Table of Contents
What causes snoring?
Snoring is a loud noise that occurs during sleep. Snoring arises as a result of the whirling effects of air as it flows through the upper respiratory tract. It is usually caused by temporary obstruction at various points in the airways (1-3). During snoring, the air that flows through the back of the throat and causes it to vibrate makes a loud noise. The air flow ultimately leads to the generation of vibrations in the throat. Air pollution can occur at different points in the throat and varies from person to person. Few people are affected by the palate, while the cause is usually either nasopharyngeal or hypopharyngeal.
Snoring is often observed in men, but can also occur in women. Snoring is reported to affect 37 million people annually. It was found that habitual snoring generally occurs in families. Nobody should feel compelled to deal with this annoying problem all their lives.
Snoring is a type of sleep disorder and sometimes affects the quality of our sleep so much that natural body functions are impaired and our own productivity suffers. Even if it is not a serious illness, snoring can be related to an underlying problem and thus manifest itself as a symptom of an underlying illness.
What Causes Sleep Apnea?
If a person suffers from symptoms such as daytime tiredness, restlessness, exhaustion, depression, lack of energy, breathlessness and feelings of suffocation, this indicates a serious form of sleep disorders known as sleep apnea. It is a very serious and serious situation that should be treated immediately, otherwise it can lead to life-threatening consequences.
Sleep apnea is caused when a person's breathing is impaired and does not function normally during sleep. It is characterized by the interruption and standstill of breathing during sleep. The effects are so severe that breathing can stop hundreds of times. This affects the entire body system, including the brain and other parts of the body that do not receive enough oxygen for normal functionality.
There are three types of sleep apnea:
- Obstructive sleep apnea (OSA)
- Central Sleep Apnea (CSA)
- Complex sleep apnea syndrome (CSAS)
Obstructive sleep apnea (OSA):
This type of sleep apnea is common in the general population. One speaks of obstructive sleep apnea if the airways are blocked during sleep due to the collapse of the soft tissue in the back of the throat (4).
It is a chronic condition that hinders the normal breathing process while sleeping. OSA can affect all ages, but is more common in middle-aged and older people (5). In this disease, breathing is temporarily stopped or reduced during sleep (6-9) and results in apnea or hypopnea in the patient. This deviation from normal breathing is caused when there is an airway obstruction that repeatedly affects the airway so that it narrows drastically (8, 10-12). Since the person concerned is unable to sleep properly, there are many breathing disorders that wake them up or even prevent restful or deep sleep in severe cases. The consequences are daytime tiredness, exhaustion, mood swings and drowsiness, which often occur in such cases (7,10). Studies have shown that smokers are at increased risk of developing sleep apnea (13).
Central sleep apnea:
Central sleep apnea is less common than OSA. In this case, the airway is not blocked, but the brain does not direct the nerve signals to the muscles that are responsible for breathing. This happens when the breathing control center is not working properly. So the breathing process is impaired. The feedback mechanism, which is necessary for a functioning respiratory process, is disturbed (14, 15, 16). Central sleep apnea (CSA) is also known as central sleep apnea syndrome (CSAS). With this disorder, breathing may be reduced or temporarily suspended for 10 to 30 seconds, either sporadically or continuously. This interruption leads to a reduced oxygen saturation of the blood (17). The so-called Arnold Chiari malformation is generally associated with this disease (18).
Complex sleep apnea syndrome
It is assumed that the signs and symptoms of obstructive sleep apnea and central sleep apnea are combined. The syndrome is also known as central sleep apnea requiring treatment.
This particular type of apnea is being researched to achieve results related to etiology and pathophysiology. Studies have shown that this type of respiratory disorder occurs when obstruction has been removed by PAP therapy, but central apnea persists. The correct diagnosis based on an evidence-based approach is still being researched because it requires a special group of people in whom the central apnea does not decrease even after chronic CPAP treatment. Therefore, there are a variety of terms in this context, such as CPAP-related periodic breathing (19) and CPAP-related CSA (20, 21) or CSA during CPAP treatment (22).
