Sleep Apnea / Snoring

Sleep apnea is a serious breathing disorder characterized by repeated collapse of the upper airway during sleep, with consequent cessation of breathing for 10 seconds or more. In snoring there is partial obstruction of the airway whereas in apnea there is total obstruction of the airway. The person with sleep apnea may have hundred of these ‘breathless’ episodes throughout the night disrupting their sleep and starving the body of vital oxygen.

Unfortunately, sleep apnea is frequently unrecognised and often the symptoms are confused with other medical conditions leaving the condition undiagnosed.

If not identified and left untreated, sleep apnea has the potential to kill you.

Incidence

Sleep apnea is more common than asthma in our society and almost as common as diabetes.

4% of men and 2% of women have the signs and symptoms of sleep apnea (6% overall)

Symptoms

• Chronic loud snoring
• Cessation of breathing or choking spells in the night
• Excessive day time sleepiness
• Automobile or work related accidents due to fatigue
• Severe –mood swings / personality changes – depression, irritability
• Frequent visits to the bathroom during the night
• Obesity
• Low sex drive
• Dry mouth and sore throat in the morning
• Lack of concentration / forgetfulness
• Morning headaches
• Learning difficulties

What causes sleep apnea?

There are three types of sleep apnea

• Central: This is uncommon and results when the signals from the brain to regulate breathing are disrupted in some way.
• Obstructive: This is the most common form of sleep apnea. This is the result of obstruction of the wind pipe leading from the nose or mouth to the lungs. The obstruction is usually the result of a narrowed airway which becomes blocked by the tongue falling backwards.
  eg.
  Obesity
  Enlarged tonsils or adenoids
  Deformed or too large uvula
  Too large or too thick tongue
  Gastroesophageal reflux disease (GERD) or heartburn
  
• Mixed: A combination of central and obstructive sleep apnea

Severity

Apnea severity is usually categorized by the frequency of apnea / hypopnea episode per hour.
This is called the Respiratory Disturbance Index (RDI)

• Mild: 5-15 episodes per hour
• Moderate: 16-30 episodes per hour
• Severe: 30+ episodes per hour

These episodes can last anywhere between 10-120 seconds each, terminating with at least a partial awakening. Typically, a patient may have as many as 300 apnaeic episodes per night.

Who gets sleep apnea?

Sleep apnea can occur at any age.

• Childhood: Apnea in children is often undiagnosed but the incidence is calculated to be as high as 4%. Usually it is the result of enlarged tonsils, adenoids or of some craniofacial abnormality.
• Adulthood: Apnea becomes more common in middle age and is more common in men than women, although after menopause, women may be at equal risk.
• Sleep apnea is often associated with being overweight, particularly with excess fatty tissue around the neck. In people who are not over weight, it is likely that they have been born with a narrowed airway or facial structure which leads to a narrow airway.

Sleep Disorders Breathing Continuum

Obstructive Sleep Apnea is a progressive disease that is more prevalent with age; snoring also increases over time and it is believed that snoring and sleep apnea represents the two extremes of a continuum of upper airway dysfunction.

Normal breathing --> Snoring --> Upper Airway Resistance Syndrome (UARS) --> Obstructive Sleep Apnea (OSA)

Almost everyone who has obstructive sleep apnea snores as snoring is also the result of narrowed or floppy upper airways.

Consequences and Co-morbidity

Social: Snoring and sleep apnea can be extremely irritating and lead to sleep disturbances in the bed partner. These problems can aggravate, or become a focus for relationship disharmony and family stress. It is made worse by the unexplained sleepiness mood swings and lack of interest in family life of the person with sleep apnea.

Accidents: Patients with sleep apnea are more likely to fall asleep at inappropriate times and have a higher rate of automobile crashes and work related accidents by a factor of 4

In fact one third of all deaths on the road are the result of drivers falling asleep at the wheel.

Medical Consequences

Numerous studies clearly demonstrate a co-relationship between patients with obstructive sleep apnea, OSA and cardiovascular disease.

57% OSA patients had Hypertension
25% OSA patients had Ischaemic Heart Disease
17% OSA patients had Coronary Heart Disease
10% OSA patients had Brady arrhythmias
8% OSA patients had Acute Myocardial Infarcts
7% OSA patients had Stroke

In short, there is strong evidence that people with sleep apnea die prematurely by either heart attacks, strokes, motor vehicle or work related accidents.

