Snoring and Sleep Apnea: Freight Train in the Bedroom

What is sleep apnea?

Sleep apnea is a condition where during sleep the muscles of the airway relax and collapse shut, cutting off the oxygen supply to the heart and brain. The body does not get into deep sleep and will struggle to re-open the airway, sometimes making a snoring, gasping, or choking sound. When this happens repetitively over the night, it leads to increased stress on the body which can lead to the development of other chronic health problems.

What causes sleep apnea?

Sleep apnea can be present at birth, due to a smaller than average upper airway that collapses easily during muscle relaxation and sleep. It can be worse due to large tonsils or adenoids, weight gain, abnormal jaw structure, and certain medical conditions (hypothyroidism, myasthenia gravis, stroke) or medicals or toxins (sleeping pills, alcohol, testosterone, et cetera).

What health problems are caused or made worse by untreated sleep apnea?

Some of the health problems that have been linked to sleep apnea include obesity, hypertension, diabetes, stroke, atrial fibrillation, heart disease, clotting disorders, and cancer. In children, sleep apnea has been associated with changes in growth, learning, aggressive behavior, and attention span.

What are the common signs of having sleep apnea?

Some of the common signs of having sleep apnea in children include snoring, mouth breathing, hyperactivity, aggressive behavior, and poor academic performance. On physical exam, they may have enlarged tonsils and adenoids, mouth breathing, and a narrow palate. Some signs of sleep apnea in adults include daytime sleepiness, inability to concentrate or difficulty with memory, dry mouth, headaches, snoring, waking up to go to the bathroom, and automatic behaviors (i.e., arriving at a destination but not remembering the journey, being on autopilot). On physical exam, adults may have increased neck size, obesity, overbite and small/narrow jaw, large tongue, low soft palate, and a large uvula (soft tissue which hangs down the back of the throat).

What makes sleep apnea worse?

Sleep apnea is made worse by weight gain, alcohol, sinus congestion, sleeping supine (on your back), hypothyroidism, and testosterone supplementation.

How is sleep apnea treated?

The most common treatment is a mask with pressurized air, called a CPAP (continuous positive airway pressure) or Bi-level / BiPAP (higher air pressure when you breathe in and low air pressure when you are breathing out). The air pressure from the mask holds the throat open and keeps it from collapsing so that oxygen can get to the heart and brain. The mask must be worn every night when sleeping, for at least four hours a night to get the benefits and prevent the stress of low oxygen on the body. Wearing extra oxygen at night will not treat sleep apnea, because the oxygen cannot pass through a collapsed throat. Other treatments for apnea can include a dental device, nasal devices, oral devices, oral surgery, nerve stimulation, or placement of a tracheostomy (in extreme cases).

Can sleep apnea be cured?

Sleep apnea can be “cured” if the causes of apnea are reversed. For children, this is usually accomplished by surgery to remove the tonsils and adenoids. Kids with a narrow palate may require a palate expander bar. For adults, this is commonly treated by reducing one’s weight if obese and having airway surgery. However, this may not work for everyone and some patients will need to stay on positive pressure nocturnal ventilation for life. There have been some early studies on improving upper airway muscle tone with implanted devices and even musical instruments (such as the didgeridoo) but these are still in the early phases of investigation.

What should I do if the mask is uncomfortable or can’t sleep with it?

Masks need to be custom fit, like shoes. Most sleep labs and sleep physician offices can perform mask fittings. There are more than 50 different types and styles of masks currently available. If you are not offered enough choices, you may want to speak to your sleep physician about your options. A properly fit mask should not pinch the skin or leave marks on your face in the morning. You should always be able to slide your finger underneath the mask and slide your mask on and off over the top of your head (like a baseball cap) without releasing the straps. The mask can leak some air (playfully called “mask farts” by some patients) but should not leak air into your eyes. If you have difficulty falling asleep with the mask on, you can try wearing during the daytime when relaxing or watching TV to help you get used to it (mask desensitization), You can also use medications, such as sleeping pills, to help you initially fall asleep with the mask on. Be sure that your bedroom is free of light and noise, and that your bed and room temperature are comfortable to also help induce sleep.

What should I do if the air pressure is uncomfortable?

