“They say they sleep 8 hours, but they wake up tired: many of them have apnea.” The link between snoring, stopping breathing and the risk of serious illness, explained by Dr. Carmen Ardelean, MedLife somnologist

Snoring is often treated anecdotally and is one of the main reasons for an increasingly common phenomenon today: divorce from sleep. However, anyone who snores every night should see a sleep specialist, because this bothersome symptom for a partner can hide a much more serious problem: obstructive sleep apnea. “Approximately 90% of patients who come to the sleep specialist's consultation come because they snore, and the relatives notice pauses in breathing during the night“reports Dr. Carmen Ardelean, primary pulmonologist with expertise in somnology at MedLife Medici's Hospital in Timișoara. The consequences: from chronic fatigue and decreased ability to concentrate to increased cardiovascular and neurological risk.

Obstructive sleep apnea is more common in men, especially after 40-50 years, in the context of excess weight. “Patients with BMI over 35 and neck circumference over 40 cm are the most prone. But we also see young women with severe forms,” ​​says Dr. Carmen Ardelean. Airway anatomy can be a predisposing factor for apnea: small and retracted mandible, ENT history, such as untreated polyps in childhood, which can alter facial bone development. “We send children to the orthodontist early; these changes can be easily corrected in childhood. In adults it is much more difficult.”

The patient with apnea rarely knows that his breathing stops during sleep, sometimes hundreds of times a night: “Many say they sleep 8 hours, but in the morning they wake up tired. It is a sign that they are not sleeping efficiently because of the interruptions caused by apnea,” says the doctor. Each apnea produces a cerebral micro-awakening, and sleep becomes fragmented, explains the specialist.

Most of the time, the partner notices the pauses in breathing and brings the patient with apnea to the doctor. But technology can also be a help in this regard: more and more often, young people end up seeing a sleep specialist because smartwatches indicate decreases in oxygen saturation during sleep or poor quality sleep: “This has no diagnostic value, but it is an alarm signal that, fortunately, brings them to the specialist.”

When snoring becomes dangerous

At least 10 seconds of breathing cessation is required to mark an apnea. “Most are 20-30 seconds, but I've had patients with minute-long apneas. In one night, severe cases can accumulate 300-400 episodes of respiratory arrest.”

During these breaks, oxygen can drop dramatically: “We have patients who start at 90% saturation and get to 60% within 30 seconds.” Intermittent hypoxia affects the blood vessels, heart and brain. “The risk of resistant hypertension, rhythm disorders, heart attack or stroke increases. There are studies linking apnea to neurodegenerative diseases, such as Alzheimer's and Parkinson's,” adds the doctor.

How is the diagnosis made?

The assessment begins with risk questionnaires regarding daytime sleepiness, irritability, decreased concentration, morning awakenings with headaches, the need to doze during the day. Confirmation, however, is done through an investigation called a polygraph—a simple, at-home monitor: a chest strap, a nasal cannula for airflow, and a flexible pulse oximeter. The device records saturation, sleep position, snoring and breathing events. In special situations (parasomnias, suspicion of restless legs syndrome), video-assisted polysomnography is indicated in a somnology center.

Apnea treatment can be life-changing, the case of a 37-year-old mother

The standard therapy for moderate to severe apnea is CPAP (continuous positive pressure): a device that, through a nasal or face mask, keeps the airway open during sleep. “I ask apnea patients to wear it every night. The first two weeks are harder for 80% of patients, but those who get over the discomfort quickly notice the benefits,” says Dr. Ardelean. The results can be seen in everyday life: “I no longer fall asleep watching TV, they are more present with the children, at work, they regain their energy and attention. Including the quality of their sexual life improves”, she states.

