Snoring and Poor Sleep? Find Out if It's Sleep Apnoea

What is sleep apnoea?

Many people dismiss loud snoring as a minor inconvenience, but it is a typical symptom of sleep apnoea. Sleep apnoea is a prevalent sleep disorder affecting 1 in 3 Singaporeans in which breathing repeatedly stops and starts during sleep.

Left untreated, sleep apnoea can lead to serious health complications such as high blood pressure, heart disease, and diabetes. It can also contribute to poor sleep quality, impact daily activities, and affect overall well-being.

Many people with sleep apnoea remain undiagnosed because the symptoms occur during sleep. Still, there are signs that can be observed by a partner or in the day. Common sleep apnoea symptoms include:

• Loud snoring
• Frequent awakenings
• Disturbed sleep with choking
• Fatigue
• Insomnia or difficulty staying asleep
• Pauses in breathing observed by a partner
• Night sweats
• Morning headache
• Dry mouth or sore throat upon waking
• Excessive daytime sleepiness (hypersomnia)
• Difficulty concentrating
• Irritability or mood swings

There are 2 main types of sleep apnoea:

• Obstructive sleep apnoea (OSA): OSA is the most common type, caused by a blockage in the upper airway. It can range from mild to severe, depending on how often breathing interruptions occur during sleep.
• Central sleep apnoea (CSA): CSA is caused by a failure of the brain to send proper signals to the muscles that control breathing.

What are the health risks of obstructive sleep apnoea (OSA)?

OSA causes a lack of oxygen, which has long-term negative consequences for your health. Related conditions include:

• High blood pressure (hypertension)
• Heart disease
• Stroke
• Diabetes mellitus
• Cognitive impairment (e.g. memory loss)
• Poor performance at work or in school
• Early onset dementia
• Depression
• Car accidents

OSA can result in drug-resistant hypertension. Patients may notice a gradual increase in the dosage of medication needed to control the hypertension.

Left untreated, OSA can lead to heart disease as well. The disturbed sleep in an OSA sufferer can lead to an increase in inflammatory markers in the blood.

These proteins are released when the body is under stress, including during disturbed sleep. They can damage the blood vessel walls, leading to a build-up of atheroma (artery-blocking plaque) and calcium deposits in the coronary arteries and neck vessels. This can significantly increase the chance of a heart attack or sudden death.

OSA is also associated with mental health risks such as depression. According to a study published in the Journal of Clinical Sleep Medicine in 2015, OSA patients tended to be more depressed. In another study in Europe conducted by Stanford researcher Maurice Ohayon, people with depression were found to be 5 times more likely to suffer from sleep-disordered breathing, of which OSA is the most common form. The good news is that if the OSA is treated, the depression can be reversed.

OSA in women usually presents atypically and tends to be underdiagnosed. Female OSA sufferers may present with different symptoms than the 'classic' symptoms of snoring, disturbed sleep and excessive sleepiness during the day.

Instead, women may experience fatigue, insomnia, morning headaches, mood disturbances, or other symptoms. However, the consequences of OSA remain the same, and it must be treated urgently as well.

Obstructive sleep apnoea in children

While the typical OSA sufferer is the middle-aged male who snores, OSA can occur in children as well. Sleep apnoea in children has been recognised since the 1970s and has been well studied.

Consequences of untreated OSA include failure to thrive, bed-wetting, attention-deficit disorder, behavioural problems, poor academic performance and cardiopulmonary disease. The most common cause of obstructive sleep apnoea in children is adenotonsillar hypertrophy (unusual enlargement of the adenoids and tonsils).

Children who snore may have OSA and develop behavioural and cognitive problems. Snoring has been associated with poor academic performance in teenagers. A 2008 study showed that when OSA is treated, children can improve in cognitive problems and academic performance.

Sleep disruption from snoring

Snoring is a frequent symptom associated with sleep disorders, prominently obstructive sleep apnoea. It occurs when airflow through the mouth and nasal passages is partially obstructed during inspiration, leading the tissues in the airway to vibrate and generate sound.

Chronic snoring may also strain relationships with bed partners due to nightly disturbances. Recognising and addressing these challenges is essential for enhancing both personal health and relationship harmony.

Treatments include simple lifestyle adjustments to stop or reduce snoring:

• Engage in regular physical exercises
• Adopt a side-sleeping position
• Elevate the head with pillows
• Steer clear of alcohol and smoking before bed
• Maintain a healthy weight

What are the risk factors of sleep apnoea?

Sleep apnoea can affect anyone, but certain factors increase the risk:

• Obesity: Fat deposits around the airway can narrow the upper airway and block breathing making obesity a risk factor for sleep apnoea.
• Gender: Men are more likely to develop sleep apnoea compared to women, although the risk for women increases after menopause.
• Age: Older adults are at a higher risk due to decreased muscle tone that can lead to airway collapse.
• Family history: A genetic predisposition may play a role in anatomical airway structure.
• Alcohol: It relaxes the throat muscles, making airway obstruction more likely.
• Smoking: Increases inflammation and fluid retention in the airway, worsening breathing problems.

