The Snoring Sickness: Obstructive Sleep Apnea
Snoring signals that the sleeper is having trouble breathing. Snoring is the most common symptom of obstructive sleep apnea (OSA), a disorder that affects more than 18 million Americans, most of whom are overweight, middle-aged men. In fact, it affects about twice as many men as women and runs in families.
When people breathe, air enters the nose or mouth, and travels through the airway to the lungs. Throat muscles, including the tongue, normally keep the airway entrance open. When people with obstructive sleep apnea try to sleep, throat muscles may fail to do that. The tongue then falls against the back of the throat, partially or totally blocking the airway opening. The sounds of snoring reflect a struggle to breathe through a partially blocked airway.
When the airway is totally blocked, breathing stops completely. A pause in breathing sounds an alarm in the brain. The brain senses the danger, and sends a wake-up call, arousing the sleeper enough to tighten throat muscles. The throat muscles re-tighten and the tongue moves out of the way resulting in the airway reopening and resumption of breathing.
People with severe obstructive sleep apnea may stop breathing hundreds of times while they sleep. These pauses in breathing may last for a few seconds to a minute or more, and they can recur dozens of times in each hour of sleep. If you were to watch people with severe obstructive sleep apnea sleep, you likely would see their struggle to breathe. You would hear characteristic thunderous snoring, interrupted by episodes of silence when breathing stops. Then you would hear a gasp or loud snort when they awaken, and take in air.
Sleepers with obstructive sleep apnea awaken repeatedly, but usually for only a few seconds at a time. They seldom remember these awakenings later. They usually recognize, however, that they sleep poorly.
Someone suffering from severe obstructive sleep apnea may drift off to sleep while watching TV, talking with someone, or even eating. Most worrisome, they may fall asleep on the job or while driving, endangering themselves or others.
Could You Have Obstructive Sleep Apnea?
Overweight middle-aged men have the highest risk of developing obstructive sleep apnea (OSA), a disorder that disrupts breathing during sleep. Obstructive sleep apnea affects women, too, most commonly after menopause. It even affects babies and children, particularly those who have enlarged tonsils, or are overweight.
Excess weight boosts a person’s risk of developing obstructive sleep apnea. Excess fat not only envelopes the outside of the body but also surrounds tissues inside the body. Excess fat on throat tissues increases the likelihood of airway blockage. Certain inherited traits, such as a small jaw or a large overbite, may increase the risk of developing obstructive sleep apnea. Consuming alcohol or a medication containing an opioid such as hydrocodone or oxycodone near bedtime may further worsen breathing while sleeping in people with obstructive sleep apnea.
While an estimated 18 million Americans have obstructive sleep apnea, many do not realize they have it. They understandably don’t know they have symptoms that occur only in sleep. A family member or bed partner may be the first to recognize their problem snoring, fatigue, and other symptoms:
- Do you snore loudly?
- Do you often feel sleepy or foggy while awake?
- Has someone told you that you stop breathing or choke or gasp in your sleep?
- Are you overweight?
- Do you have poorly controlled high blood pressure?
If you answered “yes” to these questions, you have symptoms that suggest you may have obstructive sleep apnea. You can find out more about your risk for obstructive sleep apnea by filling out the Anonymous Sleep Disorders Screening Tool.
Discuss your symptoms with a healthcare provider. This person may refer you to a sleep specialist for further evaluation. If you do have obstructive sleep apnea, treatment can help you sleep better, feel better while awake, and perform well in your safety-critical railroad job.
Consequences of OSA
People with obstructive sleep apnea (OSA) experience the consequences of poor sleep: they feel sleepy and fatigued in waking hours. Some report headaches and trouble with concentration and memory. Some feel irritable and depressed.
Women with obstructive sleep apnea may not snore as loudly as men with the disorder, but are more apt to report symptoms of depression and insomnia.
Obstructive sleep apnea forces the heart and blood vessels to work harder because when you are not breathing oxygen levels in your blood fall. If left untreated, it may cause high blood pressure, heart disease, stroke, diabetes, and impotence, and has been associated with a shorter lifespan.
