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 Health Topic: Sleep and Snoring

Snoring is a common sleep disorder that can affect all people at any age. It occurs more frequently in men and people who are overweight. Snoring has a tendency to worsen with age. Forty-five percent of adults snore occasionally, while 25% are considered habitual snorers. Occasional snoring is usually not very serious and is primarily a social issue. However, the habitual snorer can disrupt other person’s sleep patterns. Snoring is also associated with sleep disorders and is often characterized by fatigue after a night of what seems like quality rest. In general, patients suspected of having a sleep disorder require further evaluation.

What Causes Snoring?
The physical obstruction of the flow of air through the mouth and nose is the cause of snoring. The walls of the throat vibrate during breathing, resulting in the distinctive sounds of snoring. Air flow can be obstructed by a combination of factors, including nasal obstruction, poor muscle tone in the mouth or throat, bulky throat tissue associated with obesity or excess tonsil tissue, or an abnormally long soft palate or uvula. Some people snore only during allergy seasons or when they have nasal and sinus inflammation. Deformities of the nose such as a deviated septum or nasal polyps can also cause obstruction and sleep problems. Throat and tongue muscles can be too relaxed, which allows them to collapse and fall back into the airway. This can result from deep sleep, alcohol, and some sleeping pills. Normal aging causes further relaxation of these muscles and increases the potential for snoring. Being overweight can cause bulky throat tissue. Also, children with large tonsils and adenoids often snore. A long soft palate or a long uvula (the dangling tissue in back of the mouth) can narrow the opening from the nose to the throat. When these structures vibrate and bump against one another during sleep, the airway becomes obstructed causing snoring.

What Are the Health Risks of Snoring?

Habitual snorers can be at risk for serious health problems. Obstructive sleep apnea is a condition that is often associated with chronic snoring. This condition is characterized by long interruptions of breathing (more than 10 seconds) during sleep caused by partial or total obstruction or blockage of the airway. Serious cases can have total blockage occurring hundreds of times per night. Blood oxygen levels are often lowered, which causes the heart to pump harder and blood pressure to rise. Over time, the added work of the heart and lungs results in detrimental changes to a person’s cardiopulmonary system. The patient’s body detects low oxygen levels in the bloodstream and responds by waking the patient up so that normal breathing can occur. The result is a poor night's sleep, which leads to drowsiness during the day and can interfere with the person’s quality of life. Prolonged obstructed sleep can result in high blood pressure and is associated with an increased risk of heart disease, heart attack, pulmonary hypertension, and stroke.

Measurements of Sleeping and Snoring
Two measurement scales have been developed to assess the risk of a serious sleep disorder, the Epworth Sleepiness Scale and the Stanford Sleepiness Scale. Each assessment tool is used to estimate sleep quality and can help predict which people should undergo further evaluation. 

Epworth Sleepiness Scale:
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

SITUATION                                                                          CHANCE OF SLEEPING
Sitting and reading                                                                   0    1    2    3    4
Watching TV                                                                           0    1    2    3    4
Sitting inactive in a public place (theater or a meeting)                  0    1    2    3    4
Passenger in a car for an hour without a break                              0    1    2    3    4
Lying down to rest in the afternoon                                            0    1    2    3    4
Sitting and talking to someone                                                    0    1    2    3    4
Sitting quietly after a lunch without alcohol                                   0    1    2    3    4
In a car, while stopped for a few minutes in traffic                         0    1    2    3    4

SCORE
1 – 6            You are getting enough sleep
7 – 8            Score is average
9 and up       Seek the advice of a sleep specialist without delay

The Stanford Sleepiness Scale (SSS)
Assess your sleepiness/alertness at 10 different times during the day. If you go be 3 when you should be feeling alert, this is an indication that you may have a serious sleep disorder and you need more sleep or further evaluation.

Feeling active, vital, alert, or wide awake                                                   1
Functioning at high levels, but not at peak; able to concentrate                   2
Awake, but relaxed; responsive but not fully alert                                       3
Somewhat foggy, let down                                                                     4
Foggy; losing interest in remaining awake; slowed down                               5
Sleepy, woozy, fighting sleep; prefer to lie down                                         6
No longer fighting sleep, sleep onset soon; having dream-like thoughts           7
Asleep                                                                                                   8         

6 am    7 am     9 am    11 am   1 pm    3 pm    5 pm    7 pm    9 pm    11 pm     TOTAL

____    ____    ____    _____   ____    ____    ____    ____    ____    _____    ______

Add the total of your answers and divide by the number of responses. An average score (Total score divided by number of responses) of 3 or greater suggests you need more sleep or have a sleep disorder.

