The not so silent killer (1) – How much less “sexy” can it get?

Sign post of man laying down and snoring
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Abstract: Remarkably, there are still diseases of the Western and developed world which appear to escape widespread awareness and detection – ARE YOU LIVING WITH A SILENT KILLER?

Cartoon of man snoring
How much less “sexy” can it get?

While heart attack and stroke remain feared, they are closely associated with this unacknowledged epidemic which is almost ignored by the majority of healthcare professionals. Sleep disordered Breathing, the loss in full or part of the vital airway at night is composed primarily of obstructive sleep apnea and snoring, the not so silent killers.

An epidemic arises when a disease affects a larger number of people than is usual for the locality or one that spreads to areas not usually associated with the disease. A pandemic is an epidemic of global proportions.

If there was a disease that was not only considered to be an epidemic but represented a pandemic, would you think that everyone would be aware of it and its possible effect on them, their families or loved ones.

What if it could potentially kill you or a loved one or at least cause suffering now or possible serious health problems in the future, would you want to know about it?  

If the concerns were not only evidence-based on thousands of studies to show just how dangerous it was but that it was known that up to 20% of the adult population were affected or carriers, you’d want to be screened, right?

If it was known to either cause, worsen or precipitate heart attacks, strokes, car accidents, depression and destroy children’s futures, if it could lead to diabetes, the number one increasing disease of the Western World, you wouldn’t want it either misdiagnosed, mistreated or missed entirely would you?

Unfortunately, this is what’s happening every hour in England, Canada, the US, Asia, Australia and Europe.

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Why is this disease routinely missed or misdiagnosed. What if most healthcare providers often don’t know or worse still, due to billings, sometimes less than interested in either screening, diagnosing or treating it and more inclined to diagnose and treat ‘billable’ disease?

Unfortunately for us all, this disease is very much present and it affects us even if we don’t have it. So, what is it and how can it be so common, so serious and yet, so little is done?

You may (or may not) be surprised that since it is common, people tolerate it and consequently it worsens the social picture.

I feel strongly about it as it was likely a significant co-factor in my father’s death in his mid-forties. It brings a whole new meaning to “dying in your sleep” although those that die often do so in the daytime after years of night-time damage.

This illness is called Sleep Disordered Breathing (SDB), I have it, as do several family members, but you may simply know it as Snoring or Obstructive Sleep Apnea which are both forms of SDB.

There is another called UARS, but we’ll get on to that later. You may think, “ah, is that all, I’ve heard about that”, but the problem is, you probably haven’t heard the full story.

When there is an accident or need to provide emergency care of life support to someone in the street, the first responder will (after checking for safety) secure the sufferer’s airway.

Why? Because the airway is vital, it’s been said that you can go weeks without eating, days without drinking, but hardly minutes without breathing. In Sleep Disordered Breathing (SDB) there is a sleep related (Sleep) airway compromise (Breathing) dysfunction, dis-ease or illness(Disorder).

During sleep, the sufferers of this disease have no way to protect their airway, and if and when the airway becomes compromised (narrowed or obstructed) the air pressure changes and snoring can result.  While snoring is not benign, we can come back to that as I want to concentrate on the narrowing or complete closure of the airway at night with or without snoring, that occurs in up to one fifth of adults (potentially you, your family or your friends). It’s called Obstructive Sleep Apnea (an ‘Obstruction’ while ‘Sleeping’ withApnea “‘stopped breathing”= OSA), and I’d to share what I’ve seen over the last 12 years  or so during which time I’ve been seeing, screening, treating and following up those people. Also, the many changes in knowledge, attitude and beliefs, that are taking place and how they impact you.

The Cause of Sleep Disordered Breathing

So, what causes this airway narrowing or closure? It’s a combination of things, it used to be considered that women were considered somewhat immune unless they were post-menopausal and had lost their hormonal protection – that’s not what’s seen however.

It used to be considered that just older and middle-aged people had it – that’s not what’s seen. Fit, young people never had it – well they do.

Children grew out of it and it didn’t affect them in later life – absolutely wrong.

If you didn’t snore you didn’t have it – wrong.

