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CHECK UP
Thursday 30 March 2006, 3.00-3.30pm
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BRITISH BROADCASTING CORPORATION


RADIO SCIENCE UNIT



CHECK UP
Programme 8. - Snoring and Sleep Apnoea



RADIO 4



THURSDAY 30/03/06 1500-1530



PRESENTER:

BARBARA MYERS



CONTRIBUTORS:

NEIL DOUGLAS



PRODUCER:
PAULA MCGRATH


NOT CHECKED AS BROADCAST





MYERS

An estimated 15 million snorers out there - we're expecting no shortage of calls today. What is the answer? Have you found a way of stopping someone snoring that may just help others save their marriage or are you getting desperate? Heavy snoring is certainly a social nuisance but it can become a medical problem. Coupled with daytime drowsiness it may be a sign of sleep apnoea - that's the condition in which the muscles of the throat collapse causing obstruction to your breathing. Chronic sleep apnoea increases the risk of stroke and heart disease, so it needs to be treated.



If you'd like to know about the treatment options call us now - 08700 100 444 or e-mail your questions to checkup@bbc.co.uk. And here with the answers is Neil Douglas, he's professor of respiratory and sleep medicine at Edinburgh Royal Infirmary.



Our first caller is on the line. John - John Hancock in Peterborough your question.



HANCOCK
Oh good afternoon. I'm very interested in this. My - I am [indistinct words] seriously with snoring and it's only since I've put on weight and I'm wondering if that is relevant.



MYERS
Oh I think it's extremely relevant, which is to say Neil Douglas is nodding his head. Weight is an issue here isn't it?



HANCOCK
I packed up smoking and then I piled the weight on - big time.



DOUGLAS
I'm delighted to hear you've stopped smoking but weight is a major problem as far as snoring goes. The vast majority of snorers are overweight and it is something that you should address.



HANCOCK
But it's also this afternoon tiredness - I'm putting it down to my age, my age is 55, I'm putting it - going back to baby syndrome - need that nap in the afternoon. But it was when - when it was mentioned on the radio that my ears pricked up and that applies to me.



DOUGLAS
Yeah sleepy snoring is an issue that you should certainly take to your GP and we'll cover over the course of the afternoon.



MYERS
Neil, why would losing weight help, what part does that play?



DOUGLAS
Snoring's basically caused by you having a narrow throat and when you put on weight some of that weight goes on your neck and some of it also on your tummy - both of which result in your throat being narrower than average. And when you fall asleep the muscles that keep your throat open relax and you can suck your throat narrow and once it gets narrow it vibrates and produces this - what can be incredibly loud noise of snoring.



MYERS
So I mean people are all sorts of weights - always trying to lose weight - what's a key indicator for you when you see perhaps a chap in his fifties, you take a look and you say yes could be to do with your weight?



DOUGLAS
I think anybody who's got a body mass index of more than 30 and many people will know how to calculate that but anybody who's more than 20% over their ideal bodyweight, they seriously should think of losing weight. And indeed anybody whose snoring is troubling people should look at their weight very critically and see if that would be a thing that they should rectify.



MYERS
And if they wear a large collar size - something like 17?



DOUGLAS
That clearly is a major issue - it's amazing how many people don't know what their collar size actually is however.



MYERS
Okay, thanks for starting us off John with that and do stay listening. We've got another caller in Glastonbury, it's David. David's got some concerns about snoring and is using a nasal spray - does it work?



DAVID
No. Well I mean I've only been taking it - I've been taking Nasonex in the morning and Otrivine at night, as prescribed by my GP on Monday. The apnoea or my snoring and the gasping for breath has got increasingly worse over the last few months. I have had a head cold as well and the doctor also prescribed some Pseudoephedrine tablets. I'm not sure whether this is because of my sore throat or whether it's because of the sore throat as caused by the excessive snoring and gasping for air at night.



MYERS
So Neil, what part do nasal sprays play in the treatment of snoring and indeed in sleep apnoea, if the snoring is combined with the drowsiness leading to this rather more serious medical condition?



DOUGLAS
They're entirely logical therapies but unfortunately the evidence is that they don't work. They're, along with a huge list of other things, ineffective therapies for snoring. You will find many things advertised in many magazines which have people spend a lot of money on, understandably trying to cure their snoring and help their partners, the vast majority of these, indeed probably all of them that are advertised in the lay literature, do not work.



