What in the world is sleep hygiene and how do I improve mine?

The term sleep hygiene does not refer to the cleanliness of your dream content; though perhaps interesting, that is beyond the scope of this discussion. Sleep hygiene refers to your sleep habits. Proper treatment of snoring and obstructive sleep apnea begins with good sleep hygiene.

It cannot be stressed how important getting the right amount and quality of sleep is, regardless of the severity of the snoring problem. In this section, principles that promote optimal sleep and thereby minimize daytime drowsiness and fatigue are presented. These are followed by a few easy suggestions that may help alleviate snoring or at least help the bed partner deal with the problem more easily.

Seven steps to improve sleep hygiene

These principles have been borrowed from William Dement, MD, PhD, who is generally credited as being the father of sleep medicine.

1. Create an optimal environment for sleeping. Quiet, dark, secure surroundings with a comfortable bed are extremely important.

2. The bedroom is for sleeping. The more the bedroom and the bed are used for other activities, the weaker will be the association between the bedroom and sleep, and the greater tendency for reduced sleep efficiency and total sleep time.

3. Regularity. Identify a specific personal bedtime and stick with it.

4. Synchrony. Your sleep schedule should be arranged to be synchronous with your biological clock. Pay attention to when sleepiness and drowsiness occur at night. The bedtime should be routinely scheduled to coincide with this time.

5. Good general health favors optimal sleep. Exercise, proper diet, and regular timing of meals promote optimal sleep and optimal alertness.

6. Avoid all drugs that adversely affect the sleep/wake cycle. This includes alcohol, the chronic use of sleeping pills, sedating antihistamines, and alerting drugs, such as amphetamine.

7. Get enough sleep. The correct amount of nightly sleep to aim for is your own personal daily requirement. This is the amount which, when obtained on a regular basis, does not result in the accumulation of a sleep debt. This averages 8 hours per night for most adults, but may be as high as 9 or 10 hours for some individuals, less for others. One easy rule of thumb is that if there is no tendency to become sleepy after a heavy lunch, a person is likely carrying a relatively small sleep debt and is probably getting close to the required amount of sleep at night.

Six simple steps to help with snoring

Snoring may be less bothersome to the bed partner if the following steps are implemented. If they adequately take care of the problem, you may not need to read any further!

q For the bed partner:

1. Get to sleep first. Make it a race to get to sleep before that clod next to you starts up with that infernal noise. The snoring is less apt to be bothersome to you if it begins after you have fallen asleep.

2. Wear earplugs. This is not meant as a joke. Earplugs can really work. They can be purchased at most pharmacies. It’s the least you can do to try and help the situation yourself.

3. Use “white noise.” A commercially purchased sound machine, fan, or radio turned to static can make enough droning “white noise” to make snoring less annoying. Place the sound source on the your side of the bed to drown out the snorting, gasping, sputtering, and buzzsaw noises.

4. When all else fails, sleep in separate rooms. OK, so maybe it’s not a very good answer, but until the snorer gets treatment, what else can you do?

q For the snorer:

1. Develop good sleep hygiene. Follow the steps listed above. In particular, avoid alcohol or sedating medications before bedtime. These make snoring—and the obstructions—much worse and more frequent.

2. Avoid the back sleeping position. Snoring is frequently worse during this position. One simple way to avoid sleeping on the back is by placing a tennis ball in a sock and attaching it to the middle of a tee shirt, pajama top, etc. over the spine. This will soon teach the most stubborn back sleeper to avoid this position.

3. Consider the nose. Nasal blockage can contribute significantly to snoring, and can sometimes be improved upon easily. One easy way is be utilizing dilating nasal strips. Granted, these may only work for a minority of persons, but it’s easy to try, and just might be beneficial. Alternatively, one could try a few puffs of a nasal decongestant spray before going to bed—as a test only. If this significantly reduces the level of snoring, it could suggest that the snoring might be due at least in part to nasal obstruction. As such nasal blockage could be easily improved by one of a number or commonly prescribed medications, it would warrant a discussion with a physician. Note that this nasal decongestant trial is a test only, and is not a treatment for snoring. It is never advisable to use decongestant nasal sprays for more than 5 days, or severe dependence and worsening of nasal obstruction could occur.