How to diagnose sleep apnoea?

A doctor may diagnose sleep apnoea based on symptoms and a sleep history. The following tests can be used:

• Inpatient polysomnography (sleep study): Conducted in a sleep lab, this comprehensive sleep monitors brain waves, heart activity, breathing patterns, oxygen levels, and muscle movements.
• Home sleep test: Home sleep apnoea testing is done through a wearable device to measure airflow, heart rate, and oxygen saturation. It is a convenient option to remotely monitor OSA and sleep health.

Sleep studies will measure the Apnoea-Hypopnea Index (AHI): The AHI indicates the severity of sleep apnoea by determining the average number of apnoeic (breathing cessation) and hypopnoeic (shallow breathing) episodes per hour of sleep.

What are sleep apnoea treatments?

Treatments for obstructive sleep apnoea use a multi-pronged approach from lifestyle changes to CPAP therapy and surgery:

• Changes in diet and lifestyle, including exercise and weight management
• Medications to treat conditions such as allergic rhinitis, especially in children
• Oral appliances for OSA
• CPAP (continuous positive airway pressure) therapy
• Surgery in selected cases where other treatments are unsuitable

Lifestyle changes

The patient can also adopt simple lifestyle changes, such as avoiding alcohol for 4 – 6 hours before bed, sleeping on the side rather than the back or stomach, maintaining a healthy diet, and losing weight.

Obesity is a major factor for OSA and a major cause of relapse. This is because more fat around the neck can narrow the upper airway passages.

Medications

Medications are important in patients with a concomitant diagnosis of allergic rhinitis leading to nasal congestion. Frequently, these patients have narrowed nasal passages and mouth-breathe at night to obtain more air. They can also experience mouth dryness in the morning. Medications such as nasal steroid sprays and antihistamine tablets can help improve nasal airflow and improve symptoms.

Oral appliances

Oral appliances may also be used to treat OSA. They work by moving forward or advancing the lower jaw and tongue, to enlarge the space at the back of the throat. These are possible options in patients with mild to moderate OSA.

However, oral appliances have downsides such as jaw ache, bite disturbances, excessive salivation, dental misalignment, gum irritation and even temporomandibular joint disease (pain in the muscles that move the jaw).

CPAP machine (continuous positive airway Pressure)

CPAP therapy is a very effective and commonly prescribed treatment for obstructive sleep apnoea (OSA). It uses a CPAP machine and mask to deliver a constant stream of pressurised air. This keeps the airway open and prevents interruptions in breathing during sleep. The continuous airflow reduces snoring, improves oxygenation, and helps achieve restful sleep. The biggest downside of using a CPAP machine is compliance. Patients may find it difficult to use this daily for the full duration of sleep due to side effects such as difficulty exhaling or a feeling of claustrophobia. Also, CPAP helps to control OSA only when used consistently and is a long term treatment.

Surgery

Surgery for OSA is generally useful in 3 categories of patients:

1. To help facilitate CPAP therapy (e.g. clearing the nasal passages)
2. Patients with an obvious anatomical source of obstruction in the air passages (such as adenotonsillar hypertrophy), where the surgery can cure the condition.
3. Patients who will benefit from upper airway stimulation surgery.

In patients who require CPAP but have nasal obstruction, nasal surgery may be necessary to widen the nasal passage before using the machine. Otherwise, the patient may not be able to tolerate the CPAP and this treatment will inevitably fail.

An example of the second category of patient would be children with adenotonsillar hypertrophy, where the nasal and oral passages are narrowed by enlarged tonsils and adenoids. If a child has enlarged and obstructing tonsils and adenoids and has symptoms of OSA such as mouth breathing at night with snoring, choking and breath-holding (apnoea), adenoid and tonsil surgery will help to widen the nasal and oral passages and clear the obstruction.

Other surgeries may be used to treat sleep apnoea in carefully selected patients. These sometimes may include minimally invasive techniques which minimise pain and have minimum downtime and quick post-operative recovery. Surgical interventions include:

• Soft tissue surgery:
  • Uvulopalatopharyngoplasty (UPPP): The removal and tightening of excess tissue in the throat.
• Skeletal surgery:
  • Genioglossus advancement (GA): Repositions the tongue muscle to prevent airway obstruction during sleep.
  • Maxillomandibular advancement (MMA): Surgical advancement of the jaw to increase airway space and improve airflow.
• Hypoglossal nerve stimulation: A device implanted in the chest that stimulates the tongue and upper airway muscles to keep the airway open.

When to consult a doctor

If you suspect you have obstructive sleep apnoea, book an appointment to see an ENT specialist (otorhinolaryngologist). The ENT specialist will diagnose the condition, assess its severity and recommend appropriate treatment.

A sleep study can be done to diagnose and classify the type and severity of sleep apnoea. Another option is to do a home sleep test using a wearable device to monitor sleep health conveniently with a GP.

With the right treatment, you can enjoy restful sleep and improve your overall quality of life.