Sleep Should Be Silent

Posted By SHL Librarian

Presented by: Rafael Pelayo, MD
Clinical Professor of Psychiatry and Behavioral Sciences
Stanford Center for Sleep Sciences and Medicine

February 12, 2015

Snoring is the target of many jokes. But doctors have another name for it: heroic snoring. That’s because snoring actually rescues a sleeper from not getting enough air to breathe, said Rafael Pelayo, MD, in a lecture at Stanford Health Library.

While snoring may not seem so heroic to people nearby, it can wake up a sleeper enough to gasp for air when airways get obstructed. A lot of people don’t even remember snoring or waking up, but it’s a sign of potential medical problems needing a doctor’s help.

“There’s no such thing as normal snoring,” said Dr. Pelayo, a sleep specialist. “You should not be snoring at all.”

Snoring is often the tipoff to sleep apnea, a condition that blocks airways and can cause a person to go without air for as long as 30 to 40 seconds. Someone with severe apnea can go through hundreds of short awakenings each night without remembering them the next day. Often, though, the person wakes up tired, even exhausted.

“You should wake up feeling refreshed,” Dr. Pelayo said. “You should never wake up feeling tired.”

The problem may be common, but it’s not normal.  “If you go out into the wild, you never hear snoring animals,” Pelayo said. “There are no snoring deer. They wouldn’t last long.”

While humans don’t have to worry about nighttime predators the way animals do, that doesn’t mean people should ignore their snoring.

Each time apnea causes someone to wake up, even briefly, that has a domino effect on body hormones. Like animals that evolved to survive in the wild, when people wake up that triggers a “fight or flight” response.  Heart rate accelerates and blood pressure rises, only to fall again when sleep returns.

“You shoot up, and go back down. This can happens hundreds of times on any given night,” Dr. Pelayo said. No wonder someone can wake up tired.

“We’re sleeping to restore our body, but instead we’re putting it through paces,” Dr. Pelayo said. The downside of severe apnea goes beyond fatigue. Studies show people tend to get heart attacks in the early morning.

“It’s considered a risk factor for sudden death, heart attacks and strokes,” Dr. Pelayo said. Someone with severe sleep apnea—more than 30 episodes an hour—has a 25 percent chance of dying within five years, according to studies.

Sleep apnea is also linked to a higher risk of car accidents, because tired people fall asleep at the wheel.

What causes the apnea? The trouble usually starts in or near the throat, where the airway can get restricted or obstructed. The upper throat has a trap door, called the soft palate, with a muscle called the uvula that is shaped like a punching bag that hangs down. If the throat and soft palate muscles relax too much, during deep sleep, the airway can get restricted.

The airway can also get obstructed if the tongue slides back toward the throat. Extra fat at the back of the throat, or big tonsils, can also crowd the airway space. Any or all of these factors can contribute to blocking the airway, triggering apnea and snoring.

Apnea and snoring are more common as people age or if they are overweight, but it can happen at any age or any body weight. “You can be very thin and have sleep apnea,” Dr. Pelayo said.

Small changes in the neck can make a big difference in airflow. Men often put on more weight in the neck as they age. But when women reach menopause, they catch up with men in reporting problems with snoring and apnea. “We see a ton of people after their 50s,” Dr. Pelayo said.

The first steps doctors often recommend to ease apnea are to improve the position of the airway, and to keep the tongue from sliding back during sleep. Tips include:

  • Avoid anything causing throat muscles to relax, such as drinking alcohol at night
  • Lose weight
  • Sleep on the side

Stanford has pioneered the field of sleep research and has done groundbreaking work making treatments for apnea possible, Dr. Pelayo said. One of the first treatments in the 1970s was surgery called a tracheostomy, which makes a hole in the neck for people to breathe.

Although people came to Stanford from all over the world for treatment, this surgery wasn’t a good choice for everyone. In 1981 researchers came up with an alternative idea to create a “reverse vacuum cleaner” that delivered positive air pressure to keep the airway open, Dr. Pelayo said. The device became known as CPAP, for continuous positive airway pressure, which has since been refined and improved.

A CPAP device available today is essentially an air compressor machine with a hose going to a mask that fits over the nose. The CPAP continuously adjusts air pressure with each breath, and many have humidifiers and filters to keep air warm and moist. “It works a lot better than it used to,” Dr. Pelayo said. Most are silent, and there are multiple kinds of masks to fit individual needs.

Other treatments include:

  • Dental mouthpieces, which should be custom fit, to move the tongue and jaw forward at night to open up the airway. If they are moved forward too far, however, that can cause TMJ (temporomandibular joint) problems and headaches. Some dentists become board-certified specialists in this field.
  • Surgery to move the tongue and jaw forward. Although they are moved forward by only millimeters, Dr. Pelayo called the procedure “a big surgery” that includes a bone graft. It has a 95 percent cure rate, but it’s so drastic that few people choose it, Dr. Pelayo said. “It’s not the kind of surgery to jump into,” he said, especially for people in their 60s and 70s.
  • The most recent apnea treatment to win FDA approval is a device Dr. Pelayo described as a “tongue muscle pacemaker.” The small device is surgically implanted in the chest, with a wire that is connected to the hypoglossal nerve at the base of the throat. When the person struggles to breath at night, the pacemaker sends an electrical impulse to the nerve that stimulates muscles to open the airway.
  • Another treatment recently available is the Winx mouthpiece, which uses suction to pull the tongue forward and open up the airway. One of the drawbacks is that it tends to increase saliva and lead to drooling. Dr. Pelayo said it is not considered a first-line treatment.

Other devices are available without prescription, including many oral appliances designed to move the tongue forward or prevent it from sliding back.

For dental devices, Dr. Pelayo recommended checking the website for the American Academy of Dental Sleep Medicine for a board-certified specialist.

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About Dr. Pelayo