Sleep Disorders

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Snoring and sleep related breathing disorders

Sleep related disorders include snoring, obstructive sleep apnea (OSA), central sleep apnea (CSA), upper airway resistance syndrome (UARS), and sleep related hypoventilation or hypoxemic sysdromes.

Snoring

A very common condition caused by the obstruction of air into the lungs. The "extra" air gets redirected into the mouth, creating a vibration of the soft tissue of the palate.

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Snoring

Obstructive sleep apnea (OSA)

Occurs when a patient stops breathing during periods of sleep; usually as a result of blockage (obstruction) in the airway.

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Obstructive sleep apnea (OSA)

Central sleep apnea (CSA)

Pauses in breathing while asleep that are not caused by an obstruction but rather by a disorder of the central nervous system.

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Central sleep apnea (CSA)

Upper airway resistance syndrome (UARS)

A condition in which the upper airway is reduced during sleep, resulting in disturbed sleep; can lead to snoring, daytime sleepiness, cognitive impairment, un-refreshing sleep, and frequent arousals from sleep.

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Upper airway resistance syndrome (UARS)

Sleep related hypoventilation or hypoxemic syndromes

May be the result of a decreased response to low oxygen or high carbon dioxide during wakefulness and sleep and are characterized by frequent episodes of shallow breathing lasting longer than 10 seconds during sleep.

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Sleep related hypoventilation or hypoxemic syndromes

Snoring

You snore when the flow of air from your mouth or nose to your lungs makes the tissues of your throat vibrate when you sleep. This can make a loud, raspy noise. Sometimes people who snore also have sleep apnea, which means you stop breathing at times during sleep. Sleep apnea can make you feel tired during the day. It can be related to other health problems like high blood pressure and heart disease.

You may be able to treat snoring by making changes in your lifestyle and in the way you prepare for sleep. For example:

  • Lose weight if you're overweight.
  • Go to bed at the same time every night, and get plenty of sleep.
  • Sleep on your side, not on your back. Try sewing a pocket in the middle of the back of your pajama top, putting a tennis ball into the pocket, and stitching it closed. This will help keep you from sleeping on your back.
  • Limit your use of alcohol and medicines such as sedatives before you go to bed.
  • Quit smoking.
  • Raise the head of your bed 4 in. (10 cm) to 6 in. (15 cm) by putting bricks under the legs of the bed. (Using pillows to raise your head and upper body won't work.)
  • Promptly treat breathing problems, such as a stuffy nose caused by a cold or allergies.
  • Try a nasal dilator to help keep your airway open. This is a device, such as nose strips or disks, that you attach to the outside of your nose while you sleep. Nose strips widen the nostrils and improve airflow. Nasal disks create back-pressure in your airways that may help keep them open.

If you have nasal congestion, you can try clearing your nasal passages or using medicines such as decongestants and nasal corticosteroid sprays. These open the airway, permitting a smoother airflow. They may reduce snoring. Be safe with medicines. Read and follow all instructions on the label. Don't use the medicine longer than the label says.

Oral breathing devices sometimes can treat snoring, especially if it is caused by jaw position during sleep. These devices push the tongue and jaw forward to improve airflow.

If your bed partner is bothered by your snoring, he or she may try using earplugs or machines that play ambient music or natural sounds. These can block or cover up the noise.

Nutritional counseling can help people who snore and are overweight.

Positive airway pressure (PAP) therapy is a generic term applied to all sleep apnea treatments that use a stream of compressed air to support the airway during sleep. With PAP therapy, you wear a mask during sleep. A portable machine gently blows pressurized room air from into your upper airway through a tube connected to the mask. This positive airflow helps keep the airway open, preventing the collapse that occurs during apnea, thus allowing normal breathing. For optimal improvement, it's important to use your PAP machine every time you sleep – including naps.

Overall PAP therapy is a safe and effective treatment, however there are a few counter-indications. Be sure to tell your doctor if you have bullous lung disease, pneumothorax, cerebrospinal fluid leak or severe epistaxis (nosebleeds).

An oral appliance is a device worn in the mouth during sleep to keep the soft tissue in the airway from collapsing. While typically not as effective as Positive Airway Pressure (PAP) therapy, an oral appliance is an excellent option for individuals who are unable to tolerate CPAP. Oral appliances are not recommended for all types of sleep apnea.

Not all dentists are trained to treat sleep apnea, so ask one of our physicians for a referral to a dentist knowledgeable about oral appliances who can recommend a style to match your needs. Your physician may recommend that you have a follow up sleep study to test the effectiveness. It is critical that you follow up with your dentist regularly to ensure the device does not cause your teeth to shift or your bite to change.