Sleep and Snoring Testing
If a person’s Epworth or Stanford Sleep Test suggests a sleeping disorder, the patient should be evaluated and undergo a sleep study. Sleep studies can be performed in a sleep lab or in the home. During a sleep lab test, electrodes are applied to the scalp, sides of the head and under the chin, chest and leg. This allows measurement of brain waves, heart rate, and eye movements. A sensor is placed by the nose and mouth for measurement of airflow. Belts are placed around the rib cage and abdomen for measurement of breathing movements. A clip is placed on a finger for measurement of blood oxygen levels. In addition, patients are videotaped while asleep.
Apnea is defined as cessation of breathing for 10 seconds or longer. Three types are recognized:

a) Obstructive:         apnea associated with evidence of persisting respiratory effort
b) Central:               apnea associated with cessation of breathing effort
c) Mixed:                 mixture of central and obstructive features

Hypopnea defined by the presence of a clear decrease (>50%) from baseline in the extent of breathing during sleep lasting 10 seconds or longer and is associated with either an oxygen desaturation of >3% or arousal from sleep. Desaturation refers to a decrease in percentage of red blood cells carrying oxygen, which should be >95% in a normal patient. The presence of sleep apnea is determined by the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI), which is the number of apnea + hypopnea events per hour of sleep, in combination with oxygen measurements. In general, the following severity categories exist based on sleep study results:

AHI/RDI                    Lowest Oxygen saturation           Degree of sleep apnea
<5                                            95%                                      Normal
>5 < 15                                    85-95%                                  Mild
>15 < 30                                  75-85%                                  Moderate
>30                                          <75%                                    Severe

Treatment of Sleep Apnea in Adults
Obstructive sleep apnea in adults can be treated with weight loss, changes in sleep position, mouth appliances, Continuous Positive Airway Pressure (CPAP) which involves wearing a nose or face mask with pressurized air when sleeping, or surgery. In general, avoidance of substances which may contribute to sleep apnea, such as alcohol and sedatives, should be avoided. Patients with mild sleep apnea should be encouraged to pursue weight loss as a long term lifestyle change before considering CPAP or surgery. There is preliminary evidence that weight loss as a result of lifestyle change or bariatric surgery can result in significant reduction in sleep apnea severity. Patients with moderate to severe sleep apnea should be offered CPAP followed by surgery if they are unable to tolerate CPAP. CPAP is a successful treatment in approximately 75-80% of patients who use their CPAP machine regularly. Unfortunately, many patients cannot tolerate CPAP or use it intermittently. Surgery for sleep apnea generally involves correction of nasal obstruction, tonsillectomy if tonsils are present, widening of the throat surgically, with the addition of tongue base surgery or re-suspension of the larynx in selected cases. Sleep apnea surgery is successful in 60-70% of patients, depending on the severity of sleep apnea prior to surgery and the procedures performed. Patients with moderate to severe sleep apnea should be encouraged to pursue some form of treatment to avoid the potential complications of heart attack, sudden cardiac death, pulmonary hypertension, and stroke.

Treatment of sleep apnea in children
Many of the symptoms of sleep apnea, such as snoring, disordered breathing, headache, behavior change, or chronic fatigue, can occur in children. Just as in adults, patients with these symptoms should undergo sleep study for diagnosis. Should a sleep study show sleep apnea, tonsil and adenoid surgery is the generally accepted recommendation for treatment of pediatric sleep apnea. There is emerging evidence that treatment for sleep apnea, and a less severe sleeping disorder call upper airway resistance syndrome, can contribute to the overall treatment of children with behavior disorders.

Treatment of Snoring
If there is no medical history or sleep study evidence suggestive of sleep apnea, patients can be offered treatment for snoring. There are a variety of remedies advertised as treatment for snoring. In general, these products have not been subjected to scientific testing to prove effectiveness. Patients are encouraged to read the labels and product information provided and research these items carefully. Snoring caused by nasal obstruction can be treated with nasal sprays and medications designed to relieve swelling within the nasal cavity and improve airflow. Again, avoidance of sedatives and alcohol prior to sleep are helpful. If snoring is positional, sewing a pocket in the middle of a tee shirt used for sleeping and placing a tennis ball in the pocket will force the patient to sleep on their side where snoring is less likely. If these strategies are unsuccessful, there are three procedures which are available for snoring treatment.  Each technique attempts to stiffen the soft palate, or muscular portion of the roof of the mouth, and make it less likely to vibrate and produce the sound of snoring. Originally developed at the Walter Reed Military Hospital in Washington, D.C., injection snoreplasty involves injection of a sclerosing agent underneath the lining of the soft palate to promote scar formation. A second procedure, or Laser Assisted Uvulopalatoplasty(LAUP), uses a laser or radiofrequency device to make a series of incisions in the soft palate. A third procedure is called the Pillar procedure and involves the placement of three woven pieces of material in the soft palate. Each technique varies in terms of cost and recovery. Snoring is not considered a medical problem by most insurance plans and treatment is usually an out-of pocket expense.

In summary, patients with snoring and sleep related disorders should be evaluated for the presence of sleep apnea and treatment should be individualized based on patient history, physical exam, and the results of diagnostic testing.