Snoring and obstructive sleep apnea carries increased morbidity and mortality, and can also be a nuisance! Many of the signs and symptoms associated with “sleep disordered breathing” (SDB) may be attributed to other disorders or areas. If in doubt, ask your doctor.
It is important to look at SDB as a syndrome – where a combination of signs and symptoms are associated with that disease process. It is not necessary to have several or all, but they may all be associated with SDB.
DO YOU SUFFER ANY OF THESE?
☐ Heavy snoring. This is especially important when it has been going on for more than a few years or if it’s loud and disruptive. Having gasping or stopping breathing with snoring is even more significant. In many parts of the world heavy snoring is considered to be normal, or worse still, a joke. Physicians frequently don’t see it’s relevance yet snoring alone is associated with an increase in stroke and heart attack incidence yet this is rarely mentioned.
Witnessed breath holding
☐ Witnessed Breath holding or gasping at night . This is probably one of the most significant signs but unfortunately the partner’s often asleep apart when there is (in either or both parties) disruptive snoring. Consequently, it is more difficult to tell – although apps are now available for those on their own. It is always important to have a sleep test performed as while you may snore and not have OSA, you may need management of this too.
Dry mouth, sore throat
☐ Dry mouth, dry or sore throat. Mouth breathing can make your mouth and throat dry, but the vibration from snoring can cause vibrational soreness. This same vibration damages nerves in the throat affecting its ability to protect itself during airway compromise – so that snoring worsens as it becomes a vicious cycle. Bad breathe due to drying is not uncommon (hence my suggestion to review the product below). Dry mouth may be experienced with other airflow issues associated with the management of OSA and snoring too.
Excessive daytime sleepiness
☐ Daytime sleepiness or tiredness? Although it is not a universal finding, excessive daytime sleepiness (EDS) is a not uncommon finding. Although people with SDB often appear to sleep deeply (better than the bed partner!) their sleep patterns (Sleep architecture) is affected and there is therefore sleep deprivation. Your doctor may look at other issues too, just ensure that a sleep test is part of the work up.
My sleep is un-refreshing.
☐ Feeling unrefreshed when you get up? Again, a lack of oxygenation, disrupted sleep architecture and bursts of fight or flight hormones during the night often leads to feeling the need to get “just another hour” in bed.
I suffer from a lack of day-time energy
☐ Lack of day-time energy. Frequently overlooked in our often-busy lives. There are many other possible causes of a loss of energy, including the ‘retirement syndrome’ of lack of consistency, organization and ultimately ‘meaning’ in life, a potential sign of depression – which is also known to be a direct result of SDB. People suffering from OSA feel that they’re “running out of steam” earlier in the day than before.
Unexplained chronic heartburn
☐ Heart burn (GERD). There is some controversy over this but anecdotally I have seen this far too frequently to believe it a coincidence. As the airway closes the diaphragm is still dropping to pull in outside air – but due to the obstruction, it can’t.
The result is the chest cavity pressure drops and since it can’t pull in outside air it will pull up (reflux) stomach acid into the esophagus, causing heart burn. Millions of people are consuming millions of antacid tablets due to a missed diagnosis. Still it keeps the manufacturers profitable!
Why do I get repeated sinus or nasal problems?
☐ Repeated sinus problems, congestion. When this acid regurgitation occurs, it acidifies the mucous and saliva fluids covering and protecting the mouth, nose, throat and sinuses.
All of these then show some evidence of inflammation (not due to infection or allergy, but more so due to response to low grade chronic acid exposure. Another frequently misdiagnosed area both by doctors and dentists – if is commonly associated with tooth damage (since teeth and acids don’t mix well ) , especially causing pitting on their biting surfaces – this is not just due to tooth wear.
Chest and heart palpitations
☐ Palpitations, heart racing, tachycardia and ‘missed beats’ are all signs of natural heart rhythm disruption. This is likely due to ‘fight or flight’ hormones released as a result of these ‘airway closure events’ and more cardiologists are connecting these atrial arrhythmias to the drop in chest (intra-thoracic pressure) which can be highly clinically significant.
