Treatment of apnea and snoring with Deniplant
Snoring can be defined as a sleep disorder that prevents rest during the night, inducing both insufficient and problematic sleep as well as numerous respiratory problems.
The Chinese consider snoring a sign of health. However, doctors are not of the same opinion. “Snoring is a serious problem, but less taken into account, perhaps because it has become the subject of some tasty jokes. But doctors consider it a serious disease and treat it as such. Snoring torments the lives of many of us and leads to serious complications”, mentioned Prof. Dr. Ioan Paul Stoicescu, primary pulmonologist at the “Marius Nasta” Institute of Pneumology in Bucharest, during a press conference.
Snoring occurs during sleep together with inspiration, when the soft tissues of the palatine wave vibrate when air passes. A medium snoring easily reaches a sound level of 45 dB to 60 dB (the noise of the human voice) while a strong snoring can reach 95 dB which corresponds to the sound of a truck passing by.
Obviously, snoring disturbs the lives of people in the environment of the affected one and can cause insomnia
1.1 Prevalence of snoring
According to a worldwide statistic, snoring affects over 40% of adults.
About 38% of people between 25-34 years old snore, and the percentage increases to over 53% for people aged between 45-54 years old. (BMJ 1997;314:860).
The prevalence of snoring increases until the age of 60, after which it decreases, which could be due to the shorter time spent sleeping by the elderly and also to the reduced life expectancy of snorers.
At the same time, according to statistics, it seems that approximately 80% of couples affected by this problem periodically sleep in separate rooms.
1.2 Predisposition to snoring
Snoring is more common among men and overweight people and increases with age.
Between 30-35 years old, about 20% of men and 5% of women snore regularly, and at 60 the percentage increases to about 60% of men and 40% of women.
However, even the young people are not unaffected. Following a survey conducted by the University of Erlangen in Germany among medical students, it was found that 61% of subjects of both sexes snore, as indicated by their partners.
Men are more prone: the ratio between men and women is about 2:1, but balances out with age
1.3Snoring and the connection with sleep phases
In short, the division of sleep phases refers to REM (rapid eye movement) and non-REM moments. snoring can occur during any of these moments or only in certain phases, the most common being during the REM phase because one of its characteristics is represented by the decrease in muscle tone, an important event in the physiological mechanism of snoring.
During REM sleep, the brain sends relaxation signals to all the muscles in the body, slowing down the functions to promote rest. This relaxation is also induced in the muscles of the palate, tongue and throat, producing the narrowing of the airways and the sound vibrations characteristic of snoring.
1.4Snoring levels and clinical implications
The average resistance encountered by the air flow when passing through the upper respiratory tract, determined by possible narrowings, can cause a certain level of snoring, but which is not generally associated with sleep interruption or major respiratory problems.
If this resistance increases, for various reasons, the body’s efforts to maintain adequate ventilation during breathing can cause a certain level of agitation during sleep, but not high enough at the nervous level to cause a decrease in the amount of oxygen reaching the brain (hypoxia), in this case the so-called syndrome of the resistance of the upper legs is defined. (UARS)
If the resistance exceeds even this average level, ventilatory efforts can no longer ensure the adequate level of oxygen that will decrease in the blood and the result refers to sleep fragmentation, a term called obstructive sleep apnea-hypopnea syndrome.
1.5 Evaluation of the snoring problem
During the physical examination, the patient’s weight is taken into account with the calculation of the mass index (BMI), the neck circumference, the visualization of the neck, the nasal cavities, to determine the narrowing of the airways.
For a careful evaluation, it is necessary to discuss both with the bed partner and with the family members, as well as a complete physical examination.
The person’s medical history, sleeping habits, hygiene, possible daytime sleepiness symptoms, daytime sleep episodes and frequency of awakenings during night sleep must also be taken into account.
2.The physiological mechanism
Snoring occurs when there is an obstruction to the airflow in the area behind the nose and mouth, where the upper part of the pharynx and the base of the tongue meet the palatine veil and the uvula.
In this area there are soft tissues that can descend under the effect of weight, partially blocking the air circulation. Snoring occurs when these structures begin to vibrate.
2.1.The mechanism in Obstructive Sleep Apnea:
The collapse of the airways in ASO produces intense or deep snoring that is sonically translated by grunting, grunting, gasping, followed by stopping breathing for 10 seconds or more. During this short period of apnea, the snoring stops. Progressive asphyxia causes the sudden awakening of the patient and thus the normal respiratory flow is restored. Once breathing resumes, the patients fall asleep again and the intense snoring starts again. This sequence of events is repeated dozens of times a night leading to the important fragmentation of sleep.
