(Joe McIntyre) Host: Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. I'm your host, Joe McIntyre. This is part two of our two-part series with Dr. Richard Schwab, a professor at the University of Pennsylvania Perelman School of Medicine in Philadelphia, where he is the chief of the Division of Sleep Medicine. On our first episode of this series, we discussed the topic of insomnia; why it happens, how it affects us and what we can do to prevent it. If you haven't listened to that one yet, please check it out. In this episode, we will dive into another issue with bedtime, sleep apnea and snoring. Now Dr. Schwab, let's switch gears a little bit and get away from insomnia and to a couple other sleeping issues: snoring and sleep apnea. So, something I'm sure many people face, either they have or maybe their partner experiences one or the other. Why do some people snore?

Richard J. Schwab, MD: So, snoring is really common. 15% of women and 25% of men are chronic snorers, in terms of intermittent snoring, it goes up into the 40-45% range. And then alcohol, just as it was bad for insomnia is also bad for snoring. So you can take someone who normally doesn't snore, you give them alcohol and they'll start to snore. Or you can take someone who snores, and you give them alcohol; their snoring will get worse, and they may develop sleep apnea. Or if you have a patient with sleep apnea, and then you give them alcohol, they even get worse. But to answer your question, snoring is abnormal; it's typically a vibration of the uvula or the soft palate, that is the thing that hangs down in the back of your throat. So, it vibrates. And that's what causes the sound of the snoring. So, if your airway’s narrow, obesity is the primary risk factor for sleep apnea. But and so many people who snore have sleep apnea. But if you have an abnormal airway, in particular, a large tongue, big tonsils, big uvula, small jaw, or your jaw’s back, they will put you at risk for snoring. So it's really common, but it means there's something wrong with your airway. It's not normal to snore.

Host: Those nose strips that people may see in the pharmacy or on TV commercials, whether they have magnets in them or whatever they are just maybe some metal, do they actually stop you from snoring?

Dr. Richard J. Schwab: No. So snoring is a problem in the back of your pharynx where the uvula is. So, what these Breath Right strips do is they open up your nasal valve. So, for the audience, everybody take a breath through your nose. Okay, now push your nose up and take another breath. It should be easier to breathe with your nose up. So that's a nasal valve. So, if you have a nasal valve problem, these Breath Right strips or whatever you want to call them, will help that. But it won't help apnea at all. So, they're not expensive, it's not going to hurt you, but it doesn't help apnea.

Host: Good to know. One question that I'm sure a lot of listeners have in their head is how in the world do I stop my partner, or the person I'm sleeping with, or my sibling that I'm in the same room with from snoring? How is that possible? Is there a way to do it?

Dr. Richard J. Schwab: So there's no simple way. You can do a lot of things, though, to wake them up. So, you can wake them up, and they'll stop snoring. You can move to another bedroom so that the snoring won't bother you; you can try to move them. So, maybe they're on their back and you move them to their side. Typically snoring is worse in the supine position when you're sleeping on your back. So, if you move to your side that will help. But most of it involves somehow knocking your partner from a deeper stage of sleep to a lighter stage of sleep or waking them up. Hopefully, they'll go back to sleep. But what typically will then happen is they will begin to snore again or have apnea again. So, there's no simple way of getting rid of that outside of waking them up.

Host: You just mentioned that moving them from a deeper sleep to a lighter sleep, is there a certain cycle, sleep cycle, where snoring is more likely to occur?

Dr. Richard J. Schwab: Yeah, typically in your deeper stages of sleep, but even in stage two sleep, you can see loud snoring; stage three is deeper REM sleep. Apnea is typically worse in stage three, in REM. Snoring can be anywhere, pretty much across all those different sleep stages. You can figure out when somebody falls asleep because they often will start to snore. But you can't really fix that either. There's no way to modify that, so you’re kind of stuck with it.

Host: Now, if you snore really, really loud, does that mean you have sleep apnea? Essentially what is the difference between snoring and sleep apnea.

