Snoring happens to everyone at some point. It’s an extremely common occurrence and it does not necessarily mean that you have an underlying disease. It is simply the result of incoming air that causes tissue vibrations of partially blocked upper airways. However, it can be a symptom of a more serious condition such as sleep apnea, which is a disorder that actually interrupts breathing while you sleep.
“Snoring may be defined as noisy breathing produced by vibration of soft tissues in the oropharynx. Systemic arterial hypertension, heart conditions, angina, and strokes are more frequent in snorers. Snoring is a relevant diagnostic sign of the obstructive apnea syndrome, as most apneic patients snore. Depending on the age, up to 62% of men and 45% of women snore regularly.
Snoring is a social inconvenience; the noise makes it difficult for spouses, bed partners, or roommates to sleep. Bed partners of snorers may have poor quality sleep, and may develop secondary sleep disorders. A snorer may become socially unacceptable, loss of harmony in marriage, divorce, aggression, and even homicide may ensue. There is evidence that people chronically exposed to snorers tend to have presbycusis (age-related hearing loss)”1
“An increasing number of people are realizing that changes in their sleeping habits and daytime behavior may be attributable to obstructive sleep apnea syndrome (OSAS). This new awareness has led many patients to seek both information and definitive treatment. Because the jaws and related structures influence the development of this syndrome, dentists play an important role in both identifying patients who should be assessed by sleep specialists and instituting treatment in selected cases.”2
“Sleep-disordered breathing refers to momentary, often cyclical, cessations in breathing rhythm (apneas) or momentary or sustained reductions in the breath amplitude (hypopneas), sufficient to cause significant arterial hypoxemia and hypercapnia. These apneas and hypopneas are specific to the sleeping state and are accompanied by 1) a compromised, often even completely closed, extrathoracic upper airway (‘obstructive’ event); 2) a marked reduction or cessation of brain stem respiratory motor output (‘central’ event); and 3) a combination of central and obstructive events. These ventilatory inadequacies and their accompanying intermittent hypoxemia often lead to transient arousals from sleep and sleep state fragmentation throughout the night and cause overcompensatory responses of the autonomic nervous system. This phenomenon is now known to occur with varying degrees of severity in literally millions of people throughout the world.”3
In terms of chronic snoring, we can point to obesity as being the most frequent culprit. The extra weight from fatty tissue pressures the throat. To deal with this, try to change to a balanced and healthy diet to lose some weight since adipose tissue tends to appear around the neck, facilitating closure of the airway. Also, avoid smoking tobacco, consuming an excessive number of alcoholic beverages, or ingesting stimulants like coffee, energy drinks, etc., especially at night. Nasal strips can be very effective in helping you breathe at night.
Although not all snoring is indicative of sleep apnea, it is true that persistent snoring episodes also increase the risk of suffering from sleep apnea eventually, especially with age. Besides obesity, factors that favor snoring are pregnancy, alcohol intoxication, sleep medication, nasal congestion, septum deviation, and the presence of nasal polyps.
“Obstructive sleep apnea (OSA) is characterized by recurrent collapse of the pharynx during sleep, resulting in a substantial decrease in airflow (apnea or hypopnea). Respiratory events trigger intermittent disorders of blood gases (hypoxemia and hypercapnia) and can lead to sympathetic system activation.
Obstructive sleep apnea syndrome (OSAS) is associated with many symptoms and comorbidities, which include excessive daytime sleepiness, cognitive problems, obesity, type 2 diabetes mellitus, hypertension, exacerbation of chronic obstructive pulmonary disease (COPD), reduced quality of life, and significant increase in risk of industrial and traffic accidents. It is also considered an independent risk factor for cardiovascular disease and ischemic stroke.
Upper airway collapse during sleep is the result of an imbalance between the activity of pharyngeal dilator muscles and negative intraluminal pressure during inspiration. Factors that tend to narrow the pharynx lumen include mucosal adhesive forces, vasomotor tone, neck flexion, jaw opening and lower dislocation, force of gravity, increased nasal resistance, Bernoulli effect (the physics principle that explains the tendency of pharyngeal collapse), and increased dynamic compliance. Forces that dilate the pharynx include the thoracic caudal traction by increased pulmonary volume and neck extension.
Despite showing considerable variation between individuals, there are components of the disease physiopathology that have been already demonstrated, which include changes in the upper airway anatomy, variations in the capacity of the upper airway dilator muscles to respond to respiratory adversities during sleep, changes in cortical arousal threshold during an increase in inspiratory negative pressure, variations in the ventilatory control system stability, and changes in pulmonary volume.
OSAS is thought to be a progressive disease, and it is hypothesized that primary snoring and severe OSAS are opposite stages of the same disease. This pathological evolution would occur in the following chronological order: primary snoring, upper airway resistance syndrome, OSA, mild OSAS, moderate OSAS, and severe OSAS. Prompt diagnosis and appropriate treatment are important at any of these stages.”4
On the other hand, sleep apnea is accompanied by loud snoring and waking up in the middle of the night due to suffocation. As mentioned in the beginning of this article, sleep apnea halts respiration, depriving the brain and other tissue of oxygen. While sleep apnea can occur due to anatomical structure anomalies in the pharynx and upper airways, it isn’t exclusive to this. It involves other factors too, such as genetic tendencies, age (especially people between 40 to 50 years old), and gender (sleep apnea is much more frequent in men than women). Like snoring, it is also related to obesity, smoking, and excessive alcohol consumption.
