially, this device blows air into your nose to keep your airway from collapsing and creating an obstruction by increasing the air pressure in your airways. It isn’t as unpleasant as it sounds – most people get used to the sensation fairly quickly. Admittedly, having to wear a face mask to bed is not the most attractive thing in the universe. Most bed partners are usually happy to live with it rather than snoring! It is infinitely preferable to the effects of apnoea, both the fatigue and other physical effects (additional strain on the heart). The exact results vary, but a great many people report significant changes in their lives when they start using CPAP – they feel more awake, more alive – “like a whole person”, in some cases.
Bi-Level Positive Airway Pressure: Bi-level positive airway pressure is a variation of CPAP. Instead of providing air at a constant, fixed pressure all night, the machine “senses” how much air the person needs, based on inspiration and expiration, and varies its level of pressure accordingly. On inspiration, a higher pressure is needed to prevent Apnoeas, Hypopnoeas, or snoring. But on expiration, the patient typically requires less pressure. What is the purpose of this? Well, some people find that they simply cannot sleep with regular CPAP due to the constant air pressure. Bi-level pressure helps this problem by providing less pressure when you are breathing out (expiration) and more when breathing in (inspiration). Bi-level pressure devices are significantly more expensive than a regular CPAP.
Responsive and “smart” airway pressure devices: In the belief that the reduction of total airway flow would provide greater comfort to the patient and encourage patients to use the airway pressure treatment on a regular basis, several manufacturers have begun to offer a new generation of treatment devices. These devices incorporate flow and pressure sensors and automatic regulation systems. There are three basic approaches. One tries to keep overall pressure requirements low by using high pressure only when there is a specific problem, but this requires a very rapid increase in pressure if a problem is detected. The second varies the pressure delivered, providing less when problems are absent, and raising the pressure gradually as problems appear. The third gradually raises and lowers the pressure as conditions require, but also changes the pressure within a specific breath if an emerging problem is detected. Compared to CPAP, “smart” devices may offer greater patient comfort, insofar as the overall pressure is reduced, providing that the changes in pressure reduce or eliminate apnoea, snoring, or flow limitation, and also provided that the changing pressures are tolerated by the patient. They may be used for patients whose pressure requirements may vary during the course of the night, from night to night, and over longer periods of time. As professionals in the field of sleep disorders gain experience of these devices and their appropriate applications, they may provide an additional path of relief for selected patients. As with any new form of treatment, physicians and patients may need to review studies of each device before selecting the one most appropriate to the needs of a specific patient.
Tongue-restraining devices (TRDs): This is a suction cup that is gripped with the teeth and which sucks the tongue forward, thus opening the airway behind the tongue. People who snore only when lying on their back, and whose tongue is the main source of obstruction, sometimes find this device helpful.
Mandibular Advancement Devices (MADs): These are specialised dental devices (must be fitted by a dental surgeon) which clamp your teeth and jaw joint to “pull forward” the jaw to allow more space for breathing. They are only worn at night (removable) and initial research shows a certain amount of success, however side effects include excess salivation and joint pain (soreness) in some cases. They must be worn all night every night. While a relatively new way of managing sleep Apnoea, further design modifications are needed.
Surgery (of any type) where anaesthesia is used, poses a very real danger to people suffering from Sleep Apnoea. In all cases your surgeon and anaesthetist should be informed (in advance) if you suffer from sleep Apnoea. You also need to inform your sleep specialist of any impending surgery, as they will send medical data to your surgeon. If using CPAP you will probably be advised to bring your machine to hospital and possibly to theatre. It may be required during the post operative recovery period.