Many patients are treated for atrial fibrillation that have never been SDB tested.If you have AF I would highly recommend a sleep test if you haven’t had one done.
I suffer night sweats
☐ Night sweats are commonly associated with the release of adrenaline and the ‘fight or flight response’. They should be separated from hormonal changes during menopause, illness or bedroom temperature.
An increased incidence of heart attacks in yourself or family.
☐ Increased self or family incidence of heart attack, stroke and high blood pressure. There is a strong familial connection, yet unfortunately, due to a lack of information, understanding or interest, there is often no connection made between someone having had a heart attack and possible sleep disorders (snoring and obstructive sleep apnea).
Some people are hospitalized – even put on blood thinners (which themselves carry significant risks) yet are never checked for SDB ! Some are sent home and never checked, some people just have another heart attack, some die.
Clearly while there has been improvement in recognition, there is still a need for an improved understanding by many physicians to understand these disease relationships.
Does Obstructive Sleep Apnea cause Type 2 Diabetes ?
☐ Increased self or family incidence of diabetes (type 2). Type 1 diabetes is the insulin deficient type while the type 2 is the insulin resistant type. Not everyone who has SDB is obese although many are overweight.
Clearly there is a connection between overweight and obesity and type 2 diabetes, yet regular snoring and OSA are independently associated with alterations in glucose metabolism and what is termed the ‘metabolic syndrome’ – those with SDB appear to be risk factors for the development-of, and ineffective treatment of, type 2 diabetes.
Sexual dysfunction in men
☐ Men: sexual dysfunction in men. As we saw earlier, SDB causes sleep deprivation, fatigue, and stress, possible causes of erectile dysfunction in men, as is the effect on the normal production of testosterone during healthy sleep which can result in poor erections and decreased libido.
Adequate oxygenation is important for healthy erections, so any deficiency can cause a problem – although it is more likely that the effect on the walls of the blood vessels (endothelial lining) causing vessel constriction (vasoconstriction).
Irritable bowel syndrome
☐ IBS (Irritable Bowel Syndrome) – past studies have indicated evidence consistent with the model of IBS as a disorder of brain-gut interaction and a close relationship.
Chronic pain syndromes
☐ Chronic pain syndromes – poor sleep lowers pain threshold and pain produce poor sleep. This is an area we will cover in more detail later due to the importance of chronic pain and its effect on lifestyle and the quality of life.
I seem to be gaining weight and can’t shift it.
☐ Weight, overweight and obesity is another area that we will cover in greater depth later.
I dream and get nightmares
☐ Do you suffer dreams or nightmares about drowning? While it sounds likely and I’ve heard it reported, studies don’t seem to support either more or less dreaming with SDB.
I get a low grade morning headache
☐ Do you awaken with a “fuzzy head”, sometimes a dull headache at the front. Almost a alcohol hangover. A ‘frontal’ headache – dull and fuzzy, has been linked to inadequate night time oxygenation. At night, the brain requires 20% of all the oxygen breathed so is both highly active and has requirements for glucose and oxygen.
☐ Have you been diagnosed with X, Y or Z instead? I’ve seen patients referred to me for everything from Narcolepsy to Epilepsy. When I was at school I was always told, “common things occur commonly”. As you’ve seen – SDB is common.
A missed or mistaken diagnosis?
☐ Are you being treated for something else without the necessary SDB diagnosis? Here I’m referring to anything frequently linked to SDB like stroke, heart attack, atrial fibrillation and diabetes – at least check that it’s not a cofactor in development – without this, any treatment will be “against the tide” and therefore compromised.
These are important relationships and are clearly not normal, yet the problem is that when something happens frequently enough – it either becomes considered “normal” or we overlook or ignore it – it might be annoying but it’s not causing any immediate problems.