Dr. Richard J. Schwab: Almost everyone who has sleep apnea snores, but not everyone who snores, has sleep apnea. So, snoring may just be that your airway is narrowing a little bit and, again, fluttering your soft palate. Sleep apnea is where your airway narrows enough that you either reduce your airflow and drop your oxygen or you have complete apnea; apnea means the sensation of flow. So, you're not getting any air through and that's associated with a lot of cardiovascular diseases. But it's basically snoring, which is the first sign that you are potentially at risk of apnea. But then as your airway gets more crowded, maybe you gain more weight, or you start a sleeping pill or something else because those actually increase your risk for sleep apnea, then you develop apnea, but it's a progression. Snoring is a sign of sleep apnea. Again, you can snore and not have apnea, but almost everyone who has apnea snores.

Host: Okay. Why is sleep apnea such a concern? What are the risks associated with it? What happens if you have it? Take us through that a little bit.

Dr. Richard J. Schwab: So you can think about it, all of a sudden, you’re snoring, and then you have apnea, and you have sleep fragmentation. You're not even getting into deeper stages of sleep. So you're going up and down, your oxygen is dropping. There's sort of sleep fragmentation and arousals and changes in blood pressure as you're going off to sleep. And you wake up the next morning, you know, although you may have slept for seven or eight or nine hours, you feel like you didn't sleep at all because you never got into deeper stages of sleep. Because every time you go into a deeper stage of sleep, your oxygen drops and your body says, “I don't like that,” so they're going to wake you up. You have sleep fragmentation. There are the sleepiness effects of sleep apnea, and then obviously you worry about people driving, right? So they fall asleep driving, they are falling asleep at a red light, or they're falling asleep in movies, or they're falling asleep in face-to-face conversations. So there's a sleepiness effect, which can be important, especially if you're driving. And then there's a lot of cardiovascular effects because every time you have an apnea, it's like it's a sympathetic surge, or it's a surge of adrenaline. So all of a sudden, your blood pressure goes up. And then, so now you have high blood pressure, you're developing higher blood pressure, you can have heart attacks, or you can have strokes or different cardiac arrhythmias because your oxygen is dropping in atrial fibrillation. So, there are all these cardiovascular effects, and there are sleepiness effects. So, with treating sleep apnea, when we treat it, a lot of people feel like they've had a brain transplant. They go, “Oh my God, I can think again,” “I'm not falling asleep,” “I don't have to read a paragraph four times,” or “I'm not falling asleep or red lights.” And all of a sudden, their blood pressure gets better, they feel better and they're at less risk for heart attacks and strokes. So lots of reasons to treat it.

Host: Is sleep apnea only a concern for older adults or can it affect younger folks or even children?

Dr. Richard J. Schwab: Everybody. So, there are different anatomical reasons. Typically, it's an anatomic disease, and you have different structures in the back of your throat that put you at risk. Kids usually have big tonsils or big adenoids. So, you can take them out, and they'll get better. But the primary risk factor in adults is obesity. That makes your tongue larger, and you have more fat in your tongue, a bigger soft palate, and more fat in the soft palate. So, obesity is the primary risk. And then, as you get older, you can see it in those patients, too. A lot of times their apnea isn't necessarily as based on obesity anymore, but just as you get older, your apnea gets a little bit worse. So, all age ranges, but the most common is 30 or 40-year-old, overweight gentlemen with high blood pressure, or typically menopause makes sleep apnea worse. So typically, a woman in their 40s may not have sleep apnea, but a woman in their 50s will. Again, typically menopause creates some weight gain, and that's part of it. But almost any age range will have sleep apnea.

Host: Should you always see a doctor if you snore at all, or if you snore regularly, just to make sure that it's not a sign of a serious issue? When should you decide hey, I should probably see someone about this.

Dr. Richard J. Schwab: Yeah, I think if you're snoring chronically, I would do it. If you snore only when you're drinking alcohol, your intermittent or nasal allergies or something like that, probably don't have to worry about it. But if you're snoring on a regular basis, and especially if you're sleepy during the daytime, you have high blood pressure, your bed partner starts to notice you stopped breathing at night. Go see your general doctor and I would get a sleep study. It's easy. You can do sleep studies at home; it's relatively easy. Sometimes, you do them in the lab, in the sleep lab, but a sleep study is not risky. And you can make sure you don't have apnea and like I said, if you have it and you treat it, you're going to feel better.

Host: If you have sleep apnea, is the only treatment today wearing a mask or breathing machine when you sleep? Is that the only solution now or has that changed in the past few years?

