What doctors wish patients knew about snoring

Snoring is a big concern for many patients because it can cause disruptions in sleep patterns and cause tension in relationships and affect your bed partner’s ability to function the next day.  Understanding the causes and consequences and knowing when it’s more than just snoring can make all the difference.

About 25% to 50% of adults snore regularly, according to a JAMA Otolaryngology—Head & Neck Surgery Patient Page. Meanwhile, 90 million Americans report snoring at one time or another, while 37 million of those adults report snoring regularly. Meanwhile, people who are overweight, men who are middle-aged or older, and postmenopausal women are more likely to snore.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Virginia Skiba, MD, a neurologist and sleep medicine physician at Henry Ford Medical Center in Sterling Heights, Michigan, shared what doctors wish patients knew about snoring. Henry Ford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Snoring in and of itself is caused by vibration of the tissues in the back of the throat,” Dr. Skiba explained, noting that “when the air goes in, the tissues vibrate and that's what produces the snoring noise.”

“We see it more commonly in people who might have a little bit more excessive tissue in the back of the throat or if those muscles relax a little bit more while they're sleeping,” she said. “And oftentimes, it is a symptom of obstructive sleep apnea.”

When it comes to “snoring without sleep apnea … we’re talking about normal breathing, so by definition it shouldn’t cause any other long-term problems,” Dr. Skiba said. “There are some studies showing that it may increase high blood pressure” because it can be a sign of sleep apnea.

“It’s when you have sleep apnea that it’s going to increase the risk of health complications such as heart disease,” she emphasized, adding that “sleep apnea can contribute to irritability, depression, memory problems, cognitive decline, low testosterone—all kinds of issues.”

While it is hard to provide an exact percentage, research suggests about half of people who snore loudly have obstructive sleep apnea. The other half do not.

“What we call primary snoring is snoring without sleep apnea, so the tissues vibrate, and they make the noise, but the person is still getting sufficient air and it’s not disrupting the person’s sleep,” Dr. Skiba said. “Snoring can disrupt a bed partner or other people in the house, but primary snoring would not affect the person who’s doing the snoring.”

“With sleep apnea, what happens when we sleep is those tissues relax and fall back on themselves. So, you actually get less air going in,” she explained. “And when you don’t get enough air, it’s usually a partial blockage of the back of the throat, so you’re still breathing, but just not getting a full breath.

“Or sometimes sleep apnea can cause a complete blockage in the back of the throat and that would look like you’re not breathing,” Dr. Skiba added. “But either one of those will affect the person in terms of disrupting their sleep quality. Sleep becomes more fragmented, kind of choppy, lighter, so people are not as refreshed.”

“Importantly, when you don’t get enough air, the oxygen levels can go down. It causes an increase in heart rate and blood pressure,” she said. “So, in the long run, sleep apnea does increase the risk of cardiovascular complications like high blood pressure, stroke, heart attack and so on.”

“A sleep study would be the only way to figure out if it’s just primary snoring or if it is sleep apnea,” Dr. Skiba said. “For sleep studies, we do a lot of home studies these days—it’s where you sleep with a small monitor at home.

“There are a couple different types, but they monitor your breathing and your oxygen levels during the night,” she added, noting “when we do studies in the sleep center, there’s a technologist, they’re keeping an eye on things and there are a lot more monitors that monitor your brain waves, breathing and oxygen levels.”

“The in-lab studies are a lot more sensitive. Home studies can definitely miss mild and even moderate sleep apnea,” Dr. Skiba said. That is why “it’s important to know that if a home study does not show sleep apnea, you do need to have an in-center study as a follow up.” 

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“Some people will snore regardless of what position they’re in, but sleeping on the back is usually the worst because you’ve got gravity working against you,” Dr. Skiba said. “You can try sleeping on your side—either side—and then potentially sleeping elevated.

“So, sleeping with the whole torso elevated using a wedge pillow or putting a pillow under the head and torso,” she added, noting “you don’t want the neck to be kinked. You need the whole torso.”

“There are lots of different maneuvers that you can use—mechanical things—that if you roll on your back, it’s uncomfortable so it wakes you up,” Dr. Skiba said. For example, a “tennis ball sewn into a pocket of a t-shirt, or you can wear a fanny pack backwards on your back … anything that’s uncomfortable.”

