Whilst snoring may sometimes be considered funny– certainly annoying to anyone– it can indicate, especially in the obese, sleep apnoea, a serious medical condition
A 35-year-old morbidly obese lady presented with a recurrent severe headache associated with lethargy and a tendency to sleep during the day. Given her weight issues and slightly raised blood pressure, I performed a head CT scan to exclude a possible stroke. This was clear, but given the severity of the headache, I admitted her for 24-hour observation. However, the patient was admitted to the wrong bed in the high-dependency unit.
As things turned out, this was very fortunate.
On my morning round, the attending nurse reported having had to summon the on-call medical team several times during the night. This was because the monitor observation showed intermittent severe drops in the patient’s oxygen level. The nurse also reported that her blood pressure kept fluctuating, reaching worryingly high levels at times. The patient was snoring badly during the night, disturbing all the other patients.
Fortunately, I saw a senior respiratory physician enter the unit, and I asked for their medical opinion. To my amazement, they expressed great interest in the patient, muttering about the possibility of sleep apnoea.
Snoring was a major factor in her split from her boyfriend
I went back to the patient to take more history, and she admitted splitting up with her boyfriend, and that snoring had been a major part of the problem. She was desperate for treatment to resolve her headache and eliminate her snoring.
The patient underwent a sleep study, and the diagnosis of sleep apnoea was confirmed. She was offered overnight home Continuous Positive Airway Pressure (CPAP, a mask) but was keen to resolve the problem naturally. With my holistic medical hat on, I advised her to lose weight.
This is because I believed her condition to be related to obesity and metabolic dysfunction. This was confirmed on her routine blood tests, which showed a prediabetic fasting blood sugar level of 6.5, low HDL (the good guy) cholesterol at 0.9, and a very high triglyceride at 4.3 (normal <1.7).
This blog will discuss “harmless” and “harmful” snoring, the latter’s connection to sleep apnoea. We will explain the indicators and delineate the solutions.
Apnoea has been documented since 4000 BC. Charles Dickens wrote in The Pickwick Papers about Joe the fat boy, who was always asleep, and his snoring was given the term Pickwickian syndrome. The term “sleep apnoea” was introduced in the 1960s to indicate the partial or complete closure of the airways of obese people during sleep.
Many people snore whilst sleeping at night. Is this just a simple snore or a sign of the serious condition, obstructive sleep apnoea (OSA)?
Simple “harmless” snoring is when your breathing continues without interruption. Having interrupted breathing or gasping for air whilst sleeping suggests “harmful” snoring and sleep apnoea. Snoring is the most common symptom of OSA, as 94% of OSA cases snore.
Up to 60% of the general population are habitual snorers, but most do not have OSA. In fact, only 28% experience OSA.
Sleep apnoea affects the quality of sleep. You always feel tired, irritable, and unproductive; you also catch more colds, as poor sleep quality interferes with the immune system.
The life expectancy of a person who develops sleep apnoea before age 50 is between 8 and 18 years. This can improve with healthy lifestyle choices.
Predictors of OSA
Neck circumference is a better predictor of OSA than general obesity. Patients with OSA have approximately 67% more total neck fat than normal people. This causes a smaller upper airway and a greater chance of narrowing during sleep.
Snoring happens when you breathe and the soft tissue of your neck can’t relax. This narrows your airway, causing the tissue to vibrate and make noises. This can happen with a blocked nasal cavity, enlarged tonsils, deviated nasal septum, nasal polyps, excessive weight, smoking, alcohol, or drugs.
Snoring can strain your relationship with your partner (as with our patient), but you should be more concerned about it as a sign of a more serious health problem.
Snoring runs in families and usually gets worse with age. Obese and overweight people are likely to snore. Men are three times more likely to snore than women, but after menopause, women tend to catch men up.
Lying on your back, your tongue tends to fall backwards and block the airway; however, lying on your side relieves the blockage and eases snoring.
Large tonsils and adenoids are the common causes of severe snoring and sleep apnoea in children, who are 6 times at risk of developing obesity and metabolic diseases. Screening obese children for hypoxia (low oxygen level) detects the problem early to improve outcomes.
When should you get concerned about snoring?
Ask your partner or a family member about your snoring. You should be concerned if your snoring gets louder with gaps or pauses, making you gasp for air or restless in your sleep. You are more likely to have sleep apnoea if you have symptoms of fatigue, irritability, and daytime sleepiness.
Sleep apnoea occurs in snorers who stop breathing for more than 10 seconds. It is called obstructive sleep apnoea (OSA) because of partial blockage of the airways. Sufferers struggle with a lack of oxygen and tend to wake with a loud grunt to breathe again.
