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«Snoring is a sound created from turbulent airflow. It is noisy breathing during sleep caused by the exchange of a large volume of air through a ...»

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Chronic hyperventilation- asthma,

snoring & sleep apnoea

Patrick McKeown, author of

“Sleep with Buteyko”

What is snoring?

Snoring is a sound created from turbulent

airflow. It is noisy breathing during sleep

caused by the exchange of a large

volume of air through a narrowed space,

which in turn causes the tissues of the

nose and throat to vibrate.

Snoring comes in two flavors

 Simple snoring - vibration of the soft

palate. (mouth snoring)  High upper airway resistance (HUAR) - turbulent airflow in the nasopharynx and oropharynx causing inspiratory flow limitation (IFL) The next progression to snoring is sleep apnoea What is sleep apnoea?

 Apnoea is a Greek word meaning “without breath.”  Three types: central, obstructive and mixed.

 Obstructive sleep apnoea is the most common type of apnoea and is characterised by holding the breath from collapse of the upper airways during sleep. This holding of the breath, which prevents airflow to the lungs, may occur between five and fifty times per hour. Each breath hold can range from a few seconds to over one minute, causing one’s blood oxygen saturation to decline to as low as 50%.

Prevalence of snoring, sleep apnoea A study from 8,000 surveys; one-third of participants were found to have a high pre-test probability for OSA, with a higher rate in the U.S. (35.8%) than in Europe (26.3%). Sleepiness affected 32.4% in the U.S. versus 11.8% in Europe. Frequent snoring and breathing pauses were similar in both the U.S. and Europe (44%).

Netzer et al. Prevalence of symptoms and risk of sleep apnea in primary care. Chest 2003 Oct;124(4):1406-14.

Symptoms of sleep apnoea Excessive daytime sleepiness (falling asleep while eating, talking or driving) Waking up tired Patient may be unaware of sleep disturbances Loud snoring Holding the breath during the night Loud snorts and gasps upon the resumption of breathing Symptoms cont’d

• Problems with memory and concentration

• Morning or night headaches affect approximately 50% of patients

• Heartburn or reflux

• Swelling of the legs

• Needing to urinate during the night

• Sweating during sleep

• Chest pain Symptoms cont’d May cause marital problems • Sometimes dry throat, dry mouth • Blood oxygen desaturation • Arousal from sleep • Sympathetic activation • Can cause elevated blood pressure during • the day, possibly leading to hypertension and heart disease Symptoms of OSA in children (younger than five years) Frequently waking up • Snoring • Sweating • Mouth breathing • Restlessness • Symptoms of OSA in children (over five years) Snoring • Short attention span • Poor academic performance • Behavioural problems • Bed wetting • Not growing as quickly as they should • be for their age Rhinitis/mouth breathing & snoring/sleep apnea “Men and women with nasal obstruction, especially chronic night time symptoms of rhinitis, are significantly more likely to be habitual snorers, and a proportion also may have frequent episodes of apnea, indicative of severe sleep-disordered breathing.” Young et al. Nasal obstruction as a risk factor for sleep-disordered breathing.

Journal of allergy and clinical immunology. 1997 Feb;99(2):S757-62.

“Open-mouth breathing during sleep is a risk factor for obstructive sleep apnea (OSA) and is associated with increased disease severity and upper airway collapsibility. Results suggest that the more elongated and narrow upper airway during open-mouth breathing may aggravate the collapsibility of the upper airway and, thus, negatively affect OSA severity.” Kim EJ, Choi JH, Kim KW, Kim TH, Lee SH, Lee HM, Shin C, Lee KY, Lee SH.

The impacts of open-mouth breathing on upper airway space in obstructive sleep apnea: 3-D MDCT analysis. European Otorhinoaryngol. 2010 Oct 19.

“Nocturnal nasal congestion is a strong independent risk factor for habitual snoring, including snoring without frank sleep apnea.” Young et al. Chronic nasal congestion at night is a risk factor for snoring in a population-based cohort study. Internal Medicine 2001 Jun 25;161(12):1514-9.

“Patients with complaints of snoring or sleep apnea can easily breathe through the mouth during sleep, and that chronic nasal obstruction may induce obstructive sleep apnea.” Ohki M et al. Relationship between oral breathing and nasal obstruction in patients with obstructive sleep apnea.

Acta Otolaryngology Suppl. 1996;523:228-30 “In predisposed individuals, OSA, sleep fragmentation, and the sequelae of disturbed sleep often result from nasal obstruction. Since breathing through the nose appears to be the preferred route during sleep, nasal obstruction frequently leads to nocturnal mouth breathing, snoring, and ultimately to OSA.” Scharf MB, Cohen AP Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep apnea. Allergy Asthma and Immunology. 1998 Oct;81(4):279-87; quiz 287-90.