Stopping breathing causes a decrease in the concentration of blood gases: a decrease in the partial pressure of oxygen in the arterial blood and an increase in the partial pressure of carbon dioxide. Hypoxia during sleep overloads the nervous system and the cardiovascular system, in time these patients will develop arterial hypertension, coronary artery disease and present worsening of ASO, the therapeutic intervention being more difficult.
Naturally, breathing is done through the nose, but some individuals cannot breathe that way due to obstruction of the nasal passages, obstruction that can be caused either by a deviated septum, allergies, sinus infections, enlarged tonsils. In the case of adults, the most common causes are represented by septal deviations or tissue inflammation due to allergies, and in the case of children, enlarged tonsils are most often involved.
Most mouth breathers snore because the passage of air through the mouth causes various degrees of tissue vibrations.
2.2.Soft palate and snoring:
The soft palate is a muscular extension of the bony roof (hard palate) of the mouth. It separates the back of the mouth (oropharynx) from the nasal passage structures (nasopharynx). It is in the form of a sheet attached on three sides and the fourth is left free behind the mouth. This structure is important in the processes of breathing and swallowing.
While breathing through the nose, the soft palate moves forward and leaves the area behind the lungs free.
During swallowing, it moves back to cover the nasal passage thus directing food and fluids to the digestive tract.
Uvula or humus: it is a small extension of the free edge of the soft palate. It assists his function and also has a phonatory role in certain languages (eg Hebrew) for the production of certain types of guttural sounds.
In most cases, the vibration of these two structures is the one involved in snoring, being the site of action in the case of surgical therapies.
2.3.Airway narrowing and snoring:
The tonsils are two other structures with a role in immunity, the detection of infections, being located behind the mouth on one side and on the other side of the neck in the oropharynx. They are also called palatine tonsils. In the case of infections, often in children and young people, they become inflamed, increasing in size and narrowing the passage, possibly even leading to serious obstructions. After treating the infection, it is generally considered that they do not regain their original size, they decrease but can remain in a hypertrophied state, narrowing the airways.
Another influence in the case of snoring can be the position and size of the tongue.
An interesting detail is that astronauts snore much less often in outer space, because in the absence of a gravitational force the upper parts of the airways no longer collapse.
3. Factors that predispose to snoring
3.1 Consumption of alcohol or sleeping pills:
Through the increased relaxation of the muscles, including that of the neck, from the walls of the airway, which collapse inwards narrowing the airway.
The same effect as in the case of drugs that produce that much deeper level of sleep with the effects of a sharp decrease in muscle tone.
Overweight or obese people, especially those with adipose tissue around the neck, a diameter of over 43 cm.
This amount of extra fat around the neck affects muscle tone.
3.3 Mouth breathing:
Caused by whooping cough, septal deviation or polyps, especially in children.
3.4 The position:
Sleeping on your back favors airway obstruction, both due to the effect of gravity on the neck muscles and pharynx tissues, as well as the sliding of the tongue towards the back of the mouth. These structures, together with the tonsils, intervene in the usual path of the air, causing vibrations transposed by the specific sound.
It produces inflammation and even swelling of the mucous membrane of the airways from the daily passage of harmful substances, producing an at least moderate compromise of normal physiological functions, increasing the chances of snoring.
3.6 Anatomical conformation:
(e.g.: small jaw, large shoulder, etc.) or even the shape of the head – in people with heads closer to the round shape, the tissues have a shorter distance to travel until the airways are obstructed (Sleep and Breathing2001;5:79-91)
A too long palatine or uvula, cysts or tumors can also narrow the upper airways, favoring snoring, but these are rare cases.
3.7 The existence of allergies
These conditions can make breathing difficult both during the day and at night by obstructing the nasal passage, so the person is forced to breathe through the mouth, hence the already discussed implications related to the muscles of the oropharynx.
Administering anti-allergy medications an hour or even earlier before bedtime can ease breathing and therefore also improve snoring.
3.8 Cold symptoms:
Nasal congestion that occurs during a cold or due to respiratory diseases can be a main factor that leads to the appearance of snoring.
Blocked nasal passages (“stuffy nose”) require an extra effort to draw air during inspiration. This creates a depression in the pharynx, which pulls the soft tissues inward and leads to snoring.
For this reason, people who suffer from allergies, whooping cough or sinusitis most often snore
4. How to determine if there is a real medical problem
People who sleep next to a person who snores can report certain signs that indicate the existence of a real problem. They can witness episodes of apnea (stopping breathing), agitated breathing, uncontrolled movements of the limbs or various parts of the body, episodes that represent an important reason for referral to a specialist doctor.
