Snoring is
conceptually identified with deep sleep, even though we know that sleep need
not be associated with snoring. Sleep is blissful but snoring is annoying – especially
for the companions. It not only disturbs the wakeful, but troubles the snorer
as much by virtue of its medical significance. It may not be all that benign,
and is frequently a pointer towards an underlying disorder of sleep.
Even though one
spends about a third of one’s life span while sleeping, proportionate
significance to the sleep disorders has not been given. There is inadequate
data on the physiology and pathology of sleep. In India, it is only in the last
two decades that breathing disorders of sleep including the apnoea syndromes,
have been recognized. The disease is underdiagnosed because the sufferer is
unlikely to give a characteristic history himself/herself. It is often the
spouse who first notices the patient having periodic breathing-pauses, grunting
respiration or restless sleep. These pauses are characteristically present
during REM (Rapid Eye Movement) phases of sleep when the sleep is relatively
light and the breathing pattern markedly variable.
The sleep apnoea
syndrome is characterized by frequent episodes of apnoea i.e. cessation of
breathing spells lasting for 10 or more seconds each time. Some apnoeic spells
may occur during normal sleep, but 10 or more spells per hour, or 30 during the
whole night. Would qualify for the diagnosis of sleep apnoea syndrome.
Obesity is a
common feature resulting in excessive fat around the neck and the upper
air-passages. During sleep the tongue and epiglottis fall back due to the
reduced muscle tone and obstruct the opening of air passage. As a result, the
air entry is forceful resulting in rapid vibratory movements of the epiglottis
and the soft palate producing snoring sounds. It is for this very reason that
the patient is well advised to lie prone (face & chest downwards) or on one
side, while sleeping so the tongue may not fall back and obstruct the passages.
Alternatively, one needs to keep an artificial tube behind the tongue to keep
the passage patent.
Patients with
sleep apnoea may suffer from choking and breathlessness, chronic headaches,
fatigue, lethargy and depression. Daytime tiredness and dry mouth are other
important symptoms. Urinary incontinence, decreased libido and impotence may
also occur. There is excessive day time somnolence and the patient goes to
sleep at the flick of a moment even during work and sometimes while driving. It
is an important driving risk and qualifies for suspension of driving licence in
several western countries. Hypertension is a common complication. In the long
run, there is intellectual deterioration and development of pulmonary
hypertension. Most of these effects occur secondarily to oxygen deficiency
during the apnoeic spells. Snoring is only a symptom and not the cause of the
problem. It raises the suspicion.
A good sleep
study (Polysomnography) is essential to confirm the diagnosis. The sleep study
is done on two consecutive nights -first night to document the diagnosis and
the severity of the problem; on second night, the study is done to titrate the
pressures for disease-treatment and relief of obstruction.
The treatment
consists of creating positive pressure in the airways with the use of either a
CPAP (Continuous) or a BiPAP (Bi-level Positive Airway Pressure) device,
administered with the help a CPAP or a
BiPAP machine and a tight fitting mask around the mouth and nose at night while
sleeping. The positive pressure keeps the airways open thus removing the
symptoms of the disease. The application of positive airway pressure
dramatically relieves the symptoms and prevents complication.
Surgery, with which the excessive tissue from
around the upper air passages is removed, is advised for extreme cases. Drugs
do not help in the treatment except for the complications or associated
diseases such as diabetes, hypertension or hypothyroidism etc.
The use of these modalities is to be decided
by the treating physician. Some simple health
measures are also useful. It is essential to avoid alcohol and tobacco smoking,
the habits which are commonly present in the patients. It can also be said that
nothing helps more than shedding some weight to get rid of snoring and
breathing problems, whether these are present in normal subjects or in patients
with sleep apnoea syndrome.
Comfortable use
of a CPAP/ BiPAP machine
