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SLEEP DISORDERS CENTER
Obstructive Sleep Apnea
and Snoring
Do you snore loudly? Are you the target of bad jokes
or middle-of-the-night elbow thrusts? Snoring can seem funny, but it is
actually no laughing mater.
Loud snoring can be a sign that something is seriously
wrong with your breathing during sleep. Snoring indicates that your airway
is not fully open, and the distinctive sound of snoring comes from efforts
to force air through the narrowed passageway.
An estimated 10 to 30 percent of adults snore, and in
most, snoring has no serious medical consequences. For an estimated five in
100 people, however, extremely loud nightly snoring is the first indication
of a potentially life-threatening disorder: obstructive sleep apnea
syndrome (OSAS).
OSAS is a medical condition that requires careful
attention and proper treatment. This disorder, involves frequent collapse
of the breathing passageway during sleep, with partial or complete blockage
resulting. Symptoms can include excessive daytime sleepiness, poor
performance at home or work, and depression.
The process by which the airway gets blocked off during
sleep is rather complicated. During sleep, the muscles in the throat relax
and are more likely to close than when you are awake. The negative pressure
of air pulled by the lungs through a narrow airway may cause the breathing
passageway to collapse, much as a straw flattens and collapses if you pinch
one end closed while sucking on the other end.
Treatment can prevent or reverse the serious
consequences associated with OSAS.
Treatment Options
If you have been diagnosed with OSAS by a sleep
specialist, you and your healthcare provider will have a number of treatment
options to consider. Correcting your breathing problem during sleep may
involve one or more of the following treatments.
Sleep-position training
Sleeping on your back allows gravity to pull on the
soft tissues at the back of your throat and neck, causing the breathing
passageway to narrow or collapse completely. Sleep-position training can be
used to help keep you on your side during sleep, which can lead to an
improvement in your symptoms.
Sleep-position training can be accomplished in several
ways. The simplest approach, called the “tennis ball technique,” involves
sewing a pocket onto the back of your pajama top and inserting tennis balls
into it. If you start to roll onto your back during sleep, the pressure
from the balls will encourage you to roll back to your side. A foam wedge
strapped to your back can accomplish the same result. Commercial devices
with alarms are also available to help you stay on your side during
sleeping. Check with your healthcare provider to find out how long this
type of treatment should be used.
Weight loss and regular exercise
For some people, weight loss alone is a helpful
treatment. Once you reach your desired weight, it is important to maintain
that weight, because snoring and apneas are likely to return with weight
gain. If you are overweight, consult a healthcare provider to find out
about weight-loss programs.
Quitting smoking
Recent evidence suggests that the irritation caused by
smoking may contribute to the severity of snoring and sleep apnea.
Avoiding alcohol and sedatives
Even one glass of wine just before bed can result in a
worsening of your snoring and apnea. You should avoid drinking alcohol for
at least four hours before bed. Alcohol and sedative medications, such as
sleeping pills, muscle relaxants, anti-anxiety drugs and some pain
medications, can cause the tissues in your throat to relax more than usual
and cause an airway obstruction. Alcohol and sedative drugs also make it
more difficult for the brain to “wake up” and notice a lack of oxygen in the
system, which results in longer and more dangerous abnormal breathing
periods.
Oral appliances
These devices work to keep the airway open by holding
the tongue or jaw forward, increasing the airway space behind the tongue. A
clear airway is needed in order for most of these devices to be successful.
They are usually fitted by an experienced dentist associated with a sleep
disorders center.
Tongue-retaining devices
These devices are placed in the mouth just before bed
and create a slight suction, which holds the tongue forward to keep it from
falling back into the throat. They can be effective in people who have mild
to moderate apnea.
Jaw-advancement devices
These appliances are made to fit the top and bottom
teeth in a way that pulls the lower jaw slightly forward.
Continuous positive airway pressure (CPAP)
In this highly effective therapy, a small mask is worn
over the nose during sleep. Pressure from an air compressor forces air
through the nasal passages and into the throat. This gentle pressure holds
the throat open and allows normal sleep and breathing. While most patients
do well with CPAP therapy, a few may experience dryness in the nose or
feelings of claustrophobia. These and other problems can be overcome with a
few adjustments. A humidifier can be used to reduce dryness, and relaxation
techniques can help relieve feelings of claustrophobia.