Additionally, “there are devices that you can buy that go around the waist that vibrate and wake you up,” she said, noting “there are lots of different options, but they will all disrupt your sleep. That’s how they work. They wake you up and you roll over on your side.”

“Sometimes when people have a lot of nasal congestion or a deviated septum or nasal polyps, that can cause people to open their mouth when they sleep,” Dr. Skiba said. “And then when you open your mouth it worsens the mechanic so it causes a little bit more blockage in the back of the throat and that can potentially trigger snoring.

“So, keeping the mouth closed can help snoring,” she added, noting “there are things like mouth taping that can help, but only if it’s really mild. It does not help if it’s sleep apnea.”

Beyond trying different sleeping positions or using other devices to nudge you awake, Dr. Skiba recommends an oral appliance “from a dentist because they can monitor for any potential complications.”

“What those do is they move the jaw forward when you sleep. It creates a little bit more space in the back of the throat,” she explained. “There are also surgeries, which typically involve a laser procedure that scars the tissues, so they don’t vibrate as much.”

But “none of those treatments are covered by insurance because snoring is not considered a medical condition by insurances, so they don’t cover it,” Dr. Skiba said, noting there are also continuous positive airway pressure (CPAP) devices “for treatment of obstructive sleep apnea, which are typically covered by most insurance plans.”

There are some devices that “you can put in the nose. There are ones that are like a Band-Aid. Then there are devices that actually go inside the nostrils,” Dr. Skiba said. “Basically, you breathe out against resistance and it’s the resistance that creates a little bit of back pressure that help with the snoring.”

“It’s hit or miss if it’s going to work for an individual person. But you can always try it out,” she said. “The big thing to remember is, you probably want to get tested to make sure that you don’t have sleep apnea because you don’t want to mask the sleep apnea and not get proper treatment for that.”

“We know that weight affects snoring and sleep apnea, so losing weight can help,” said Dr. Skiba, noting “we know that obesity being overweight is a big risk factor for sleep apnea and primary snoring, so maintaining normal weight can definitely be helpful.”

“Having said that, we see sleep apnea and snoring in people who are not overweight, who have normal weight,” she said. “So, it’s one of those things that … makes a big difference for an individual patient. But it’s always hard to know for sure if it’ll completely get rid of the primary snoring or the sleep apnea.”

“Anything that suppresses the breathing and relaxes muscles more can affect snoring and sleep apnea,” Dr. Skiba said. For example, “alcohol is going to be the big one—probably the most common one.

“A lot of people find when they drink alcohol, the snoring gets quite a bit worse,” she added. “And then medications that can affect your breathing and your muscle tone. So, narcotic medications and benzodiazepines. Those would be the two big classes that affect breathing.”

Some people may be under the assumption that fixing their deviated septum will help minimize snoring, but “it’s hard to predict ahead of time if it will work,” Dr. Skiba said. “We know that people who have a lot of obstruction in the nasal flow—whether it’s from a deviated septum, congestion or polyps—they tend to have worse sleep quality.

“And when those issues are fixed, they sleep better at night because they can breathe better,” she added. “Whether it’s going to help snoring, it really depends because the sound of snoring is generated from the throat. If it helps you keep your mouth closed, then that might help the snoring.”

“So, it’s something that might help, but it’s a little bit more unpredictable,” Dr. Skiba emphasized.

When it comes to snoring, “the biggest challenge is getting people to realize that it is a potential sign of something more serious and getting them to come in and get evaluated,” Dr. Skiba said, noting “some people are really surprised when we find out they have sleep apnea, and we treat it how much better they feel.”

“Give yourself the chance to get evaluated and if it is more than just snoring, give yourself a chance to treat it and see how that’s going to improve your quality of life,” she said.

“If you feel like your snoring is affecting your sleep quality, if you’re waking up in the morning tired, groggy, not as refreshed as you should be. If you have any of those symptoms like irritability or if somebody tells you that it looks like you stop breathing in your sleep,” reach out to your physician, Dr. Skiba said. “If you actually stop breathing, then that’s much more likely to be sleep apnea and we know that is more common in people as we get older and in men and people who have high blood pressure.

“So, generally, anybody who has high blood pressure or heart disease, who is older and male, all of those things will increase your risk for sleep apnea,” so it is important to talk with your doctor, she said.