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Author: Zl Hao
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Source: Zhihu
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I. Snoring and sleep apnea.
Snoring is a noise. In sleep breathing, the airflow in the narrow airway movement produces noise, in addition to the soft palate tongue and other soft tissues vibrate under the action of the airflow, the two **** with the formation of snoring. Therefore, the essence of snoring is the narrowing of the airway during sleep.
When the narrowing of the airway to a certain extent, there will be a situation of airway atresia, which is sleep apnea. Repeatedly occurring multiple apnea during sleep will lead to lack of oxygen at night, and then repeatedly suffocated to wake up and interrupt sleep, and due to poor sleep quality will have a series of physiological changes such as daytime drowsiness, known as sleep apnea syndrome. This disease is one of the risk factors for hypertension and cardiovascular embolism, which is potentially harmful.
Sleep apnea is an "upgraded version" of snoring, which is a potentially harmful disease. And simply snoring is not a disease, known as benign snoring. Snoring is also not a sign of a good night's sleep, but rather the possibility of sleep hypoxia.
How can I tell if I have benign snoring or sleep apnea syndrome? Dr. Hao gave you two initial screening indications:
1. Is there breath holding at night, even waking up with a sharp intake of breath?
2. Is there daytime sleepiness, fatigue, drowsiness, etc.?
If the answer to both questions is "yes", then sleep apnea is highly suspected, and you need to go to the hospital in time.
Two, snoring prevalence.
Often hear people complaining: someone on the train snores like thunder simply can not sleep! Dormitory someone snoring seriously affect sleep! Husband snoring can not stand even divorce ...... then exactly how many people snoring it?
Some literature I looked up, in China, Gao Xuemei equal to the 1997 Beijing survey found that the prevalence of snoring is 13.4%. Among them, the prevalence increases with age, and the prevalence of snoring in 61-70-year-olds reached 23.6%. And the prevalence of sleep apnea is 3.1%. Some scholars in the United States believe that the prevalence of snoring above the age of 60 is 50%! The prevalence of sleep apnea in American adults is 9% for men and 4% for women. Think about the people around us, one in five is a snorer!
Obesity is a risk factor for snoring, so it's understandable that Americans have a slightly higher prevalence than China. But as our standard of living improves, I privately believe that the prevalence of snoring and sleep apnea must be higher than it was in 1997.
Snoring and sleep apnea are also associated with gender, male snorers are about 2.0-3.7 times more likely than women, while clinically visible 8:1 to 10:1.
So around the male obese snorers, more concerned about their own sleep, whether there is sleep apnea?
Three, the gold standard of diagnosis, polysomnography.
Two days ago, Dr. Hao introduced snoring and sleep apnea (OSAS), so how to determine whether they are benign snoring or sleep apnea? The gold standard for diagnosis is polysomnography. It is usually performed in the respiratory department or ENT department of a general hospital.
Polysomnography (PSG) is the continuous and synchronized recording of multiple parameters such as electroencephalogram (EEG), respiration, mandibular electromyography (EMG), oro-nasal airflow and respiratory motility, electrocardiography (ECG), blood oxygenation (BOG), snoring, limb movement, and position, etc., throughout the night's sleep. The full next day was automatically analyzed by the instrument and then manually verified item by item.
We can get the sleep condition, breathing condition, heart condition, etc. from PSG, and at the same time, we can find some sleep disorders, especially sleep breathing disorder. Finally we can get a sleep monitoring report. Dr. Hao is here to teach you how to read the report.
The two most important indicators in the sleep monitoring report are: Apnea Hypopnea Index (AHI) and Minimum Oxygen Saturation (minSpO2).
AHI refers to the number of apneas and hypoventilations per hour, reflecting the severity of apnea, in which the AHI of a normal person is 5, and the AHI of a patient with mild sleep apnea (OSAS) is 5. ;AHI<20, 20<AHI<50 in patients with moderate OSAS, and AHI>50 in patients with severe OSAS.(Classified according to the severity of the disease in stomatology, the respiratory classification is more stringent.)
Minimum oxygen saturation refers to the lowest level of blood oxygenation during sleep, which reflects the severity of hypoxia due to apnea. Normal people>90%, patients with mild hypoxia at 80-90%, patients with moderate hypoxia at 70-80%, and severe hypoxia at less than 70%.