MYERS
So you do need to pursue this a bit further, go back to your doctor and see whether there's anything else he might recommend. I'll move on if I may David, we've got so many callers and they're all relating to this business of what to do about the snoring and indeed this further problem if they get very sleepy during the day, which seems to be connected with the apnoea. So Mike Strawson in Lincoln I think has this problem, falling asleep at rather inappropriate times Mike?



STRAWSON
Absolutely.



MYERS
You're awake now.



STRAWSON
Yes I've fallen asleep during a performance of Aida, during Les Miserables, and that is anything but boredom, I was very frustrated, as you can imagine.



MYERS
Have you been diagnosed then with sleep apnoea?



STRAWSON
No I haven't, no.



MYERS
Is this the first you've heard about it?



STRAWSON
I confess it is, yes.



MYERS
Are we talking about sleep apnoea if Mike, who otherwise should be hugely entertained by these musical performances is actually nodding off, could this be - do you snore, I mean ...?



STRAWSON
I'm told I do yes. But even worse I actually have been known to fall asleep in mid sentence when I'm speaking at dinner parties, for example and I have just nodded off in the middle of a sentence.



MYERS
Well that is worrying.



STRAWSON
My head's gone backwards not forward into the dinner plate, I hasten to add.



MYERS
Okay, well where do we go with this?



DOUGLAS
This sounds like a classical story of sleep apnoea - somebody who is a loud snorer, snores every night, probably finds - you'll find that the snoring is intermittent, it's punctuated by breathing pauses, this is the classical story of somebody with obstructive sleep apnoea.



MYERS
And what is happening during this time?



DOUGLAS
What happens is that whereas snoring is caused by the throat being sucked narrow, the apnoeas or breathing pauses are caused by the throat being sucked absolutely closed, every time the individual tries to suck air into their chest when they're asleep. Their breathing's fine when they're awake but when their muscles are relaxed and they go to sleep they suck their throat absolutely closed every time they try to suck air into their chest.



MYERS
So this could be dozens, hundreds of times a night?



DOUGLAS
Yeah, I mean these breathing pauses may last up to a minute at a time - every breathing pause ends with a brief wakening and this may happen hundreds of times through the night, the highest I've seen is around a thousand times through the night and you know how you feel when you've been woken up a few times through the night, if you woke up a thousand times through the night you feel extraordinarily sleepy, dangerously sleepy during the daytime.



MYERS
But wouldn't you know if this is happening to you, I mean I don't know whether you feel this is happening to you Mike, or does the sleeper really not know?



STRAWSON
I don't notice it, no, other than when my wife digs me in the ribs to turn me over.



DOUGLAS
That's an unhelpful thing for her to do but totally irresistible, every partner does it, tell her just to leave you to sleep peacefully. The problem is that the patient - the individual who's suffering - feels that they sleep absolutely fine but they wake up in the morning not feeling refreshed and very, very sleepy during the daytime. And sleeping when you're in the middle of chairing a meeting or at an opera is socially inconvenient and highly undesirable. The bits that are really very dangerous are the fact that you may fall asleep whilst you're driving particularly.



STRAWSON
I'm very conscious of getting sleepy when I drive and I do actually stop at sort of hourly intervals.



MYERS
So where should Mike go next with this problem?



DOUGLAS
He must go - really as a matter of significant urgency - to see his general practitioner to get referred to a sleep centre to be evaluated.



MYERS
Okay, and what would be the first thing that would happen there because you are involved in such a sleep centre in Edinburgh, what would you do if Mike came to you, for example?



DOUGLAS
I mean what we will do would be to send him out a questionnaire that he would fill in and also one to his wife, because his wife's got a better story of what happens during the night than he does and preferably ask both of them to come up to the clinic so that we can interview them both and then go on to study their - his breathing pattern overnight and his oxygen levels overnight.



STRAWSON
Would the fact that in the day I actually breathe very deeply - I use both my chest and my diaphragm in my breathing, so my chest expansion, if you like, my intake of air, is fairly large, I do use my full lung capacity when I breathe?



DOUGLAS
No the fact that your lungs are large is not important, the question is are you large?



STRAWSON
No, no twelve and a half stone.



DOUGLAS
Good, well that's comforting. About 50% of people with obstructive sleep apnoea are significantly overweight, so if you're in the non-overweight category than it makes the therapy in some ways significantly easier.



