Snoring and Sleep Apnea: Missing the Warning Signs
There are few individuals who have not had at least one sleepless night because of someone else's snoring. Among roommates, family members and travel companions the friendly teasing is accepted as harmless. However, if that same person is chronically tired, falls asleep easily and suffers from morning headaches the problem may be much more serious.
It is easy to see why this is such a common problem since 60% of men over 60 years of age snore. This is not something unique to age, gender, or body weight although all of these factors do play a role. As an individual grows older the incidence of snoring increases steadily. This is due to the decrease in muscular activity during sleep with aging. Since the soft palate, throat and tongue are all muscles they tend to fall together in a closed position obstructing the flow of air into the lungs. If this is only for a few seconds a brief harmless snore or snort is the result. If this blockage is for minutes a serious health threat exists. The short term result can be a slowing or speeding of the heart rate. In more severe cases it can result in a cardiac rhythm change and even a heart attack. If there are no acute changes long term effects may still occur. Patients may develop high blood pressure and heart failure. These effects develop slowly over time but ultimately lead to a heart attack as well.
One of the predisposing factors in this condition called "obstructive sleep apnea" is body weight. It is true that the classic "Pickwickian" of Mark Twain fame undoubtedly suffered from sleep apnea. People assumed he was fat and tired because he was lazy. No one could have guessed that he was obstructing his airway whenever he was asleep and hence unable to have continuous, restful sleep that was uninterrupted by periods of snoring, snorting and the telltale gasping for air.
While it is the stocky and overweight body shape that is most prone to obstructive sleep apnea as many as one-third of all sleep apnea patients do not fit this profile. Careful history taking is the key to identifying the patient with this problem. Failing to diagnose sleep apnea may lead to serious complications in any patient undergoing a general anesthetic. Anyone who is moderately overweight should be questioned about excessive daytime sleepiness, snoring, morning headaches and periods of "breath holding" or apneas as noted by their bed partner. If there is a suspicion of sleep apnea, a sleep study called a " polysomnogram" should be performed prior to any procedure to assess the presence of, and extent of, any lack of oxygen flow while asleep.
If a surgical patient is identified as having sleep apnea prior to their operation the use of heavy narcotics during the postoperative period should be minimized or avoided all together. These patients should also be monitored more closely during both the recovery phase as well as during the remainder of their hospitalization. If their procedure is one that involves the head and neck region further concern about their airway is warranted.
The treatment of sleep apnea can take one of several forms. Initially the patient is typically tried on CPAP (constant positive air pressure). This is a small bedside device that pushes a gentle jet of air into the nose and throat by way of a nasal mask. When this is worn by the patient during sleep it can frequently eliminate apneas all together. Many patients however, cannot tolerate the mask and opt for alternatives. The most common is the option for surgery. Through operations directed to opening up airspace in the back of the throat patients can successfully diminish the amount of apneas. When this is achieved the patient no longer snores and loses their daytime sleepiness. Moreover their risk of heart attack and stroke are both returned to normal.
Patients with sleep apnea who are overweight benefit greatly from significant weight loss. This in and of itself may be enough to correct their problem. The trouble is achieving a "significant" loss of weight and finally maintaining the loss. In reality few individuals ever do the first step and few still both steps. Typically these patients will elect to enter into other treatment modalities.
In summary snoring may be a sign of underlying obstructive sleep apnea syndrome. History taking should include questions about daytime sleepiness, morning headaches and gasping for air as noted by the sleep partner. A sleep study should be performed in all patients where the history is positive or body size, shape or weight may cause concern. Sleep apnea patients undergoing surgery need special attention including the avoidance of heavy narcotics and the need for closer post operative monitoring.
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