What’s the deal with snoring?

Snoring is one of those things that we come to terms with that we do. Whether it requires a recording as proof or we take someone’s word for it, for those of us who snore it’s a burden we bear. 

But at a certain point you might end up wondering: what is snoring and should I be worried about it?

Let’s take a thorough look at the entire spectrum of snoring. We’ll explore some ways to stop snoring that can help a good night’s sleep for you and your bed partner. 

What is snoring? 

Snoring is a respiratory sound heard while inhaling and exhaling during sleep. Simple snoring is usually noted by a bed partner and it has no health implications itself. 

Usually, people who snore wake up rested and don’t experience daytime sleepiness. The same state of feeling rested might require some earplugs for the earlier-mentioned bed partner.

How to stop snoring?

For those of us who snore, addressing the problem effectively may mean making some lifestyle changes around alcohol or tobacco, it might also mean losing some weight or consciously sleeping in a position where our airways stay open. 

The first things to do to fix snoring is to:

  • Change your sleep position (sleeping on your side is the best).
  • Try a different pillow.
  • Avoid drinking alcohol, smoking, and hypnotic medications.
  • Lose weight. 
  • Try out an oral apparatus to keep the airway open. 

If you also have awakenings at night due to breathing difficulties and daytime sleepiness, you should see a doctor or a sleep specialist for a sleep evaluation. Testing might include an electrical test of brain waves, measuring the level of oxygen in the blood, and measuring esophageal pressure.

What causes snoring?

The size and shape of the airway (jawbone and mouth) and the process of breathing combine to cause pharyngeal collapse, which means that the opening to the airway (trachea or windpipe) narrows creating an imbalance between airflow forces.

The following factors are often causing factors for airway collapse:

  • Small airway size. Airway consists of the mouth, tongue, pharynx (by the voice box), trachea (main tube to the lungs).
  • Upper airway resistance from the small airway size.
  • Pressure on the tissue surrounding the respiratory tract such as excess fat.
  • Small jaw bone.
  • Large neck size.
  • Lying flat on your back.
  • Upper airway inflammation-colds, influenza, pneumonia, asthma.

The following factors promote airway flow:

  • Muscles that help the pharynx dilate.
  • Larger airway and jaw.
  • Higher lung volume.

Let’s talk airflow

There are two basic principles of fluid or airflow known as the Bernoulli principle and the Venturi effect, The Bernoulli principle describes fluid/air flow in a column or tube — think drinking through a straw. 

The smaller the diameter of the column (straw), the faster the flow. If too much sucking is generated within the straw, it collapses. Airflow is faster in a narrower tube as demonstrated by the Venturi effect. Water spraying out of hose after it had been kinked off is another example. In the case of human breathing, the pharynx is the tube or passageway of the air to the lung via the windpipe.  

Airway pressures and collapse

Snorers have a much more flexible airway that closes more easily with low pressures than non-snoring adults. 

This results in a pharyngeal collapse that causes the person to stop breathing for a few seconds or breathe less often, which ends when the body becomes aroused as it strives to open the airway to breathe.

Snoring is one type of Sleep-disordered breathing (SDB) that includes a continuum of disorders with implications to many other body systems. The spectrum consists of upper airway resistance syndrome (UARS), and obstructive sleep apnea-hypopnea syndrome (OSAH) or (OSA). The distinctions between these disorders can be blurred. 

Apnea means cessation of breathing for 10 seconds. In obstructive sleep apnea (OSA), the apnea is accompanied by visible chest rising and falling. Hypopnea means a slowing down of the process of breathing or shallow breathing. 

Snoring is the most common form of SDB. On occasion, snoring is totally normal and not harmful and considered a consequence of another problem such as nasal congestion, excess fatigue, central nervous system [CNS] or brain depressants, and abnormal sleep positions. 

Persistent snoring usually indicates that a more serious condition is evolving. The bed partner is usually the first to notice this noise. 

Risk factors for sleep apnea

Sleep apnea is a potentially serious sleep disorder characterized by heavy snoring and temporary obstructions of airflow during sleep. The following conditions are risk factors for sleep apnea:

Obesity

Obesity is defined as having a body mass index [BMI] >30 kg/m2. It is a primary risk factor for obstructive sleep apnea syndrome (OSAS). A 10% increase in weight is associated with a 6-fold risk of developing sleep-disordered breathing (SDB). 

Gender

Obstructive sleep apnea affects up to 4% of men and 2% of women which increases with menopause. Other studies cite higher prevalences of up to 4%(women) and 9% (men). Children can be affected especially those who are obese. Estimates are that up to 6% of children have some form of SDB.

Obstruction

Due to the relative positioning of the jaw, soft tissues, and pharynx. The degree of airway obstruction is categorized by the Mallampati Classification. This is a system to classify the size of the airway when the patient is sitting upright and sticking out their tongue. It ranges from zero to four, with four being the worst form of obstruction.