If you meet the initial screening two indicators, please go to the hospital for sleep monitoring. Once you get the sleep monitoring report, you can read the most important part of the report for yourself!
Four, treatment one, behavioral measures.
Today to share behavioral measures. What are behavioral measures? It is a way to improve snoring without going to the hospital and changing your behavior on your own.
The most effective way is to lose weight because the fatter you are, the worse you snore. Fat accumulates around the neck, compressing the airway and making it narrow; the airway narrows as the neck gets fatter. Here is an indicator - body mass index BMI = weight / (height ^ 2). The Chinese standard is greater than 24 is overweight, greater than 27 is obese. Lose weight to a BMI of less than 24 or less, and the snoring will be much, much better.
Another very effective method is to sleep on your side. When you sleep on your back, your tongue tends to fall back and press on your airway, but when you sleep on your side, your tongue doesn't fall back and press on your airway, so your snoring is significantly reduced. Here is a way to maintain side sleep - the back ball. In the back of the pajamas with a safety pin a pocket, the pocket installed a ball, so that in the sleep of supine sleep will be in a daze in the back of something pinching uncomfortable, will be turned back to the side of the sleep. The size of this ball need to grasp, if too large to pinch people awake can not, too small no feeling also can not.
Additionally, you have to quit smoking and drinking to avoid drinking strong tea and coffee at night. Smoking can cause chronic hypoxia, because tobacco combustion will produce carbon monoxide, and hemoglobin combined with the oxygen binding sites. In addition, these tobacco, alcohol, tea and coffee can increase neural excitability, this excitability is an advance form of excitement, when the stop tobacco, alcohol, tea and coffee, sleep will appear less excited than normal, both the innervation of the respiratory center, or the innervation of the muscles around the airway. Therefore, to drink alcohol should not drink at night!
Also, relieving nasal obstruction will help with breathing. The airway is a continuous whole from the nose to the lungs, and any narrowing and obstruction in any part of the airway can cause snoring or sleep apnea, so actively treating conditions such as rhinitis and improving nasal ventilation will help with sleep breathing.
Once again, do not take sleeping pills with central inhibiting effects. Some sleeping pills are to inhibit the excitation of the central nervous system, so that people enter the sleep state. But this sleeping pill will inhibit the excitation of the respiratory center, leading to sleep during the person's ability to perceive the lack of oxygen decreased, the emergence of severe hypoxemia or sleep apnea still can not be compensated or awake, increasing the harm of the disease.
Lastly, keep regular exercise. Exercise helps increase nerve and muscle excitability and tension, which helps maintain muscle tone around the airway during sleep and reduces airway collapse.
V. Treatment two, the ventilator.
Today Dr. Hao continues to bring you a series of treatments for snoring, sharing the classic treatment of respiratory medicine - positive pressure ventilation CPAP, commonly known as ventilator.
Modern respiratory medicine has three major branches: traditional respiratory disorders (emphysema, COPD, etc.), emergency medicine, and some sleep disorders. And snoring/sleep apnea is a sleep breathing disorder. Respiratory medicine is very high level, there are many, many means to control lung disease and improve daytime and nighttime breathing, Dr. Hao's ability to mention the ventilator can only be a small part. I would welcome any comments and additions from fellow respiratory professionals.
Don't be afraid of the ventilator! Don't think that a ventilator can only be a large, noisy machine placed next to an ICU bed in a hospital. Ventilators can be very small, handy and compact little boxes, portable for home use.
After getting rid of your preconceived notions about ventilators, Dr. Hao introduces the therapeutic principles of ventilators. As mentioned before, snoring and obstructive sleep apnea OSAS are both caused by the narrowing and collapsing of the airway, so by providing airflow from the outside and pressing it into the airway, the obstructed airway can be flushed out to achieve the goal of opening up the airway. The core component of a ventilator is a pump that provides pressure, and positive pressure air is pressed into the airway through the mouth and nose mask to open the airway.