If a person’s sleep is interrupted due to snoring, then he or she may also notice other symptoms such as difficulty waking up in the morning or the feeling of insufficient sleep as well as more or less frequent moments of sleepiness during the day,
4.1 Types of sleep studies:
.From home (with a certain degree of supervision) which includes the measurement of some basic parameters of sleep and breathing, pulse oximetry (measuring the level of oxygen in the blood), recordings of movements, snoring and apneic events.
- Complete sleep study (polysomnography), the clinically performed method, is the investigation of choice for the purpose of establishing the diagnosis of the main disorders during sleep.
Non-invasive, risk-free investigation, dedicated to the recording of electrophysiological parameters with sleep stages and respiratory events: apnea, hypoapnea, snoring, ARDS (increased upper airway resistance syndrome). It is performed in specially equipped polysomnography laboratories.
4.2Epworth sleepiness scale:
The Epworth sleepiness scale is a test based on the patient’s personal testimony that determines the severity of sleepiness. The person grades the possibility and probability of falling asleep during some specifically chosen activities. Grading is:
|0 = Unlikely to fall asleep
|1 = Minimal risk of falling asleep
|2 = Moderate risk of falling asleep
|3 = Increased probability of falling asleep
|Rest and read
|Idle state in a public place
|As a passenger in a car trip, for an hour, without breaks
|Rest in the afternoon
|I stood and talked to a person
|Sit quietly after the meal without alcohol
|In the car, during traffic stops
After grading each category, the total score is calculated and the working margin is between 0-24, the highest score represents the highest degree of drowsiness.
0-9 = Average sleepiness during the day
10-15 = Excessive sleepiness during the day
16-24 = Moderate to severe drowsiness
People who suffer from that type of primary snoring that does not involve other medical problems generally get a score lower than 10 and individuals with moderate sleep apnea get a score higher than 16.
5.The clinical importance of snoring
It is very important to differentiate if snoring is an isolated problem or a result accompanying another medical condition. It is most often associated with Obstructive Sleep Apnea (OSA) in about 20-40% of people who snore or Upper Airway Resistance Syndrome (UARS).
In addition, OSA is also associated with increased risks of cardiovascular diseases due to the increased prevalence of hypertension in the case of patients with this type of apnea. And a person suffering from apnea is 3-4 times more likely to be affected by a stroke or myocardial infarction.
In the case of isolated snoring, hypertension is not associated as the primary problem, according to studies.
5.1 Obstructive sleep apnea:
Sleep apnea is a condition of the respiratory system characterized by repeated, frequent breathing pauses during sleep. The duration of the air flow stop period is 10 seconds. SAS presents different degrees of severity: mild, moderate or severe, depending on the duration and frequency of episodes of apnea or bradypnea (decrease in breathing rate)
In OSA, the air flow stops despite the respiratory impulses, due to the obstruction or narrowing of the upper airways, usually at the nasopharyngeal level. During sleep, the muscles of the pharynx and tongue relax and cause partial obstruction of the airways. Stopping breathing in ASO leads to a decrease in the concentration of oxygen in the blood (hypoxia).
In most patients with ASO, the configuration of the airways is structurally affected, which predisposes to obstruction, or there are obvious anatomical defects in the nose, mouth or throat, such as tonsillar (tonsillar) hypertrophy. In the supine position, during sleep, the hypertrophied tonsils contribute to the narrowing of the airways, triggering sleep apnea. During the day, during wakefulness and in the orthostatic position, these physiopathological changes do not occur.
as risk factors: – age: ASO appears more frequently after the age of 30
- male gender: studies from sleep research laboratories show that ASO is 5 times more frequent in males
- family history. Family history of sleep apnea increases the risk of developing this condition
5.2 Other deficiencies:
A recent study showed that snoring, like other breathing problems during sleep, can increase the risk of developing cancer. American researchers have discovered that depriving the body of oxygen increases the probability of the appearance of cancerous tumors, reports Independent.ie.
They are of the opinion that the simple help given to people who face this problem, snoring, could make the number of cases diagnosed with cancer decrease.
In the study carried out by the University of Wisconsin-Madison, in the USA, it was shown that people who snore strongly have an almost 5 times higher risk of being diagnosed with cancer. Those who snore moderately have a risk of facing the disease twice as high as those who are not affected by this problem.
As expected, people who suffer from sleep apnea have the highest risk of cancer, a condition already associated with obesity, diabetes, high blood pressure, heart attacks and strokes.
Hypertension and heart disease are more common in snorers, both men and women, due to insufficient oxygenation during sleep – a fact that has serious consequences for the cardiovascular system. People who are snoring are recommended to ask the doctor for a periodic blood pressure check.