The data on the spread of sleep apnea have made it clear that it usually affects 2 to 14% of the population examined. It can range from 20% to 90% for people seeking medical attention and participating in sleep studies. Men are three times more likely to develop OSA than women. Obese people and postmenopausal women are often affected. The observed extent of the effects is similar in postmenopausal women and men, taking into account their BMI and their age (10, 14, 15). With increasing age, the spread of OSA also increases. Studies have shown that higher obesity rates and more older people lead to an increased OSA rate (1,2,8,10).
What are the consequences of a partial blockage of the airways?
By blocking the airways, a person is no longer able to release a sufficient amount of oxygen into the lungs. This leads to a decrease in the level of oxygen in the blood and, in contrast, an increase in the level of carbon dioxide, which is a by-product of normal metabolism. If this continues for a few minutes, the worst case scenario could be the death of a person. However, breathing difficulties do not occur continuously at OSA. During the repeated cycle of irregularity, the brain wakes up and the normal breathing process is resumed. This phenomenon can take from a few seconds to a minute. The person is then able to breathe, but the airways are still reduced. The surrounding structures and tissues vibrate around the narrowed airway. We perceive this process as snoring. Snoring means that the airway is blocked or blocked, but it does not mean that breathing is taking place; Silence can also mean that the airway is completely blocked (8).
What Are the Causes of Sleep Apnea?
Obstructive sleep apnea
This type of apnea is caused when the muscles in the back of the throat relax. These muscles are very important because they give strength and support to the soft palate, the suppository (a triangular piece of tissue that hangs from the upper soft palate), the walls of the throat and tongue, and the tonsils.
When the muscles reach a state of relaxation, the airway narrows and continues to close as the breathing progresses. This constriction leads to an insufficient air supply, which causes a decrease in the oxygen content in the blood and thus affects all organs. Since the brain does not receive the required amount of oxygen to function properly, a feedback mechanism is activated that warns and wakes you up during sleep so that the airways can open again. Since the mechanism works within seconds, you don't usually remember that you woke up in your sleep.
The consequences may include snoring, breathing, or gasping for breath. Since the oxygen content must be maintained, this cycle can be repeated five to thirty times. In the chronic state, this cycle can expand even further and disrupt the normally deep and calm sleep state all night long (11).
Central sleep apnea
This type of apnea is rather rare. It occurs when the respiratory muscles do not receive enough signals. This in turn means that the brain receives no signals for a short time and therefore no breathing can take place. Because of the impediment to breathing, it can happen that you wake up completely out of breath in the middle of your sleep or you experience sleep disorders that keep you awake (15).
Who is at risk of snoring and sleep apnea?
There are various risk factors for sleep apnea that can affect all sex and age groups - even children. Here is a list of factors that increase the risk of illness.
Risk factors for obstructive sleep apnea (23-25) include:
Excessive weight gain can affect the normal breathing process. If fat accumulates around the upper respiratory tract, it becomes obstructed. This can result in sleep apnea.
If there is an anatomical problem or allergy, breathing through the nose may be difficult. This insufficient air supply leads to an increased risk of developing sleep apnea.
Studies have shown that people with a thicker neck have narrower airways than people with a narrower neck. It is likely that sleep apnea will develop.
The male gender
In general, men are more often (two to three times as likely) affected by sleep apnea than women. However, obese women run an increased risk of sleep apnea due to narrowing of the airways.
Because of their genetic makeup, some people have a narrower throat. In children, the tonsils and polyps are sometimes enlarged so that the airways are blocked. This also increases the risk of sleep apnea.
Sleep apnea affects the older population more than younger people
Due to familial inheritance, the likelihood of developing sleep apnea may be higher, since the genetic predisposition is increased.
Smoking increases the risk of obstructive sleep apnea by a factor of three compared to people who have never smoked. Because smoking causes inflammation and increases the accumulation of fluid in the upper respiratory tract, sleep apnea can develop.