“The presence of nasal obstruction will most likely have an impact on the severity of sleep-disordered breathing. Identification of nasal obstruction is important in the diagnostic work-up of patients suffering from snoring and sleep apnea.” Pevernagie DA et al Sleep, breathing and the nose Sleep Medicine reviews. 2005 Dec;9(6):437-51 “Nasal congestion, which is one of the most bothersome and prevalent symptoms of AR, is thought to be the leading symptom responsible for rhinitis-related sleep problems.” Storms W, Allergic rhinitis-induced nasal congestion: its impact on sleep quality.Prim Care Respir J. 2008 Mar;17(1):7-18.

“Rhinitis alone is associated with mild OSA, but commonly causes microarousals and sleep fragmentation. Reduction of nasal inflammation improves sleep quality and subsequent daytime sleepiness and fatigue.” Staevska MT et al. Rhinitis and sleep apnea.

Allergy Asthma Report 2004 May;4(3):193-9.

Rhinitis and children's sleep “Allergic symptoms, daytime mouth breathing, shaking the child for apnea, restless sleep and hyperactivity were significant and independent risk factors and sleep-related symptoms for Habitual Snoring.” Sahin U et al. Habitual snoring in primary school children: prevalence and association with sleep-related disorders and school performance.

Medical Principals and Practice. 2009;18(6):458-65.

“Allergic rhinitis is more than just sneezing and an itchy nose. Complications of this disease are numerous and can have a significant impact, both mentally and physically. Mental functions such as learning, sleep and activity levels can deteriorate, and the eustachian tubes, sinuses and airway functions can be affected.” Borres MP. Allergic rhinitis: more than just a stuffy nose. Acta Paediatr. 2009 Jul;98(7):1088Epub 2009 Apr 17.

Children who mouth breathe:

“a mouth breather lowers the tongue position to facilitate the flow of air in to the expanding lungs. The resultant effect is maldevelopment of the jaw in particular and deformity of the face in general.

Setting of the teeth on the jaw is also affected. All these make the face look negative.” Care of nasal airway to prevent orthodontic problems in children. J Indian Med association 2007 Nov; 105 (11):640,642) “Oral breathing in children may lead to the development of facial structural abnormalities associated with SDB. We postulate that the switch to oronasal breathing that occurs with chronic nasal conditions is a final common pathway for SDB.” Rappai M et al. The nose and sleep-disordered breathing: what we know and what we do not know. Chest 2003 Dec;124(6):2309-23.

Rhinitis, snoring and ADHD “Most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis.” Brawley A, et al. Allergic rhinitis in children with attentiondeficit/hyperactivity disorder. Ann Allergy Asthma Immunol 2004 Jun;92(6):663-7.

“Children who mouth breathe typically do not sleep well, causing them to be tired during the day and possibly unable to concentrate on academics. If the child becomes frustrated in school, he or she may exhibit behavioural problems.” Dr Yosh Jefferson “Mouth breathing leads to problems with behaviour, sleep, health.” Published April 18th 2010 in ADHD “Sleep disturbances, poor school performance, and hyperactivity are all mental complications seen in many children related to their nasal allergies.” Blaiss MS.Pediatric allergic rhinitis: physical and mental complications. REVUE DU PRATICIEN. 1996 Apr 15;46(8):975-9.

“Atopy was the strongest risk factor for habitual snoring in Singapore, and the effect was cumulative. Children attending psychiatric services in Singapore may also have sleep disorders, the highest prevalence being in children with attention deficit hyperactivity disorder.” Chng SY.Sleep disorders in children: the Singapore perspective. Ann Acad Med Singapore. 2008 Aug;37(8):706-9.

“Sleep quality can be significantly impacted by nasal congestion, a common symptom related to allergic rhinitis (AR). This may lead to decreased learning ability, productivity at work or school, and a reduced quality of life.” Davies et al A practical approach to allergic rhinitis and sleep disturbance management. Allergy and Asthma proceedings 2006 May-Jun;27(3):224-30.

“Inattention and hyperactivity among general paediatric patients are associated with increased daytime sleepiness andespecially in young boys-snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behaviour, the current results suggest a major public health impact.” Chervin rd et al. Inattention, hyperactivity, and symptoms of sleepdisordered breathing. Pediatrics 2002 Mar;109(3):449-56.

