Snoring: Wake up call for concern

Jayanthi LIYANAGE

It is time for Sri Lanka to recognize snoring as a serious health disorder. Dr. Mrs. Chandra Jayasuriya, Consultant ENT Surgeon of the newly established :Sleep Lab" at the National Hospital says that this problem may be linked to sleep apnoea which means cessation of breathing for about ten seconds.

"People think of snoring as a laughing matter and do not know that snoring may be linked to an obstruction in the air way. We take air from our nose which goes to the throat and then to the lungs and there should be a clear passage for air to go into the lungs", Dr. Jayasuriya explained. "When the air passage is obstructed, there will be a problem in the oxygen-carbon dioxide air exchange. Lungs are like the oxygen pump of the body. You breathe in and there is the oxygen - carbon dioxide air exchange within the body and you get oxygenated. If that does not happen, there is bad haemoglobin in the blood. When people snore, the air passage is obstructed and there is low oxygen saturation in the body".

Sleep apnoea

But all the snorers are not apnoeic. Of the different levels of snoring which includes simple snoring, the dangerous symptom is obstructive sleep apnoea. A patient who suffers from this symptom, stops breathing for a few seconds while sleeping and start breathing again and emit a noise or snore as if there is an obstruction in the throat. This cessation of breathing may happen for a few seconds or about 30 times per hour and you get less oxygen during your sleep. In this process, the patient vacillates between deep sleep and light sleep and do not get a refreshing sleep. The result is he or she may feel very tired during the day and fall asleep.

How do we know whether we have apnoeic attacks? "When a child snores, parents may wonder whether that is due to an apnoeic attack. A bed partner may suspect his or her spouse as having sleep apnoea", Dr. Jayasuriya said. "The reason is that during the day, they feel sleepy. If you get adequate sleep in the night, you should feel refreshed in the morning.

But apnoeic patients feel tired in the morning. They fall asleep while watching TV. They cannot concentrate while reading a book. A child's studies may suffer and a worker's work performance may lessen. If you have a similar problem, you must see a doctor to see whether you need a sleep study".

Before you obtain a sleep study, a doctor needs to do blood tests and X-rays to decide whether you really require a sleep study. Those with such a disorder are advised to see an Ear-Nose-Throat (ENT) doctor. You may even be required to see a chest physician or a neurologist.

"Why you need to see an ENT doctor first is to determine the causes for the air way obstruction above the neck level", Dr. Jayasuriya said. "You may have nasal pholips which obstructs your breathing. If the mid line partition of your head is deflected towards one side, you may develop air way obstruction. A large stomach, large tonsils and a short fat neck too can cause such an obstruction. Tonsils and pholips can be removed by surgery. Hyper thyroidism, low levels of thyroxin, too can be treated. If you palate is flappy and moving, it can be tautened. Obesity is the number one cause in the world for snoring which can be corrected by losing weight which is the most important message we need to give".

Smoking and alcohol

Smoking and consuming alcohol can also cause snoring. "During the day, we forcefully keep our airways open", explained Dr. Jayasuriya. "But during the night, without our knowledge muscles relax and the air way is covered which is why snoring happens. Alcohol too cause muscles to relax. You must stop smoking, stop taking alcohol and lose body weight".

If an obvious cause for snoring cannot be found and cannot be corrected by surgery, your doctor may decide to do a sleep study. Here, the oxygen saturation of the patient during the night needs to be checked. This test is called polysomnography and the report is called a polysomnograph. The machine installed for the first time in a government hospital as a Sleep Lab is worth nearly Rupees two million, a certain amount of funding for which was obtained through a stage drama and a pooling of resources by the ENT doctors in the island.

During the sleep study, the patient is required to sleep in the ward in the night connected to the computerised machine through wires. A nurse needs to spend the whole night observing the patient. It is required to test whether the poor oxygen supply affect the patient's heart or brain. The printed out report from the computer is automatic. If the patient is diagnosed to have a serious problem, he or she is advised to buy a Continuous Positive Air Way Pressure (CPAP) machine. Small in size, it is available in Sri Lanka and costs about Rupees one and a half lakhs.

CPAP machine

During the night, the patient is required to don the mask connected to the CPAP machine which keeps the air way forcefully open by giving positive air pressure. While the patient sleeps, he or she is dependent on the machine for breathing easily. "Even if you are going overseas, you have to carry it", says Dr. Jayasuriya. "But living with the machine is not easy. With it, you can never have a normal life. It is better if you can lose weight and get rid of snoring".

Dr. Jayasuriya points out that a patient can get the help of a dietician to lose weight. "There are surgical methods to reduce the volume of your stomach. We eat to satisfy our hunger and are not satisfied until our stomach is full. If you have a smaller stomach, you will be satisfied quickly. Baria Tric surgery can reduce the volume of your stomach so that you eat less. A lot of obese people have undergone this operation". Being obese is risky if a patient needs to undergo anaesthesia and nurses will have difficulties when trying to shift him or her from bed to trolley. "If your body weight is slightly higher than the ideal body weight, diet changes will work".

As she sums up, snoring cannot be cured through drugs. The only options are surgery, using the CPAP machine or losing weight. The decision is made by the physician after the required tests.

Dr. Jayasuriya says that so far only about five to six patients have been tested at the Sleep Lab as it does not have enough nurses to function the lab. "We now have the room and the machine. Nurses doing night duty needs to attend to ward duties as well. We need to get more nurses and train them to observe patients sleeping during night so that we can test everyday.

We need to send a circular to doctors at the National Hospital so that they can refer patients to us. When a sleep study is done, there are disposable items costing about Rupees two thousand which the patient needs to buy. If a patient can't afford to buy these disposable items, there is no point in testing as the CPAP machine costs Rs.1.5 lakhs".

She sees obesity as an affluent society problem. "I have worked in the peripheries and have not come across village people with huge bodies. The problem is more in Colombo". She also adds that some people by birth have short chins and necks and there are congenital syndromes in snoring.

The private hospitals Apollo and Navaloka have had Sleep Labs operating for some years. Machine importers have reported that since the functioning of these labs began, about 50 CPAP machines have been sold. "Some people do not like the CPAP. A patient who did not like it, got an operation done and donated his machine to us", Dr. Jayasuriya said.

Statistics

Statistics on local sleep apnoic patients are not available as sleep awareness is low in Sri Lanka. But, in the United States of America, about 12 million people are found to suffer from sleep apnoea and about half of this number is obese.

For every 25 middle aged males, one has the symptom. For every 50 females, one is found with apnoea.

This is not about sleeplessness, stressed Dr. Jayasuriya. "We are not talking about people who do shift duty and work in the night.

This is about people who work during the day and sleep in the night and do not get adequate sleep and have problems during the day".

Sleep apnoea can also lead to high blood pressure, heart ailments, paralysis, diabetes and uneven heart beat. Sleep apnoic people are also prone to accidents as they feel sleepy and tired during the day time.