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13.09.2018 Feature Article

Does your partner snore? How To Control Snoring and Sleep Apnea

Does your partner snore? How To Control Snoring and Sleep Apnea
13.09.2018 LISTEN

Snoring is the noisy breathing that occurs when the upper airway (nose, mouth, throat) gets narrowed or becomes occluded, during sleep.

The soft tissues in the nose, soft palate, uvula, tongue, lateral walls of the throat, epiglottis, encroach on the airways, and vibrate as respiring air blows over them, to generate the noise.

Intensity of Snoring varies from very soft to very loud noise.

Almost, everybody snores occasionally, when they fall asleep, however, some are habitual snorers.

SLEEP CYCLES.
Sleep period is a continuous repetition of the sleep cycle every 90 minutes.

A sleep cycle is divided into 4 stages. The first 3 stages are grouped under non-REM, the 4th stage occurs when there is rapid eyeball movement (REM) during sleep, and is known as REM sleep stage.

NON-REM sleep (approximately 70 minutes duration)
This begins early in sleep.
Stage 1 starts with light sleep, associated with hypnic jerks/jolts, as individuals try to stay awake.

Stage 2. There is loss of awareness but individuals can easily be aroused from the sleep.

Stage 3. Deeper sleep state where it is difficult to arouse someone in this stage. When aroused from sleep, they would still feel sleepy with impaired mentation for about 30 minutes

Stage 4. REM Sleep (approximately 20 minutes)
The last 20 minutes of a sleep cycle is known as REM sleep. Two events occur during REM sleep

  1. Vivid dreams occur during this stage.
  1. Muscles lose their tone (except the muscles of eyeball and the diaphragm).

SLEEP CYCLE AND SNORING
Light snorers do snore uniformly throughout all the sleep stages.

Heavy snorers, snore more during REM sleep when there is generalized loss of muscle tone.

CAUSES OF SNORING
Snoring occurs anytime the airways are partially or completely occluded.

NOSE:
. Nasal congestion (from nasal allergies and viral colds), Swollen nasal turbinates, Nasal polyps

. Abnormalities of Nasal septum (deviations, dislocations and hematoma)

MOUTH/THROAT: structures that may narrow the airways include

. Enlarged Tonsils (especially in children).
. Large and/or soft tongues preclude air passage from nose/mouth into the lower airways

. Long and soft uvula. Uvula of habitual snorers contain less muscles than non-snorers

. Long soft palate.
. Loss of tone in Throat muscles due to Alcohol, Sleep deprivation, Sedative medications

RISK FACTOR FOR SNORING
. Male sex
. Being overweight/ Obese leading to bulky neck/throat tissue that could narrow the airway

. Use of Central Nervous System depressants: Alcohol consumption, sleeping pills

. Family history of snoring
. Daytime mouth breathing
. Frequent sore throats
. Low maternal Education is a risk factor for boys.

. Tobacco exposure
. Sleeping supine/back position, allows tongue to fall back, under gravity, to block the airways

COMPLICATIONS OF SNORING
. Snoring disturbs the sleep of bed-partners and room-mates. Loud snoring may even, strain relationships.

. The vibrations of snoring may damage lining of blood vessels and promote atherosclerosis formation (1)

. Heavy snoring may interfere with sleep and results in inadequate sleep. Snorers may fall asleep while driving

Snorers may also complaint of tiredness and headaches.

. Snorers may develop Depressive disorders, Inattention and inability to complete tasks and school home works

. Snoring becomes a major health problem when it as associated with sleep apnea. 50% of snorers have sleep apnea

Most heavy snorers do experience repetitive interruptions of their sleep cycle. They snore loudly, then stop breathing for 10-20 seconds, then restart breathing. This stop and start breathing pattern may occur throughout the sleep period. It is due to narrowing/occlusion of upper airway during sleep. It interrupts their sleep cycle.

A bed-partner may observe the following signs of Sleep apnea:

. Loud snoring
. Gasping
. Pauses in breathing
Affected persons may have these symptoms:
. Frequent awakening
. Dry mouth
. Snorting
. Non-refreshing sleep
. Men would get up to void urine several times at night

Complications of Sleep Apnea:
. Excessive daytime sleepiness. Car drivers, fall asleep behind the wheels, leading to frequent vehicular accidents.

. Sleep Apnea destabilizes the autonomic nervous system. Affected persons may develop: (a) High blood pressures (b) Cardiac arrhythmias, and (c) Impotence/Erectile dysfunction. These conditions are affected by autonomic nervous system.

. Mood disorders including Depression may occur
. Difficulty concentrating/inattention
. Difficulty completing assignments at school and work places

RISK FACTORS FOR SLEEP APNEA
Risk factors are Same as the risk factors for snoring.

Obesity which causes fat to be deposited in the neck region is the most important risk factor

DIAGNOSIS OF SLEEP APNEA:
History of pauses in breathing, observed by bedmates History of daytime sleepiness

POLYSOMNOGRAPHY
This is the gold standard to assess airway obstruction. Polysomnography has to be performed in a sleep laboratory. The test monitors brain activity, muscle activities, heart rhythm. Airflow through nose and mouth, chest wall motions and oxygen saturations.

OUT OF CENTER SLEEP TESTS (OCST)
Devices that monitor. airflow through nose/mouth. Chest wall motion and oxygen saturations. These self-monitoring devices do not monitor brain, muscular and heart activities during sleep.

OCSTs are used in healthy patients with high degree of suspicion for sleep apnea.

INDICATION FOR SLEEP TESTS:
History of Excessive daytime sleepiness and snoring

Any symptoms suggestive of sleep apnea
PRIMARY & SECONDARY PREVENTION OF SNORING AND SLEEP APNEA.

This includes adopting measures to control the preventable risk factors for snoring

Behavioral:
. Weight loss if overweight
. Avoid evening/bedtime alcohol consumption.
. Avoid smoking, avoid sleeping pills and muscle relaxants.

. Postural therapy: Avoid sleeping on your back. You may sleep on your side or on your belly.

INTERVENTIONS AVAILABLE FOR SNORING: Snoring treatments are not permanently curative, usually temporary

  1. Nasal Obstruction: Nasal steroid sprays, daily antihistamines, and oral anti-inflammatory medications, help.
  1. Tongue: If tongue is found to contribute to snoring, Oral devices may be used to bring the lower jaw forward and prevent tongue from moving backwards during sleep.
  1. Soft Palate: Snoring traceable to soft palate problems may be managed by ENT surgeons. Radiofrequency ablation of soft palate, Palatal suspension surgery, and surgical implants and injection of chemicals to stiffen the soft palate may be done

An intervention is deemed successful if Bed partners, are no more disturbed by snoring.

INTERVENTIONS AVAILABLE FOR SLEEP APNEA
Positive Airway Pressure maintenance devices
These devices will keep the airway patent by blowing air under pressure through the upper airways. It is required by patients with sleep apnea

The devices include continuous positive airway pressure (CPAP) and Auto-titrating positive airway pressure (APAP).

ORAL DEVICES
Useful for those with milder cases of sleep apnea. Oral devises help to keep upper airways patent, by:

. moving the lower jaw forward, and
. Preventing the tongue from falling backwards during sleep

References: 1. laryngoscope, 2014;124:1486-1491

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