When your doctor recommends a ventilator, he or she will ask you to try it overnight, buy it if it works well, and give it up if you can't tolerate it. The pressure needed to open the airway varies from person to person, so it is important to have the pressure adjusted by a professional technician after purchasing the ventilator! Pressure is too small to open the airway, too much pressure and will feel suffocated can not tolerate, some complex cases even need to adjust the pressure many times, and finally find the right pressure for their own.
Of course, simply snoring with a ventilator is a big deal. Benign snoring is not harmful to the body, with a small later introduction of snore blocker can stop snoring; but sleep apnea is harmful to the body, must be cured, moderate to severe sleep apnea patients recommended the use of respiratory machine in order to cure.
Six, treatment three, ear, nose and throat surgery.
Today, Dr. Hao continues to introduce the treatment of snoring series. Today to talk about what technologies are available in ENT to treat snoring and sleep apnea. Because Dr. Hao's ability is limited, ENT colleagues are welcome to criticize and add.
First of all, there is a term - point of obstruction. Snoring is a manifestation of airway narrowing, and airway narrowing is not necessarily uniformly narrow, there are wide and narrow, the narrowest place in the airway collapses during sleep and appears to be blocked, and becomes the point of obstruction. The most common points of obstruction are the posterior border of the soft palate and the base of the tongue. In the supine position the soft palate and the base of the tongue fall back, leading to obstruction and sleep apnea. If we ask the patient to open his mouth, in a normal person we may see the patient's uvula (suspensory), but in a patient who snores, due to the thick and long soft palate, it may be a struggle to see the uvula, or it may not be visible at all.
The classic ENT procedure, uvulopalatopharyngoplasty (UPPP), is designed to remove the uvula, the long posterior border of the soft palate, and the loose mucosa of the lateral pharyngeal wall to prevent the long soft palate from dropping back and touching the posterior border of the soft palate, the point of obstruction, in the course of sleep.
As the procedure has evolved, there have been many improved surgical approaches, all designed to minimize trauma and preserve as much of the original tissue as possible, while still maintaining the results of the original procedure. In addition surgery has introduced minimally invasive concepts and methods such as lasers and radiofrequency ablation to further reduce the pain of surgery for patients.
In addition to the most classic procedures, ENT still has many surgical methods to improve nasal ventilation, such as inferior turbinate ablation, radiofrequency tissue reduction, cryoablation palatoplasty, soft palate scaffolding therapy (to increase the stiffness of the soft palate and to reduce the posterior fall and collapse), and deviated septoplasty.
It is important to note that, unlike a ventilator, not every patient with snoring and sleep apnea is a good candidate for ENT surgery. If the patient has only a single point of soft palate obstruction, then the results will be very good after UPPP surgery; if the patient has multiple points of obstruction, only one point of obstruction is lifted or even on the contrary, it will aggravate the obstruction of other points. Therefore, ENT surgery must be selected for the indications of surgery!
Also, the problem with soft tissue surgery is that after the meat is cut off, it can still grow back - recurring. So it may be that the results are great right after the surgery, and the snoring is completely gone; but as time goes on, the results may be less effective. But even if it recurs, the results will definitely be better than before the surgery.
VII, treatment IV, oral appliances.
Today, Dr. Hao continues the series of treatments for snoring/sleep apnea OSAS - oral appliances.
First of all, I will take you to review why snoring/OSAS, because during sleep the airway is narrowed, the airway collapses, and complete or partial obstruction occurs in the soft palate, the root of the tongue, and so on, which is known as the point of obstruction. In this sense, removing the point of obstruction improves snoring.
Broadly speaking, oral appliances are categorized as mandibular advancement appliances, soft palate actuators, and tongue retractors. The soft palate is used to lift the soft palate, to lift the soft palate falling back during sleep, but due to easy to produce vomiting reaction, the patient intolerance and application of the reduction; tongue retractor is a vacuum tongue bubble, rely on the negative pressure to attract the tongue outward, to lift the root of the tongue obstruction, but due to the easy to fall off, poor sleep, etc., not much; mandibular anterior displacement device so that the patient's jaw to maintain the position of the forward position during sleep, and at the same time to lift the tongue root and the soft palate obstruction, and to improve snoring. The mandibular advancement device keeps the patient's lower jaw in a forward position during sleep and relieves the obstruction of the tongue root and soft palate at the same time, thus improving the symptoms such as snoring, which has the widest clinical application.