Your sleep physician may be able to adjust the air pressure to allow you to have more comfort with the machine. Ramp features allow the pressure to start low and slowly increase over the night. Auto-titration features allow for the pressure to vary depending on how deep your sleep is. There are even machines that can time the cycling of the mask to coincide with your breathing. Rarely, the sleep physician may need to reduce the pressure initially and slowly increase it over several weeks to allow you to build a tolerance to it. Getting used to the pressure is like getting used to wearing glasses or a hearing aid, it sometimes takes time.

What should I do if I have a very dry mouth when using the mask?

Most machines can have heated and humidified air added, which may make this more comfortable. Saline nasal sprays and saline nasal gels also help. Over the counter, mouth rinses for dry mouth may help, as may lemon glycerin mouth swabs. Sometimes the addition of a chin strap, to prevent the mouth from popping open during the night, may also help.

How do I know if I need my pressure or the machine needs adjustment?

The pressure or machine may need adjustment if you again start to snore or have worsening of your daytime sleepiness. It should also be adjusted if you have significant weight gain.

What if there is a lot of water in my tubing and it is very noisy?

The water that accumulates is from condensation when the warm humidified air in the tubing is exposed to the cooler room temperature. Adjusting the temperature of the room or the humidifier may decrease the amount of water that accumulates in the tubing. Also, you can cover the tubing with cloth (i.e., a “tube sock”) which can insulate it and decrease the amount of condensation. Heated tubing is also available.

What is complex sleep apnea and how is it treated?

Complex sleep apnea refers to the combination of obstructive sleep apnea (throat closings) with central sleep apnea (no signal from the brain to breathe). Central apneas can be caused by severe obstructive disease, heart disease or gastric reflux (acid). The device of choice for the treatment of this is called AutoSV. It is a more sophisticated sleep apnea machine. This machine does not only deliver the required pressure to keep your airway open, but also can sense the timing of your breathing and appropriately adjust. For some patients, this may still not be enough to control their apnea and they may require a home ventilator, airway stimulation device or implant, or tracheostomy (hole in the airway).

Will my children also have sleep apnea?

Sleep apnea does run in families. There are several physical characteristics that you can have your child evaluated for and that can be corrected and treat apnea. The most common cause of apnea in children is enlarged tonsils and adenoids. This reduces the size of the airway which makes it more prone to becoming obstructed (i.e., apnea). Having the tonsils removed can be highly effective for preventing and treating sleep apnea in children. Children are usually evaluated for this age 2-6.

Another common problem is having a narrow palate. When the palate is narrow, the teeth are close together and the tongue is pushed backward, partially obstructing the airway. Palate expanders made by dentists can completely correct this problem if the bone has not finished growing, usually ages 6-18. Similarly, an overbite, small mandible or irregular jaw can also contribute sleep apnea and can be corrected by either an orthodontist or an oral maxillofacial surgeon, if severe.

Children with sleep apnea can have poor learning, poor attention span, hyperactivity, and poor growth (i.e., underweight). However, obesity in kids can lead to apnea just as it does in adults. Children who are obese and having apnea, will benefit from weight reduction.

What other treatments are available for sleep apnea?

There are several alternative treatments for sleep apnea. If the apnea is positional and occurs only when you sleep supine (on your back), positional therapy is available. For positional therapy, a tennis ball is sewn into the back of your pajama top and this prevents you from turning and sleeping on your back.

Some patients with mild apnea may also benefit from a dental device, which moves the jaw forward to allow for more air to travel down the back of the throat at night. However, if the throat has excessive soft tissue (tonsils, adenoids, soft palate), this tissue can be surgically removed to create more room for air flow. This procedure is commonly referred to as UPPP (uvulopalatopharyngoplasty). There have been anecdotal reports that learning to play a musical instrument, such as the didgeridoo, can increase upper airway muscle tone and improve apnea. Finally, there are nerve stimulators that are implanted under the skin (like a heart pacemaker) that can stimulate the nerves of the upper airway leading to decreased apnea.

People often ask if there is a pill that can treat sleep apnea. Sleep apnea, in and of itself, does not have a magic pill to resolve it. However, if endocrine abnormalities (disorders of the glands), such as hypothyroidism, are causing the apnea, then the pills that treat this will also improve or resolve the apnea.

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