Obstructive sleep apnea (OSA)

Obstructive sleep apnea occurs when the airway completely or partially collapses repeatedly throughout the night. During sleep, the soft tissues in the throat relax. For someone with OSA (obstructive sleep apnea), these tissues can block the upper airway enough to disrupt sleep related breathing.

When the airway is blocked, the oxygen levels in the body drop causing the person to wake up long enough to begin breathing normally again. These awakenings are often very brief, sometimes only a few seconds, and this is the reason that the affected individual is often not aware that they have these awakenings during sleep. This pattern repeats during the night, and someone with severe sleep apnea may wake up hundreds of times each night. Even though the awakenings are usually very short, they fragment and interrupt the sleep cycle. This sleep fragmentation can cause significant levels of daytime fatigue and sleepiness, which is a common symptom of sleep apnea.

Obstructive sleep apnea in children
While some types of snoring can be considered benign in adults, snoring or noisy breathing is never normal in children. Obstructive sleep apnea in children is often overlooked in kids because the symptoms are more different in children than they are in adults and they tend to be more subtle. Not all children with OSA snore, and when they are tired they rarely nap, instead they become hyperactive (and may mimic those children with attention deficit-hyperactivity disorder) or develop behavioral problems. These behavioral problems may manifest themselves as irritability, lack of concentration, easy distractibility, and acting out which can lead to problems at school. Additionally, many children with obstructive sleep apnea are not overweight, so they don't fit the stereotypical picture of some with sleep apnea.

Children with medical conditions impacting the shape of their face, nose and airway or neuromuscular system are at a higher risk of developing sleep apnea. Parents of children with disorders such as Down Syndrome should be aware of the elevated risk and should be evaluated when there has been a change in behavior that may be related to OSA. Common symptoms of obstructive sleep apnea in children may include:

  • Snoring
  • Daytime cognitive and behavior problems, including problems paying attention, easy distractibility, aggressive behavior and hyperactivity
  • Mouth breathing
  • Enlarged tonsils and adenoids
  • Problems sleeping and restless sleep
  • Parasomnias such as sleep walking or night terrors
  • Bed wetting
  • Failure to thrive (weight loss or poor weight gain)
  • Excessive daytime sleepiness

Snoring is a major symptom of obstructive sleep apnea. But even though most people who have sleep apnea snore, not all people who snore have sleep apnea.

If you have sleep apnea:

  • How loud and how often you snore changes often.
  • Your snoring disturbs your sleep.
  • You stop breathing at times, and oxygen levels in your blood go down.

If you snore but don't have sleep apnea:

  • Your snoring is steady.
  • Your snoring doesn't disturb your sleep.
  • You don't stop breathing, and oxygen levels in your blood don't change.

Obstructive sleep apnea usually occurs when the throat muscles and tongue relax during sleep and partly or completely block the airway. When you stop breathing or have reduced flow of air into your lungs during sleep, the amount of oxygen in your blood decreases briefly.

Obstructive sleep apnea can also occur if you have enlarged tissues in your nose, mouth, or throat. For example, you may have enlarged tonsils. During the day when you are awake and are standing up, this may not cause problems. But when you lie down at night, the tonsils can press down on your airway, narrowing it and causing sleep apnea.

In children, a common cause of sleep apnea is large tonsils or adenoids.
Obstructive sleep apnea may occur if you have a facial bone deformity or a jaw problem.
You're more likely to have sleep apnea if you:
     Are overweight.
Fat in the neck area can press down on the tissues around the airways. This narrows the airways and can cause sleep apnea.
     Use certain medicines.
Medicines such as sleeping pills and sedatives can relax the muscles and tissues in the throat, causing it to narrow.
     Drink alcohol.
Alcohol affects the part of the brain that controls breathing. This may relax the breathing muscles and cause narrowing of the airway.
     Sleep on your back.
Sleeping on your back and using one or more pillows may make sleep apnea worse.

There are 3 types of obstructive breathing events:
Apnea: A period of at least 10 seconds during which there is a complete or near complete pause in breathing.
Hypopnea: A decrease in airflow lasting at least 10 seconds.
Respiratory effort related arousal (RERA): A limitation in breathing that results in increased respiratory effort and culminates in an arousal; it does not meet the criteria from an apnea or hypopnea.

The gold standard for diagnosis is a Polysomnography (PSG), or, sleep study. This test is performed while the patient is asleep at a sleep laboratory, and monitors brain waves, blood oxygen levels, heart rate and breathing, as well as eye and leg movements. A home monitoring device may be a useful alternative for some patients under the guidance of a knowledgeable sleep professional.

However, the sleep test itself does not provide the location of the obstruction, so evaluation methods of the upper airway are necessary to identify potential sites of collapse that lead to OSA.

Nasopharyngoscopy is an office procedure in which a flexible fiberoptic endoscope is introduced through the nose and throat to observe anatomical structures that narrow the airway and compromise airflow and cause snoring.