A concrete example is that of a 37-year-old woman who went to Dr. Ardelean because of snoring. “She had severe apnea, with obvious breathing pauses – a typical apnea, which we mostly see in men. She accepted the CPAP treatment and was extremely compliant. After a few months of wearing the mask night after night, she told us that she feels completely changed: she is much more present during the day, can take care of the children, is no longer so tired and concentrates better at work as well”, says the sleep specialist. This is one of the cases that shows, says the doctor, how spectacular the results can be when the patient consistently follows the treatment.

In mild forms of sleep apnea, ENT interventions can be recommended (in case of hypertrophic tonsils, prolonged lute, lowered base of the tongue), dental devices for mandibular advancement. Also, weight loss is an important factor that can significantly alleviate apnea episodes.

Losing weight can actually cure apnea

“The more the weight increases, the more the apnea episodes intensify. Conversely, weight loss reduces the severity. In morbid obesity, after bariatric surgery, we see spectacular decreases in the apnea-hypopnea index,” says the doctor. Some patients go from 90–100 events per hour to near normal values. “When the trigger is corrected, the apnea can disappear. We repeat the test after weight loss, because the tone of the neck muscles changes.”

Insomnia: the first treatment is patience

90% of Dr. Ardelean's patients are those who are bothered by snoring, but in second place are those who cannot sleep. Insomnia is all the more present among the population, as the level of stress in society increases, but it is also a frequently encountered problem in certain age groups.

“Most patients with insomnia are women – especially premenopausal and menopausal – or very stressed people. Many also have associated depression,” says Dr. Ardelean. Most frequently, patients experience either initiation insomnia – they fall asleep very hard or even say they don't fall asleep at all all night – and maintenance insomnia – patients wake up around 2.00-3.00 in the morning and can't get back to sleep.

To make the diagnosis of chronic insomnia, difficulties falling asleep or maintaining sleep must persist for at least three months and affect the following day: fatigue, lack of concentration, low performance. “We ask patients to keep a sleep diary – bedtime, awakenings, coffee/alcohol consumption, physical activity. This way we see what the specific patterns and triggers are for each individual.”

The first-line treatment is cognitive-behavioral therapy for insomnia, carried out by psychologists. “They teach him concrete rules and exercises to retrain his brain and body. As somnologists, we do basic education: no alcohol in the evening, no high-fat, high-carb meals before bed, no overstimulating screens and action movies. But step-by-step tracking and targeted retraining are the preserve of psychologists.”

In the case of insomnia associated with the period of perimenopause and menopause, gynecological and endocrinological consultations may be necessary for hormonal evaluation, and in depression a psychiatric consultation is necessary. “Insomnia is not easy to treat, and patients must know that the first and most important ingredient is patience,” says the somnologist.

Melatonin: how and when to take it correctly

One of the most touted treatments for people who have trouble sleeping is melatonin, but these supplements are only effective if taken correctly.

“If the patient is unable to fall asleep, we recommend 5 mg of melatonin, which is administered two hours before bedtime – that's how long it takes for it to take effect. It should take at least two months to notice a change.“ For those who fall asleep easily but wake up in the middle of the night, “melatonin is recommended immediately before bed to prolong sleep.” Melatonin's role is to help the brain relearn to manage and produce the sleep hormone. Any non-psychiatric treatment has effects over time, so patience and perseverance are needed.

Top mistakes that maintain insomnia

According to the somnologist, rumination is one of the most harmful factors for the initiation of sleep: the mind runs over the day's problems, bills, emails, projects. In second place, Dr. Ardelean places the chaotic schedule – meals, sleeping and waking up at variable times, plus the 10-15 minute nap during the day, which “steals” the evening sleep. Alcohol and stimulants also fragment sleep and sabotage therapeutic interventions.

Signs that should send the patient to a sleep specialist

Daily snoring, breathing pauses noticed by the partner, frequent awakenings, morning headaches, sleepiness in traffic, watching TV or even at the office, plus, difficulties falling asleep for at least three months – all these are manifestations that should send the patient to the sleep doctor, regardless of gender or age.

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