Snoring & Obstructive Sleep Apnea

 

Snoring – the Silent Killer

 

An American research study showed that in a 30 to 45 year old population, 20% of men and 5% of women will snore, and by the age of 60, 60% of men and 40% of women will snore habitually. Obstructive Sleep Apnea (OSA) is a common sleep disorder and is estimated to have an incidence of 24% in men and 9% in women in the US.  Many authorities believe that up to 93% of females and 82% of males with moderate to severe OSA remain undiagnosed.

 

 

A recent report in Singapore, published in The Straits Times, showed that 1 in 3 Singaporeans have Snoring/Obstructive Sleep Apnea, and 1 in 3 of these patients have moderate to severe OSA. 

 

 

Obstructive Sleep Apnea is related to reduced airflow through the upper airway during sleep. This is due to complete or partial upper airway obstruction or increased upper airway resistance.

 

 

Snoring is frequently deemed as a social nuisance. Not a nuisance to the snorer, but a nuisance to the bed-partner. The presence of snoring is an ‘alarm’ that alerts one to the possibility of OSA. Snoring implies an increased resistance to the inflow of air during breathing at the level of the upper airways. 

 

 

WHAT CAUSES SNORING?

 

Snoring is due to the vibration of the tissues in the nose, mouth and oral cavity (namely the soft palate, uvula, tonsils, base of tongue and lateral side walls of the mouth). The vibration of excess tissue and the narrow airway leads to collapse, partial or complete, of these structures, which then leads to upper airway obstruction during sleep. This upper airway obstruction cause stoppages in breathing (apnea) and low oxygen at night during sleep. This results in increased heart rate (as the heart is trying to compensate for the low oxygen), and increased blood pressure (hypertension). Hence, the patient with OSA has poor quality unrested sleep.

 

 

WHAT ARE THE SYMPTOMS OF SNORING AND OSA?

 

DURING THE NIGHT

 

Commonest clinical symptom for patients with OSA is snoring.

 

 

Most of my patients come to see me saying: “Hey doc, you know I snore; but you know what, it doesn’t bother me, it bothers my wife!” This would be the social aspect behind the snoring.

 

 

Frequently, the bed partner prompts the patient to see a sleep doctor because of concerns over repeated choking at night/gasping/apneas (stoppages in breathing). Patients may complain of frequent awakenings with a choking and gasping sensation, teeth grinding, nocturia (frequent passing urine at night), or nightmares.  Many bed partners have witnessed their partners choking and holding their breaths during their sleep. Patients with severe OSA may be unable to sleep supine (on their back), as this causes the tongue to fall backwards resulting in obstruction of the airway.

 

 

DURING THE DAY

 

Common daytime patient complaints include early morning tiredness and morning headaches (attributable to the repetitive nocturnal low oxygen levels).  Morning dry mouth and throat are caused by mouth-breathing and snoring. Other symptoms include forgetfulness, depression, irritability and, less commonly, impotence.

 

 

Excessive daytime sleepiness is very common in patients with OSA, and is caused by a combination of frequent arousals, sleep fragmentation, repetitive oxygen desaturations, and reductions in delta and rapid eye movement (REM) sleep. Excessive daytime sleepiness can be measured by a simple questionnaire known as the Epworth’s Sleepiness Score (ESS) (see figure below).

 

 

SUMMARY

 

The commonest symptoms related to obstructive sleep apnea are:

 

During the day:

 

  • Daytime sleepiness, tiredness
  • Poor concentration
  • Poor memory
  • Morning headaches
  • Mood changes
  • Irritability

 

 

During the night:

 

  • Choking sensation at night
  • Gasping for air at night
  • Frequent arousals
  • Nocturia (frequent passing urine)
  • Loud snoring
  • Teeth Grinding

 

 

Epworth Sleepiness Scale

 

Activity Chance of Dozing
Sitting and Reading
Watching TV
Sitting inactive in a public place (Meeting, theatre)
A passenger in a car for one hour without a break
Lying down in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Total

 

Each question is rated from a zero to a three.