How Sleep Specialists Diagnose OSA
A sleep specialist will ask how you sleep, and how you feel when awake, and perform a physical exam. You may be asked to complete the Epworth Sleepiness Scale, Stanford Sleepiness Scale, and other measures of sleepiness. You also may be asked to have blood and urine tests, and undergo studies to examine the anatomy of your airway.
Additionally, you will need to undergo a sleep study. These are now usually performed in the home with equipment that you can easily put on by yourself. However, in some cases, they may need to be done at a sleep center. Sleep studies can show whether you have obstructive sleep apnea, and, if so, how severe it is.
If you undergo a home sleep study, you will wear devices to assess breathing patterns and oxygen levels. At a sleep center, technicians will attach electrodes to your scalp and elsewhere on your body to monitor brain activity, breathing patterns, and heart rate. They also will measure oxygen levels in your blood.
OSA Treatment Options
Treatment for obstructive sleep apnea (OSA) aims to restore normal breathing in sleep, ease wake-time symptoms, such as fatigue and sleepiness, and reduce the risk of experiencing medical disorders, such as high blood pressure, heart disease, stroke, diabetes, and impotence. Effective treatments exist. They include:
Continuous positive airway pressure (CPAP). This is the gold standard treatment for moderate to severe obstructive sleep apnea. It can reduce, and sometimes eliminate obstructive sleep apnea symptoms. CPAP involves wearing a mask over the nose, or over both nose and mouth in sleep. The CPAP device sends a constant, low-pressure stream of air to keep the airway open. Advances in technology have made CPAP devices portable and as compact as 3.6 inches in diameter. Railroaders who must overnight at stations away from their home and who require CPAP may find that such a device will easily fit in their overnight bag.
Oral appliances. These dental devices, worn in the mouth, aim to reposition the lower jaw forward and keep the airway open. They may benefit people with mild to moderate obstructive sleep apnea, but some with severe obstructive sleep apnea may benefit as well.
Weight loss. If you are overweight, losing extra pounds may reduce the severity of obstructive sleep apnea, or eliminate it altogether. Weight loss diminishes pressure on the airway in sleep, and benefits overall health, as well.
Sleep position. Some people experience sleep-disrupted breathing only when they sleep on their back. Place pillow bolsters on the side of your body, or attach objects to the back of pajamas, such as tennis ball in a sock, to help discourage back-sleeping. Commercial devices that discourage back-sleeping also exist. One, worn on the back of the neck, starts to vibrate when a person sleeps on his or her back, prompting the sleeper to shift position.
Surgery. Several surgical procedures may be useful for treatment of obstructive sleep apnea.
- Uvulopalatopharyngoplasty (UPPP) or its variants focus on reducing excessive tissue in the throat and/or the tongue in order to widen the airway. It may benefit some people with obstructive sleep apnea.
- Bariatric (weight reduction surgery) in people with obstructive sleep apnea who are overweight may decrease the severity or eliminate it entirely.
- Hypoglossal nerve stimulation (Inspire®) is a recently approved device for treatment of obstructive sleep apnea. An electrode is surgically placed next to the hypoglossal nerve which is the primary nerve controlling the tongue. The device senses when you begin to breathe and then causes the electrode to stimulate the tongue muscle. This prevents collapse of the airway. Currently, hypoglossal nerve stimulation is only indicated for people who cannot use CPAP, are not extremely obese and have obstructive sleep apnea that is moderate to severe. There are other eligibility criteria as well and the device and implantation procedure are very expensive. Consultation with a sleep specialist is essential to determine if you are eligible to have this procedure.
Medications. To date, there are no medications when used alone that have been shown to be effective for treatment of obstructive sleep apnea. However, some people may experience persistent sleepiness even after effective treatment for their obstructive sleep apnea. For these individuals, medications such as modafinil (Provigil®), armodafinil (Nuvigil®) or solriamfetol (Sunosi®) may improve their sleepiness when used with their obstructive sleep apnea treatment.
If you have obstructive sleep apnea, successful treatment likely will help you sleep better, and stay more alert and focused in waking hours. It will enable you to perform your job better, and improve your odds of staying safe at work and while driving.