Surgery for Sleep Apnoea: The goal of surgery is to enlarge the airway and prevent snoring and airway collapse. Surgery is site specific (to enlarge a specific portion of airway). Due to the risks associated with anaesthesia or an operation surgery should NOT be considered as a first option. There is also risk that surgery may cure snoring, but if the patient has Apnoea, one of the primary symptoms will have been removed while the Apnoea remains and may go undiagnosed while further damage is being done to the respiratory and cardiovascular systems possibly leading to a stroke (which may have been avoided). We are unable to source reliable figures for success/failure with surgery. In general, with the exception of tracheotomy (see below) surgery for “curing” Apnoea is not successful and is quite painful. In Europe surgery is seldom used to treat/cure Apnoea. In America an increasing number of ENT (Ear, Nose and Throat) surgeons continue to pioneer this method of treatment and now offer a “cocktail” of surgical procedures over a period of two to four years. In some cases “success” has been claimed, however they are usually short lived as symptoms of Apnoea start to reappear within a short space of time. There are no “quick fixes” for Sleep apnoea. The following is a list of all the known surgical procedures currently in use to treat/cure Apnoea. There are no reliable figures available for the success or failure of any one procedure. The best estimates for UPP surgery is a”50% improvement in 50% of cases”. Unfortunately for anyone with mild to severe Apnoea this means that CPAP must still be used after the operation.
Septoplasty: The septum is the divider between the two nasal passages. A deviated (crooked) septum may obstruct the nasal airway. A Septoplasty is performed through the nostrils. The cartilage and bone of the septum is straightened.
Turbinate Reduction: The turbinates within the nose are made of bone surrounded by soft tissue whose functions are to warm and moisten the air as you breathe. There are three turbinates in each nostril (lowest, middle and upper). Reduction of the size of an enlarged turbinate can improve the size of the nasal airway. Turbinate reduction may be performed with surgical instruments, lasers, radio frequency or cauterisation. Removal of polyps Nasal polyps can obstruct the nasal airway. Removal of polyps can “free up” the airway. Sinus Surgery Sinus infection can contribute to nasal obstruction and surgery may be necessary.
Upper Airway Surgery
Uvulopalatopharyngoplasty (UPPP) surgery: The surgery removes the uvula the lower edge of the soft palate is trimmed. If present, the tonsils are generally removed and the tissues around them trimmed. It can be done separately or in conjunction with other treatments, depending on where the airway obstructions occur. There are the usual surgical risks involved with surgery. Notable ones are general anaesthetic (depresses breathing reflex and can be risky in people with breathing problems like Apnoea), swelling of the airway, need for pre and post-operative medication (can depress the breathing reflex), bleeding, and significant pain lasting several weeks.
Is it effective? Will it free me from having to wear a CPAP machine for life?: This surgery seems to have a history of being effective in 50% of patients 50% of the time. In other words many of the people who have UPPP will end up having to use CPAP anyway. It is almost never a “cure all”. The risks and side effects of surgery are usually not worth it. This is a decision that each person has to make, but you should give it a great deal of thought beforehand. Surgery is not something to be undergone on a whim, and certainly not for the sole reason of ridding yourself of CPAP. The vast majority of people who have undergone UPPP for the treatment of Obstructive Sleep Apnoea do have to continue using CPAP. UPPP is seldom, if ever, used for treating OSAS in the UK or Eire.
Laser assisted Uvulopalatopharyngoplasty (LAUP): LAUP is a relatively new laser surgery on the uvula and soft palate that is reduced to diminish snoring, but no controlled studies have been done to show that it reduces apnoea. As it is less extensive than UPPP, it is unlikely to be more effective in treating apnoea. It is usually done in several steps, and is an outpatient procedure. For that reason it is less risky than UPPP. While the procedure may sometimes be effective in helping people who snore but do not have apnoea, the main danger from LAUP is that people may eliminate their snoring and assume their problems are solved, when in fact they may still have untreated sleep apnoea which may continue to get worse but be ignored because its primary alarm signal (snoring) has been silenced. Potential patients should be careful that they don’t see an “ad” in the paper, call the doctor, and rush into an LAUP procedure without research and consideration.
Somnoplasty (Radio-frequency Tissue Ablation of Palate): Deliverance of Radio frequency waves by a needle electrode to the underside of the soft palate to cause contraction of excessive tissues that cause snoring. This procedure involves a progressive shrinkage of the soft palate and uvula. Usually patients require up to four treatment sessions of 15/20 minutes under local anaesthesia. This procedure is relatively painless.