Diagnosis

Symptoms such as snoring, obesity, observed apnea and sleepiness in the day may suggest that a person has sleep apnea but the best way to be really sure is with an overnight sleep study.

Screening Questions...

• Do you wake up refreshed?
• Do you have trouble falling asleep?
• Do you have trouble keeping asleep?
• Do you snore loudly?
• Has your bed partner reported episodic snoring…. starting, stopping, starting again?
• Have you been told you snort during the night?
• Do you have trouble with being excessively tired during the day?

Treatment

Treatment is required when the RDI score is higher than 5 per hour of sleep in the presence of symptoms and when the RDI is higher than 30 per hour of sleep, regardless of symptoms.

Lifestyle Changes

• Lose weight
• Avoid alcohol 4 hours before retiring
• Maintain regular sleeping patterns
• Avoid caffeine late at night
• Avoid eating late at night
• Quit smoking

CPAP (Continuous Positive Airway Pressure)

This is the treatment of choice for sleep apnea and it consists of a pump that blows air through a mask worn over the nose.

The treatment is immediately effective at controlling the symptoms and long term consequences of sleep apnea.

Dental Appliances

Studies in the USA reveal that unfortunately only 3 people out of 10 continue with CPAP machines after a six month period. Patient compliance is a major issue.

Dental appliances have been shown to be very effective in controlling the symptoms in mild and moderate sleep apnea patients. Additionally, in recent studies dental appliances have been shown to be effective in severe apnea patients and patients are much more likely to continue to use them compared to CPAP machines.

Dental Appliance	Change Lifestyle	CPAP	Surgery
Comfortable	Lose weight	Uncomfortable	Painful
Travels Easily	No Alcohol	Unattractive / Noisy	Non-reversible
Non-invasive	Stop Smoking	Irritatil and Rashes	Unpredictable Result
Reversable	Eliminates sedatives	Dry Throat	Recovery Time
Lifetime Warranty	Sleep on your side	Cumbersome for travel	Side effects may be permanent
10 of 11 patients chose the Silencer over CPAP	Requires a Lifetime Commitment	Less than 50% of CPAP worn on a Nightly Basis	Success may range from 30% to 50%

It is essential that the correct appliances are fitted and the TMJ’s and occlusion are monitored with the appropriate technology over time.

SNORING

Snoring is a major social problem for many people and families. It is disruptive to family life and creates major problems in relationships. Snorers are often the object of ridicule and their snoring cause other household members sleepless nights and deprivation of rest fullness.

Until recently, it was thought that snoring’s only health hazard was being threatened by an infuriated partner! However, research now shows that there are serious medical complications associated with snoring and more importantly, snoring often is a precursor of serious upper airway disorders which if left undiagnosed and untreated, seriously affect the snorers’ quality of life and may result in death!

Who Snores?

Snoring is extremely common, with up to 60% of men and 40% of women snoring to some extent or on some nights. About 25% snore on most nights. Snoring occurs in all age groups, including children, but is most common in the middle aged.

It has been estimated that over 60% of people above the age of 60 snore!

What is snoring?

Snoring is a noise generated by vibration of the soft or floppy parts of the throat, on breathing in, during sleep. The noise, which is particularly likely to occur if the throat is abnormally narrow, is made by the walls of the pharynx – the part of the throat at the back of the tongue, which is held open by several small muscles.

During sleep, those muscles relax, narrowing the airway and partially block off the air passage so that breathing in makes the pharyngeal walls vibrate, making the noise of snoring. The narrower your airway becomes, the greater the vibration and the louder the snoring.

Symptoms

1. Loud, fluttery sound during sleep: Usually noticed by others but sometimes loud enough to wake the sleeper.
2. Dry mouth: Caused by sleeping with mouth open.
3. Sore throat: Caused by sleeping with the mouth open and the strain of snoring.

What Causes Snoring?