Obstructive sleep apnoea (OSA) represents a growing problem, affecting 28% of the population due to the obesity pandemic of the last few decades.
Metabolic dysfunction contributes to OSA and vice versa.
OSA is more prevalent among patients with type 2 diabetes than others in the same age range and with similar BMI. On the other hand, OSA may increase the risk of developing type 2 diabetes through a deterioration in insulin sensitivity.
OSA and nocturnal hypoxemia (low oxygen) likely lead to elevated blood glucose levels because frequent low oxygen levels activate chronic stress and insulin resistance that can progress to type 2 diabetes. Adequate treatment reduces insulin resistance and prevents diabetes.
On the other hand, people with nocturnal hypoglycaemia (low blood sugar) are at increased risk of OSA. Low blood sugar results in sleep disturbance and late-night eating, weight gain, obesity and OSA.
It is possible that elevated leptin, observed in obese people with leptin resistance, may contribute to OSA. This is because leptin tells you to stop eating after you have had enough. The loss of this effect sees people eat more, gain weight, and become at risk of OSA.
High blood pressure is a common sign of sleep apnea. Management of apnoea will result in blood pressure control and will reduce the risk of heart attack and stroke. OSA causes cardiac arrhythmia (change in heart rhythm) that can result in extreme bradycardia (slow heart rate) or ventricular asystole (cessation of heartbeat) for more than 10 seconds.
Treatment with CPAP (see below) will abolish the life-threatening complications of bradycardia and ventricular asystole. Studies showed that CPAP restored normal cardiac (heart) rhythm in eight patients out of 10 with OSA.
Diagnosis and treatment
Sleep studies are the most accurate test for diagnosing sleep apnoea and its severity. These include a polysomnogram (PSG), which records your brain activity, eye movement, heart rate, blood pressure, oxygen level, air movement through your nose (snoring) and chest movement. PSG is usually done in a sleep centre.
Alternatively, you can use a home-based portable sleep test that monitors the same factors while sleeping in your home bed.
The treatment involves making simple changes in your sleep routine to improve your snoring and lifestyle changes.
Simple changes include quitting smoking, avoiding alcohol, wearing nasal strips to keep your nose open or nasal sprays to open congested and blocked nose, and maybe sleeping on your side to keep your tongue from relaxing into your airway. Avoid medications that relax your throat muscles, like sedatives, muscle relaxants, antihistamines and sleeping pills.
A Study demonstrated that singing for 20 minutes daily strengthened the neck muscles and abolished snoring.
Obesity is the most modifiable risk factor for OSA since a 10% weight gain is associated with a 32% increase in disease severity, while a 10% weight loss results in a 26% reduction.
Intensive lifestyle interventions – calorie restriction, eating real food, eating less often, intermittent fasting and increasing physical activity – effectively reduce obesity and the severity of OSA.
Many simple devices are fitted in the mouth to relieve snoring. The aim is to lower the jaw and move the tongue forward to clear the airway during sleep.
In the case of chronically enlarged tonsils, a nasal polyp or a deviated nasal septum, your doctor may send you to the hospital for surgery.
As for exercise, the American College of Sports Medicine currently recommends at least 250 minutes per week of moderate-intensity cardiorespiratory exercise for significant weight loss, in addition to two strength training sessions. The typical characteristics of the OSA patient, being sleepy and lacking energy, may compromise their ability to comply with this level of training. Therefore, tailored exercise programmes with a progressive workload are recommended.
Continuous Positive Airflow Pressure
CPAP is the gold standard treatment for severe OSA. It controls blood pressure, improves insulin sensitivity and prevents diabetes.
CPAP machine has a mask that fits over your mouth and nose or just your nose. The machine gently blows air into your throat, keeping your airway open during sleep. Despite the great benefits of CPAP, compliance is low. Only 39–50% of users will use CPAP for the recommended minimum of 4 hours a night, 5 days a week.
So, once again, my friends, the solution to yet another metabolic problem lies in the right diet and exercise. Sleep apnoea will respond better to these relatively straightforward lifestyle changes; in all but the most severe cases, more complex medical (CPAP in this case) will meet the need.
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Metabolic syndrome and sleep apnoea
Correlation between metabolic syndrome and sleep apnoea
Sleep apnoea and metabolic dysfunction
The bidirectional relationship between obstructive sleep apnoea and metabolic syndrome
Dietary patterns and the heart
Snoring and sleep apnoea
British snoring and sleep apnoea Association
A simple snore or something more? Snoring and sleep apnoea