Sleep endoscopy is similar to Nasopharyngoscopy, however it is performed under mild sedation (with an hypnotic drug, such as propofol) and it is an outpatient procedure. The objective of this test is to reproduce what occurs to the patient's upper airway in a sleep state, and identify structures and areas causing the obstruction.

Still under our research protocols, imaging methods such as computerized tomography scans (CTs), awake and sleep magnetic resonance imaging (MRI) may provide useful information as well in select candidates. CTs are routinely used in the pre-operative evaluation of patients who undergo any surgery that involves the facial skeleton such as maxillomandibular advancement.

These tools should be used together to establish a diagnosis and guide the physician's decision-making towards the appropriate treatment for each patient.

Once the diagnosis of obstructive sleep apnea (OSA) is established, Stanford Sleep Group believes the patient should be included in deciding an adequate treatment strategy.

Non-surgical treatments include Continuous Positive Airway Pressure (CPAP), positional therapy, use of oral appliances, nasal resistors, oropharyngeal exercises, and behavioral measures, including weight loss when indicated, frequent physical exercise, avoidance of alcohol and sedative medication before bedtime.

Continuous positive airway pressure (CPAP) remains the primary treatment for most adults with obstructive sleep apnea, however some patients don't accept or cannot tolerate it, or have primarily correctable upper airway anatomic problems that can be causing the obstruction.

For these cases the advances in upper airway surgical techniques and appropriated patient selection can offer a definitive solution for OSA. In other cases surgery can be part of a comprehensive approach, improving the severity of obstructive sleep apnea and/or making the use of CPAP or oral appliances more tolerable.

Importantly, a detailed clinical and endoscopic - and in some cases radiologic evaluation - in conjunction with the sleep test will provide us with the available data to decide with the patient what is the best approach, in an individualized manner.

Central sleep apnea (CSA) & Sleep related hypoventilation/hypoxemic syndromes

Central sleep apnea (CSA) and sleep related hypoventilation/hypoxemic syndromes are sleep related respiratory conditions.

CSA occurs when you repeatedly stop breathing during sleep because your brain does not cue your body to breathe. This differs from obstructive sleep apnea since in central sleep apnea, there is no breathing effort because there is no drive to breathe. In its primary form, CSA is the result of instability of the breathing control system as the individual transitions from wakefulness to sleep.

Sleep related hypoventilation/hypoxemic syndromes may be the result of a decreased response to low oxygen or high carbon dioxide during wakefulness and sleep and are characterized by frequent episodes of shallow breathing lasting longer than 10 seconds during sleep.

Continuous positive airway pressure (CPAP) is typically ineffective at resolving these conditions.

Bilevel airway pressure (BPAP) or auto servo-ventilation (ASV) devices may help to normalize sleep related breathing in patients with central sleep apnea or sleep related hypoventilation/hypoxemic syndromes.

Positive airway pressure (PAP) therapy is a generic term applied to all sleep apnea treatments that use a stream of compressed air to support the airway during sleep. With PAP therapy, you wear a mask during sleep. A portable machine gently blows pressurized room air from into your upper airway through a tube connected to the mask. This positive airflow helps keep the airway open, preventing the collapse that occurs during apnea, thus allowing normal breathing. For optimal improvement, it's important to use your PAP machine every time you sleep – including naps.

Overall PAP therapy is a safe and effective treatment, however there are a few counter-indications. Be sure to tell your doctor if you have bullous lung disease, pneumothorax, cerebrospinal fluid leak or severe epistaxis (nosebleeds).

Upper airway resistance syndrome (UARS)

Upper airway resistance syndrome (UARS) is a condition that was first identified and described at Stanford University. It is very similar to obstructive sleep apnea (OSA) in that the soft tissue of the throat relaxes, reduces the size of the airway, and results in disturbed sleep and consequent daytime impairment, including excessive daytime sleepiness.

Although the increase in upper airway resistance is not enough to meet criteria of the sleep disordered breathing that define obstructive sleep apnea, the resulting increase in breathing effort does cause a brief awakening from sleep that is often undetected by the affected individual. When this scenario repeats throughout the night, sleep is impaired, just like in obstructive sleep apnea.

The symptoms of UARS tend to be similar to OSA but may be less in severity. People with UARS usually complain of snoring, daytime sleepiness, cognitive impairment, un-refreshing sleep, and frequent arousals from sleep.

There are several ways to treat UARS; however, treatments taken are different for adults and children.

