Sometimes I snore like a steam shovel, other times more like a teakettle. This "gentle, unromantic music of the nose," as William Makepeace Thackeray called it, is the nighttime soundtrack in many homes. For most of us, snoring is no more than an irritant to those trying to sleep within range. But for 12 million American men, the cause of snoring is an invisible, though not-so-silent, epidemic -- obstructive sleep apnea, a cessation of breathing during sleep.
We snore -- about half of adult men snore, according to studies -- for one of two reasons. Mostly we snore because our airways narrow in sleep, creating resistance in the passageways that connect our nose and mouth to the lungs. The narrower the tube, the greater amount of pressure needed to establish enough flow. The fatter we are -- and in particular, the thicker our necks -- the more pressure there is on the airways, and the more they tend to collapse as we sleep.
A small percentage of men have a structural problem, a small jaw or a "shallow midface" -- the area between your nostrils and the back of your head -- which can cause snoring even in thin men. In either case, the more suction pressure on the soft tissues of the mouth, the more vibration and the more snoring.
"If there's enough pressure, you collapse the airway and obstruct it," explains Patrick Strollo, MD, assistant professor of medicine at the University of Pittsburgh. An obstructed airway means your lungs aren't getting enough oxygen. If your blood oxygen level plummets when your airway is blocked, a message is sent to your brain to wake you up so you can breath again.
Sleep is a foreign country to the sleeper. You can't see yourself sleep, or hear yourself snore. The typical apneic -- a person with apnea -- will wake up dozens or even hundreds of times each night without knowing it.
"Usually it's the wife or girlfriend who brings them in, horrified by what they see when these men are asleep," says Nancy Collop, MD, a pulmonologist and director of the sleep clinic at Johns Hopkins University Hospital in Baltimore. "The patients themselves are often unaware of sleep apnea -- it's pretty unusual for a patient to wake up complaining of not breathing. All they realize is that no matter how much they sleep, they can't get good sleep."
But just because it's not noticed doesn't mean apnea isn't a problem. Hypertension and diabetes have been linked to sleep apnea. Apnea symptoms can include headaches and sleepiness throughout the day, and diminished alertness on the job. The Institute of Medicine estimated last year that undiagnosed sleep disorders cause 100,000 traffic accidents each year.
Equally serious is the damage that sleep apnea does to your heart, arteries and metabolism. Strictly speaking, it isn't the oxygen depletion that does the most damage. When the snorer briefly awakens and breaths, oxygen-depleted tissues fill with oxygen. The pattern of depletion and re-oxygenation stimulates the nervous system and releases chemicals that can damage tissue and leave plaques in the blood vessels.
Not everyone who snores is apneic, says Strollo, who is also the chief of the sleep medicine laboratory at the University of Pittsburgh. But there's a continuum between snoring and apnea, and if you snore for enough years, you can become apneic. Sleep specialists define apnea by the number of times a person wakes per hour -- five is often the number given -- but also by the degree of daytime sleepiness.
Although good sleep is probably as important as good diet and exercise to overall health, it's a latecomer to medicine. In 1956, C.S. Burwell, MD, characterized sleep apnea as the "Pickwickian Syndrome" in honor of Joe, the Fat Boy, a character in Dickens's Pickwick Papers who "goes on errands fast asleep, and snores as he waits at table."
Doctors didn't get into the business of diagnosing the condition until the 1970s. Even now, only about 10% of primary physicians ask questions about sleep, and as a result, an estimated 90% of sleep apnea goes undiagnosed and untreated.
The typical sleep apnea patient is an overweight, middle-aged man. Among men with a more healthy physique, sleep apnea seems to occur disproportionately in people of Asian descent, possibly because of the shape of their faces, according to Collop.
Luckily, there is an effective therapy for sleep apnea. Unluckily, it's a rather ungainly apparatus that makes the wearer look like a brain-damaged hospital patient. It's called CPAP, for continuous positive airway pressure, and it consists of an air hose attached to a mask that's fastened around the head and blows air through the nose.
The device was introduced in 1981 and remains the standard of care for treating breathing problems during sleep. "I can almost guarantee that CPAP will cure almost anybody with sleep apnea -- if they wear it," says Collop. "They feel better usually the first night, and within two or three weeks they've shaken off sleep deprivation. The problem is to get people to wear it consistently."
Improvements of the sleep apnea machine have made the generator smaller and quieter, able to vary the air pressure depending on the patient's breathing patterns, and able to humidify the air to prevent dehydration in the airway. Currently, the device is about the size of half a loaf of bread, and can easily be taken on trips. Chin straps keep the mask in place during sleep (although they also make it look like you're wearing a bandage that holds your head together). In studies, compliance ranges from 50% to 60%.
Additional treatments for snoring and sleep apnea include weight loss, antihistamines to clear the sinuses, nasal dilators, and avoidance of alcohol at night. Snorers are also encouraged to change their sleep posture to avoid lying on their backs. Sometimes doctors recommend a variety of oral appliances, similar to an orthodontic retainer, which may improve airway pressure.
In the 1990s, a snoring surgery that involved "lasering off" bits of flesh from the soft palate of the mouth was popular. But this turned out largely to be a disaster because "it doesn't necessarily unblock your breathing. You decrease the snoring sounds -- the feedback to patient and bed partner is that they don't snore. But they might still have obstruction," says Strollo.
A last resort is maxillomandibullar advancement, a major operation. In this procedure, the jaw is surgically broken in two places and moved forward a centimeter. After the surgery, the patient is required to wear a retainer for 18 months. Strollo recommends it in fewer than 5% of the patients he sees.
"The challenge we have is to have patients take sleep seriously as part of their health," Collop says. "People think sleep can be put aside for other, more important things. We think it's as important as what you eat and how much you exercise."