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Breathing disorders in sleep

Although relaxed and steady breathing is natural for most sleepers, some people snore so loudly that they literally wake the neighbors. Loud snoring may be a sign of sleep apnea, a life-threatening condition marked by frequent interruptions in breathing. In most cases, however, people who snore only suffer from simple snoring produced when the muscles of the airways relax during sleep — a condition that doesn't cause medical complications but may disrupt others sleeping nearby.

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Snoring

With the onset of sleep, muscles in the airway relax and the airway narrows. Snoring occurs when the airway narrows too much, causing turbulent airflow. This, in turn, makes the surrounding tissue vibrate, producing noise. More than one-third of adults in one survey said they snored at least a few nights a week in the previous year.

When a person's nasal passages are swollen by a cold, allergies, or a reaction to smoking, temporary snoring may occur. For someone with a deviated septum, the problem is ongoing. A particularly large uvula; enlarged tonsils, adenoids, or tongue; an elongated soft palate; or a very small jaw may also contribute to snoring.

In yet other people, excess fat in the neck area may reduce the width of the air passage and promote snoring. The hormones progesterone and estrogen may play a protective role; before menopause, women snore less than men, but snoring increases among women later in life. Many women snore late in their pregnancies, a phenomenon attributed to hormone-related swelling of airway tissues.

Although snoring is rarely life-threatening, sleep specialists take even simple snoring seriously. A person who snores heavily deserves a thorough examination of the throat, mouth, palate, tongue, and neck and may need to undergo sleep studies.

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Treatments for snoring

Hundreds of devices are marketed as aids for people who wish to stop snoring or improve their nighttime breathing. Some encourage you to sleep on your side; others are dental appliances that try to keep your airway open by preventing your tongue from falling back or by moving your jaw forward. Check with your physician before investing in such a breathing device. He or she may be able to recommend simple, inexpensive ways to prevent snoring.

For example, some people snore only when lying on their backs and can be encouraged to lie on their sides by having a tennis or golf ball sewn into the back of their pajamas (which makes back-sleeping uncomfortable). Others keep air passages open by raising their heads with an extra pillow or by propping up the head of the bed a few inches.

Doctors usually encourage an overweight snorer to lose weight. It may also help to quit smoking, forgo alcohol in the evening, and avoid sleeping pills or tranquilizers, which slow breathing and decrease muscle tone.

If swollen nasal tissues are the problem, a humidifier or medication may reduce swelling. An operation may be necessary to correct a deviated septum or remove large tonsils and adenoids. In extreme cases, physicians may recommend more extensive surgery, similar to that used to treat sleep apnea.

Laser surgery. In 1990, a French physician reported successfully treating snoring with a type of laser surgery called laser-assisted uvulopalatoplasty (LAUP). Some ear, nose, and throat specialists in the United States use the procedure, which is done on an outpatient basis. In this surgery, the physician uses a carbon dioxide laser to shorten the uvula and to make small cuts in the soft palate on either side of the uvula. As these nicks heal, the surrounding tissue pulls tighter and stiffens. Because snoring results from the flapping of loose tissue at the back of the soft palate, it is less likely to occur when the tissue is smaller and stiffer. The procedure, done under local anesthetic, causes little bleeding. Patients usually have a sore throat for about a week. After five weeks of healing, the treatment may be repeated if snoring persists. Three or four procedures may be needed.

LAUP is not considered an essential therapy and may not be covered by insurance. Also, while LAUP can be quite effective in stopping snoring, the technique doesn't appear to ease apnea. In fact, this procedure can be dangerous for people with apnea because it removes the warning signal of this breathing disorder. Therefore, be sure you have a physician rule out sleep apnea before undergoing LAUP.

