Waiting to Inhale
Snoring is not just bothersome; it can be downright dangerous, a warning sign of sleep apnea, a disorder that can seriously impair your health.
By Barbara Sande Dimmitt

The sound begins with a growl, wheezing buzz, or snort. Slowly it builds, until it resembles the rhythmic cycling of a chainsaw or a motorcycle. This industrial-strength snoring has the power to drive spouses to the spare bedroom, aggravate bunkmates, or even alert the enemy to troop locations.

Simple snoring, caused by the vibration or fluttering of tissues in the wind tunnel of the throat, is normal. Most of us do it occasionally, more often as we get older. Some 60 percent of people over the age of 60 have significant, or loud, snoring, and the incidence is higher in men. But very loud, sometimes called “heroic,” snoring can be more than just an annoyance— it can indicate a serious, even life-threatening, health problem. 

“It was my loud snoring that irritated my wife; only in search of peace did I go to my doctor,” recalls Dale Snape, who later became chair of the American Sleep Apnea Association (ASAA). “I never imagined that I stopped breathing in my sleep more than 300 times during the night.”

It isn’t surprising Snape was unaware of his problem, according to Dr. Safwan Badr, a sleep specialist and president of ASAA. “Most people who have untreated sleep apnea don’t even realize it, partly because, as a rule, sleep apnea has no sudden onset,” he says.

What is sleep apnea?

Apnea is a word of Greek derivation that means “no breath”; sleep apnea is a sleep disorder characterized by multiple pauses in breathing during sleep. These pauses, or apneas, are clinically defined as lasting at least 10 seconds, but they might continue for more than a minute. When the brain registers a lack of oxygen, it sends a wake-up signal to the body. Breathing resumes, often with a gasp or loud snort. This process might be repeated a few times an hour to hundreds of times during the night. Sleep becomes fragmented and of poor quality, often never reaching the deeper, restorative stages.

Sleep apnea is estimated to affect 4 percent of men and 2 percent of women in the United States. Although the disorder can occur at all ages, like simple snoring it is more common as people get older. 

This apnea causes chronic sleep deprivation and daytime fatigue. Sufferers might find themselves falling asleep at dangerous or inopportune times. Judgment and reaction time become impaired. Nearly 20 percent of sleep apnea patients say they had auto accidents as a result of nodding off at the wheel, according to a study reported in Sleep magazine in 1989. Another study found that sleep apnea patients performed worse on driving tests than nonapnea subjects who had been given enough alcohol to be legally drunk.

Sleep deprivation and frequent low blood-oxygen levels cause neuropsychological problems, too. People with sleep apnea suffer from irritability and depression. Their memory, alertness, and ability to concentrate can decline. As a result, their family, social, and work relationships might deteriorate. 

The condition also stresses the body, especially the cardiovascular system. Studies have shown a link between the disorder and high blood pressure. There’s also evidence that sleep apnea sufferers face increased risks of irregular heartbeat, heart attack, and stroke. The health hazards are even more dangerous for patients with diabetes, kidney problems, emphysema and other lung conditions, and heart disease.

What causes sleep apnea?

The most common form of sleep apnea is obstructive sleep apnea (OSA). OSA is caused by a narrowing of the airway that interferes with breathing. Like snoring, this interference occurs during sleep or near-sleep, when the muscles surrounding the soft palate, tongue, and uvula relax and sag. Sagging further narrows the airway, and as the sleeper inhales, the base of the tongue and soft tissues fall back into the airway and block air flow.

Obesity and large neck size (17 or more inches in men, 16 or more inches in women) are considered risk factors for sleep apnea, because excessive or fatty tissue can decrease airway circumference. Other contributing structural factors include enlarged tonsils and adenoids, a short or malformed lower jaw, abnormalities or obstructions inside the nose, nasal congestion, and polyps or other growths. 

As is true of simple snoring, sleep apnea gets worse if you drink alcohol or take sleeping pills or other medications that increase muscle relaxation. Some people have more problems when they sleep on their back. 

Sleep apnea’s other two forms are less common. Central sleep apnea (CSA) occurs when the nervous system malfunctions and fails to send the body the normal signal to breathe. People with CSA usually have other health problems, such as congestive heart failure, pulmonary disease, stroke, or brain injury. Mixed sleep apnea is a combination of the central and obstructive forms of apnea. 

Diagnosing sleep apnea

Loud snoring is a warning sign, especially if the snoring is punctuated by gasps and choking noises. Pauses in breathing during sleep that last at least 10 seconds are cause for concern. Un-fortunately, people who have sleep apnea rarely wake sufficiently to notice these breathing disturbances.