 

  • Zero – being no chance of falling asleep
  • One – a little chance of falling asleep
  • Two – good chance of falling asleep
  • Three – definitely will fall asleep

 

 

A final score of zero (minimum) to 24 (maximum). In general, a score less than 10 is considered normal, any result between 11 to 14 is considered fairly sleepy, and any score above 14 is considered sleepy.  A score of 20 to 24 is a dangerous patient who might fall asleep anytime, even when driving.

 

 

WHO SHOULD I SEE IF I SUSPECT I HAVE SNORING/OSA?

 

Clinical evaluation is the most important step in managing a patient with snoring and/or sleep apnea. An ear, nose and throat endoscopic examination of the upper airway assessment is crucial. 

 

 

All patients should have weight and height recorded, body mass index (BMI) calculated, blood pressure taken, and neck circumference measured.

 

 

AIRWAY ASSESSMENT IS MOST IMPORTANT

 

The upper airway assessment is the most important step in the evaluation of the snoring patient. This would be fundamental, in assessing and deciding the modality of treatment in all snoring/sleep apnea patients.

 

  • Nose swelling – the nose is physiologically essential in breathing, any swelling within the nose needs to be corrected in order for normal breathing to be restored.
  • Tonsil size – the patient’s tonsils are assessed with regards to how obstructing they are. They are graded based on their size within the oral cavity.
  • Tongue size – the tongue is very essential in the evaluation, as the tongue is the final “gate-keeper” to the opening of the lungs.
  • Palate thickness – if the palate is too thick or redundant, it would not only cause loud snoring but may lead to obstruction of the airway and hence, sleep apnea.
  • Lateral (side) throat wall thickening – many patients with OSA have very thick and bulky lateral walls of the throat. These side walls actually cause collapse and obstruction of the upper airway during sleep, resulting in stoppages in breathing and low oxygen.

 

 

Based on the patient’s BMI, neck circumference, oral cavity adequacy, tonsil size, palate size/length, tongue size, upper airway assessment, and the nasal passage size, the modality of treatment is decided together with the patient.   

 

 

Treatment of snoring and sleep apnea may be conservative and/or surgical (see chapter on Treatment of Snoring/Sleep Apnea).

 

 

DO I HAVE OBSTRUCTIVE SLEEP APNEA?

 

Many studies have shown that the symptoms of a patient alone are fairly useful in predicting if one has sleep apnea or not. There are strong indicators of sleep apnea.  Many of my younger patients (between 30 to 40 years old) who come to my clinic with severe symptoms of sleep apnea are already on anti-hypertensive (high blood pressure) medication.

 

 

It is not normal for a young male to have high blood pressure; an underlying cause should be sought for. There are some strong tell tale symptoms of sleep apnea. If you snore and have excessive daytime sleepiness, you have a close to 70% chance of having sleep apnea. If you snore, have excessive daytime sleepiness and your bed-partner noticed that you stop breathing (or noticed you gasping at night), you have an 80% probability of having sleep apnea. If you snore, have excessive daytime sleepiness, your bed-partner says you stop breathing at night, and you have high blood pressure (hypertension), you have a 90% chance of having sleep apnea. 

 

 

Some simple questions that you may ask yourself to see if you might have sleep apnea:

 

 

While awake:

 

  • Do you wake up in the morning tired and foggy, and unrefreshed?
  • Do you have headaches in the morning?
  • Are you very sleepy during the day?
  • Do you fall asleep easily during the day?
  • Do you have difficulty concentrating, and completing tasks at work?
  • Do you feel in a daze, like you are not in your “body”?
  • Have you ever arrived home in your car but couldn’t remember the trip from work?