Oral orthodontic appliances do not have a corrective effect, like wearing glasses, wear the effect, take off the effect disappears, so every night need to wear.
Because of its exact efficacy and small side effects, the oral appliance is the best choice for patients with simple snoring, patients with mild to moderate OSAS, and patients with severe OSAS who cannot tolerate CPAP. However, there are only no more than ten hospitals in China that can carry out oral appliances for OSAS treatment. We welcome more oral surgeons to participate in the treatment of snoring, and hope that more patients can enjoy the comfortable and convenient treatment.
Eight, treatment five, orthognathic surgery.
Today Dr. Hao continues his series on the treatment of snoring and obstructive sleep apnea. Obstructive Sleep Apnea (Obstructive Sleep Apnea) hereinafter referred to as OSA.
Let's review, snoring and OSA risk factors, a very important one is the maxillofacial deformity, such as mandibular retraction, double jaw retraction. Patients with mandibular retraction generally have a narrow airway gap, and if they encounter other risk factors, such as obesity, tongue hypertrophy, etc., they are prone to develop obstruction points, and these obstruction points lead to airway collapse and apnea during sleep.
And as the growth of adults has ended, it is impossible to change the length of the jaw through growth improvement. From the treatment point of view of lengthening the jaw to open up the airway alone, either temporary nightly use of oral orthodontic appliances to maintain the forward extension of the jaw during sleep, or surgical lengthening of the jaw is possible.
This surgical method of changing the length of the jaw is called orthognathic surgery. Shifting the position of the jaw forward significantly increases the patient's airway clearance, making it one of the most effective treatments for snoring and OSA.
The full course of treatment includes: because the teeth have an occlusion, direct surgery often results in an inability to eat, so first pre-operative orthodontic teeth lining, to release the occlusal disturbances that may occur after surgery (it takes about 1-2 years); the second orthognathic surgery to cut off the jawbone, rejoin it and then fix it; and post-operative orthodontics to finely adjust the occlusion (it takes about 0.5-1 year).
In fact, orthognathic surgery can not only treat mandibular retraction, but upper/lower jaw protrusion/retrusion can be surgically lengthened and shortened. In addition, given the importance of the lower third of the face to facial aesthetics, the surgery can achieve the effect of improving the face (lateral appearance), so some people jokingly call it "cosmetic surgery". That said, angelababy said she only did the orthognathic surgery, and became so beautiful.
But orthognathic surgery is a major surgery that involves moving bones, unlike ear, nose, and throat surgery, which involves removing some soft tissue, and is therefore relatively less acceptable to patients. Despite the risks of anesthesia and surgery, the surgery is very effective. If you would like to learn more about orthognathic surgery, please visit the Orthognathic Surgery Department at the Dental Specialty Hospital for a consultation.
Nine snoring risk factors.
Today, Dr. Hao introduced you to the knowledge of snoring risk factors. You can test yourselves to see if these risk factors exist in yourselves.
What is the difference between the two faces above? In the former, the lower jaw is retracted, and it is obvious that the lower jaw is not in the same vertical plane as the upper jaw, and the lower jaw is further back. And the latter jaw position is normal. Which one snores easily? The answer is the former. Mandibular retraction is a very obvious risk factor for snoring. In addition to looking at it from above the side view, you can also look at it from the dental side. If the distance between the upper and lower teeth is too large (greater than 3mm), called deep coverage, you are likely to have mandibular retraction. The lower jaw is the bony border of the outer part of the tongue, and if the lower jaw is positioned posteriorly, the tongue is positioned relatively posteriorly, and the volume of the airway will be relatively compressed and narrowed, thus making it easier to snore.
Another important risk factor is overweight/obesity. A fat circle around the neck narrows the airway, making it easier to snore. In addition to using body mass index BMI to check if you are overweight and obese, neck circumference is more sensitive than BMI in snoring prediction. Thick neck circumference is also the most relevant risk factor for sleep apnea OSAS.
In addition to this, men are also a risk factor for snoring. The distribution of fat in the body is different due to androgens and estrogens. Estrogen causes most of the fat to be deposited under the skin, in the chest, and in the buttocks. While androgens make most of the fat deposited in the neck and abdomen. The neck rears its ugly head once again! Thick neck circumference tends to snore, and men tend to have thick necks, so, hmmm. Also when women pass menopause and estrogen levels drop, the incidence of snoring/sleep apnea goes up.
