Snoring & Sleep Apnoea

Sleep Disorders

Sleep apnea is a condition in which breathing stops for more than 10 seconds during sleep. Sleep apnea is a major, though often unrecognized, cause of daytime sleepiness.

A sleeping person normally breathes continuously and uninterruptedly throughout the night. A person with sleep apnea, however, has frequent episodes (up to 400–500 per night) in which he or she stops breathing. This interruption of breathing is called "apnea." Breathing usually stops for about 30 seconds; then the person usually startles awake with a loud snort and begins to breathe again, gradually falling back to sleep.

Millions suffer from sleep disorders, which can lead, to high blood pressure, heart disease and even early death. Most people with sleep disorders do not know it.

If you have the following symptoms, you may well be suffering from one form of sleep disorder

1. Headaches (migraines, tension headaches, cluster headaches)
2. Jaw joint pain, joint sounds, muscle tenderness in the face, limitation of mouth opening
3. Worn teeth caused by bruxism (clenching or grinding of teeth)
4. Neck and back pain
5. Tiredness/fatigue and irritability in the mornings and during the day
6. Snoring
7. Excessive daytime sleepiness whilst sitting and reading or watching TV, or in a car whilst stopped at a traffic light, or lying down in the afternoon etc.
8. Poor memory
9. Reflux problems (acidity)

Diagram (below) shows lower jaw with tongue dropping back and blocking the airway

Normal Sleep Cycle

Sleep consists of 2 distinct states – Non REM (Rapid Eye Movement) sleep and REM Sleep.

This alternate in 90 to 110 minutes cycles with a normal sleep pattern of 4 to 5 cycles.

Non REM sleep accounts for 75% of sleep and has four sequential phases. Delta sleep is the final phase and is a deep sleep that is important for physical rest, restorative, and is characterised by large, slow delta waves in the brain. This delta sleep accounts for a greater proportion of total sleep time in children and decreases by age 50 to 60. By 60 it is almost absent.

REM sleep improves the ability to sustain attention when awake and improves learning. In its absence, recollection of newly learned material is impaired. A decrease in tone of the upper airway muscles during REM sleep predisposes individuals to obstructive sleep aptness.

Sleep-Disordered Breathing

This is a result of an anatomical abnormality of either the oral or nasal passages.  It is of non-psychological origin.

Oral Airway problems include

1. narrow upper jaw
2. retruded lower jaw
3. malocclusion (bad bite)
4. swollen adenoids and tonsil
5. dysfunctional breathing
6. hormonal imbalances (such as menopause)
7. obesity
8. excessive alcohol consumption
9. pregnancy
10. sinus problems

In a person suffering from sleep-disordered breathing, the AIRWAY COLLAPSES in on itself when the person breathes in and out, shutting of the airway either completely or partially. (very important concept in the treatment for these conditions)

There are 3 categories of sleep-disordered breathing

1. snoring (the mildest form)
2. upper airway resistance syndrome
3. obstructive sleep apnoea

Snoring

Snoring is often a cry for help. Modern medicine practically ignored this nightmare distress signal until recently.

Snoring is a clear signal that an airway is blocked.

1. Enlarged tonsils and adenoids easily block airways in children and in some adults.
2. A narrow upper jaw and /or a retruded lower jaw can result in a small airway that is more easily blocked when the sleeping jaw drops.
3. Compressed and crowded throat tissues can result in choking a sleeper hundreds of times a night.

Habitual Snoring

Habitual snoring often signals the presence of dangerous nighttime sleep disorders.  Sleep disorders are known to be an independent risk factor for a number of diseases, including hypertension, cardiovascular disease, cardiovascular disease (strokes) and diabetic insulin resistance.

Snoring alone is hard the heart and brain Research suggests that snorers have low night oxygen even if they do not have a sleep disorder.  Snoring has been found to be a predictor of poor school performance.  A study that compared childhood snoring at 2 to 6 years of age to school performance and middle school were more likely to have snored during early childhood.  They were also more likely to require later tonsil and adenoid removal.

Sleep Apnoea

There are 2 major types of sleep apnoea

Obstructive Sleep Apnoea is a complete cessation of breathing during sleep for at least 10 seconds.

During an episode of OSA, the entire upper airway is blocked causing airflow to stop.  This disrupts sleep as a lack of oxygen results.  Th person awakens repeatedly as a result of making an effort to breathe in the presence of a lack of oxygen.

Central Sleep Apnoea is defined as a period of 10 seconds without airflow due to lack of stimulus form high levels of the brain and the apnoea can be longer periods of time.

Mixed – Combination of the 2 above

Risk factors for sleep apnoea include obesity, increasing age, male gender, family history, alcohol, sedative use, smoking, hypertension, breathing disorders such as asthma, menopause, and anatomic abnormalities of the upper airway.  A further risk factor is malocclusion (bad bite) and bruxism.

Diagnosis

Initial evaluation is done using and Epsworth Sleepiness Scale.

Definite diagnosis is made using an overnight sleep study called polysomnorgram (PSG)

The person’s sleep is monitored and measured throughout the night.

Sleep Disordered Breathing is further divided in problems of nasal origin and those with oral airway problems.

Treatment

The 3 treatment options are

1. CPAP
2. Surgery
3. Oral Appliance therapy

CRAP uses a device that forms a pneumatic splint and is placed over the person’s nose during sleep. It opens up the airway with positive pressure and has been found to be effective in moderate of severe OSA. However compliance is very poor. Its use is associated with laceration of the nose, rawness of the throat, bloating of the stomach, nasal congestion and ironically sleeps deprivation.

Surgery is helpful where there is an anatomical obstruction such as enlarged tonsils and/or adenoids, an, enlarged uvula or nasal anatomical problems. Surgery has only been found to be 30-50% effective.

Oral Appliances (Mandibular Advancement Splints) are indicated for people with mild to moderate OSA who prefer them to CPAP (continuous positive airway pressure) therapy, or who do not respond to are not appropriate candidates for or who fail treatment attempts with CPAP.

Oral appliance therapy is non-invasive, less obtrusive than CPAP, effective in the treatment of mild to moderate cases of sleep-disordered breathing.

Success rates have been found to be as high as 76%

Oral appliances can sometimes cause mild discomfort and temporary minor shifts of your bite that are easily corrected by removing the appliance and by opening and closing the mouths a few times. Often the minor shifts can have positive effects on jaw joint function and comfort.

We have used many appliances over the years and selecting the correct appliance is important.

EXAMPLE : The SomnoMed MAS: