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Publication Date: Friday, December 14, 2001

Breathing space Breathing space (December 14, 2001)@12subhead:Holidays can be a good time to catch up on sleep. But if snoring is stopping you from getting the shuteye you need, beware of other problems that could follow.

By:Diana Reynolds Roome

Snoring has always been a subject for hilarity rather than concern _ at least for those who don't suffer from it. The image of a paunchy old gentleman fast asleep, with pipe in hand and mouth wide open, is more likely to prompt an indulgent smile rather than a phone call to the doctor's office.

Yet snoring, which afflicts men, women and children of all ages, is anything but amusing. It is often highly disruptive, and not only to those who have to listen. The kind that sounds funniest _ loud raspy breathing, with a period of silence, followed by a gasping snort _ can be deadly serious.

This is obstructive sleep apnea (OSA), a blockage of the airways that sometimes wakes a person hundreds of times each night.

Snoring is a problem that leads to other problems. Not surprisingly, constant interruption of deep sleep can cause drowsiness during the day, and often irritability. Many people who suffer from disruptive snoring will drop off regularly in front of the television or while reading a book.

This might seem merely eccentric, but when they nod off at work, employers and colleagues may start to wonder. Falling asleep in the middle of a conversation is apt to be misunderstood. Dozing behind the wheel of a car can prove fatal. 20 percent of car accidents are caused by sleepiness, the effects of which are very similar to alcohol, and people with OSA have a seven times greater than normal chance of a car accident.

Many of the estimated 9-15% of men and 4-9% of women who suffer from sleep apnea have no idea they've got a problem. Their partners are often grimly aware of the sleep disruption, but learn to put up with it because it is generally assumed that snoring is no more than a harmless annoyance.
Understanding the affliction

Researchers at Stanford's Center for Sleep Disorders are working to understand the effects of sleep apnea on general health. By hooking patients up to monitors in the Sleep Clinic, they are able to analyze breathing, heart rate and movement during sleep. The air intake system is generally where the trouble begins.

"The throat muscles relax, the tongue and soft palate drop down into the airway and block it," explains Luciana Palombini, MD, who has observed the breathing patterns of thousands of patients as they struggle through a night's so-called sleep. "The pause in breathing can last up to 60 seconds, and can occur hundreds of times a night."

When the brain registers the lack of oxygen, it alerts the body awake, if only enough to take a gasp of air through the mouth.

"Each time there is a drop in oxygen, there's a disruption of sleep pattern, though it's not enough to make the person wake up," said Palombini. "It often takes a long time for them to realize there's a problem."

The consequences can be numerous, even when snoring is less severe than full-blown sleep apnea. Dry mouth, nighttime visits to the bathroom, and morning headaches sap energy. Often the normal stresses of life seem too much to handle. Family and co-workers may wonder why sufferers are often inattentive and irritable.

When children sleep badly due to snoring, parents and teachers sometimes misinterpret poor progress as hyperactivity or learning disability. Naturally enough, interrupted sleep often has a profound effect on an adult's performance at work.

"Chronic sleep deprivation interferes with cognitive functioning," says Palombini. "Years of sleep fragmentation will cause a little brain dysfunction."
Compounded problems

"Harold wasn't alert and would fall asleep during the day," says Marjorie Iseke, whose husband was part of the Stanford sleep study since suffering a stroke earlier this year. "He didn't know he was snoring, but all of a sudden, he would gasp _ he was really lacking in oxygen, but we didn't know it."

It was only after the stroke that Harold Iseke discovered the link between sleep apnea and cardiovascular problems.

"Sleep apnea increases risk of high blood pressure, coronary heart disease and stroke," says Palombini, who is researching the link between sleep apnea and cardiovascular risk for ResMed, a company that manufactures a device that ensures a continuous supply of positive air pressure during sleep. "More than half of the people who suffer a stroke have sleep apnea."

Though the connection was only recently discovered, the reason is not hard to understand. When sleep is repeatedly interrupted by disrupted breathing, blood pressure fluctuates. The heart has to pump harder each time the oxygen supply goes down. At each gasp, adrenaline increases, too, and this in turn can lead to higher risk of blood clots.

So what makes some people chronic snorers? Any problem with the nose can cause a breathing obstruction: polyps, allergies, sinusitis, or deviated septum (where the cartilage dividing the nostrils is crooked). Clearing up allergies and sinusitis with an appropriate decongestant can help.

Getting more regular exercise and losing weight also makes a difference: the less fatty tissue in the face and neck, the less likely it is that airways will collapse during sleep. Sleep position can make a big difference, and typically lying on the back makes snoring worse. Alcohol in the evening and muscle relaxants such as sleeping tablets can also exacerbate the problem by relaxing the muscles too much.

In some cases, an operation is appropriate to decrease the size of the uvula _ the little v-shaped flap that hangs down at the back of the throat, or to correct a deviated septum. Tonsillectomy can reduce OSA in certain cases.

A major but less drastic remedy is CPAP or continuous positive airway pressure, currently being used at the Stanford Sleep Clinic. This is an artificially delivered supply of air, applied via a mask that attaches to the face during sleep. The pressure acts like an "air splint" to keep the upper airway open.

Improvements in breathing patterns during sleep can result in a rapid return to a high quality of life. In some cases, people did not even realize it was possible to feel so good.

"I used to toss all night," said Harold Iseke. "Now the quality of my life is much better." His wife agrees, adding that his disposition is much improved, too.

This year, Stanford researchers identified a gene associated with sleep apnea. Dr. Emmanel Mignot, MD, PhD and his team at Stanford's center for narcolepsy _ another sleep disorder _ found that people with variants of the gene are twice as likely to suffer from sleep-disordered breathing as people without the gene.

So if someone tells you they can't help snoring, they're probably right. On the other hand, they can now do something about it. For everyone's sake they surely should.

Stanford Center for Sleep Disorders, Stroke Project, 650-723-5204

Cartoons used with kind permission of ResMed. Copyright ResMed.


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