Once treated you were fine – wrong.

The cause is just that closure of the airway and it can be pressure from the outside (anatomy, fat, etc.) or the inside (anatomy, muscle wall, etc.)

The Effects of Sleep Disordered Breathing

It makes you tired right – so, if you’re not tired and sleep well, you’re OK? No. What if you sleep “like a log”? No. What if you don’t snore? No. What if you’re a slim, athletic woman who sleeps well and doesn’t snore? No, sorry, you could still be affected.

There are at least some pointers, but just like most tests, you shouldn’t rely on just one of them alone. Could there be due to something else involved – yes but this is sufficiently important for you to at least review for your own safety. The clearest indication is witnessed apnea (or stopping breathing followed by gasping) during sleep.

It doesn’t seem to bother me, why worry?

Any of the above and other signs and symptoms can be caused in part or completely by this disease. It increases the chance of a car accident (up to seven times even if you have only moderate level of OSA. If you want the best quality of life (and best longevity) it’s a good idea to be aware of this very common, and potentially fatal disease and to manage it just as would plan to manage diabetes.

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The problem with SDB is this;

When you can’t get air into your lungs several things happen as in actual fact you’re being suffocated. The body fights to correct it but sometimes adds other problems in so doing.

No oxygen to the lungs means no (or less) oxygen to the blood and therefore tissues including the brain which requires approximately 20% of the body’s oxygen requirements, when you’re asleep! The other tissues and body organs also require oxygenation as sleep is considered to provide (amongst other things) rejuvenation. Lack of oxygen is called Hypoxia, and this is what the sufferer experiences, it’s measured as desaturation. Normally around 95-97% during sleep, it becomes more significant below 90%.

Sleep deprivation follows repeated awakenings during episodes of apnea (stopping breathing), even if you’re not aware of them (don’t wake into consciousness). You are unable to achieve normal sleep patterns and without this the sufferer experiences sleep deprivation which may or may not be apparent. If snoring is a factor the sleep privation can certainly often be seen in the bed partner too as they’ll be quick to point out.

There is tremendous pressure exerted on the chest cavity (containing heart, lungs and great vessels, etc.) as the diaphragm drops to unsuccessfully pull in the air from the outside. This is believed to be a factor in the development and worsening of atrial fibrillation.

Oxidative stress takes place and inflammatory markers in the blood increase. Oxidative stress is considered an “aging factor” inflammatory markers a sign of systemic disease. There are known relationships to certain cancers and it is believed that this is partially due to oxidative stress. Oxidative stress is a significant factor in ageing. While taking anti-oxidants is encouraged, ignoring such a potent cause makes no sense.

Adrenaline overload. Last but certainly not the least on this list, is the burst of adrenaline released in order to “shock” the sufferer from their sleep (and co-incident suffocation) into consciousness and the ability to breathe. Adrenalin release causes  the “fight or flight” response, just like a serious fright or shock like a near miss in a car. The sufferer may be experiencing upwards of 10 , 20 or even more of these, every single hour, imagine that nightmare journey home with 10, 20 or more near misses that are only just avoided! How would you feel when you got home?

So clearly one should know a little about something so common, that may be impacting us significantly, and that many of our healthcare providers are missing. Investigation should at least be considered by those wanting their best, healthiest and longest life.

Findings and “red flags” of SDB or Obstructive Sleep Apnea

Do you suffer from any of these?

Heavy snoring

☐         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.

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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.


While I don’t recommend that you forgo a diagnostic sleep test the potential benefits from this easy muscle exercise program are significant in this area. I would always recommend baseline (now) and three month later testing as the minimum review.

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. Let me know how you get on with them.

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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.

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.

Missed diagnosis?

☐         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. We can go over the different management approaches and the “truth” that’s often not told for these but In future articles we’ll look at these and snoring specifically as it is part of this overall picture of  Sleep Disordered Breathing (SDB) and considered to be annoying yet benign. It might definitely be the former, but it is most definitely not the latter.

How to get Obstructive sleep apnea diagnosed. – in In Part II

Dr Stephen Bray 2019

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