Sleep Apnea
Written by Professor Adrian Williams; Edited by Sepi Latifi
Laugh and the world laughs with you, weep and you weep alone.
[Solitude, in Poems of Passion]
Snore and you snore alone [anonymous wit], a problem recognised by most of us.
But is this a modern disease?
Apparently not with a quote by A Roger Ekirch in his At Day’s Close:
“in 1737 a snoring husband received a shovel of hot embers in his gaping mouth”!
Snoring is common.
One half of middle-aged men and 25% of middle aged women snore intrusively.
Why does this happen?
It relates to the anatomy of the breathing passage in the throat.
- When we are awake, the muscles in our throat are sufficiently active to keep the breathing passage open so that we don’t snore.
- When we go to sleep the muscles relax (as do all muscles), thus allowing the passage to narrow. This passage becomes narrow enough to allow the air that passes through to cause vibrations, which creates the snoring noise we all know (our parents are therefore at blame!). This occurs in spite of the muscles in the throat doing their best to dilate that passageway.
Given this, one can imagine that the breathing passage might narrow to the point of closing off, or almost closing off, the condition called obstructive sleep apnea.
This is also very common with a half of snorers having some interrupted breathing during the night. This occurs first in the state of dreaming sleep [REM or Rapid Eye Movement sleep] in which the body is literally paralysed to prevent us acting out our dreams.
This happens every 90 minutes during the night with extended periods later in the night, times during which that interrupted breathing might first be seen by bedpartners. It might then extend to other times of the night. This is dependent in small part upon aging but in greater part upon weight gain.
The problem is therefore a “continuum” in which individuals may just snore without interruptions of sleep, or may snore to the point of waking [called snore-arousals] or may progress to interruptions of breathing, obstructive sleep apnea.
This condition may go unrecognized for many years but over time there are consequences which become apparent. These are grouped as neurocognitive, cardiovascular, and metabolic and when these changes occur the condition is then called the obstructive sleep apnea syndrome.
Consequences:
- disrupted sleep (interpreted as insomnia)
- sleepiness during the day
- impact on family life or on work capacity
- impact on the ability to drive safely. It is believed that as many as ¼ of road traffic accidents are related to falling asleep at the wheel and although not all of these would relate to sleep apnea [simple lack of sleep being another important cause] sleep apnea is a frequent consideration. This is of significant concern.
- Cumulative physical consequences — heart and blood vessels (high blood pressure and ultimately perhaps heart attack and stroke).
- Metabolic consequences — development of diabetes. The epidemic of this condition in the setting of an overweight population has suggested to many that sleep apnea maybe an important contributor by promoting resistance to the effects of insulin.
With all this concern about snoring and sleep apnoea…
What can the medical community do?
- The answer is of course to diagnose or recognize the condition as early as possible. This is not difficult, perhaps because snoring is a marker for the condition with witnessed interruptions to breathing. The observance of this marker would support the notion that sleep apnea exists within the individual, especially in patients with high blood pressure and those that are overweight.
- Examination of patients whilst asleep also helps — this can be done very easily these days with a variety of home studies available.
Assuming that a sufficient degree of sleep apnea is identified…
What treatments are available?
- There are no medications to activate the muscles in the throat and surgeries are hardly ever contemplated these days.
- Therefore, treatment relies on medical devices to keep the breathing passage open (in other words, to maintain the patency of that upper airway). Two very effective treatments that are often tried across-the-board include…
- Dental devices [so-called mandibular advancement splints], usually being suggested for those with a milder form of the condition.
- Pump device called CPAP [for Continuous Positive Airway Pressure] which creates a pneumatic splint, used for those with the more severe form.
What can individuals do themselves to minimise these problems?
- Severe nasal congestion will make them worse and should be addressed, and of course any weight gain is detrimental.
- Sometimes too, the conditions are almost always confined to times when one is sleeping on one’s back and therefore preventing that sleeping position might help.
- It will also be appreciated I’m sure, that things that cause the muscles in the throat to be more relaxed than usual such as medications and alcohol will also worsen these problems.
What does the future hold in the area?
- There may be medications that increase the activity of the airway muscles and these are being searched for but have you not yet been identified.
- Exercises for these muscles have been tried and have of marginal benefit; remember that the one of the 2018 Ig-nobel prizes went to the authors of a paper about the didgeridoo, a musical instrument which exercises those muscles and reduces snoring.
- Electrical treatment of the muscles is also being in investigated and maybe a future alternative.
A final insightful thought however, posed 7 years before sleep apnea had been recognised:
“The sleeping patient is still a patient. His disease not only goes on while he sleeps, but may progress in an entirely different fashion from its progression in the waking state, or indeed may originate in sleep.The interrelations between sleep and the pathologic physiology of disease constitute a fruitful field for a more complete understanding of many diseases.”
► Eugene Robin MD. Archives of Internal Medicine. 1958