Alcohol relaxes the muscles and thus narrows the airways, which creates the conditions for obstructive sleep apnea.
Risk factors for central sleep apnea (15.17) belong:
The older and middle age group is more affected than younger people.
The male gender
Men have an increased risk of developing central sleep apnea compared to women.
Congestive heart disease
People with congestive heart problems are more likely to develop central sleep apnea than healthy people.
People who have had a stroke in the past are at increased risk of central sleep apnea.
Narcotic pain medication
Narcotic pain relievers such as methadone, which affect brain signals, increase the risk of central sleep apnea.
The risk of obstructive sleep apnea can be assessed using the STOP bang questionnaire that takes the following into account (26):
STOP Bang questionnaire
Please answer the following questions by ticking “yes” or “no” for each question
|Snoring (Do you snore loudly?)||❏||❏|
|Tiredness (often feel tired during the day,||❏||❏|
|exhausted or sleepy?)||❏||❏|
|Watched apnea (Did someone watch||❏||❏|
|that you stop breathing while sleeping,||❏||❏|
|gasp or gasp?)||❏||❏|
|Hypertension (have high blood pressure||❏||❏|
|or are you being treated for high blood pressure?)||❏||❏|
|BMI (Is your body mass index higher than 35 kg per m2?)||❏||❏|
|Age (Are you older than 50 years?)||❏||❏|
|Neck circumference (is your neck circumference greater than 40 cm [15.75 inches]?)||❏||❏|
|Gender (Are you male?)||❏||❏|
|(1 point for each positive answer)|
|(Rating: 0 to 2 = low risk, 3 or 4 = medium risk, ≥ 5 = high risk)|
What Are the Negative Consequences of Sleep Apnea?
Sleep apnea is a condition that can become serious and even life threatening if not treated in time. It can have a negative impact on your life and affect the quality of life in various ways (24, 25, 27, 28):
Tiredness during the day
Because of the constant interruptions, a state of permanent or deep sleep is never reached, daytime tiredness, exhaustion, mood swings and irritability occur. In addition, a sufficient amount of sleep is excluded, which means that the person concerned carries out their activities and tasks slowly and slowly. People may fall asleep while watching TV and in the office - in the worst case, even while driving. This can lead to serious accidents that are often caused by individual suffering with OSA.
Sleep plays a vital role in maintaining an alert and happy state. People affected by sleep apnea tend to become depressed, restless, and moody. Both children and adolescents can have behavioral problems and perform poorly in the academic field.
Risk of developing type 2 diabetes
Various studies on sleep apnea have been shown to increase the risk of type 2 diabetes and insulin resistance.
High blood pressure and heart problems
Since the level of oxygen in the blood drops due to sleep apnea, the brain and other important organs in the body are not adequately supplied with oxygen. This drop in oxygen leads to an increase in blood pressure and affects the functioning of the cardiovascular system. In this way, the OSA increases the likelihood of high blood pressure.
Various heart-related problems are also directly related to the severity of the OSA. The risk of stroke, heart attack and atrial fibrillation is increased in OSA patients. Because blood oxygen levels fluctuate during recurrent episodes of shortness of breath due to OSA, in the worst case this can lead to sudden death because the heart is unable to adequately support blood flow.
Sleep apnea also affects liver function. Studies have shown that liver function tests show abnormal results (deviations from the normal range) and OSA patients show signs of scarring (non-alcoholic fatty liver disease).
Different types of metabolic disorders, usually based on a combination of high blood pressure, high cholesterol, and high sugar, are associated with an increased risk of obstructive sleep apnea.
Complications from surgery
If surgical intervention or prescription of medication is required on OSA patients, a correct medical history should be taken beforehand and preventive measures should be taken. Since it is breathing difficulties during sleep, sedation should only be done taking all factors into account.