Dr. Richard J. Schwab: So it's changed. First of all, the masks are much better than they used to be. They're much more comfortable, a lot of them fit under your nose. CPAP stands for continuous positive airway pressure, which is the machine you're talking about. They are good in the sense that we can at least track your use. We know how many hours people use it, how many days, if it's working or not, there's a measure of efficacy and if they have mask leak. So that technology has improved, and in time, I think you're going to see personalized masks that even make it better. But it is a nuisance, and probably 30 to 50% of patients can't use CPAP. There are other options; there's oral appliances, which are appliances that fit in your mouth to pull your lower jaw forward. So, your tongue, the part you can't feel inserts into your chin. So if you move your jaw forward, it's going to pull your tongue forward, the base of the tongue, and that's going to help apnea. There are a lot of different oral appliances there; they can be a little pricey, but they work pretty well. And then there's a lot of surgeries, especially if you have big tonsils, you can take them out, that works. The newest surgical procedure is something called hypoglossal nerve stimulation, which is basically a pacemaker for your tongue. So it's a device that is inside your body and inside the right side of your chest. And then there's a lead that goes to the hypoglossal nerve, which is under your chin, and it stimulates that nerve to push your tongue toward your lips. And what's cool about that surgery is that it works about three-quarters of the time, which is better than almost any other surgery. It's reversible. It's expensive, but if insurance covers, you can take it out. But you know, if you take out your gallbladder, you can't put it back in. This you can take out and so from that standpoint, it's kind of nice, it's reversible. So if you hate it, you can take it away.

Host: Are there any other misconceptions or myths about snoring or sleep apnea that we haven't talked about yet that you want to address here?

Dr. Richard J. Schwab: So, couple points again, one with alcohol, alcohol makes sleep apnea worse, snoring worse. So be careful. And one of the things I kind of make fun of is, you know, if you drink alcohol at lunchtime, you're good to go. So the martini lunches, no problem. But if you're drinking at dinner, and you're going to be sleeping the next four to six hours, not a good idea. The other thing that's going to change, that is already here, are these GLP-1 agonists for weight loss. They're going to be a game changer, we believe, in terms of not only treating hypertension and obesity but sleep apnea and in people who are heavy. These medications do a really good job of suppressing your appetite and can absolutely help sleep apnea. So, I think that's something that people listening to this should think about and talk to your general doctor about these GLP-1's, there's a bunch of different types, and there's going to be newer ones coming out. But I think that's something people should pay attention to, at least in the treatment realm for sleep apnea.

Host: So Dr. Schwab one final question, at least from me, before we close out. I actually just purchased this book, “Why We Sleep” by Dr. Matthew Walker, that gets into some of the background, historical aspects of why mammals sleep in general. But in your perspective, why do humans, why do we need to sleep?

Dr. Richard J. Schwab: I would say that's a million-dollar question. It's probably a Nobel Prize kind of answer. If I knew the answer. If you think about it, from a Darwinian standpoint, survival of the fittest, sleeping is a bad thing. If you're an animal and you're sleeping, somebody can come gobble you up, right? I mean, that doesn't sound good. And so there's nothing really beneficial from a survival standpoint in sleeping. So, it must have a huge impact. It has an important effect. And as far as we know, every mammal sleeps, even fish, part of the brain shuts down in dolphins etc. So, it is clearly important. The why though, whether it's important because of memory, whether it's important for cleaning sort of waste in your brain. I mean, there's been lots of theories, but I don't think we know. But I think it's fair to say that it's really important and that you need, everyone needs to sleep and obviously if you get a good night's sleep, you have a better day at work, you can function better, think better and the whole nine yards. But to answer your question, I don't think we really know why it is, but someone will win a Nobel Prize if they figure it out.

Host: Someday soon, hopefully. Final question. Dr. Schwab. If our listeners are looking for more information or have questions about snoring, sleep apnea, insomnia, where should they go?

Dr. Richard J. Schwab: Well, absolutely go to the Merck Manual, or merckmanual.com. There's lots of information there. You're going to not only see these podcasts, but there's information on all these different sleep disorders. So pay attention to that. That's where I would go first.

Host: Dr. Schwab, thank you so much for joining us on this podcast. Great conversation busting some of the myths surrounding insomnia, snoring and sleep apnea.

Dr. Richard J. Schwab: Thanks Joe, it was fun as usual.

Host: As we close out, I’ll let Dr. Schwab leave our listeners with the final word.

Dr. Richard J. Schwab: Medical knowledge is power. Pass it on.