Poor Awareness “The vast majority of health care professionals are unaware of the negative impact of upper airway obstruction (mouth breathing) on normal facial growth and physiologic health.” General dentist: Mouth breathing: adverse effects on facial growth, health, academics and behaviour. Jefferson Y, 2010 Jan- Feb; 58 (1): 18-25 “approximately 74% of asthmatics experience nocturnal symptoms of airflow obstruction secondary to reactive airways disease.” Bonekat HW, Hardin KA, Severe upper airway obstruction during sleep. Clin Rev Allergy Immunol. 2003 Oct;25(2):191-210.

88% of patients in the severe asthma group, 58% of patients in the moderate asthma group, and 31% of patients in the controls without asthma group had more than 15 apnoeic events per hour.

Julien JY, Martin JG, Ernst P, Olivenstein R, Hamid Q, Lemi?re C, Pepe C, Naor N, Olha A, Kimoff RJ.Prevalence of obstructive sleep apnea-hypopnea in severe versus moderate asthma. J Allergy Clin Immunol. 2009 Aug;124(2):371-6.

Epub 2009 Jun 26.

“Obstructive sleep apnea-hypopnea was significantly more prevalent among patients with severe compared with moderate asthma, and more prevalent for both asthma groups than controls without asthma.” Julien JY, Martin JG, Ernst P, Olivenstein R, Hamid Q, Lemi?re C, Pepe C, Naor N, Olha A, Kimoff RJ.Prevalence of obstructive sleep apnea-hypopnea in severe versus moderate asthma. J Allergy Clin Immunol. 2009 Aug;124(2):371-6.

Epub 2009 Jun 26.

“Study showed an unexpectedly high prevalence of OSA among patients with unstable asthma receiving long-term chronic or frequent burst of oral corticosteroid therapy.” Tov N, Solomonov A, Rubin AH, Harlev D, Yigla M Difficult-to-control asthma and obstructive sleep apnea. J Asthma. 2003 Dec;40(8):865-71 “Association of Obstructive Sleep Apnea Risk With Asthma Control in Adults,” which found from a study of 472 asthmatic patients that poorly controlled asthma resulted in a threefold increase in the risk of obstructive sleep apnea.

Teodorescu M, Polomis DA, Hall SV, Teodorescu MC, Gangnon RE, Peterson AG, Xie A, Sorkness CA, Jarjour NN. Association of obstructive sleep apnea risk with asthma control in adults. Chest. 2010 Sep;138(3):543-50 During a study of 574 patients with OSAS, researchers found that there were at least double the amount of apneas/hypopneas when patients slept on their back rather than their sides. “Body position during sleep has a profound effect on the frequency and severity of breathing abnormalities in OSA patients.” Oksenberg A, Silverberg DS, Arons E, Radwan H. Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest. 1997 Sep;112(3):629-39.

2,077 OSA patients over a period of ten years, it was found that 53.8% had at least twice as many breathing abnormalities while sleeping in the supine (back) position compared with sleeping on their side.

Oksenberg A, Arons E, Greenberg-Dotan S, Nasser K, Radwan H. [The significance of body posture on breathing abnormalities during sleep: data analysis of 2077 obstructive sleep apnea patients]. [Article in Hebrew] Harefuah. 2009 May;148(5):304-9, 351, 350.

“Even in patients with severe OSA who have a high number of apneic events in the supine and lateral posture, the apneic events occurring in the supine position are more severe than those occurring while sleeping in the lateral position. Thus, it is not only the number of apneic events that worsen in the supine sleep position but, probably no less important, the nature of the apneic events themselves.” Oksenberg A, Khamaysi I, Silverberg DS, Tarasiuk A. Association of body position with severity of apneic events in patients with severe nonpositional obstructive sleep apnea. Chest. 2000 Oct;118(4):1018-24.

CPAP compliance

• Patient wears a mask over the face and air is applied at a pressure that exceeds the airway opening pressure, thereby enabling the patient to breathe without cessation.

CPAP compliance

• In a study of 80 patients, side effects were disturbance of the mask during the night (71.3%), dry mouth (47.5%), dry nose (46.3%), pressure marks from the mask (41.3%), crusts within the nasal cavity (38.8%), and hearing loss (26.3%).

Verse T, Lehnhardt E, Pirsig W, Junge-Hülsing B, Kroker B. [What are the side-effects of • nocturnal continuous positive pressure ventilation (nCPAP) in patients with sleep apnoea for the head-neck region?].[Article in German] Laryngorhinootologie. 1999 Sep;78(9):491-6.

CPAP compliance

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