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FOR years physicians have suspected that snoring is generally associated with sleep apnea, and sleep apnea was linked to sudden cardiac death.

Unlike heart attack not related to sleep apnea, which could occur anytime of the day, cardiac death from sleep apnea happens while the patient is asleep.

A 69-year-old pulmonologist friend of mine in Texas, who had sleep apnea, but did not use his CPAP the evening before, developed cardiac arrest in his sleep at around 2 a.m. on July 15, 2013.

Obviously, it was a case of sudden death from anoxia (lack of oxygen) and fatal arrhythmia (serious heart irregularity) caused by his sleep apnea.

In an article in the June 11, 2013 in the Journal of American College of Cardiology, Dr. Apoor Gami, a cardiac electrophysiologist at the Midwest Heart Specialists-Advocate Medical Group in Elmhurst, Ilinois, and leader of the study, confirmed the link between sleep apnea and sudden cardiac death.

What is sleep apnea?

Usually associated with snoring, sleep apnea means the involuntary cessation of breathing during sleep, which deprives the individual valuable oxygen during the episodes.

This breath-holding initially lasts for 10 seconds and progresses to 20 to 30 seconds, and each episode is immediately followed by gasping for air.

This cycle could repeat itself several times (20 to 100 times per hour) the whole night long.

The snorer is totally oblivious of all this and only the roommate is aware of this bothersome snoring and scary sleep apnea.

How common is sleep apnea?

The incidence is about 2 percent among middle-aged women and 4 percent among men of that age group, which is similar to the incidence of diabetes and asthma.

Sleep apnea is a primary risk factor for hypertension (high blood pressure).

Breath-holding during sleep affects about 12 million American adults, but many more are not reported or are not diagnosed.

Some studies say the incidence is rising because of the epidemic of obesity.

How does obesity contribute to sleep apnea?

In some people, especially after middle age and who are obese, the muscles of the upper airways in the back of the throat, like the soft palate (the back end of the roof of the mouth), the uvula (tiny appendage that hangs down), tonsils, adenoids, become flabby and vibrate with the airflow, causing the various classical noises of snoring.

These structures could also cave in and out (like a floppy valve) with respiration, blocking the upper airway and causing sleep apnea and oxygen deprivation.

Besides the anatomical component, there could also be central (neuro-hormonal) factor, especially among obese persons.

Weight reduction could help some individuals.

How is the diagnosis made?

To confirm the diagnosis is sleep apnea, a Sleep Test is performed, where the patient sleeps in a Sleep Laboratory, attached to brain, heart and blood oxygen monitor, with a video cam showing his/her sleep activity, body movements, etc.

All these data are then analyzed the following day.

If the patient stops breathing for 10 seconds or more at least five times every hour while asleep, the diagnosis is confirmed.

What are the complications of sleep apnea?

The person wakes up with a dry mouth and throat, perhaps with a headache, and a lousy feeling akin to a hangover.

There may also be fatigue and sleepiness throughout the day, together with some memory deficiency, poor attention and concentration, and bad mood — all signs of lack of sleep, due to sleep apnea.

The psychological stress of all this impacts negatively on the individual.

The recurrent transient hypoxemia (low blood oxygen level) and daily impairment of sleep are added risk factors for the development of hypertension and coronary heart disease.

Some develop sudden death due to cardiac arrhythmia (heart irregularity) from lack of oxygen, as the new study shows.

What is the incidence of sudden cardiac death?

In general sudden death kills 450,000 people annually in the United States, from various causes which lead to cessation of breathing, triggering serious abnormality in the heart’s electrical system, ending as fatal irregularity of the heartbeats, if resuscitation is not performed immediately.

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Does singing lessen snoring?

Singing helps tone the flabby muscles of our upper airways, the soft palate, in particular.

Singing exercises for 20 minutes a day appear do the trick for some.

Belting out a few songs, even off key, everyday in the family room or in the shower might annoy your house mate, but it will at least please her in bed every night when you snore less.

Are “snore stoppers” effective?

“Snore aids” advertised in the various media, such as nostril clips, nasal or throat sprays, magnetic wrist bands do not work to stop snoring, much less cure sleep disorders.

One contraption, the jaw sling, which prevents the jaw from dropping while the person is asleep, appears to show promise for some snorers, but uncomfortable to wear.

What is the non-specific therapy?

Weight loss for those who are overweight can minimize the episodes of sleep apnea.

Avoidance of sleeping pills, sedatives and alcohol, all of which increase the frequency and duration of sleep apnea, is most essential.

Lying flat on the back induces sleep apnea for a lot of people.

This could be avoided by placing a pillow at the back and lying on the side.

What are the various treatment regimens?

Sleep apnea must be treated because the risk of sudden death is real and scary.

The three modalities are:

(1) Physical or Mechanical,

(2) Surgery, and

(3) Non-specific therapy.

The specific prescription depends on the medical examination and laboratory findings.

The physical or mechanical treatment works only when used as the patient sleeps and apnea returns when the regimen is not utilized.

There are two forms: Continuous Positive Airway Pressure (CPAP) and Dental/Oral Appliances.

CPAP, the most commonly prescribed, uses a snugly fitted face mask where continuous positive pressure air is blown into the nose, forcing the airway to stay open for proper breathing.
 
Dental/oral appliance, which is fitted by an ortho dentist, uses a device that moves the lower jaw forward to cause an under bite, which opens the airway.

What is the surgical treatment?

Surgery removes tissues, like nasal polyps, adenoids, tonsils and any oro-pharyngeal deformities that causes obstruction to airflow.

One of them is called uvulopalatopharyngoplasty, which excises tissues at the back of the throat.

The success rate is low, between 30-60 percent and it is hard to know which patients will benefit from it, its side effects and eventual outcome.

The others are tracheostomy (creating a hole in the windpipe for those with severe obstruction, which is not too common), surgical reconstruction for those with deformities, and surgery to treat diet-and-exercise-resistant obesity, which contributes to sleep apnea.

Indeed, sleep apnea is a warning and nothing to snore about.

***

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