Partners who suffer from sleep deprivation
Snoring while you sleep not only affects your own but also your partner's sleep. They prefer to sleep in separate rooms or even move to another floor so as not to be disturbed while sleeping. This can seriously damage relationships because OSA is a long-term condition that should always be treated. In this way, unnecessary tension and mood swings at your partner are avoided.
What are the ways to test for sleep apnea?
Based on the signs and symptoms, your doctor can assess your sleeping habits and evaluate your history. You can get this information from your partner or from people who live with you.
After a thorough examination, the doctor may advise you to go to a center for sleep disorders. There, a sleep specialist will assess the relevant details regarding the cause of sleep apnea and, after consultation with you, plan treatment. In the sleep center, sleep and other related functions are monitored overnight while sleeping. Optionally, you can suggest an assessment of breathing through sleep monitoring at home.
There are three types of sleep apnea tests (6,8,10):
Home sleep tests
This type of test is conveniently done from home. The doctor suggests a simple test that can be easily done at home and generally assesses the following parameters: rhythm and measurement of heart rate, blood oxygen levels, air flow, and breathing consistency (regular or irregular).
This is a common test to assess OSA severity. This method can be used to determine various parameters such as lung capacity, brain function, heart rate, breathing pattern, movement of the arms and legs and the oxygen content in the blood during sleep. It is considered the “gold standard” for the diagnosis of sleep apnea. With this method, various electronic signals are transmitted and recorded simultaneously. It is generally done in a sleep laboratory and monitored by a technician. Sleep studies in OSA patients have shown that they continue to experience episodes of breathing difficulties or interruptions, even though they try to keep breathing.
If sleep apnea is diagnosed, the doctor can immediately set up a treatment plan and initiate therapy depending on the signs and symptoms. Even if the results are shown as normal, the doctor may recommend taking a second, polysomnographic test to confirm the test results and recommend the best therapy.
You can also be referred to an ENT doctor to rule out a blockage in the ENT area. In the case of a central sleep apnea problem, a diagnosis by a cardiologist or neurologist is sometimes required to determine the underlying problem.
Polysomnography has the following advantages:
- The entire recording is carried out under the supervision of an experienced technician.
- The sleep pattern is recorded and can be discussed with the patient.
- Any other anomaly associated with a sleep disorder can be detected.
- Elaborate process.
- The recording is carried out in an unfamiliar environment.
Restricted channel monitoring
In comparison to polysomnography, a smaller number of signals are monitored. This method can easily be done at home without the help of a sleep specialist. It evaluates the signals related to breathing and oxygen levels in the blood. People with OSA and other related medical problems can be easily tested through restricted channel monitoring.
To the Advantages The restricted channel monitoring includes:
- The signals are recorded in a comparatively quieter and more comfortable environment in your own home.
- It is cheaper than polysomnography.
- Since the evaluation is carried out in the absence of a technician, there is a risk of errors.
- Sleep is not recorded.
Other diagnostic tests
Aside from home testing, polysomnography, or limited channel monitoring, there are few other tests that help diagnose sleep apnea. The following alternatives may serve as additional methods, but may not fully diagnose sleep apnea.
- Oximetry: measures the oxygen content in the blood.
- Sleep questionnaires and diaries: Serve as a guide to get a vague and first idea about sleep behavior and other habits.
- Blood tests: Even if there is no blood test to detect OSA, it can help assess whether there is an associated disease that makes sleep apnea worse.
- EEG (electroencephalogram): For recording signals and wave activity in the brain.
- EMG (Electromyogram): Helps to assess different types of movement and muscle activity of the face and legs and records sleep during the REM phase.
- EOG (electrooculogram): For recording eye movements, especially during the REM phase of sleep.
- ECG (electrocardiogram): For recording heart rate and rhythm.
- Nasal airflow sensor: For recording the airflow.
- Snore microphone: To record snoring activity.
What treatments are there for sleep apnea?
If not treated in time, sleep apnea can become a life-threatening problem. Therefore, all measures should be taken to prevent the disease from progressing. Here are the important treatment strategies that can help treat this condition.