Adults
Continuous Positive Airway Pressure (CPAP) is the most effective treatment for sleep apnea, however there are also surgical options, oral appliances, and behavioral approaches that can be used to treat OSA. Weight loss, although always a good idea in reducing obesity-related conditions (e.g., hypertension, diabetes), is considered supplementary or adjunctive therapy rather than primary treatment for OSA. Other underlying medical conditions, especially nasal allergies, should also be treated. A nasal steroid might help improve nasal obstruction associated with allergies as well as the OSA symptoms. For a more comprehensive explanation of the treatment options for this condition, go to the Treatments Section in the Tests and Treatments Section. The same treatments that are successful for OSA can be used to treat UARS. While CPAP remains the most effective treatment, this population may find it difficult to tolerate. Alternative treatments such as surgery, oral appliances, positional therapy (restricting the individual to sleeping on his/her sides), and weight loss may be effective in improving sleep disordered breathing in individuals with UARS.

Children
Surgery is usually the first line of treatment for children; removing a child's enlarged tonsils and adenoids by a tonsillectomy and adenoidectomy (or T&A) will often resolve the OSA. However, in some children, CPAP, further surgery, or specialized orthodontic treatment may be necessary to treat the OSA.

Positive airway pressure (PAP) therapy is a generic term applied to all sleep apnea treatments that use a stream of compressed air to support the airway during sleep. With PAP therapy, you wear a mask during sleep. A portable machine gently blows pressurized room air from into your upper airway through a tube connected to the mask. This positive airflow helps keep the airway open, preventing the collapse that occurs during apnea, thus allowing normal breathing. For optimal improvement, it's important to use your PAP machine every time you sleep – including naps.

Overall PAP therapy is a safe and effective treatment, however there are a few counter-indications. Be sure to tell your doctor if you have bullous lung disease, pneumothorax, cerebrospinal fluid leak or severe epistaxis (nosebleeds).

An oral appliance is a device worn in the mouth during sleep to keep the soft tissue in the airway from collapsing. While typically not as effective as Positive Airway Pressure (PAP) therapy, an oral appliance is an excellent option for individuals who are unable to tolerate CPAP. Oral appliances are not recommended for all types of sleep apnea.

Not all dentists are trained to treat sleep apnea, so ask one of our physicians for a referral to a dentist knowledgeable about oral appliances who can recommend a style to match your needs. Your physician may recommend that you have a follow up sleep study to test the effectiveness. It is critical that you follow up with your dentist regularly to ensure the device does not cause your teeth to shift or your bite to change.

Sleep surgery can be an excellent option for certain populations of sleep apnea patients. Most surgeries work by increasing the size of the airway to reduce the likelihood that it will collapse during sleep.

The Stanford Sleep Surgery Division offers a range of surgical options to treat obstructive sleep apnea. Our knowledgeable pediatric and adult sleep surgeons work closely with the Stanford Sleep Disorders Clinic to choose the best surgical option for each patient based on factors such as anatomy, severity of sleep apnea and age.

It's important to realize that surgery is not an appropriate treatment for all patients. While the procedures performed at Stanford are safe, every surgery comes with some risk, so it’s important to carefully explore the risk to benefit ratio with your doctor.

Positional therapy
Some people only have sleep apnea symptoms when they're sleeping on their back. Those individuals can effectively resolve or reduce their sleep disordered breathing by sleeping exclusively on their side. Positional therapy is not appropriate for everyone and for many will not provide enough relief when used on its own.

There are several approaches to train yourself to avoid sleeping on your back. One easy method is to sew a tube sock lengthwise down the back of a sleep shirt and then put 2-3 tennis balls inside the sock. This will make it uncomfortable to lie on your back. You can also use foam positional pillows to manage your sleep position. Or you can buy an alarm that can sense when you roll onto your back and will sound an alarm to cue you to change positions. While these types of tools can be helpful, positional therapy has its limitations because there's no fool proof method to control body position. Therefore, it's critical that you discuss this approach with your sleep physicians so you understand the risks of untreated sleep apnea.

Weight loss
Sleep disordered breathing can be related to obesity, so for some over-weight individuals, losing weight can reduce or eliminate their symptoms. However, dieting and weight loss can be a very difficult task given the daytime fatigue that often accompanies sleep apnea. If you're overweight, talk to your doctor about using a PAP therapy as a tool for weight loss. Treating the apnea can give you the energy you need to maintain a healthy diet and exercise program to lose weight.
You should be aware that weight isn't the only factor for sleep disordered breathing. If there are anatomic abnormalities present, weight loss alone won't be sufficient to normalize breathing.

Avoiding alcohol and sedative medication
Alcohol use and sedative medication impairs breathing during sleep by relaxing the muscles that support the airway, making it more likely to collapse. In addition, they blunt the body's reaction to low oxygen levels. Even people who normally don't snore can have issues after a night of drinking. So if you have untreated sleep apnea, the consequences of alcohol and sedative use will be even more dramatic.

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