What is nasal CPAP and how does it work?

The mainstay of medical treatment of obstructive sleep apnea is nasal continuous positive airway pressure, or CPAP. CPAP involves the administration of pressurized air to the throat during sleep, delivered through a nasal mask. Just as a bicycle pump inflates a tire and keeps the walls of the tire from collapsing inward, nasal CPAP keeps the walls of throat of the sleep apneic from collapsing while he or she sleeps. CPAP is generally utilized as the primary treatment of significant OSAS, as it is noninvasive, relatively inexpensive, and effective.

The amount of pressure necessary to keep the throat open is measured in centimeters of water pressure, or CWP. Typical CPAP pressures run in the range of 8-16 CWP, and vary from person to person. The specific pressure for any given patient can be determined at a sleep study—either during the initial night of study (a so-called “split-night study”) or at a subsequent study.

There are a variety of newer generation CPAP machines which can to some degree find their own optimal pressures, or auto-titrate, for a given patient. Others can vary the pressures between inspiration and expiration, or work only on demand. Many patients benefit from having a humidifier installed in the CPAP machine, to help with nasal stuffiness and dryness. Your physician can work with you to find the best machine for your particular needs.

How often do I need to wear CPAP?

When use faithfully, CPAP acts as a pneumatic splint, and usually abolishes snoring and OSAS, reverses daytime sleepiness, and acts on the cardiovascular consequences of OSAS. Failure to use CPAP for even one night, however, may result in the reappearance of pre-treatment levels of sleep apnea and daytime sleepiness, even though the number of obstructive respiratory events may be reduced. You therefore have to use it religiously for it to be effective.

Physicians realize that subjective patient reporting of CPAP compliance is inaccurate. For instance, it has long been thought that CPAP compliance is the 75% range, based on patients told their physicians. Yet objective measurement of compliance shows that CPAP is often used much less often that what is admitted or possibly realized by the patient. Accurate compliance data can now be obtained through computer chips installed on CPAP units, and studies using such equipment has shown compliance rates as low as 46%.

Because CPAP compliance cannot be assumed, all patients who are placed on this form of therapy need to be followed for compliance. If patients are intolerant of CPAP, another form of treatment needs to be offered to the patient.

What can be done to improve CPAP compliance?

Granted, CPAP ain’t sexy. It’s not the most comfortable thing you could imagine wearing at night. It’s a hassle. The arguments against using go on and on. But it works. When it is used.

There are a variety of things that can be done to improve tolerance of nasal CPAP and thereby increase its effectiveness. Good communication with your physician is important so that these problems can be dealt with and CPAP usage maximized.

The most common problems interfering with CPAP usage include nasal irritation, rhinorrhea, claustrophobia, and inconvenience. If nasal obstruction is the main problem interfering with CPAP compliance, this can frequently be improved without much difficulty. The most common medication used to help the nose with CPAP is a nasal steroid spray, taken just once daily, usually just before bedtime. If allergies are part of the problem, this can be treated with a variety of other medications, such as non-sedating antihistamines, decongestants, etc. Sometimes there is a structural problem with the nose that is restricting airflow enough to interfere with CPAP. This can usually be dealt with via an outpatient surgical procedure, perhaps even in the surgeon’s office.

If mask fit is the problem, other masks can be tried, as there are a variety of different sizes and shapes of masks available. These include soft gel masks, full-face masks (which cover the mouth as well as the nose), nasal pillows (which fit over the nostrils rather than the whole nose), and others. Your CPAP vendor can show you a number of different masks, one of which might be best for you. A chin strap can be worn to keep your mouth shut during sleep, if your mouth has a tendency to open to allow the pressurized air escape.

If the problem is one of too high of a continuous pressure, bi-level positive airway pressure, or BiPAP can be offered. This involves a higher inspiratory pressure and a lower expiratory pressure, and is sometimes better tolerated than traditional CPAP.