Smoking and alcoholism are also risk factors for snoring. In addition to both can temporarily make neuromuscular over-excitement, but smoking and drinking after the airway peripheral neuromuscular complete relaxation and airway collapse; smoking and drinking affects the body's fat metabolism, alcoholics will have a beer belly, which will further lead to obesity and increase the likelihood of snoring.
Age is also a risk factor for snoring. With age, nerve reactivity decreases and muscle tension decreases, so in the airway, a tube with no bony support but only soft tissue, muscle relaxation makes it easy to narrow and collapse, and snoring/sleep apnea occurs.
Nasal obstructions such as deviated nasal septum and enlarged inferior turbinates are also risk factors for snoring. The airway is a complete tube from the nose to the throat, and any narrowing and blockage of one section affects the smoothness of the entire tube. An unventilated nose increases resistance to inhalation and can lead to open-mouth breathing during nighttime sleep. When the mouth is open, the jaw rotates downward and backward, and the airway narrows and then collapses easily.
The tongue is also a risk factor for snoring. An obese person's tongue will also be plump and very full-feeling. People with large tongues will notice traces of dental pressure on either side of the tongue body - teeth marks - when they stretch their tongue.
For children, enlarged tonsils and adenoids are also risk factors for snoring. Children's immune system is not developed, tonsils, adenoids and other pharyngeal lymphatic ring is an immune organ, when the child has a cold, the most likely to have inflamed and enlarged tonsils, the child may snore, or even sleep apnea, the danger is great. In the future, I will specialize in children's sleep apnea.
If there are these risk factors, it is likely to be a potential sleep apnea patient. Then it's time to lose weight, stop smoking, stop drinking, exercise, and aggressively treat nasal disorders!
Ten, the dangers of sleep apnea.
This article will tell you "snoring is not a disease," how terrible, because snoring, sleep apnea harm is quite serious, known as a potentially fatal disease. Dr. Hao will introduce you to its harm one by one.
Sleep apnea is initially characterized by fatigue and drowsiness during the day due to repeated interruptions of sleep at night. The degree of sleepiness varies from person to person. What is the extent of sleepiness in severe cases? The first thing you need to know is that you can't concentrate on your work during the day, you don't know what you're doing, and you can't engage in work that requires concentration, such as driving, working at heights, and so on.
Long-term sleep apnea and poor rest at night will affect the functioning of the brain, and there will be memory loss, inability to concentrate and other distant manifestations, and these indicate that you may be aging prematurely.
Sleep apnea has now been shown to be an independent risk factor for high blood pressure. What is an independent risk factor? It's when a healthy person, with no physical problems, can develop hypertension simply because of sleep apnea. And this kind of high blood pressure and ordinary high blood pressure is different, ordinary high blood pressure in the morning after a night's rest after the lowest blood pressure, and after a day of hard work after the highest blood pressure; sleep apnea hypertension is the night blood pressure is low, but due to the lack of oxygen at night, apnea, sleep compartmentalization, and so on, resulting in the morning up the highest blood pressure. And this kind of high blood pressure to take antihypertensive drugs is to treat the symptoms but not the root cause, even if you take the drug may not have good blood pressure control effect.
The latest research confirms that sleep apnea is also an independent risk factor for diabetes. Lack of oxygen at night can lead to disturbances in the body's glucose metabolism, affecting insulin's regulation of blood glucose, leading to abnormal glucose tolerance, and ultimately leading to diabetes.
Sleep apnea affects not only glucose metabolism but also fat metabolism. We found that OSAS patients are often accompanied by high blood fat and fatty liver. High blood fat increases the risk of atherosclerosis. Moreover, obesity makes sleep apnea worse, and in turn sleep apnea leads to more obesity, in a vicious circle. And this obesity tends to central obesity, that is, visceral obesity, this obesity increases the load on the body, further leading to hypoxic damage. Sleep apnea is therefore also known as metabolic syndrome.