“Typically the spouse says, ‘You’re not breathing very well. Sometimes I think you’re choking or gasping. I’m concerned, because you used to just snore, and now you’re kind of breaking up in your breathing,’ ” explains Dr. H. William Bonekat, a sleep specialist at the University of California, Davis, Medical Center. “People who sleep alone or don’t have family members in the same household frequently will go for long periods of time before recognizing [they have a problem].” 

Other possible indicators include daytime sleepiness or fatigue, obesity, high blood pressure, changes in behavior (such as depression, irritability, or loss of energy), impotence, dry mouth, and morning headaches. 

Diagnosis is made during a thorough evaluation, preferably by a sleep specialist or a doctor familiar with sleep disorders, and includes a study of the quality of your sleep. Called poly-somnography, this sleep study typically is conducted in a sleep laboratory and usually involves at least one overnight stay. Throughout the night, a polysomnograph machine collects data on your brain waves, eye movements, blood pressure, heart rate, blood oxygen level, breathing patterns, and many other physical indicators.

I have it. Now what?

Treatment for sleep apnea includes lifestyle changes, mechanical devices to keep your airway open, and surgery. Often, a combination of therapies proves necessary. “There’s no guaranteed cure for sleep apnea,” says Dr. Eric Mair, an otolaryngologist, surgeon, and former head of the sleep clinic at Walter Reed Army Hospital in Washington, D.C. “You can control it, but we recommend a multidisciplinary approach and periodic follow-up.” 

No matter how severe your apnea is, you should start by making lifestyle changes. Lose weight if you’re obese, stop smoking, don’t drink alcohol close to bedtime, and avoid taking sleeping pills. Use decongestants or antiallergy medication if nasal congestion is narrowing your airway. If your apnea is worse when you lie on your back, try sleeping on your side. 

For moderate to severe apnea, the gold standard of treatment is the continuous positive airway pressure device, or CPAP. The CPAP comprises an air pump, adjustable pressure gauge, connecting hose, and mask or other interface that you wear over your mouth and/or nose. The CPAP blows just enough air pressure into your airway to keep it open during sleep.

The CPAP is effective in eliminating apneas when used consistently and correctly. But compliance is a problem for as many as half of all patients. People often abandon the device because it makes them feel claustrophobic and uncomfortable, or they haven’t received a properly fitting mask. 

Military personnel have another reason to seek non-CPAP options. They must go before a medical board that evaluates their worldwide status qualification. “If it’s determined that the machine interferes with their ability to ‘go anywhere at any time,’ that can be a significant problem for their career,” explains Mair. 

Oral appliances provide an alternate source of relief for people who have mild to moderate sleep apnea. Custom-made by dentists and originally intended to reduce snoring, oral appliances include mouth guards to hold the lower jaw in position and devices to secure the tongue. Clinical studies have shown success rates comparable to some surgeries. So far, however, oral appliances usually reduce, rather than eliminate, apneas. 

Because presurgical identification of the specific problem area can be difficult, surgery for sleep apnea doesn’t always work and might need to be repeated. As a result, surgery usually is reserved for patients who have obvious structural abnormalities or for those with mild to moderate apnea who cannot tolerate the CPAP. 

Surgical interventions include removing enlarged adenoids, tonsils, nasal polyps, and other growths or tissues; correcting structural abnormalities in the nose, such as a deviated septum; and operations on the tongue, palate, or uvula. Constructing a tracheostomy — a hole in the throat through which a patient can breathe — is usually considered a last resort for people whose sleep apnea is deemed life-threatening and cannot be controlled by other means. 

What does the future hold?

Technological improvements are making it easier to diagnose and treat sleep apnea. New home sleep study methods can help, according to Mair, who reports that Walter Reed has begun using them to advantage.

Also showing promise are a new generation of “smart” CPAP devices that can adjust the pressure of air automatically in response to a patient’s varying needs. And more effective and comfortable masks and other CPAP accessories are coming on the market. 

A new treatment developed at Walter Reed, called injection “snoreplasty,” is an inexpensive, 5-minute office procedure. A medication is injected into the uvula to cause minor scarring, which stiffens the uvula and reduces vibration. The procedure has been shown to reduce snoring about as effectively as conventional palate surgery. A study is being conducted to determine whether injection snoreplasty can alleviate sleep apnea, too.

But you can’t be treated for a disorder you don’t know you have. So one final warning for those who dozed off while reading this: Maybe it wasn’t because the article was boring!