 

 

At night, while asleep:

 

  • Do you snore loudly each night?
  • Do you have frequent pauses in breathing while you sleep (do you choke or wake up choking)?
  • Are you restless during sleep, tossing and turning from one side to another?
  • Do you have to sleep sitting up or propped up by pillows, because you find that you are breathless sleeping flat?
  • Do you have to get up to urinate (pass urine) several times during the night?
  • Have you wet your bed?
  • Do you have frequent nightmares?
  • Does your bed partner tell you that you clench and grind your teeth?

 

 

If you answer “yes” to any 3 of these questions, there would be a strong probability that you might have sleep apnea.

 

 

IS SNORING / OBSTRUCTIVE SLEEP APNEA DANGEROUS?

 

Nightmare time comes in the wee hours of the morning for people with obstructive sleep apnea. But it’s no dream: That’s when they’re at highest risk of sudden death. It has been said that “Sleep apnea is the phantom cause of heart disease and sudden death”. It is well known that patients with sleep apnea have a 6 times higher risk of dying between midnight and 6am, compared to normal non-apneic patients. As these patients with snoring and sleep apnea have numerous dips in their oxygen levels while asleep, it would not be surprising that they suffer from significant stress on the heart and brain during these low oxygen events. This in turn leads to high blood pressure, lack of oxygen in the blood and hence, strokes, heart attacks and sudden death. 

 

Overall, it is well known that patients with sleep apnea would not live as long as people without sleep apnea. Medical research studies done over 10 years have shown that patients with severe obstructive sleep apnea (patients who stop breathing more than 30 times per hour) have a mortality rate of about 3% per year.

 

TREATMENT OF SNORING & OBSTRUCTIVE SLEEP APNEA

 

In general, patients with snoring/sleep apnea are classified into those with a “global” problem, i.e. obesity, and those with a “local” anatomical problem (those with huge tonsils, long thick palate, big tongue and/or a small jaw).

 

 

Patients with OSA are generally advised:

 

  • a strict trial of weight loss,
  • exercise regime,
  • nutritionist consultation (dietary advise),
  • regular close follow up and
  • a nasal mask continuous positive airway pressure (CPAP) trial.

 

 

CONSERVATIVE MANAGEMENT

 

NASAL CPAP 

 

This is a non-invasive method of treatment, it entails using continuous positive airway pressure (forced air) by a mask worn by the patient on the nose or the face throughout the night (it is somethings compared to a “reversed vacuum cleaner”). For most patients with OSA, it is not easy to wear the mask throughout the entire night and for every night for the rest of his life. Hence, the issue of compliance is a major problem.

 

 

The CPAP machine and its mask would only be effective if the patient wears the mask; it would not work if it is kept in the closet. Moreover, many patients wake up with the mask on the floor, and hence, would not use it the entire night. The CPAP machine and mask is as effective as the duration that it is worn. 

 

 

CPAP IS NOT A CURE, IT IS A CONTROL; IT IS ONLY EFFECTIVE WHEN IT IS WORN ON THE FACE.

 

 

The main drawback to the use of nasal CPAP is compliance. Common reasons for poor compliance with nasal CPAP include:

 

  • nasal problems – nasal stuffiness, irritation, discharge, pain
  • mask problems – poor fit, air leak, dry eyes, skin breakdown
  • equipment problems – noisy, cumbersome, high air pressure, pressure-related arousals
  • concept problems – failure to understand medical benefit

 

 

Failure of CPAP

 

The CPAP machine is effective provided the patient can tolerate it the entire night. Compliance is the main problem. Most people do NOT use the machine the entire night and every night of the week. Hence, the treatment effectiveness is based entirely on the patient’s use.