MYERS
Mike, if I can leave you holding on and listening, let me take another call from Joe Martin in Oxford who's concerned about sleep apnoea and perhaps we can get a bit closer to some of the - well the treatment options for this condition. So Joe, what's the story with you.



MARTIN
Well my family say that my snoring is very, very loud and actually when they've come into the bedroom they have noticed - and when my wife was still alive she noticed it - sometimes I stop breathing altogether. So I wonder how do you know when the condition is serious or even dangerous and what are the sources of treatment?



DOUGLAS
The dangerous bit is the sleepiness and if you're not sleepy during the daytime, by which I mean either falling asleep against your will or falling asleep in obviously - in dangerous situations such as driving but I also have airline pilots, helicopter pilots - all sorts of people who have this condition, so it can be very, very dangerous indeed. If you are not sleepy then you're principally dealing with a situation that is social inconvenience of snoring. But if you are sleepy then it moves into a completely different category because you may well have this condition called obstructive sleep apnoea which not only has the danger of sleepiness but also has a risk of increased blood pressure, increased risk of heart attacks, increased risk of strokes and an increased risk of diabetes.



MYERS
Why do you have those health risks on top of your sleep apnoea?



DOUGLAS
As I've said you may wake thousands of times through the night, each time you wake your blood pressure shoots up and recent evidence that has been produced largely in Britain, from ourselves and from a group in Oxford, have shown that the blood pressure goes up through the daytime as well by about 5 millimetres of mercury in these people. And that on its own increases your risk of heart attack or stroke by about 30%, so this is a significant health problem, as well as a major social one.



MYERS
If I can just again take this on - we've got a caller in Gloucestershire, it's another Jo - I think is being treated for sleep apnoea and if you hold on Joe in Oxford and have a listen to this. Jo, what's the question about the treatment - I think you're having treatment or is it a partner?



JO
No it isn't me, I'm ringing on behalf of my husband who's 75 years old and he was diagnosed with sleep apnoea probably about five or six years ago. And I felt myself there was something wrong because we've always slept together and have slept very close and I was conscious of the fact that every time I seemed to be awake he seemed to have stopped breathing, which was very frightening and I can understand anybody getting really scared by this. Although he was totally unaware of it. And so eventually he saw a consultant, he had a sleep study done, which I'm afraid he had to pay for because there was a two year waiting list at that time. And to begin with they were just monitoring him and this went on for about a year and then after that time he had a mask prescribed and he's gone on using that - it's been a hard battle because it was quite difficult to use and they had to progress from a small mask, which just covered part of his face to a mask that now covers the whole of his face. He is so much better, I cannot tell you the difference it's made to him.



MYERS
And to you I expect.



JO
Pardon?



MYERS
And to you.



JO
Absolutely, because I wasn't getting sleep either and I was worried out of my wits because he wasn't a snorer, he snored very rarely. So again people were saying oh well you only get sleep apnoea if you're a snorer but certainly with my husband's case that wasn't so.



MYERS
Jo, that's a very good story. Perhaps we can get Neil Douglas to explain a little bit more about the system for treating sleep apnoea, Jo's mentioned this mask - what actually is the procedure?



DOUGLAS
The apnoea - the breathing pauses and the sleep disturbance - result from the throat being sucked shut, the machine - so-called continuous positive airways pressure machine, normally shortened to CPAP using the initials - merely blasts the throat open by blowing a positive pressure through the throat at night. I mean that sounds very aggressive but in fact it's a very gentle stream of air that comes in, either through the nose or through the mouth, depending on the system that suits the patient better. Most of us, normal people, would not sleep very well with these machines on but they are incredibly effective therapy for people who are sleepy with obstructive sleep apnoea. And indeed the improvements, as Jo has said, are huge. And one of the reasons that I am in this field is that you get incredibly grateful patients because you can completely transform their life and the life of their partners via this very simple and very cheap treatment.



MYERS
So how many patients would you have on CPAP then in your own practice?



DOUGLAS
I look after 7,000 patients on these machines in Scotland.



MYERS
And they're all successful?



DOUGLAS
Not everything is always successful in anything in life but the vast majority of these patients have benefited enormously and that's why they go on using the machines and we know they're using the machines.