Surgery
An operation may be an option if your healthcare
provider finds an obstruction in your airway or if more conservative
treatments have not worked. Whatever type of operation is recommended, be
sure you are aware of all possible risks and side effects before
proceeding. While an operation can be an effective treatment for some
patients, it is not the right choice for everyone.
Nasal operations
Nasal surgery is used to remove blockages in the nose
(such as growths), or to repair a deviated septum (a displacement of the
wall that divides the nose into halves). These operations may be one part
of an overall plan to treat apnea, and are generally used along with other
forms of treatment or other operations.
Laser-assisted uvulopalatoplasty (LAUP)
This relatively new procedure is used mainly for the
treatment of snoring. With LAUP, the surgeon uses a laser to remove part of
the uvula and soft palate. The procedure takes place in several sessions in
a doctor’s office. While this technique appears promising, patients need to
be aware that its effectiveness in the treatment of sleep apnea has not yet
been completely evaluated.
Uvulopalatopharyngoplasty (UPPP)
This operation involves removing the uvula (the soft,
fleshy projection that hangs in the back of the throat), the tonsils and
part of the soft palate. Approximately 50 percent of patients who undergo
this operation are helped by it. Side effects, such as severe throat pain,
nasal-sounding speech, and the regurgitation of liquids into the nose when
swallowing, have been reported.
Inferior sagittal mandibular osteotomy (ISO) and
geniohyoid advancement with hyoid myotomy (GAHM)
This reconstructive surgery involves cutting the bone
that connects the jaw to the face and moving the upper and lower jaws
forward. This operation is done under general anesthesia and requires a
hospital stay of a few days. After the operation, the jaw is wired shut to
hold it in place for about 4 weeks. A liquid diet is required, and weight
loss often results. Once the wires are removed, orthodontic work may be
needed to realign the teeth so they fit together properly. This treatment
is time-consuming and expensive, but its results are positive for some
patients. The best candidates for this type of treatment are those born
with a smaller-than-normal jaw or a jaw that is set too far back.
Laser midline glossectomy (LMG) and ligualplasty
These operations are rarely used. They involve
enlarging the area behind the tongue by removing a portion of the back half
of the tongue.
Tracheostomy
This surgery is rarely used to treat sleep apnea, and
is only applicable to an immediately life-threatening sleep apnea
condition. It involves the creation of a small surgical opening in the
windpipe. The tracheostomy bypasses any obstructions in the throat and
allows air to flow freely into the lungs while the patient is sleeping. The
opening is covered during the day and normal breathing and speech resume.
Medications and Alternative Treatments
Medications used alone are of limited benefit for the
successful treatment of snoring and obstructive sleep apnea. They may be
most useful in cases of mild apnea or used as part of an overall treatment
program.
Nasal sprays
Over-the-counter sprays that help clear the nasal
passages can be habit-forming and should not be used for more than a few
days. Prescription nasal sprays can help unblock the nose, but sometimes
take days or weeks to work. Nasal sprays are usually not helpful if there
is a permanent blockage caused by a growth or a deviated septum.
Decongestants
Medications to relieve congestion in the nose are
sometimes helpful, but are not considered to be a treatment for sleep apnea
itself. Although decongestants may help you breath better, they can cause
difficulty falling asleep, staying asleep, or both.
Respiratory stimulants
Protriptyline is one medication used to treat mild
cases of apnea. It is an antidepressant that decreases REM (dreaming)
sleep, a time when apneas are likely to be longer and more frequent.
Protriptyline may help strengthen and tone the muscles of the throat. It
can produce mild side effects (such as dry mouth and constipation), and is
not recommended for people with high blood pressure or an abnormal heart
rhythm. A less-frequently prescribed medication for the treatment of OSAS
is medroxyprogesterone, a hormone, which can produce such side effects as
unwanted hair growth, mood changes, and fluid retention. Results from this
treatment are inconsistent.
Oxygen
This treatment may be used to correct low oxygen levels
in the blood due to heart or lung disease. It may be used along with CPAP
treatment for best results.
Follow-Up Care
No matter which form of treatment is used for OSAS, it
is important that a follow-up sleep study be done by a sleep professional to
determine success. Regular follow-up appointments with your healthcare
provider are also essential because the severity of your apnea may change
with age. If your snoring resumes or if you are sleepy during the day, it
may mean the apnea has returned, and additional or other treatment may be
necessary. |