Somnoplasty. Another treatment for snoring is somnoplasty, or radiofrequency tissue volume reduction, developed by ear, nose, and throat specialists at Stanford University. In the mid-1990s, the FDA approved this procedure as a treatment for snoring; since then, it's become a treatment option for obstructive sleep apnea. Somnoplasty is performed on an outpatient basis using a local anesthetic. The doctor delivers radiofrequency waves through the tips of tiny needles inserted into the obstructive tissue to shrink it. Somnoplasty only takes a few minutes to perform and doesn't cause bleeding, but it may have to be repeated to achieve results. People typically experience some swelling immediately following the procedure; over-the-counter painkillers can usually control post-treatment pain.

Palatal implants. In 2004, the FDA approved this procedure (also known as the Pillar procedure) in which up to three matchstick-sized stiffening rods made of polyester are implanted into the soft palate. The rods help prevent collapse of the palate, limiting obstruction of the back of the nose when a person falls asleep. The procedure, done under local anesthesia in an office, is reversible. If it causes pain or does not work, the rods can be removed, again under local anesthesia in the office. Sometimes the rods come out on their own, but without significant discomfort. If palate collapse is the main reason for the snoring, then the procedure may improve the symptoms; it has limited benefit if other anatomical problems are involved.

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Sleep apnea

Sleep apnea is a life-threatening condition in which breathing stops or becomes shallower hundreds of times each night. It affects approximately 18 million adults in the United States and is most common among overweight men. By far the most common form is obstructive sleep apnea (OSA), in which the airway becomes blocked during sleep.

Untreated, sleep apnea can have serious consequences. The relentless daytime fatigue that often results may lead to failed careers, broken marriages, and automobile and workplace accidents. It can even be life-threatening, leading to the development of hypertension, heart failure, and stroke. A 2005 New England Journal of Medicine study found sleep apnea doubles a person's risk of stroke over a seven-year period.

Sleep apnea used to be considered uncommon, and it often remained undiagnosed. Physicians rarely checked for it except in the stereotypical patient — an overweight, middle-aged man who snored. But in 1993, researchers at the University of Wisconsin School of Medicine learned that apnea is more common in both men and women than previously thought. They looked for sleep apnea in 600 state employees, ages 30 to 60, as part of a larger sleep study, and were surprised to find that 9% of women and 24% of men had at least five episodes of reduced breathing, or hypopnea, per hour. About 4% of men and 2% of women were estimated to have the full syndrome of sleep apnea, which includes abnormal breathing events and daytime sleepiness.

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Obstructive sleep apnea

OSA occurs when the upper airway is blocked by excess tissue such as a large uvula, tongue, tonsils, fatty deposits in the airway walls, nasal congestion, or a floppy rim at the back of the palate. People with OSA tend to have smaller airway openings than those who don't. A narrow airway makes obstruction all the more likely when airway muscles relax at the onset of sleep.

A potentially life-threatening lack of oxygen and buildup of carbon dioxide, as well as increasing efforts to breathe, cause the sleeper to wake and gasp loudly for air until blood oxygen levels return to normal. At worst, a person with OSA cannot breathe and sleep at the same time.

Some people with OSA repeat this cycle hundreds of times a night without being fully aware of what is happening. They don't realize how little sleep they're actually getting and may routinely feel lethargic. Others wake up after bouts of apnea and have difficulty getting back to sleep; they reason that insomnia — not a breathing problem — makes them sleepy during the day. The condition can become even more perilous if a person with OSA is treated with sleeping pills that further relax airway muscles or suppress arousal or breathing.

Symptoms and signs of OSA are as follows:

Snoring. Although many snorers have no medical problems, the hallmark of OSA is frequent snoring that is loud enough to disturb a bed partner. The snorer may choke, gasp, or appear to hold his or her breath during sleep.

Thick neck. Men with a neck circumference of 17 inches or more and women with a neck circumference of 16 inches or more are at higher risk. As with snoring, obesity is a major risk factor, since fatty deposits surrounding the throat expand as people gain weight, narrowing the airway.

Hypertension. More than half of patients with OSA have high blood pressure. Research has shown that OSA is a cause of hypertension.

Grogginess, fatigue, and sleepiness. People with OSA are excessively sleepy during the day and have two to six times as many traffic accidents as individuals without this condition.

