If you watch the Today Show, then you may have seen a recent segment where Matt Lauer came clean. He snores, and he snores pretty loudly. He doesn’t really look like a person typically associated with having a snoring problem, since it’s often related to being overweight or being diagnosed as obese.
But when it comes to snoring, is snoring a sign of disturbed sleep and is it a clear indicator of sleep apnea? Is it just loud, annoying noise, or always a sign of a health condition and more serious? Maybe it’s something in between?
What is the connection between snoring and sleep apnea?
Snoring is caused by excessive muscle relaxation in the tongue and the soft palate. This phenomenon can certainly be exacerbated in heavy people with their thick necks and also exacerbated by drinking alcohol or taking drugs that cause sleepiness. To begin the discussion, I will start by saying a relationship between snoring and sleep apnea has been articulated by experts, including the American Academy of Otolaryngology. These specialists include ENT doctors who usually treat snoring with surgical procedures.
Although sleep apnea, which is the stoppage of air entry to the lungs, is often related to snoring, this is not always the case. An individual can have sleep apnea and not experience a snoring component, because the site of the obstruction is not in the palate of the mouth or the tongue, but rather further down in the pharyngeal tube.
For this reason, the Academy recommends that before anyone undergoes a procedure to treat snoring, a diagnosis of sleep apnea should be ruled out and if it is present, treated as a separate condition.** What are some signs that suggest a diagnosis of sleep apnea and not just snoring?**
The most common complaint that prompts people to seek medical attention is when a bed partner notices that their partner, who regularly snores quite loudly, also has “pauses in breathing and then a loud gasp.” Those pauses in breathing represent moments where the body is not oxygenated. The individual himself may also complain about regular daytime sleepiness.
What are some objective tests to determine the probability of sleep apnea?
There are several written tests that help to identify sleep pathology:
The Berlin questionnaire is designed to identify individuals with high risk for sleep apnea. It offers eleven questions that focus on three categories of apnea signs: snoring, daytime sleepiness and obesity/high blood pressure. It has been validated as correctly identifying sleep apnea in patients over 18 years old.
The STOP-Bang questionnaire is a** newer test** that is the preferred test by anesthesiologists when performing a preoperative evaluation, as well as anticipating possible complications in individuals with undiagnosed sleep apnea. It consists of four “yes or no” questions, and four questions that require the patient to fill in the blanks. It has been validated as effective in identifying sleep apnea in people over 50 years of age, who are surgical patients.
The Epworth Sleepiness Scale is the most popular test given before ordering a sleep study, and serves to determine the degree of abnormal daytime sleepiness. It poses eight situations, and points are given according to the likelihood of a person dozing off. The maximum score on the test is 24 and a score above 10 is considered abnormal. The problem with the test is that it is very subjective, and it has not been validated when compared with objective measures of sleepiness.
After any or some of these questionnaires identify a suspicion of sleep apnea, the sleep study is then performed to confirm the diagnosis of sleep apnea. If the results of the sleep study are positive, then the positive pressure mask (CPAP) is prescribed and use is initiated. The sleep specialist will determine the pressure setting necessary to eliminate all of the nighttime apnea event.
Can you identify the obvious sleep apnea patient by appearance?
There are certain genetic risk factors common for obesity and sleep apnea. Both can influence and cause each other. Common genes that determine fat distribution in the neck, ventilator control and upper airway muscle function have been found in individuals who have both obesity and sleep apnea. However, just like the TOFI, a slim person who actually has internal fat around organs and who passes as healthy because they appear lean or of normal weight.
Slim people can have sleep apnea too
Skinny people can also have sleep apnea. This has been found especially in females, many of whom complain of migraine headaches. Many of these women have been prescribed sleep aids which would actually make a breathing disorder worse. A study done on these patients showed that CPAP therapy improved the presenting symptom of sleep disorder and headaches, better than traditional medications.
Can ethnicity influence a certain propensity for sleep apnea?
Studies have shown that Asians have craniofacial features that would increase the propensity for sleep apnea without the degree of obesity. The position of the mandible and the angle of the chin results in narrowing in the pharynx without having excess fat tissue in the neck. Matters are further complicated by the fact that, quite often, they do not have the typical presenting complaints of daytime sleepiness. So it can take a real doctor detective to identify sleep apnea in these patients.
What can we learn from this discussion?Patients with sleep apnea can present in many shapes and with different presenting symptoms. Snoring may be the first sign of sleep apnea, but further evaluation is necessary to identify and confirm sleep apnea**.** As a doctor, it is important to keep an open mind and consider different types of people with unusual presentations when assessing patients for sleep disorders.
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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, Qualified Medical Examiner for the State of California Department of Industrial Relations, and Director of Intensive Care Services at Glendale Memorial Hospital. His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.