Tonsillectomy and Adenoidectomy: Tonsils are tissues on the sides of the upper throat and if enlarged may narrow the width of the upper airway. Adenoids are at the back of the nose and can obstruct the nasal airway. This surgery is most common in children as adenoids usually shrink with age.
Lower Airway Surgery
Genioglossus Advancement: The Genioglossus muscle attaches from the back of the tongue to a spot on the back of the chin. This surgery attempts to pull the back of the tongue forward in an effort to enlarge the airspace behind the tongue. The procedure pulls forward a rectangular or circular segment of chin bone (below the four front teeth) and hols it in place with a plate or screw. A minimal change in the appearance of the chin results.
Hyoid Advancement: The Hyoid bone is just above the Adam’s apple. This bone is move forward and either attached to the Adam’s apple or jaw bone. The purpose is to enlarge the space behind the tongue.
Midline Glossectomy, Lingualplasty, and Lingual Tonsillectomy: Midline Glossectomy involves a reduction in size of the tongue (if enlarged). The back of the tongue is reduced in size by excising a V shaped portion of the centre part of the tongue. Lingualplasty is a more aggressive resection with additional removal of side wedges. Lingual Tonsillectomy involves the removal of the tonsil like tissue on the back part of the tongue; it may also be performed with a laser. A temporary tracheotomy is usually performed with these procedures to avoid breathing difficulties that might arise from temporary swelling. The purpose is to reduce the size of the tongue thereby increasing the air space behind the tongue.
Bimaxillary Advancement (Lafort 1 Maxillary Osteotomy with Bilateral Sagittal split Mandibular Osteotomy): The upper and lower jaw bones are moved forward along with all the teeth in an effort to pull soft tissue structures forward and make more room for the tongue. Metal plates and screws are used to hold the realigned jaw in place. Orthodontic work prior to or following the procedure may be necessary in order to maintain the proper alignment of the teeth. Change in facial appearance relates to the extent of the advancement. Tongue Suspension Suture (Repose) The tongue is pulled forward by way of a permanent stitch to a screw which has been placed through the back of the tongue. This is to prevent the tongue falling back during sleep and obstructing the airway.
Surgical Bypass of the Airway
Tracheostomy: An opening is made at the front of the neck to the windpipe and a plastic or metal tube is inserted. During sleep the patient breathes through the tube, while during the day it is covered to allow normal breathing and speech. There are considerable hygiene problems with this procedure.
It is wiser and safer to get professional treatment. You can use the techniques below, in consultation with your sleep specialist/doctor, while your treatment progresses. Sleep apnoea is a disorder and as such cannot be cured, it can however be managed effectively. There are several things doctors suggest you do that can greatly alleviate it:
Weight Loss: If you are overweight, loose it! Excess weight contributes to sleep apnoea in two ways.
- Fat deposits in the neck tissue compress the airway and make it more likely to collapse.
- Excess weight in the abdomen makes the breathing muscles operate inefficiently, which contributes to breathing difficulty when sleeping.
Weight loss by itself is very difficult (as many of us know). Sometimes people are only able or much better able, to lose excess weight after treatment for apnoea has begun, they are able to be more awake and vigorous, and increase their energy use. Naturally, weight loss is just a generally healthy thing (if you are overweight – if your weight is normal do not starve yourself!).
Smoking: As with the loss of excess weight this is, of course, just a good idea in general. However, quitting might also help your apnoea in addition to countless other health benefits, by returning lung capacity to normal.
Alcohol: Eliminate alcohol in the evening. Alcohol depresses your breathing reflexes and significantly worsens apnoea. Apnoea sufferers should be very careful about excessive drunkenness. It’s possible that if you depress your reflexes enough, you might not wake up at all. The same thing applies to sleeping pills, drugs or anything that might affect your breathing.
Allergies and respiratory infections: These cause nasal congestion, which narrows the airways and contributes to apnoea. Consult your doctor for medications to treat these which will not interfere with your sleep.
Medications: Many common medications interfere with the breathing reflex, sleep or both. Some of the most common are “sleeping pills”, tranquilisers, and short acting beta-blockers. Consult your sleep specialist about seeking alternative medication.
First, read the manual with your CPAP unit.
Adjust the headgear: This is, probably, the easiest and most effective thing you can do; spend time learning how to adjust the headgear and mask. Many people struggle with it and call it uncomfortable when they haven’t really tried to adjust it properly. It’s especially tough when you are sleepy and fumbling around with it in the dark. Take some time. Sit down at a table with the headgear during the day. Take it apart. See where all the straps, buckles and Velcro seams are. Work out what each one does. Generally familiarise yourself with the kit. Try it on. Adjust it so that it is at its most comfortable, and note where each strap has to be to achieve this. Ask for help, if necessary. A lot of people mistakenly think that the solution to air leakage is to adjust the straps more tightly. This frequently increases the leak. Usually air leakage problems are due to positioning not pressure. Naturally, there has to be enough pressure to maintain a seal, but make sure that everything is positioned correctly before resorting to tightening the straps. It is a very personal thing, what works for one person may not for another. Some people have found that putting a hook in the wall over the bed, and hanging the hose over that helps to keep the hose from “tugging” on the mask and head gear.
Humidifiers: If you find the incoming air too dry, and your sinuses are drying out, many manufacturers offer a humidifier as an option. Essentially, this is (rather expensive for what it is) a piece of plastic which you fill with water and place in between your machine and the mask. The air flows over the water picks up moisture, just like a house humidifier. A heated humidifier used with CPAP can make a significant difference in comfort. The water container sits on a hot plate which ensures that the air you breathe is both moist and warm. This form of humidification is proving very popular.
Noise: Most CPAP machines are quite quiet. Most people don’t mind it, and some even find the soft “white noise” of rushing air relaxing. Some, however, find the noise disturbing. The only two things you can do are 1) block the noise somehow, or 2) move the machine. To block the noise, try putting the machine behind something – a dresser or board perhaps. However, DO NOT PLACE ANYTHING OVER THE CPAP UNIT OR BLOCK THE FLOW OF AIR IN ANY WAY! Remember, this machine pumps air- if you cut off the flow, you could damage it or even start a fire. There must have plenty of space around it so air can circulate.
Appearance: Unfortunately, there is really nothing that can be done about this. Even if you bought “Gucci” or “Armani” headgear and mask, there is no hiding that you are wearing headgear and a mask! If your bed partner doesn’t like it ask them if they preferred you snoring.
What are “nasal pillows” and “Adam Circuits”?: Nasal pillows (“Adam Circuit” is another name for the same thing) refer to a different method of delivering air with a CPAP machine. Basically, these are nose plugs that you use in place of a traditional mask over your nose (you still connect to the hose of a CPAP machine, like your mask) It is less bulky than a mask, and there aren’t as many problems with air leaking out, particularly at low pressure.
Which CPAP Machine is the Best?: There are several different manufacturers of CPAP machines, each with different models. They all perform the same function; the major differences are in price, weight and options. Some are the “bare bones” while some have many options including such things as voltage converters (handy for foreign travel) and even remote controls! In particular some machines make less noise than others. This website contains details of the machines that may be prescribed for your use by The Newport Sleep Centre.
The simple answer is “Yes, if you are tolerating treatment”. All of us who have been diagnosed with OSA have been told of our legal responsibilities regarding OSA and driving. You MUST, by law, inform both the DVLA and your insurer that you have been diagnosed with apnoea. As a responsible Society we urge all our members who hold a licence to follow this advice. We realise that, quite naturally, when your living depends on driving you may be reluctant to inform the “authorities”. There are several members who can, and will, attest to the fact that both the DVLA and insurers are quite happy to continue to allow you to drive and provide cover if you tolerate treatment. It is well worth knowing that the DVLA are aware of the fears of apnoea sufferers and have been involved in dialogue with Dr. Hack concerning this matter. They produce a booklet on the guidelines of fitness to drive. Visit the website: www.dvla.gov.uk
No matter what your fears please do the sensible thing and inform both the DVLA and your insurers. You know it makes sense.