The hypoxia of sleep apnea is not ordinary high-altitude hypoxia, but a moment of hypoxia and a moment of reoxygenation, similar to the damage of ischemia and reperfusion, that is to say, the patient at night for a moment in the Tibetan Plateau, a moment in Beijing. The body will produce a lot of free radicals, these free radicals on the human body caused by oxidative stress damage, in layman's terms, our body is over-oxidized, so it will be premature aging.
Sleep apnea also causes an increase in blood viscosity, and more viscous blood means an increased risk of thrombosis, which means an increased risk of X-rays.
Sleep apnea also affects the endocrine system, with men experiencing a loss of libido and reduced sexual function. If you didn't care about any of the previous ones, you should care about this one, right?
Many people are worried that sleep apnea will cause them to choke on their own breath. This will not, I believe that the body's own ability to regulate, it is impossible for people to actively hold their breath to suffocate! So why the potentially fatal disease? In order to alleviate the lack of oxygen, relieve suffocation, suddenly be suffocated to wake up, take a deep breath, causing a transient increase in blood pressure, followed by cardiovascular and cerebrovascular accidents.
Please answer the following 8 questions, if there are ≥ 4 questions with "yes" answer, then it is a high-risk group, please consult a doctor; if less than 4, then it is a low-risk group (it just means that it is low-risk, not absolutely not, if snoring persists for a long period of time, it is recommended to consult a doctor, if it only occurs after exertion or drinking, then it is usually benign snoring). If it only occurs after exertion or alcohol consumption, it is usually benign snoring):
1. Snoring? (Snoring)
2. Feeling tired during the day? (Tired)
3. Observed stopped breathing during sleep by others? （Observed stopped breathing
4. High blood pressure. （High blood Pressure, defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg
5. Body Mass Index more than 35 (BMI more than 35) Body Mass Index (BMI) = weight in kilograms (kg)/height in meters (m) squared
6. Age over 50 yr old? （Age over 50 yr old
7. Gender male
8. Neck circumference greater than 40 cm
(Using the above criteria, studies in Asian populations have shown a sensitivity of 84.7% for AHI ≥5. The sensitivity was 84.7% and the specificity was 52.6%. There is a lack of data from domestic studies. (Please search for the meanings of sensitivity and specificity.)
2. Can children be affected?
Yes. The prevalence in foreign studies is about 2%, and no reliable studies have been found in China.
3. Are mouth appliances (oral appliances) effective?
Some patients with abnormal maxillofacial anatomy may be effective, consult your doctor.
4. What should be done to prevent it?
Lifestyle interventions are effective in preventing sleep apnea syndrome. These include: stopping smoking, stopping drinking, sleeping on your side, and losing weight. These methods are therapeutic~
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While snoring and Sleep Apnea/Hypoventilation Syndrome (SAHS) both include snoring as a clinical manifestation, they are completely different disorders. The latter is much more dangerous as far as the risk to the human body is concerned. Differential diagnosis has to be made on the basis of other clinical manifestations, severity, duration and complications. We will only talk about SAHS here because the disease has the greatest impact and is most likely to be overlooked.
SAHS is categorized as obstructive, central, and mixed. Long-term SAHS can lead to metabolic diseases such as diabetes, metabolic syndrome, and obesity, as well as cardiovascular diseases such as hypertension and coronary artery disease, and memory impairment, among others.
It is recommended that any student with chronic snoring should go to a large hospital in time (because most doctors also lack sufficient knowledge of the disease). It is best to register with the department of sleep disorders. However, most hospitals do not have this department, then you can hang up the number of respiratory medicine, and to a lesser extent, you can also hang up the number of otorhinolaryngology.
Confirming the diagnosis is as simple as a one-night polysomnography test (price around 300). A sleep apnea/hypopnea index (AHI) of ≥5 confirms the diagnosis. The grading of severity is also based on the AHI, but the current guidelines from two academic organizations in China have different criteria for grading severity. There is no need for students to look into this.
As for treatment, some patients with obstructive SAHS can be treated with surgery at an ENT. Most patients cannot be operated, and if the degree of severity is severe, the conventional method is to use CPAP non-invasive ventilation treatment. Just bring a portable ventilator with you every time you go to bed. CPAP ventilators commonly available on the market today cost from 10,000 to tens of thousands of dollars.
Above.