Sleep apnea can wreak havoc on the cardiovascular system because the heart must work harder every time blood oxygen levels dip. People with the disorder have a higher risk for stroke, heart attack, and heart failure. Arrhythmias (irregular heartbeats) may accompany apnea spells.

OSA occurs on a spectrum from a wide open airway (no problem) to a completely blocked airway. In some cases, the airway is only slightly narrowed but people must work extra hard to inhale, although they have no significant drop in blood oxygen levels. This extra work wakes them up many times each night, and they may complain of insomnia or daytime sleepiness. The same treatments that help individuals with a fully closed airway are also effective for these cases.

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Treatments for obstructive sleep apnea

Treatments for OSA fall into four general categories — lifestyle changes, air pressure devices, dental devices, and surgery. In addition, medication may be used along with these treatments.

Lifestyle changes. Weight loss is the best treatment for weight-related OSA. Sleeping on one's side instead of the back can work for people who have OSA only while on their back. Everyone with OSA should avoid alcohol, sedatives, and muscle relaxants. Nasal strips, mechanical dilators, and moisturizing gels and sprays have not been shown to help. Because weight loss takes time and can be very hard to achieve and maintain, and because other simple measures are usually not sufficient for more severe cases, additional treatments are often required.

Positive airway pressure. The first-line therapy for most people with moderate to severe OSA is positive airway pressure, or PAP, the use of an air-pressure device connected by a hose to a mask that covers the nose. The air pressure delivered through the mask opens the airway, preventing collapse when muscles relax during sleep and allowing the person to sleep normally and breathe regularly without interruption. The most common form of PAP is continuous positive airway pressure (CPAP), in which the air pressure stays the same while breathing in and out.

CPAP was once quite cumbersome but has become more comfortable. Newer models are lighter and quieter, and many offer options such as warmed humidified air (which alleviates nasal congestion, skin dryness, and dry mouth) and a timer that slowly builds up pressure to give you time to adapt and fall asleep more easily. There are also a variety of mask styles, allowing users to find the one that best fits the face and is most comfortable.

People usually try CPAP for the first time in a sleep laboratory, so a technician can adjust the pressure during sleep. Many people adjust to it without any problem and report that their night in the laboratory is the best night's sleep they've had in years. Others find it difficult at first to breathe out against a constant stream of air and to sleep with their mouth closed, but they usually get used to it with time.

CPAP generally leads to a great improvement in the amount of time spent in restorative deep sleep, which improves alertness the next day. In many cases, CPAP also reduces or eliminates hypertension. For some people, CPAP is a lifelong treatment.

For people who have difficulty exhaling against the pressure of CPAP, a refinement called bi-level PAP (often referred to by the trademarked name BiPAP) may be more tolerable. It delivers air under higher pressure as the sleeper inhales and switches to a lower pressure during exhalation to make it easier to breathe out. An important innovation (called AutoPAP) is the inclusion of an internal regulator that moves the pressure up and down, rather than staying at a fixed setting, depending on your pressure needs at any particular moment.

Dental devices. Oral appliances that reposition the lower jaw and tongue, permitting the airway to remain open, are fairly well tolerated and have a success rate of 50% to 70% for mild to moderate OSA. They are less successful with severe OSA.

These devices are less cumbersome and easier to travel with than CPAP. However, they can cause shifting of teeth and problems with the temporomandibular joint (TMJ), so be sure to get the device from a dentist trained in managing OSA patients and get regular follow-ups, including a sleep study done with the device in place to make sure it eliminates the OSA.

Surgery. Most surgical procedures for sleep apnea do not have good success rates. Although some patients improve, a sizable percentage of patients don't get better, and some patients' symptoms actually worsen — that is, they have more episodes of apnea after the surgery than they had before.

What's behind these poor success rates? Surgeons must deal with a long soft tube of tissue that can collapse at any point — or even at several points — and they can't always predict exactly where it might collapse in the future. Surgery corrects collapse at a single spot, so if a collapse later occurs at a different spot or in several spots, OSA can return.