MYERS
So it is a real tried and tested remedy - it works. I partly say that because I've got an e-mail from Alan who says that he's been treated with CPAP for the last 18 months, it has been effective but now he's finding that he can only use it for three nights out of seven because he wakes in the morning with his nose congested, it's as though he has a bad cold, and it takes several hours to clear up. He feels he has a raw feeling inside the top of his nose which is very uncomfortable.



DOUGLAS
Yeah, like any treatment there's the potential for side effects, they're relatively uncommon but they can all be handled and it really is a matter of going back to your sleep centre and asking for advice. On that particular one the normal thing that we would do would be to try them with the heated humidifier, having something blowing air through your nose at night tends to make you stuffy, partly because you're drying the nose and if you can put a humidifier into the system, which most of these devices can take now very readily, then you can get round that problem in the vast majority of people.



MYERS
We've got another caveat here, it comes in an e-mail from Barry who says that he went to a sleep clinic for an overnight stay, told that he snored and this CPAP was suggested but he was also told they're not supplied by the NHS and he finds them to be beyond my means. He also says that having tried one it's noisier than his snoring and when he pointed this out to the doctor he was told that he could put it in a cupboard. He's wondering whether he has to move to a shed, he's so concerned. So a bundle of questions there, how could he be helped, I mean are they available on the NHS?



DOUGLAS
Absolutely they are. There are difficulties in certain parts of England with getting them available or as available as they should be and certainly the devolution of the healthcare budget around England has not helped that. There are some areas in England where I know the waiting times for this treatment can be up to four years at present, which is absolutely disgraceful. And it's one of the things that has been used as a lever to try to get NICE to look at this, to make a statement that these machines should be available throughout the country on an equal basis. Having said that the devices are not expensive and it's ludicrous for any healthcare system not to provide this therapy. The machines cost around £250 each and they can last 10 years, it's a very cheap, very effective therapy which saves the health service money, in terms of heart attacks and strokes, it saves lethal road accidents and it's beyond the wit of man, as far as I'm concerned, that the NHS in England does not provide this readily in all areas.



MYERS
Well that's a very clear message thank you very much. You're listening to Check Up with me Barbara Myers and my guest today is Neil Douglas, professor of respiratory and sleep medicine from Edinburgh. We've got another caller waiting - John Jenkinson, also form the North, County Durham, John yes.



JENKINSON
Good afternoon Barbara.



MYERS
Hello.



JENKINSON
Yes I have a serious problem of snoring to a point that I waken myself. Also it goes to the other extreme that my wife will also waken me thinking I've stopped breathing.



MYERS
Ah okay, this is ringing a lot of bells isn't it.



JENKINSON
Yes and I'm overweight, I agree, but I've tried exercise - I've tried cycling - and to no avail.



MYERS
Have you tried any techniques such as the one we've been describing - the CPAP machine?



JENKINSON
No, I've tried the little clips on the nose, I've tried closing my nose altogether, leaving it open. I know that I have to have fresh air during the night and on odd occasions in staying in hotels I have had a knock on the wall that woke me - I must have woke the person next door.



MYERS
You snore for the county do you. I can just say here an e-mailer - Jo - has said that her husband, who's mild mannered, turns into a raging snorting bull when he's asleep - snoring in approximately 10 different styles - she says - grunting, puffing, gagging or just roaring and she can hear him through two closed doors. It really is a problem isn't it, let's see whether there's an answer for you John.



DOUGLAS
Absolutely. Snoring is a major nuisance to a lot of folk and I've had people referred by their next door neighbours and even by people walking up the street who've been horrified at the noise that they've been hearing from inside the house. If you're a snorer but not sleepy the things to do, firstly, as I've said already, is to ignore things that you might find to buy in magazines, also avoid surgery - there's no evidence that surgery, at the moment, helps at all. You're quite correct in saying that trying to lose weight is an important thing - cycling's fine but you've got to combine that obviously with taking in less in the way of calories of food and alcohol. Avoid evening alcohol because that relaxes the muscles and makes the snoring worse. And obviously if you've gone through all of that then the last thing to do is to find a dentist - you may have to go through your GP to find a dentist with the expertise - who can advise you on a device - a dental device - that will pull your lower jaw forward during sleep which definitely reduces snoring in people.



MYERS
So what should John ask for with this device that pulls your jaw forward.



DOUGLAS
It has different names - a mandibular repositioning splint is probably the commonest name that's used. But the average GP will know what that is. May need to refer you to a sleep service to get the local expert dentists - these are things that need to be fitted by an expert who has experience in them.



