Snoring, sleep and breathing

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