6.Methods of treatment
Correction of nasal obstructions
In cazul sforăitului foarte puternic – care se manifestă în orice poziţie sau care este foarte deranjand pentru restul familiei – puteţi apela la medic pentru a investiga dacă nu sunteţi afectat de apnee în somn.
Un medic ORL va examina nasul, gura, vălul palatin şi gâtul şi va indica dacă este necesară corectarea unei obstrucţii nazale (deviaţie de sept sau polipi). O examinare în laboratorul de somnologie ar putea fi necesară pentru a determina cât de grav este sforăitul şi dacă este cuplat cu apneea în somn, afectând sănătatea pacientului.
De-a lungul ultimilor 20 de ani au fost puse la punct diferite tehnici chirurgicale la nivelul vălului palatin sau omuşorului: uvulopalato-faringoplastia (populară în anii ’80), interveţii de palatoplastie cu laser (populare în anii ’90) sau cu un ac incandescent (palatoplastie diatermică), proceduri de ablatie prin radiofrecventa (“somnoplastie”) care au în general scopul de a îndepărta ţesuturile sau straturile considerate “în exces” şi / sau de a produce cicatrici care întăresc o parte din ţesuturile moi.
Pe lângă faptul că sunt invazive şi ireversibile, metodele chirurgicale nu sunt întotdeauna eficiente iar de cele mai multe ori eficienţa lor este doar temporară, după câteva luni sau ani sforăitul revenind. Spre exemplu, la intervievarea după 18 luni a unui număr de pacienţi asupra cărora s-a efectuat o “somnoplastie”, 78% dintre aceştia au declarat că încă sforăie puternic (Journal of Laryngology and Otology 2002;116:116-8).
De asemenea, aceste procedee pot lăsa pacientul cu diferite complicaţii mai mult sau mai puţin deranjante, incluzând modificarea vocii, recuperare lentă după intervenţie, senzaţia de uscăciune a gâtului sau alte probleme (5-10% din persoanele operate au semnalat că în timp ce beau lichide o parte din cantitatea de lichid pătrunde în nas).
În ultimul timp s-au încercat şi metode chimice (de exemplu cu tetradecil-sulfat) cu scopul de a induce o cicatrice şi de a produce întărirea ţesuturilor moi, dar efectul este temporar. Atât aceste metode cât şi cele bazate pe implaturi nu sunt diponibile pe scară largă iar efectele adverse sunt insuficient documentate.
Use of certain devices
| In Western countries there is a wide range of products against snoring, more or less effective. More than 300 anti-snoring device patents are registered in the United States alone. Some of these have a harmful effect rather than a beneficial one, contributing to sleep deprivation: -devices that wake up the patient the moment he starts snoring.
-devices that prevent sleeping on the back -devices that change the position of the mandible (by moving the mandible forward, the upper airways are opened more widely). In some countries, such as Great Britain, there is the possibility of using, on the recommendation of the dentist or orthodontist, some devices that fix the mandible in a more advanced position. These devices must be specially manufactured, tailored to the patient (it is not recommended to purchase a “ready-made” device) and are fixed in the mouth during the night. Some studies show that these devices can reduce snoring in certain patients, especially those who snore without sleep apnea. However, certain disadvantages make these devices not very popular: they can only be applied to healthy teeth and require increased hygiene to prevent infections, they are expensive (about €1000) and often have to be replaced after about 2-3 years, can cause jaw pain, dry mouth or hypersalivation.
Despite all these attempts, the truth is that if a person snores, it is not under their control. A doctor with a sense of humor remarks: If an anti-snoring device works, it probably works because it keeps you awake.
Mask therapy and pressurized air. A completely different, non-invasive and completely risk-free approach is the CPAP (continuous positive airways pressure) method. This method involves wearing a silicone mask at night, which is attached to a machine. The device provides a flow of air under pressure, which keeps the upper airways open. By removing obstructions, this method prevents not only snoring, but also obstructive sleep apnea and is currently the most used method for their treatment. In Western countries, the cost of CPAP devices is borne by health insurance companies, when the patient has been diagnosed with sleep apnea.
If a small mask is used, covering only the nose, the method is also called n-CPAP (nasal CPAP). There are also more complex versions of devices, for example BiPAP (with two pressure levels) or devices with self-regulation of pressure.
Since their appearance until now, CPAP machines have become more powerful, quieter and smaller. Also, the construction technology of the masks and the materials used have evolved a lot, so that nowadays the masks are comfortable and the patients usually get used to them in a few days.