That's not to say surgery is always a bad idea. Next to weight loss, it's one of the only options for a cure. If you have OSA, consult with a sleep specialist to review all your options. Then, if you decide on surgery, find a surgeon who has a lot of experience with these procedures to improve your chances for success. Types of surgery for OSA include the following:

Uvulopalatopharyngoplasty (UPPP). When used to treat OSA, UPPP helps about 40% to 45% of patients. The rest may need to have further upper airway surgery or use PAP.

Somnoplasty. Somnoplasty is sometimes used to treat mild OSA when other treatments have not helped. There are limited data supporting its use.

Corrective jaw surgery. Surgery to move the upper or lower jaw forward may enlarge the upper airway for some people with OSA. Centers with specialists in this procedure report success rates up to 90%. However, the procedure requires extensive training and experience. The procedure changes the facial appearance and teeth alignment and requires an extensive recovery period.

Palatal implants. Some specialists have started using palatal implants to treat people whose OSA results from an elongated soft palate. It's not yet clear what percentage of patients benefit or how long improvements last.

Bariatric surgery. Bariatric surgery helps extremely obese people lose weight by reducing the size of the stomach and intestines. A 2004 review of earlier studies found that OSA resolved or improved in 84% of patients who had the procedure. However, this surgery comes with significant risks — including a need for additional surgery, serious medical complications, or even death — so it should be considered only after other options have been tried.

Tracheostomy. Tracheostomy, the first surgical treatment for OSA, is rarely used today, given the success of PAP and other treatments. The surgeon makes a small hole through the lower neck into the airway below its point of collapse and inserts a tube. During the day, the tube is plugged; at night, it's opened to allow air to enter, bypassing the obstructed area. Tracheostomy is 100% effective, but because of its major effect on quality of life (including speech difficulties), it is reserved for life-threatening cases or when all other treatments have failed.

Medications. Medications for OSA (see Table 3) are used primarily in conjunction with other treatments.

Antidepressants. Certain antidepressants have a mild positive effect on airway muscle tone and are helpful for a small percentage of people with mild OSA. Two classes of antidepressants are used: tricyclics and SSRIs.

Oxygen. Supplemental oxygen, administered through tubing in the nose, can prevent the drops in blood oxygen that accompany airway collapse. However, oxygen does not prevent an airway collapse or sleep fragmentation, so it's used in addition to other treatments.

Modafinil. Some people with OSA still feel sleepy during the day even after successful treatment. In 2004, the FDA approved the use of the drug modafinil (Provigil) to treat this post-treatment sleepiness. The drug, which seems to temporarily stop the brain from making neurotransmitters that promote sleep, was originally approved in 1999 to treat sleepiness from narcolepsy. While modafinil can help people with OSA who have trouble staying alert in the day, bear in mind that the drug does not address the source of the problem and is therefore used with other treatments, not in place of them.

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Central sleep apnea

Central sleep apnea, or CSA, occurs when respiratory centers in the brain fail to send the necessary messages to initiate breathing. Although the airway isn't blocked, the diaphragm and chest muscles stop moving. Shortly, falling blood oxygen and rising carbon dioxide levels set off an internal alarm, triggering the person to resume breathing (and often waking them as a result). This rare condition warrants a thorough evaluation, including a sleep study, to establish the underlying cause, which in turn guides treatment. CSA becomes more common as people age and is more frequent and severe in those with congestive heart failure, chronic lung disease, or neurological damage. CSA doesn't cause snoring, but people with this problem are usually aware of waking up during the night and often complain of daytime sleepiness.

Therapy usually involves treating the underlying medical condition that has disrupted breathing. For example, if the CSA is caused by heart failure, medications to treat the heart failure may eliminate CSA. Some patients use PAP and may also receive added oxygen. For people who have CSA only as they begin to fall asleep, a mild sleeping pill may help them fall asleep and stay asleep, solving the breathing problem. Medications such as acetazolamide (Diamox) and theophylline (Theo-4, Uniphyl) benefit some people (see Table 3).

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Review Date: 2007-10-01

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