12/23/2009 - Articles

Snoring, snorting, and sleeping poorly

By: Robert W. Griffith, MD


Some people as they get older experience interruptions in their breathing while asleep. This is called sleep apnea, a condition first described in 1965.

Some people as they get older experience interruptions in their breathing while asleep. This is called sleep apnea, a condition first described in 1965. There are two types, the commonest being obstructive sleep apnea (OSA), in which there is partial blockage of airflow in or out of the nose and mouth. As untreated OSA is associated with an increase in mortality, it should be taken seriously. Information on the diagnosis and treatment of OSA is contained in a recent review article. 1

The symptoms, often first reported by the sleeping partner, comprise periods of loud snoring, gasping and apparent choking episodes during sleep. The sufferer is unusually tired during the day, even falling asleep at the wheel when driving, or nodding off at work.

The airway obstruction can come about in several ways. The pharynx (gullet) may be narrowed due to thickness in the neck from fat, fluid in the tissues, or enlarged tonsils. Sometimes a slack pharynx wall together with a receding chin can cause temporary partial obstruction. The existence of nasal polyps or swollen nasal tissues due to irritants or allergies can make matters worse.

OSA is seen twice as often in men as in women -- roughly 4% of men and 2% of women in the USA are affected. Obesity, especially if the neck circumference is more than 17 inches in men or 16 inches in women, is a risk factor. It is more common in older persons, and may run in families -- for instance, if caused by a high palate arch or a receding chin. Smoking, excess alcohol and use of sedatives can aggravate OSA, as well as nasal irritants or allergic substances.

Apart from a careful account of the patients sleeping behavior, the doctor will be interested in blood pressure, and possible signs of heart disease. Half the patients with OSA have high blood pressure, and a small percentage may have an associated heart condition. Sometimes a questionnaire is used to rate daytime sleepiness, and to assess progress. 2

The diagnosis is confirmed by a procedure called polysomnography. This involves spending a night in the sleep laboratory, where electrodes are used to measure brain, eye, and chin-muscle activity, airflow movement, the oxygen level in the blood, and respiratory and heart function. The results measure the number and depth of the pauses in breathing during the night., which allows estimation of the severity of the condition. Sometimes, if nasal mask treatment is considered, the second part of the night is used to determine the best pressure to use.

Treatment can be surgical, or by the use of a mask giving continuous positive airway pressure through the nose (nasal CPAP). If there is a definite correctable cause for airway obstruction, surgery is recommended. Otherwise, nasal CPAP is most suitable for all OSA patients except those with only mild symptoms and signs.

Nasal CPAP helps keep the upper airway open while the patient is asleep. This reduces the number of episodes considerably, so that it improves the oxygen level in the blood and lessens daytime sleepiness. Successful nasal CPAP lowers blood pressure and restores a normal life expectancy. The success of nasal CPAP depends on the patient's readiness to wear the mask. Three-quarters of the patients can do so satisfactorily for about five hours each night. There are a number of side effects -- leaking of air near the eyes causing irritation, dryness of the nose and mouth in the morning, nasal congestion and sneezing. These effects can be helped by a good-fitting mask, nasal saline sprays and, if necessary, nasal medicines.

There are several approaches to surgery in patients with OSA, and they are all fairly successful. Sometimes devices worn inside mouth are used to reposition the jaw or tongue, but they are usually only helpful in mild cases, and patients don't tolerate them well. Weight loss can be extremely beneficial, even a slight reduction leading to major improvement in OSA symptoms. Patients should stop smoking and taking sedatives or excess alcohol, and they should try to sleep on their side.

Obviously, OSA is a condition worth recognizing and treating, so that patients can lead a more normal life, and their spouses can sleep better too.


Obstructive sleep apnea: diagnosis and treatment. IT. Khawaja, BA. Phillips, Hosp Med , 1998, vol. 34, pp. 33--36



Obstructive sleep apnea: diagnosis and treatment. IT. Khawaja, BA. Phillips, Hosp Med, 1998, vol. 34, pp. 33--36


2. If you want to see how you rate on a daytime sleepiness scale, visit: http://www.daytimesleep.org/default.html

Created on: 10/08/2002
Reviewed on: 12/23/2009

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