Difficulty breathing, particularly in OSA, is due to the collapse of the pharynx and / or larynx tissue. Fat deposits in the process, which reduces the patency of the throat [26, 27]. Weight loss can reduce pressure and reduce the severity of OSA. (28).
Mandibular advancement splint
Continuous positive airway pressure (CPAP) is the number one method of treating sleep apnea. However, there are many people who do not tolerate CPAP well. Oral devices can be used in such patients to achieve the desired results. There are two types of oral appliances that are commonly used:
- Protrusion splints that maintain an open airway by pushing the patient's jaw forward.
- Tongue holding devices which ensure an open airway by holding the tongue (29).
The use and effectiveness of tongue holding devices are currently still being investigated, since their use has so far been unsatisfactory. Therefore, protrusion splints are used more often because they reposition the mandibular joint forward and down during sleep. This improves the patency of the upper respiratory tract by enlarging it. It also reduces the likelihood of snoring and OSA.
A new and advanced device is on the market is the protrusion splint (noson.ch) with all functions that contribute to the treatment of breathing problems in connection with OSA. It is one of the highest quality products that differs from the other rails.
A recent meta-analysis showed that blood pressure did not decrease during CPAP treatment and when treated with protrusion splints (30). The American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine have published guidelines (2015) stating that oral devices, when used correctly, have achieved superior results in managing sleep parameters (31,32).
The main features of our protrusion splint (noson.ch) include
- It fits over the incisors because it is made of a thermoplastic material and acts as a gum protector by positioning the lower jaw and tongue forward and down.
- It is as effective as any splint because it can be easily adjusted to the patient's needs (33)
- It is very helpful for patients who have problems snoring and do not need surgery.
- It achieves effective results in patients with mild to moderate sleep apnea. This method has proven particularly useful for patients who have difficulty breathing on their back.
The use of nasal dilators can be of great help. By expanding the nostrils, the air supply to the nose is optimized. The collapse of the nostrils is prevented and nasal breathing is improved, which ensures undisturbed sleep.
The Noson nasal dilator is a very versatile product which is distributed by various Swiss ENT doctors and pharmacies. It widens the nostrils and exerts a very gentle pressure from the inside due to its elastic properties. The main features of this device are the following:
- It extends the nostril by 14-25%, which reduces the resistance to air flow and also improves the oral component of ventilation during sleep.
- People with a snoring habit or OSA will get effective results with the Noson.
- The nasal resistance is reduced between 31-65%, so the airflow is drastically improved.
- In people suffering from any nasal symptoms, the condition improves considerably after using this device.
- Patients who snore loudly at the beginning of the use of nasal dilators show a decrease in volume over time (34, 35).
Positive airway pressure
CPAP is an effective method and is most commonly used to treat OSA. It ensures splinting of the pneumatic part of the upper respiratory tract. The pressure on the respiratory tract can be exerted in various ways, including oral, oro-nasal and nasal devices (36). Just as the air pressure is controlled, it also causes the airways to splint:
- Improvement of the quality of life, the sleep pattern and the associated parameters
- Lowering blood pressure and reducing episodes of arrhythmia and strokes
- Change in the outcome of fatal cardiovascular events (37-40).
- Maintaining the left ventricular ejection pressure and avoiding the risk of stroke
There are several types of surgical procedures that can be performed to modify and treat airway obstructions in OSA patients. But all of these procedures are generally avoided when treating OSA because they are invasive and expensive (42). In obese OSA patients, bariatric surgery has been shown to improve sleep-related parameters in more than 75% patients (43, 44, 45). There are the following different types of surgery:
- nasal surgery (e.g. septoplasty),
- Oral interventions (e.g. uvulopalatopharyngoplasty),
- Hypopharyngeal procedures (e.g. tongue reduction and stabilization)
- larynx surgery (e.g. epiglottis)
- Global airway procedures (eg maxillomandibular protrusion).
Treatment of sleep apnea at home
Sleep apnea can be treated at home by changing your lifestyle in different ways.