 

 

SCIENTIFIC EVIDENCE

 

  • Long term follow up and research done on over 20,000 patients (by Weaver et al) compared patients on the CPAP mask and those who underwent surgery. This study (done in Seattle, Washington) was published in the American Otolaryngology Journal in 2004 and showed that patients who underwent surgery had a better survival advantage (patients who went for surgery lived longer) on average, over patients who were using CPAP (this was due to the poor usage of their CPAP). From this study, it was implied that patients who underwent surgery lived longer than patients on the nasal CPAP mask.
  • Scientific study from Adelaide, Australia, published in the prestigious New England Journal of Medicine, September 2016, compared 1346 OSA patients using CPAP and 1341 OSA patients not on any treatment; after 7 years, they found NO difference in incidence and risk of heart attacks, strokes and heart failure between the 2 groups. This indicated that OSA patients on CPAP treatment is NO BETTER than OSA patients who are not treated.
  • Longer term study from Korea, published in February 2018, in the American Sleep Medicine Journal, investigated 22,231 OSA patients who had surgery and 170,085 OSA patients who had no treatment, and found that, after 8 years, patients who had surgery lived longer that those who did not.
  • Pang KP et al, investigated the usage of CPAP over the past 20 years in 82 international scientific papers, and found that the average usage of CPAP in patients was only 34%. This is a very low and inadequate level of CPAP usage in OSA patients. 

 

 

ORAL APPLIANCES FOR SLEEP APNEA /BRUXISM

 

Oral appliances (like dentures) are designed to bring the mandible (lower jaw) and base of tongue forward, either by stabilizing the lower jaw position during sleep or by attempting to pull the tongue forward, in an effort to increase the posterior airway space. Oral appliances are offered especially when the patient is a poor candidate for surgical intervention, or is unable to tolerate nasal CPAP.

 

 

Oral devices can be divided into two basic types:

 

  • Mandibular (lower jaw) repositioning device – these are removable devices worn at night. They are affixed to the upper and lower teeth and are gradually adjusted to advance the mandible.
  • Tongue-retaining device (TRD) – these come in the form of a soft suction cup that is placed in the mouth, creating a negative pressure to hold the tongue in a forward position during sleep.

 

 

These oral devices are not for every OSA patient, and also has an issue with patient usage (compliance) and because the lower jaw is held forward at night, the jaw joint might start to hurt or feel the strain.

 

 

SURGERY IN SNORING / SLEEP APNEA

 

The key to surgical success is patient selection (for a successful surgery, the doctor has to select the suitable patient). 

 

Success rates of surgery depend on

 

  • type of patient selected for surgery – including height and weight of patient, age of patient, tonsil size, palate length, tongue size and nasal pathology
  • type of palate surgery performed – including Uvulopalatopharyngoplasty (UPPP), Pang’s Expansion Sphincter Pharyngoplasty (ESP) (invented by Dr Kenny Pang), and/or Lateral Pharyngoplasty,
  • type of tongue surgery performed (if needed) – Tongue Reduction Surgery (minimally invasive tongue volume reduction surgery)
  • whether nose, palate and tongue surgery is performed together
  • severity of Sleep Apnea (disease) as noted on the sleep test

 

 

Severity of OSA can be classified according to the Apnea-Hypopnea Index (AHI) and lowest oxygen saturation level (LSAT). The severity is usually graded as the worst of the two.

 

 AHILSAT
Mild OSA5-1486% - 95%
Moderate OSA15-2975% - 85%
Severe OSA>30<75%

 

TYPE OF SURGERY REQUIRED   

 

NOSE

 

Type of nose surgery is dependent on the patient’s nose anatomy. In general, the radiofrequency of the inferior turbinates are easy, simple, painless, quick and has minimal side-effects. Other types of nose surgery:

 

  • Nasal Turbinate Reduction – Laser, Radiofrequency, Micro-debrider, Coblation
  • Nasal Turbinectomy – cutting of the turbinate
  • Endoscopic Sinus Surgery – involves the use of endoscopes through the nose to correct anatomical deformities, reduce or remove nasal swellings and enlarge sinus openings (improving sinus drainage).

 

 

This new technique is minimally invasive surgery; it is safe, convenient and effective in treating sinus diseases.