As noted above, there are also newer “smart” CPAP units, which can vary the inspiratory pressure based on one of two different software algorithms. One type of machine titrates the pressure to the snoring noise; as long as the machine detects snoring, it keeps slowly elevating the pressure until the noise disappears. The other technology involves the detection of limitation of nasal airflow. The machine slowly increases the pressure until flow limitation is abolished. Both types of machines will then slowly lower their pressures until a steady state is reached. These types of machines are of course more expensive than are the more traditional units, but can be extremely helpful with selected patients.

The bottom line is: good communication with your physician is frequently helpful so that your CPAP unit is tailored to fit your needs and your usage of it optimized.

What is the role of oral appliances?

Another form of non-surgical treatment is an oral appliance. This type of mechanical device is worn in the mouth during sleep, and resembles a football mouthpiece. Its job is to reposition the lower jaw, or mandible, forward, and thereby pull the tongue away from the back wall of the throat. It also pulls the palate forward due to the attachments of the tongue to the sides of the palate.

Like nasal CPAP, oral appliances must be worn nightly for maximal benefit. They are noninvasive, and are custom fabricated by a physician or dentist, usually from dental molds made in the office. A wide variety of these are now being actively marketed by a number of dental laboratories.

The American Academy of Sleep Medicine has endorsed these devices for use in select cases of snoring and mild to moderate apnea. They are generally not recommended for more significant OSAS. Additional valid studies showing efficacy are needed.

Compliance is reported to vary from 25-75%. These appliances should not be worn by patients who have pre-existing jaw joint pain or dysfunction, known as TMJ, as they can aggravate or even induce TMJ problems in some people.

What if I just lose some weight? Isn’t that good enough?

It may not be a cure-all, but it should definitely help.

Weight has a decided influence on this problem. As pointed out earlier, snoring and OSAS is much more common in the obese population, and weight gain can make the situation worse. It needs to be stressed, however, that there is frequently more to sleep apnea that just fat; sleep disordered breathing—from simple snoring to severe OSAS—is seen even in the thin population.

Being overweight can affect the upper airway in several ways. Fat deposition in the throat and neck can circumferentially narrow the throat. A fat neck might put pressure on the throat tissue. Excessive fat in the abdomen and torso can interfere with breathing during sleep by compressing the chest and repositioning the diaphragm, thereby changing the length and tension on the trachea, which affects the stability of the walls of the throat.

Weight loss should therefore be an integral part of any treatment plan for this disorder, as it can improve patency of the throat and stabilize the pharyngeal walls. It should not be relied upon as the only form of treatment of significant OSAS, though, as most patients are generally not able to lose enough weight to eliminate their apnea, and they are usually not able to maintain the weight loss.

Weight loss surgery—otherwise known as bariatric surgery—might have some role in helping morbidly obese patients lose weight as part of a comprehensive treatment plan. This specialized surgery involves surgically reducing the size of the stomach, and can be quite effective for a select group of such patients.

Aren’t there just any medicines that can make the problem go away?

Nope. Not yet there aren’t.

A variety of medications have been suggested as possible treatments of OSA, in an attempt to improve pharyngeal muscle tone or respiratory drive. Unfortunately, no such “magic bullet” has yet been found. Following is a partial list of medications that have studied for this disorder:

q Progesterone: a known respiratory stimulant, it is of limited benefit in patients with obesity-hypoventilation syndrome, a severe form of OSAS associated with morbid obesity

q Acetazolamide (Diamox): produces metabolic acidosis, and has some use in certain types of central apneas

q Protriptyline: a tricyclic antidepressant that is of benefit in certain mild cases of OSA. It decreases REM sleep and may increase pharyngeal dilator muscle tone. Its side effects limit its use.

q L-Tryptophan: slight usefulness was seen in one uncontrolled study only

q Theophylline: though tried in several studies, it is not thought to be of help with adults with OSAS

q Nasal steroids: often used to help with CPAP compliance by reducing nasal resistance. Frequently used nasal medication for allergies, nasal obstruction, etc.

q Phosphocholinamin nose drops: tissue lubricant that reduces friction; reportedly decreases number of snores per hour. Very limited data is available.