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Snoring

Introduction

Most people recognise that there is nothing quite as refreshing and important as a good night's sleep, waking up in the morning bright and active to start the new day. There is also something very necessary about good sleep because if sleep is shortened or disrupted even for one night, most of us will feel tired and irritable until we have good quality sleep again. For most of us, sleep at night re-fuels and services both body and mind, so that we are prepared for activity during the day. This night-day cycle has been described as the circadian rhythm, and many of the body's hormones and functions depend on this rhythm and rise and fall with it.

Over the past couple of decades, research into sleep has received increasing attention and many important discoveries have been made. For example, there are now tests available to determine the quality of sleep, in addition to tests to diagnose conditions which might disrupt normal sleep.

The following information is designed to help patients, their families and friends, and the general reader understand the common sleep problems, the tests performed to diagnose them and the treatment options available. Practical advice, such as how to get in touch with self help and support groups, and where to find the facilities or hospitals around Australia specialising in the investigation and treatment of sleep disorders is also provided.

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Snoring Overview

Snoring is not only disruptive to family life, it causes other family members to lose sleep and can lead to social isolation, especially from spouses. Snorers are unwelcome for roommates on holidays and business trips. Holidaying roommates have reported sleeping in the bathroom just to get away from the loud snoring!

"Simple" 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. These muscles relax when we go to sleep, narrowing the airway and partially choking off the air passage so that breathing in makes the pharyngeal walls vibrate, making the noise of smoring. "Simple" snoring is a term used to describe the situation when airway narrowing is only partial and airflow is not severly reduced. Whether simple snoring has mild harmful effects on the body (like those definitely present in obstructive sleep apnoea) is at present uncertain and is receiving extensive scientific investigation.

Apnoea

The word apnoea is derived from two Greek words "A" meaning absence or lack of, and "PNOEA" meaning to breathe. In some circumstances, breathing is severly reduced but does not completely stop and this is called Hypopnoea,, where "HYPO" means less or a reduction.

Obstructive Sleep Apnoea (OSA)

OSA, in contrast to simple snoring occurs when the pharyngeal narrowing is more severe and results in a complete block to breathing during sleep. This can cause repetative interruptions to breathing during sleep.

Causes, Symptoms and Effects of Snoring and OSA

Central Sleep Apnoea (CSA)

In Central Sleep Apnoea, there are again repeated interruptions of breathing but, unlike OSA, no throat obstruction occurs. Instead, there is a reduction or no effort made to breathe.

Causes and Solutions for CSA

CSA results from:

(1a) The diaphram and/or chest breathing muscles being weak or fatigued. This occurs in a variety of conditions such as: poliomyelitis or motor neurone disease where the nervous and musclular mechanisms of breathing are impaired. OR

(1b) In kyphoscoliosis - a condition in which the bony rib cage of the chest wall is very deformed and stiff.

(2) The brain being slow to recognise or not responding to the fall in oxygen or rise in carbon dioxide blood levels when breathing decreases. This can occur in people with heart disease following a stroke (particularly one which affects the breathing centres in the mid brain).

Daytime sleepiness and spouse-reported apnoeas are common but usually there is no snoring present (unlike OSA). Insomnia or difficulty sleeping is another common symptom. All the complications of sleep fragmentation and of low oxygen levels during the night may occur as for OSA.

Narcolepsy

Narcolepsy is another cause of severe daytime sleepiness. It is a condition consisting of attacks of excessive daytime sleepiness (sleep attacks), falls (cataplexy), vivid dreams or hallucinations when going to sleep or waking up, and episodes of sleep paralysis in which one will wake up but in unable to move for a time. The cause of narcolepsy is unknown, however, an abnormal protein on some blood cells (called HLA DR2) has been found, which might indicate a genetic or viral cause. Narcolepsy affects about 0.05% of the population and usually comes to notice during puberty or adolescence. There is sometimes a history of other family members being affected. The symptoms of narcolepsy can be similar to sleep apnoea and your doctor will need to distinguish between the two conditions.

Sleep Attacks consist of an irresistible desire to sleep, coming on without warning, lasting from a few minutes up to an hour and recurring several times per day. They occur irrespective of the amount of sleep obtained the night before. Between attacks, patients with narcolepsy may feel tired and lethargic, similar to the sensation in sleep apnoea. If brain activity is monitored during one of these attacks, then a specific sleep pattern of rapid eye movement (REM) or dreaming sleep may be seen, and this finding can help make the diagnosis.

In addition to sleep attacks, episodes of sudden muscle weakness occur, often causing the person to collapse unexpectedly to the floor. This is called cataplexy, and it is often triggered by emotion such as laughter. Some people with narcolepsy do not have sleep attacks but just chronic sleepiness. Complete muscle weakness at the onset of waking from sleep or sleep paralysis may occur. very vivid and frightening dreams or hallucinations (abnormal sensations such as feeling as if you are looking at your body from above) can also occur when drifing into or waking from sleep.

There is no known cure for narcolepsy, and the treatments provided are aimed at controlling the symptoms. Treatment involves a great deal of education and support in addition to medication. Initial treatment should be to improve "sleep hygine", that is, to have a regular sleep-wake schedule and an adequate quantity of sleep. Avoidance of sleep deprivation is important. Regular planned naps during the day may help.

Medication used to treat narcolepsy are divided into two groups:

(1) Stimulants - which prevent sleepiness during the day. These may have some side effects such as weight loss and mild anxiety.

(2) Drugs to reduce REM sleep - which are similar to the drugs used to treat depression (although narcolepsy is not a disease of depression). Side effects may include dry mouth, blurred vision. Some drugs require a special diet.

Social and occupational lifestyles may need to be altered so that regular physical exercise is undertaken, and monotonous boring ocupations and shift work are avoided. Small regular meals, low in carbohydrates, may also help. Alcohol is best avoided.

With education and medication much can be done to improve the lifestyle of people with narcolepsy, but again, no permanent cure has been found for the condition to date. Patient and family support groups are available.

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The Alfred Sleep Disorders & Ventilatory Failure Service
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