Snoring, Obstructive Sleep Apnoea (OSA) and Upper Airways Resistance Syndrome (UARS)
Continuous Positive Airway Pressure (CPAP)
Mandibular Advancement Devices (MAD)
Non Invasive Ventilation (NIV)
Restless Legs Syndrome (RLS) and Periodic Limb Movements During Sleep (PLMS)
There is a minefield of so called ‘treatments’ for snoring and sleep disordered breathing, many available from the internet. These range from sprays, pillows, and clips to stick up your nose, to the ridiculous idea of wearing a watch-like device that gives you an electric shock every time you snore. Get advice from a properly qualified sleep physician who knows what can and can’t be done, and the likely hood of success will be increased.
Message number one:
Don’t pay good money for something that probably won’t work!
Message number 2:
Never consent to surgery on your soft palate after hearing claims that it will cure your snoring or sleep apnoea. It probably won’t.
I tell my patients that if any product worked reliably beyond the treatments that are recognised as medical interventions, I would be selling it too, and I’m not!
The treatment for snoring and disorders of breathing in sleep are basically the same. Treating breathing disorders will always treat snoring also, although the converse may NOT apply.
All treatments are aimed at keeping the throat open during sleep. One day there will almost certainly be a tablet for this, and life will be much easier for patient and doctor alike! But science hasn’t got that far yet, so the following treatments are the ones we recommend currently.
CPAP is often regarded as the gold standard of treatment for snoring and sleep apnoea, although with careful selection of suitable patients, other treatments are also equally effective.
Essentially, a CPAP machine is an air-compressor with a mask to breath from. Pressure is applied to the space in the throat from the mask, and this keeps the throat open so that the air flows quietly during breathing (see the section on Snoring which explains why noise occurs). A properly set up and correctly used CPAP machine will stop snoring completely, much to the surprise of many bed partners.
CPAP machines come in many guises. The simplest are Fixed Pressure Devices, but more sophisticated designs monitor the breathing and adjust the required pressure automatically during sleep. These are known as autoset devices.
Many devices now have inbuilt humidification, using a heated water bath to warm and moistened the air as it is breathed in. This helps to keep the nose in good condition by reducing the tendency for nasal inflammation and cold-like symptoms.
Some people find CPAP a bit daunting, and the services of a skilled and experienced sleep technician makes a big difference to the acceptability of the technique.
Undesirable effects of CPAP include difficulty tolerating the mask, leaks around the mask, and noise from the machine. The patients who accept CPAP most easily are those with personal symptoms of excessive daytime sleepiness, which should be cured by CPAP.
Non Invasive Ventilation (NIV)
Sometimes using CPAP does not correct the problem with sleep apnoea, particularly in very overweight patients suffering from Obesity Hypoventilation Syndrome.
This is because even though the throat is kept open by the pressure, breathing is still inadequate because the muscles are too weak move the chest during sleep, particularly when lying down in bed. Sufferers from this condition often find it easier to sleep sitting up, and may spend the night in a comfortable chair rather than in bed. This poor breathing leads to an accumulation of carbon dioxide in the blood, and morning headaches are a common symptom. Characteristically, headaches pass off soon after waking when breathing improves.
In these cases, it may be necessary to use NIV rather than CPAP, and this is a highly specialized area requiring a skilled and experienced team of clinicians and technicians. Needless to say, all this is available in our unit.
Put a MAD in your mouth, as the saying goes. A MAD is a bit like a pair of false teeth worn at night. A plate made of plastic or similar material in moulded to fit the upper and lower jaw and teeth, and should have retaining clips as part of the device to help it stay in place. The idea is to pull the bottom jaw forwards so that the bottom front teeth lie in front of the top front teeth. This jaw advancement pulls the tongue forwards also, leaving more space in the back of the throat for the air to flow more easily and quietly.
Not everyone will find a MAD helpful, and there are many dental practitioners making devices for patients who are quite unsuitable for the technique. Before embarking, make sure that you get agreement for your money back if you are not satisfied with the result! We have treated over 1500 patients since 1996 with an exceptional level of satisfaction.
Like CPAP machines, MADs come in various guises, and prices vary accordingly. The cheapest devices can be purchased from the internet for as little as £40, whilst bespoke devices range from acrylic at a few hundred pounds, to the Somnowell which is made from titanium at around £1500. Expert advice from an experienced orthodontist specialising in this field of practice is essential, and my colleague Dr Lindsay Winchester has undertaken this work for over 15 years.
Provided no underlying associated medical conditions are present that require treatment, tablets are prescribed if required. Suffering from restless legs is unpleasant but not dangerous, and treatment may not be needed unless sleep is disturbed, or the sufferer find the sensation distressing.
A common association is the finding of low iron stores in the body, and a blood test should be carried out to measure the level of ferritin. If ferritin levels are low, iron supplements in the form of ferrous sulphate should be administered under the care of a sleep physician or GP.
Other treatments include tablets such as Clonazepam, Dopamine Compounds, and Gabapentin or Pregabalin, and Opiates.
Clonazepam has fallen from favour over the last few years. Coming from the benzodiazepine group of drugs, many GPs prefer not to prescribe it for longer periods. However, it can be effective but is likely to make any element of snoring worse if the patient is not being treated for this at the same time. It is a useful adjunct when patients are on CPAP because of its relaxing properties.
Dopamine is a chemical neurotransmitter in the brain associated with movement and implicated in Parkinson’s Disease. Supplementing dopamine also works to reduce restless legs and periodic limb movements during sleep.
There are three drugs that are used commonly: Pramipexol, Ropinerol, and Cabergoline. Cabergoline is available as a skin patch. All are effective, but side effects of nausea and dysphoria are common and often spoil therapy. My own choice in Pramipexol, and many patients use this compound over the longer term. Tolerance to the drugs is also a problem, and sometimes a so called ‘drug holiday’ ie time off therapy, is needed to re-establish effectiveness. As tolerance develops, symptoms return, and often occur earlier in the day.
Gabapentin and Pregabalin
These drugs are better known as painkillers, and both are in common usage by pain doctors. However, they have been reported in the medical literature as being effective in restless legs and PLMS, and our unit has certainly seen benefit for patients. Side effects of dysphoria sometimes occur.
Occasionally it is necessary to use opiate compounds such as oxycodone or morphine to gain control, and are usually effective but with obvious disadvantages. Some patients find that codeine helps, because this is metabolized to morphine in the body.
Treatment for narcolepsy is aimed at treating the excessive daytime sleepiness (EDS) and associated cataplexy.
Until only few years ago, amphetamines were used, and some patients are still using dexamphetamine today. However, newer drugs such as Modafinil and Sodium Oxybate have largely replaced amphetamines. Both are brain stimulants that improve daytime alertness and wakefulness, and Sodium Oxybate may also promote Deep Slow Wave Sleep.
Modafinil is effective but can cause side effects of agitation and headache, and occasionally liver dysfunction.
In 2008, I wrote an article in the London Evening Standard on recreational use of Modafinil as a brain stimulant. You can download the article below.
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Sodium Oxybate is very expensive and its use is often restricted in the NHS for that reason. It is also less easy to use, coming as a powder that requires dilution, with a dose needed in the middle of the night as well as before bedtime. However, it does the advantage of helping reduce cataplexy also, which Modafinil does not.
Cataplexy often responds to the anticholinergic side effects of tricyclic antidepressant drugs such as clomipramine, or Serotonin re-uptake Inhibitors (SSRI) such as Venlafaxine, and these may be used in combination with Modafinil to gain control of symptoms.