Neck circumference

A neck circumference of more than 17 in. The average neck size for men is 16 inches and for women 13.5 inches

Pulmonary disease

Emphysema or chronic obstructive pulmonary disease is the result of lung damage primarily due to smoking. 

Central Nervous System (CNS) or Brain depressants

Alcohol and sleeping pills cause a more relaxed airway, which may result in the collapse of the airway or shallow breathing.

Tobacco use

Smoking damages the upper and lower airways, including the lung tissue itself. Inflamed airways become swollen which narrows the airway. 

Low thyroid levels

Low thyroid levels thicken the airways reducing airflow. Some reports show that correcting the thyroid level will stop the snoring.

Gigantism

Acromegaly is a genetic condition that causes the bones and soft tissues to enlarge beyond normal due to excess growth hormone. It can cause an enlarged tongue which increases the risk of SDB.

Previous trauma or congenital birth defects

Previous trauma or congenital birth defects of the jaw and pharynx can affect breathing while awake and asleep. Micrognathia or small, receding jaw is a birth defect that can affect the ability to breathe while asleep.

Long term sleep apnea can harm the heart and lungs

During an apneic episode, the lack of oxygen causes the heart rate goes down with blood pressure initially. Then, there is a rebound elevation of heart rate and blood. 

These repetitive changes in the heart’s function and output can cause damage that continues to elevate the blood pressure. Any time the heart is stressed from lower oxygen levels due to labored breathing or lack of breathing, the body responds by elevating blood pressure to get the lower oxygen levels to the tissues faster. 

Chronically elevated blood pressure puts stress on the heart muscle and makes it pump harder against more resistance. Muscles enlarge when subjected to this type of stress which can ultimately cause the pumping action of the heart to weaken over time. This is called low heart output or heart failure. 

Treating sleep apnea

There are a variety of treatment options for obstructive sleep apnea, depending on the severity of the condition. Some of them may be lifestyle changes, others involve wearing appliances or masks during the night. The most severe cases may require surgical procedures.

Nonsurgical behavioral therapy

Oxygen supplementation and drugs are not effective. Weight loss can be an effective solution for individuals who are over their ideal body weight.

Improved sleep hygiene by avoiding alcohol or sedative-hypnotic medication before sleep.

Positional therapy, which involves avoiding the supine position (lying completely flat on your back) to decrease snoring and potentially, obstruction.

Nasal strips can be helpful to open up the nasal passages, making it easier to breathe during the night. This strategy is effective if nasal congestion is the cause of snoring. 

Oral appliances

Dental devices are simple devices that provide a nonsurgical alternatives for simple snoring and mild sleep apnea. They fall in the categories of (jaw) mandibular advancement devices (MAD) and tongue-retaining devices.

Dental devices change and reposition the upper airway to prevent obstruction by increasing the air space, by keeping the jaw more forward, moving the soft palate and tongue, or both. These devices are well-tolerated and do not make a noise like the CPAP machine. 

CPAP (continuous positive airway pressure) is a mask that is worn over the nose and/or mouth while sleeping. It delivers continuous flow of air into the nostrils, helping to keep the airways open so breathing is unimpaired. 

Reasons to have surgery

Surgical management of snoring and sleep apnea is considered when a surgically correctable abnormality is thought to be the source of the problem and the patient has tried continuous positive airway pressure (CPAP) without success. 

If other treatments have failed or are difficult to tolerate, then surgery might be undertaken. The types of surgery depend on the section undergoing correction. It may involve removing the tonsils or adenoids to prevent snoring, or reducing the amount of soft tissue in the back of the throat or upper airway. 

Glossary 

Sleep hygiene: The different practices, habits, and behaviors that one should adopt in order to both get better sleep at night and be more alert during the day.

References

  1. Memon J, Manganaro S. Apnea, Snoring And Obstructive Sleep, CPAP. 2017 Jun. [Medline]. [Full Text].
  2. Hanley M, Welsh C, eds. Current Diagnosis and Treatment in Pulmonary Medicine. New York: McGraw Hill; 2003.
  3. Avidan AY, Zee P, eds. Handbook of Sleep Medicine. Philadelphia, Pa: Lippincott; 2006. 13-33.
  4. Melamed KH, Goldhaber SZ. Obstructive Sleep Apnea. Circulation. 2015 Aug 11. 132 (6):e114-6. [Medline]. [Full Text].
  5. Peppard PE, Ward NR, Morrell MJ. The impact of obesity on oxygen desaturation during sleep-disordered breathing. Am J Respir Crit Care Med. 2009 Oct 15. 180(8):788-93. [Medline]. [Full Text].
  6. Riley RW, Powell NB, Li KK, Troell RJ, Guilleminault C. Surgery and obstructive sleep apnea: long-term clinical outcomes. Otolaryngol Head Neck Surg. 2000 Mar. 122(3):415-21. [Medline].
  7. Verse T, Baisch A, Maurer JT, Stuck BA, Hörmann K. Multilevel surgery for obstructive sleep apnea: short-term results. Otolaryngol Head Neck Surg. 2006 Apr. 134(4):571-7. [Medline].