• Obesity: Particularly around the neck, causes additional fatty deposits in the throat narrowing the air passage, making breathing difficult.
• Drinking Alcohol: Causes greater muscle relaxation during sleep than normally occurs, and can result in an abnormally floppy upper airway.
• Medications: Can cause throat muscle relaxation ie. Sleeping tablets, anaesthetic drugs, oral steroids, epilepsy drugs, testosterone, narcotics and barbituates.
• Age: As we grow older, the flesh and throat muscles tend to lose some of its elasticity and become flabby.
• Anatomical Factors
• Fleshy or Deformed Uvula
• Enlarged tonsils and/or adenoids: this is a common cause of snoring in children.
• Large Tongue
• Thyroid Swellings
• Nasal Polyps
• Deviated Nasal Septum
• Blockage of nasal passage: May cause snoring because it makes the person breathe through their mouth. A blocked nose also creates a vacuum inside the throat, which may suck air passages closed.
• Allergies, hay fever and smoking may lead to narrowed nasal passages and aggravate snoring.
• Breathing through the mouth may cause snoring because tissues at the back of the mouth are more floppy than at the back of the nose.
• Inherited factors: Variations in the shape of the jaw, airway, face or nose may result in some people having small upper airway.
• Sleeping on your back can lead to, or aggravate snoring as it allows the flesh of the throat to relax and block airways.

Is Snoring Serious?

Socially, YES! It is disruptive to family life and potentially has a significant effect on the quality of life for many people.

Medically, definitely! Recent research demonstrates that habitual snorers have higher chances of suffering from cardiovascular disease.

Habitual snorers have increased risk of...

• Hypertension
• Stroke
• Cardiovascular arrhythmias
• Myocardial infarction (heart attack)
• Angina

Snoring and Sudden Death

A study in Finland of habitual snorers and sudden death concluded...

• Cardiovascular cause of death was more common in habitual snorers
• Habitual snorers died more commonly while sleeping
• Snoring was a risk factor for sudden death between 4am and noon

However the most significant thing to recognize about snoring is that it is a signal to a life threatening condition called sleep apnea.

Almost everybody who has sleep apnea snores, but not all snoring involves sleep apnea.

Should snoring be treated?

That is up to the individual and others who may be affected by the snorer. What is important if you are a snorer is to have appropriate tests to diagnose whether the snoring is a sign of sleep apnea particularly if the snorer has daytime drowsiness, or wakes up feeling tired. It may just save your life.

Diagnostic Tests

• Complaints from other people
  Many times the bed partner or roommate suffers more sleep deprivation than the snorer does.
• Sleep Disorder Specialist
  There are medical specialist who conduct thorough health histories and physical examinations to determine if further testing is required for a proper diagnosis in sleep disorders.
  It can be ascertained by the use of easy questionnaires whether a snorer should continue to the next level of testing.
• Pulse Oximetry Test
  This is a well established tool routinely used in medicine to determine a patients arterial oxygen saturation and heart rate. This is an economical test used to determine if a snorer has sleep apnea.
• Sleep Study
  This is a test that investigates snoring and helps to diagnose sleep apnea. Simple non-invasive equipment is used to measure your sleep and breathing in special rooms in diagnostic centres called sleep units.

Treatment of Snoring

• Life Style Changes
• Sleep on your side
• Lose weight
• Avoid alcohol at least 4 hours before sleeping
• Give up smoking
• Eliminate sedatives
• Avoid or remedy colds, allergies and sinus problems
• Surgery: to remove tonsils, adenoides or change the shape of the mouth or jaws
• Surgery: to reduce and tighten soft tissues in the soft palate or throat making them more open, rigid and less able to collapse.

CPAP Machine - Continuous Positive Airway Pressure

This is a machine that inflates the throat by blowing air into the nose with a mask preventing collapse of the airway during sleep. Many people find the mask and pump inconvenient. The noise is annoying.

Dental Appliances

We are able to produce simple, versatile non-invasive, dental appliances that advance the lower jaw the optimum amount to open the airway and virtually eliminate snoring.

Be aware of cheap substitutes...they don’t work.

The use of correct dental appliances have proven extremely effective in treating snoring and sleep apnea.

Technology and Snoring

Since the antisnoring device works by advancing the lower jaw, it is critical to ensure that we do not create problems with the tempomandibular joints (TMJ’s) or the snorers bite.

By using the technology at our disposal (JVA’s, JT’s, EMG) we are able to monitor the TMJ’s and the occlusion to ensure that the patient does not develop other problems.

No other member of the healthcare team can do this.

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WEST LAKES SA 5021 
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