Your doctor may recommend the following:
- To lose weight
- No excessive alcohol consumption and avoid taking sleeping pills
- Changing sleeping positions to improve breathing
- Quit smoking: smoking causes inflammation and increases upper respiratory tract swelling, which can aggravate both snoring and apnea.
If all efforts have not been successful, the first option should be to optimize nasal breathing. This can be done through the Noson nasal dilator. With around 30-50% of people, an optimized nasal breathing is enough to reduce the snoring severely or to get it completely away.
If the nasal dilator does not help you either, an anamnesis must be carried out immediately, since you are dealing with a serious problem. This can be done via any Medbase pharmacy or ENT doctor. If in doubt, write to us. We try to pass you on to an expert as best we can.
Sleep apnea is a very common problem that should be treated appropriately. Even though different treatment methods are available, each option should be considered individually based on personal needs and severity. Regardless of whether it is a surgical procedure or a less invasive device such as a protrusion splint, the method should always be suggested only after a proper medical history. A multidisciplinary approach should be optimized, in which the patient is supported in every way to return to normal, stress-free sleeping behavior.
1. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during respiration in normal subjects and patients with sleep disordered breathing. Am Rev Resp Dis 1993; 148: 1385-400
2. Horner RL, Shea SA, McIvor J, Guz A. Pharyngeal size and shape during wakefulness and sleep in patients with obstructive sleep apnoea. Quart J Med 1989; 72: 719-35
3. Fleetham YES. Upper airway imaging in relation to obstructive sleep apnoea. Clin Chest Med 1992; 13: 399-416
5. Qaseem A, et al. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(7):471-483.
6. Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative Effectiveness Review no. 32. AHRQ publication no. 11-EHC052-EF. Rockville, Md .: Agency for Health Care Research and Quality; July 2011.
7. Greenstone M, Hack M. Obstructive sleep apnoea. BMJ. 2014; 348: g3745.
8. Qaseem A, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(3):210-220.
9. Bratton DJ, Stradling JR, Barbé F, Kohler M. Effect of CPAP on blood pressure in patients with minimally symptomatic obstructive sleep apnoea: a meta-analysis using individual patient data from four randomized controlled trials. thorax. 2014;69(12):1128-1135.
10. Balachandran JS, Patel SR. In the clinic: obstructive sleep apnea. Ann Intern Med. 2014; 161 (9): ITC1-ITC15.
11. Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea? The rational clinical examination systematic review. JAMA. 2013;310(7):731-741.
12. Mohsenin V. Obstructive sleep apnea and hypertension: a critical review. Curr Hypertens Rep. 2014;16(10):482.
13. Krishnan V, Dixon-Williams S, Thornton JD. Where there is smoke ... there is sleep apnea: exploring the relationship between smoking and sleep apnea. Chest. 2014;146(6):1673-1680.
14. Bixler EO, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001; 163 (3 pt 1): 608-613.
15. Zancanella E, et al. Obstructive sleep apnea and primary snoring: diagnosis [published correction appears in Braz J Otorhinolaryngol. 2014;80(5):457]. Braz J Otorhinolaryngol. 2014; 80 (1 suppl 1): S1-S16.
15. Becker, K; Wallace JM (2010-01-22). “Central Sleep Apnea”. emedicine. Medscape. Retrieved 2010-07-31.
16. AASM (2001). The International Classification of Sleep Disorders, Revised (PDF). Westchester, Illinois: American Academy of Sleep Medicine. pp. 58-61. Archived from the original (PDF) on 2011-07-26. Retrieved 2010-09-11.
17. Becker K, Wallace JM (2010-01-22). “Central Sleep Apnea: Follow-up”. emedicine. Medscape. Retrieved 2010-09-17.
18. Watson (2009-11-09). “Sleep Disordered Breathing and Sleepiness in Patients with Chiari type I Malformation”. Retrieved 2014-04-17.