 

 

PALATE

 

The recently invented Pang’s Expansion Sphincter Pharyngoplasty technique (invented by Dr Kenny Pang) has been shown to be over 80% effective in patients with obstructive sleep apnea

 

 

Types of Palate Surgery

 

  • Radiofrequency of the Palate
  • Laser Palate Surgery
  • Anterior Palatoplasty  (invented by Dr Kenny Pang)
  • Coblator Palate Surgery
  • UvuloPalatoPharyngoPlasty (UPPP)
  • Pang’s Expansion Sphincter Pharyngoplasty (ESP) (invented by the author) – very useful technique, has shown to be over 80% successful in a randomized controlled trial.

 

 

TONGUE

 

Types of Tongue Surgery

 

  • Tongue Reduction Surgery
  • Minimally Invasive Tongue Suspension Suture (effective)
  • Radiofrequency of Tongue Base
  • Genioglossus Advancement Mandibulotomy

 

 

Notes for OSA patients

 

  • 70% OF PATIENTS WITH SNORING AND SLEEP APNEA HAVE PALATE OBSTRUCTION AS THE MAIN CAUSE
  • THE NOSE CONTRIBUTES TO SNORING AS WELL
  • TREATING THE NOSE AND PALATE AT THE SAME TIME WILL SIGNIFICANTLY IMPROVE SUCCESS RATES
  • TREATING OSA PATIENTS REQUIRES A HOLISTIC APPROACH WITH WEIGHT LOSS, HEALTHY LIFESTYLE, SURGERY AND CLOSE FOLLOW UP

 

WHAT ARE THE VARIOUS SLEEP TESTS AVAILABLE?

 

Sleep Tests

 

Many patients who see me present with two ends of the spectrum in sleep disorders, they usually have 2 main complaints:

 

“Doc, I’m so tired but I just can’t fall asleep!” or

 

“Doc, I sleep 8-9 hours, but I’m still so tired, I can’t keep awake!” 

 

These sleep disorders range from insomnia (unable to fall asleep) to obstructive sleep apnea (excessive daytime tiredness, unable to keep awake).

 

 

Some self administered sleep test questionnaire might help. 

 

These sleep tests are not intended to be diagnostic, they are just helpful for patients who suspect that they have a sleep disorder.

 

Answer some of these questions:

 

  • I have been told that I snore and that i grind my teeth while asleep
  • I have been told that I hold my breath when I sleep
  • I wake up choking, gasping, or have difficulty breathing at night
  • I wake up in the middle of the night with palpitations (fast heart beat)
  • I am told that I kick violently at night
  • I feel very tired during the day despite sleeping for 6 to 7 hours per day
  • I wished I had more energy
  • I get morning headaches often
  • I noticed that I am grumpy and irritable lately
  • I often feel sleepy and have trouble staying awake at meetings
  • I frequently awake with a dry mouth and throat
  • I have high blood pressure
  • I am slightly overweight
  • I have frequent sore throats
  • I have “sinus” problems on most mornings of the week
  • I have fallen asleep while driving
  • I often feel like I’m in a daze
  • I have difficulty falling asleep
  • I feel sad and depressed
  • Sometimes I can’t keep my legs still at night; I just have to move them to feel comfortable.

 

 

In general, with more than 5 answers as positive (yes), one should seek a sleep specialist consult. It might indicate that you could have a sleep disorder.

 

Sleep Assessment Tests

 

To say that a patient has high blood pressure, one would have to take the blood pressure reading; to say that a patient has diabetes, one would have to take a glucose blood test. Similarly, to diagnose a patient with a sleep disorder, one would have to perform a sleep assessment test.

 

 

There are 2 main types of sleep test:

 

  • in hospital overnight sleep test (in-patient)
  • at home overnight sleep test (done in the patient’s own home)

 

 

Depending on the type of sleep disorder suspected, the sleep specialist would order the appropriate sleep test. The type of sleep test ordered would be dependent on the number of parameters required.