People with sleep apnea may present symptoms such as snoring (almost every night, if not every night), cessation of breathing for a few seconds, frequent movement of legs or arms while sleeping, waking up several times to urinate, rousing suddenly due to the lack of air (suffocation), and headaches. During day time, you may suffer from fatigue, depression, memory loss, irritability, and mood swings. If you present these symptoms, you should visit a specialist that deals with sleep apnea. These include, pulmonologists, otolaryngologist, and neurologists.
“Recognizing and treating OSA is important for a number of reasons. The treatment of OSA has been shown to improve QOL, lower the rates of motor vehicle accidents, and reduce the risk of the chronic health consequences of untreated OSA mentioned above. There are also data supporting a decrease in healthcare utilization and cost following the diagnosis and treatment of OSA. However, there are challenges and uncertainties in making the diagnosis and a number of questions remain unanswered.
Individuals with OSA can also have other sleep disorders that may be related to or unrelated to OSA. Co-morbid insomnia has been found to be a frequent problem in patients with OSA. It is also possible that undiagnosed OSA may be masquerading as another sleep disorder, such as REM Behavior Disorder. Therefore, when OSA is suspected, a comprehensive sleep evaluation is important to ensure appropriate diagnostic testing is performed to address OSA, as well as other comorbid sleep complaints.
The diagnosis of OSA involves measuring breathing during sleep. The evolution of measurement techniques and definitions of abnormalities justifies updating the guidelines regarding diagnostic testing, but also complicates the evaluation and summary of evidence gathered from older research studies that have included diagnostic tests with diverse sensor types and scored respiratory events using different definitions.”5
Once apnea is diagnosed, following the prescribed treatment is essential to improve sleep and to control other pathologies which your specific apnea might be related to, such as hypertension or diabetes. According to some studies, many people do not even know that sleep apnea is an actual disorder and cannot distinguish it from simple snoring.
Continuous airway pressure devices (CPAP) are a very effective treatment for those who suffer from sleep apnea. Its goal is to prevent the airways from closing during sleep by providing a constant flow of air through the CPAP mask, avoiding tissue from collapsing when sleeping.
“In mild sleep apnea, lifestyle considerations should be addressed as part of management. Weight loss, aiming for a BMI of less than 25, is recommended. Other therapies should ideally be considered alongside this, as there is evidence to suggest that weight loss can decrease the severity of OSAS, but it may not reverse the pathophysiology completely owing to the multifactorial nature of the disease. Advice should also be given about changing sleeping position, eg advising a patient to sleep on their side rather than on their back, and on avoidance of alcohol or stimulants prior to bed. In moderate to severe OSAS, or where the impact on daily life is significant, the mainstay of therapy is the use of positive pressure ventilation at home, via a continuous positive airways pressure (CPAP) machine. The patient is provided with a small device and a mask, which they wear over their nose and mouth overnight. The machine produces a continuous positive filtered airflow, which splints the upper airways open, allowing the patient to breathe spontaneously but preventing upper airway narrowing or collapse. The pressures can be altered to meet the needs of individual patients.”6
(1) Shiomi, F. K., Pisa, I. T., & Campos, C. J. R. D. (2011). Computerized analysis of snoring in sleep apnea syndrome. Brazilian journal of otorhinolaryngology, 77(4), 488-498. Available online at http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1808-86942011000400013
(2) Goodday, R. H., Precious, D. S., Morrison, A. D., & Robertson, C. G. (2001). Obstructive sleep apnea syndrome: diagnosis and management. Journal-Canadian Dental Association, 67(11), 652-658. Available online at https://pdfs.semanticscholar.org/14d6/d4939bdb67b9755d66f4c6e7d7acc4a2192c.pdf
(3) Dempsey, J. A., Veasey, S. C., Morgan, B. J., & O’Donnell, C. P. (2010). Pathophysiology of sleep apnea. Physiological reviews, 90(1), 47-112. Available online at https://www.physiology.org/doi/pdf/10.1152/physrev.00043.2008
(4) Kapur, V. K., Auckley, D. H., Chowdhuri, S., Kuhlmann, D. C., Mehra, R., Ramar, K., & Harrod, C. G. (2017). Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(03), 479-504. Avilable online at https://aasm.org/resources/clinicalguidelines/diagnostic-testing-osa.pdf
(5) Zancanella, E., Haddad, F. M., Oliveira, L. A. M. P., Nakasato, A., Duarte, B. B., Soares, C. F. P., … & Ramos, B. D. (2014). Obstructive sleep apnea and primary snoring: diagnosis. Brazilian journal of otorhinolaryngology, 80(1), 1-16. Available online at http://www.scielo.br/scielo.php?pid=S1808-86942014000800001&script=sci_arttext&tlng=en
(6) Ratnakumar, P., & Manuel, A. (2016). Management of obstructive sleep apnoea syndrome. Prescriber, 27(8), 23-27. Available online at https://onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1488