19. O. Marrone, A. Stallone, A. Salvaggio, F. Milone, V. Bellia, and G. Bonsignore, “Occurrence of breathing disorders during CPAP administration in obstructive sleep apnoea syndrome,” European Respiratory Journal, vol. 4, no. 6, pp. 660-666, 1991
20. GS Gilmartin, RW Daly, and RJ Thomas, "Recognition and management of complex sleep-disordered breathing," Current Opinion in Pulmonary Medicine, vol. 11, no. 6, pp. 485-493, 2005.
21. T. Dernaika, M. Tawk, S. Nazir, W. Younis, and GT Kinasewitz, “The significance and outcome of continuous positive airway pressure-related central sleep apnea during split-night sleep studies,” Chest, vol. 132, no. 1, pp. 81-87, 2007.
22. S. Lehman, NA Antic, C. Thompson, PG Catcheside, J. Mercer, and RD McEvoy, “Central sleep apnea on commencement of continuous positive airway pressure in patients with a primary diagnosis of obstructive sleep apnea-hypopnea,” Journal of Clinical Sleep Medicine, vol. 3, no. 5, pp. 462-466, 2007.
23. Lee W, et al. Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med. 2008;2(3):349-364.
24. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163(1):19-25.
25. Wheaton AG, Perry GS, Chapman DP, Croft JB. Sleep disordered breathing and depression among US adults: National Health and Nutrition Examination Survey, 2005-2008. Sleep. 2012;35(4):461-467.
26. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):821.
27 Shelton KE, Woodson H, Gay S, et al. Pharyngeal fat in obstructive sleep apnea. At Rev Respir Dis 1993; 148: 462-466.
28 olives A, Aspandiarov E, Gankin I, et al. Collapsibility of the relaxed pharynx and risk of sleep apnoea. Eur Respir J 2008; 32: 1309-1315.
29. Schwartz AR, Gold AR, Schubert N, et al. Effect of weight loss on upper airway collapsibility in obstructive sleep apnea. At Rev Respir Dis 1991; 144: 494-498.
30. Chan AS, Lee RW, Cistulli PA. Non-positive airway pressure modalities: mandibular advancement devices / positional therapy. Proc Am Thorac Soc. 2008;5(2):179-184.
31. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827.
32. Bratton DJ, Gaisl T, Wons AM, Kohler M. CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis. JAMA. 2015;314(21):2280-2293.
33. Shadaba A, Owa A, Battagel J, Croft C, Kotecha B. Evaluation of the Herbst mandibular advancement splint in the management of patients with sleep-related breathing disorders. Clinical Otolaryngol 2000; 25: 404-12
34. McLean HA, Urton AM, Driver HS, et al. Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea. Eur
Respir J 2005; 25: 521-527.
35. Todorova A, Schellenberg R, Hofmann HC, et al. Effect of the external nasal dilator Breathe Right on snoring. Eur J Med Res 1998; 3: 367-379.
36. Gay P, Weaver T, Loube D, Iber C; Positive airway pressure task force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for.
37. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046-1053.
38. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879-887.
39. Iftikhar IH, Valentine CW, Bittencourt LR, et al. Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a meta-analysis. J Hypertens. 2014;32(12):2341-2350.
40. Kaneko Y, Floras JS, Usui K, et al. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med. 2003;348(13):1233-1241.
41. Littner M, Hirshkowitz M, Davila D, et al. Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report. Sleep. 2002;25(2):143-147.
42 Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev.. 2005; (4): CD001004.
43.Sarkhosh K, Switzer NJ, El-Hadi M, Birch DW, Shi X, Karmali S. The impact of bariatric surgery on obstructive sleep apnea: a systematic review. Obes Surg. 2013;23(3):414-423.
44. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis [published correction appears in JAMA. 2005;293(14):1728]. JAMA. 2004;292(14):1724-1737.
45. Won CH, Li KK, Guilleminault C. Surgical treatment of obstructive sleep apnea: upper airway and maxillomandibular surgery. Proc Am Thorac Soc 2008; 5: 193-199.