 

 

HOSPITAL OPTION

 

Overnight Hospital Sleep Test (Polysomnogram)

 

The in-hospital overnight attended (monitored by a sleep technician throughout the night) sleep test comprises of multiple parameters including:

 

  • Electroencephalogram (EEG) – monitoring brain waves
  • Electrooculogram (EOG) – monitoring eye movements
  • Electromyogram (EMG) – muscle tone in the chin
  • Electrocardiogram (ECG) – heart muscle electrical activity
  • Nasal/Oral Airflow – thermistor or pressure transducer in the nose and mouth
  • Respiratory Effort – monitoring the chest and abdominal movements and effort
  • Oxygen Saturation – monitoring the amount of oxygen in the blood
  • Body Position – surveillance of the patient’s sleeping position
  • Video monitoring system – monitoring the entire night’s sleep.

 

 

With these parameters, the sleep specialist would be able to determine the sleep stage (dream sleep versus non-dream sleep), the stoppages of breathing, and whether there is continued chest/abdominal effort to breathe.

 

 

Apnea – stoppage in breathing by more than 10 seconds duration

 

 

Obstructive – some form of obstruction in the upper airway

 

 

In obstructive sleep apnea, there would be no nasal or oral airflow (stoppage in breathing), but there would be persistent effort by the patient to breathe (body trying to breathe despite an obstructed airway). 

 

 

In central apnea, there would be no nasal or oral airflow (stoppage in breathing), but no effort nor attempts by the body to breathe (brain forgetting to breathe).

 

 

Although the in-hospital overnight sleep test is useful, it suffers from a few disadvantages (see figure) namely:

 

  • limited resources,
  • limited recording beds,
  • high cost,
  • long waiting lists,
  • intensive labor requirements (requiring a sleep technician overnight),
  • difficult for elderly or sick patients to travel to the hospital and spend the night in the sleep laboratory,
  • many patients often find the polysomnogram equipment too cumbersome and
  • the first night effect (due to new environment, patients might not be able to sleep at all)

 

 

Hence, due to these short-comings of the in-hospital overnight sleep test, many sleep specialists have moved away from asking the patient to stay in hospital for the sleep test and have encouraged patients to monitor their sleep in the comfort of his own home. 

 

 

HOME OPTION

Home Based Overnight Sleep Test (done in the patient’s own home)

 

 

A wrist-worn device known as the Watch PAT (American FDA approved) has been used to detect OSA. The PAT (peripheral arterial tonometry) technology represents a unique and accurate concept of non-invasive measurement of stress levels that appears to be very accurate for detecting sleep-disordered events (see figure). This is a self-contained device worn around the wrist.

 

 

It is lightweight and silent, easy to use, portable, and accurate, which is essential for a practical ambulatory device.  Only ONE finger probe is used in this device.  One is the optico-pneumatic (light and pressure) sensor that detects the peripheral arterial tonometry (PAT) signal (stress level in the finger); the other measures arterial oxygen saturation (amount of oxygen in the blood). The body of the device also contains an actigraph (which measures and detects muscle tension and tone), which is used to differentiate sleep stages from wakefulness.

 

 

Simplistically speaking, the Watch PAT looks at any desaturation in oxygen level in the blood and correlates this with the arterial tone in the finger probe.

 

  • Low Oxygen level + no stress detected in the finger tone = central apnea event
  • Low Oxygen level + high stress detected in the finger tone = obstructive apnea event

 

 

Pang K.P. and his researchers found that this wrist worn device had very close correlation and accuracy with the in-hospital overnight sleep test. As discrete obstructive airway events (i.e. stoppages in breathing) cause stress to the heart, lungs and brain, this increases arousal from sleep, stress activation and hence these events would markedly increase peripheral arterial tone (finger tone) signal. Many other authors have also found good correlation between the Watch PAT and the overnight sleep study in the hospital.

 

 

Suffice to say, the paradigm has shifted from the cumbersome in-hospital laboratory overnight sleep test, to the convenient, cheaper and accurate home based device (Watch PAT). It is of important note that the Watch PAT is already FDA approved in the United States of America and most insurance companies in the USA recognize its advantages and are proponents of it.

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