MYERS
John, thank you very much for your call. Good luck with that. There's clearly no question about your loud snoring but we have had a call from Mike Mitchell who says living on my own, how can I tell whether I snore. I tend to think well does it matter but he goes on: Does BT have a remote snoring service, for example, dial a number, leave the phone off the hook and in the morning they'll tell you whether they detected any snoring? I think it sounds a very interesting idea.



DOUGLAS
Not to the best of my knowledge do they have such a service. Try leaving a tape recorder on. It really doesn't matter enormously unless you are intending to develop a relationship obviously or unless you are sleepy during the daytime, if you're sleepy then it matters a huge amount whether you're a snorer or not.



MYERS
In talking to John just now I think you said Neil that surgery may not be the way forward. Mrs Salmon in Leicestershire is on the line now and I think has had surgery or is it your partner?



SALMON
It's my husband, hello, good afternoon.



MYERS
And what happened?



SALMON
Our GP recommended that my husband had the pallet - the flap removed from his throat - which was very nasty surgery. He was in a great deal of pain afterwards and got very angry with me because he was in so much pain, he had stitches in the throat and in fact he was a very, very loud snorer but in fact that made it even worse.



MYERS
Oh it's made it worse?



SALMON
Oh absolutely severe. And I wrote to the surgeon and he just wrote back and he said - Well it doesn't suit everybody. Which was no consolation to me.



MYERS
And when was this - how long ago?



SALMON
Seven years.



MYERS
That's very distressing isn't it.



SALMON
So Cliff sleeps on the ground floor and I sleep on the upper floor because we're fortunate we can sleep on two different floors.



MYERS
Well let's see if we can get a comment on that, it does certainly sound tough and it actually ties in with an e-mail from Peter, who says that he's had laser treatment for back of the throat to get rid of the flap and in his case he said it was not only expensive, it's produced no difference. So Professor what do you have to say about surgery? It is still I think offered and has been widely available for people but it's not worked in these cases.



DOUGLAS
And doesn't work on average. It was very much in fashion about 15 years ago but the evidence now is that it is ineffective and as you say can be extremely sore and even worse it can make the treatment of obstructive sleep apnoea, if the patient goes on to develop that, very much more difficult because the CPAP machines are very difficult to use if you've had one of these operations.



SALMON
It's strange because my husband can sleep at the drop of a hat, any time of the day.



DOUGLAS
Well it sounds to me as if he needs to be evaluated by a sleep centre as to whether he now has obstructive sleep apnoea and to see if another form of therapy would be better for him.



MYERS
Okay, thank you for that. We'll have a call from Malvern in Worcestershire, Theresa, looking for alternatives to surgery. For you or for a partner?



THERESA
No this is my partner, my husband. He's snored for as long as we've been married and probably before and we've used - now used a mandibular advancement device and it's like a miracle, it worked very, very well for him. And the first night he used it was the first night I'd known where we slept all through night and hadn't snored.



MYERS
That's a very good news story. So that supports what you were saying earlier that these mandibular devices can be helpful. You have to get it fitted appropriately, Neil, I guess so you have to find an orthodontist to do that. You can buy some things like mouth guards, again off the shelf, but is that the same thing?



DOUGLAS
No there are lots of different mandibular repositioning splints and I would strongly recommend that you go to a skilled orthodontist to get this, this is something that can be uncomfortable if fitted wrongly and can be ineffective if you do it yourself. So go and get the expert. I'm delighted to hear that it worked very well.



MYERS
Good, thank you very much for that. I have to say there's another e-mail from William saying his mandibular advancement device worked for a year but is now not very effective and a bit painful.



DOUGLAS
Go back and see an orthodontist, if necessary a different one, there are hundreds of different mandibular repositioning splints, get one that fits and is comfortable for you.



MYERS
Okay, and if I can throw in a very quick last e-mail from Alex in Southampton. His answer for snoring: I've had a partial solution worked out to my partner snoring. I send her off to her elderly mother's for three days and three blissful nights each week, this keeps her mother sweet and guarantees me some good nights sleep each week. Well he says Alex possibly about to be partnerless. That's it, that's all we have time for. Thank you very much to all our callers and to Professor Neil Douglas. More information: you can go to the action line 0800 044 044 or to our website and join me again next week when we'll be talking about Type II diabetes.


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