One of the lighter moments along my journey to receiving a sleep apnea diagnosis was learning that “heroic snoring” is a clinical term. It sounds more like an oddball super power — snores that can be clearly heard through walls. Many of us have such a snorer in our lives, and some endure the disruption it causes nightly.
We hardly need research to appreciate the difficulties this poses. Yet some studies on it have been done, and they document that snoring can lead to marital disruption, and that snorers’ bed partners can experience insomnia, headaches and daytime fatigue.
But heroic (and less-than-heroic) snoring can also be a sign of an even deeper problem: obstructive sleep apnea, which is marked by a collapse of the upper airway leading to shallow breathing or breathing cessation that causes decreases in blood oxygen.
Sleep apnea can be downright deadly, and not just for those who have it. It’s associated with a greater risk of depression, heart attacks, strokes and other cardiovascular conditions, as well as insulin resistance.
As I learned, there’s no reason to meekly accept sleep apnea: There are many treatment options that can control it.
The stakes are not small. In the last five years, crashes involving an Amtrak train in South Carolina, a Long Island Rail Road train, a New Jersey Transit train and a Metro-North train in the Bronx have resulted in multiple deaths, hundreds of injuries and tens of millions of dollars in property damage. Undiagnosed or untreated sleep apnea was blamed in each case.
And these are far from the only sleep apnea-related accidents involving trains, buses, tractor-trailers and automobiles. Up to 30 percent of motor vehicle crashes are caused by sleepy drivers. Drivers with sleep apnea are nearly five times more likely to be involved in a motor vehicle accident than other drivers. One study found that 20 percent of American truck drivers admit to falling asleep at traffic lights.
You can have sleep apnea without being a loud snorer, just as you can snore without having sleep apnea. But because they’re related, what controls sleep apnea also controls snoring. A variety of machines and devices, even surgery for extreme cases, can address both conditions. But relative to the population that snores (about 40 percent of adults) or that has sleep apnea (about 25 percent of adults), few are diagnosed or get treatment. One study, for example, found that 90 percent of people with sleep apnea aren’t diagnosed.
There are several reasons the condition often goes undiagnosed and untreated. For one, it’s not always evident you have it. Though sleep apnea disrupts sleep, you usually remain unconscious while it does so, and not everyone with the condition notices feeling tired or snores in ways that seem problematic. I can attest to the fact that even light sleepers and occasional (non-heroic) snorers (like me) can have sleep apnea and not know it.
But it ultimately wears you down. If snoring doesn’t drive you to the doctor, fatigue may. Still, many power through, gradually becoming too tired to perform their jobs well or safely. Untreated train, bus and truck drivers clearly pose a significant public safety risk.
Definitively diagnosing the condition requires a sleep test — either at home, or more extensively in a lab. Getting wired up for bed isn’t much fun, which is another reason people may avoid seeking a diagnosis. Professional drivers and train operators also may worry that doing so could threaten their livelihood. To dodge screens for the condition, they may underreport feeling drowsy.
There may also be fear of sleep apnea treatments. The gold standard for treatment is a continuous positive airway pressure machine, which forces the airway open with pressure delivered through a mask. The prospect of sleeping with a mask, and next to a machine, can be off-putting and, for some, uncomfortable. Compliance with treatment is about 60 percent. But the devices have become far more comfortable and quiet over the years. (The newest models are entirely silent.)
For obese patients, losing weight can reverse sleep apnea. But keeping the weight off is notoriously hard.
Other options include oral appliances (think of them as fancy mouth guards), nasal patches and, for extreme cases, surgery. Costs for devices can range from hundreds of dollars to thousands. Even at the high end, you may feel a considerable boost in quality of life that could be worth the cost.
Although these options work for snoring, too, insurance won’t cover them for that condition. Similar over-the-counter oral appliances are cheaper, but less extensively studied, making it hard to say for whom they will work well. Studies document that patients use over-the-counter versions less, perhaps because they may be less comfortable than professionally customized ones. So, although snoring is highly curable, the cost and uncertainty of exactly how to do so may be a barrier for many to treat it.
There’s a public safety interest in treating sleep apnea more widely. Yet last summer, in an effort to reduce regulations, the Trump administration withdrew a proposed rule that would have required drivers of trucks and buses, as well as railroad engineers, to be tested for the condition. This may be one area where a little more regulation is warranted.
Article written by Austin Frakt for the NY Times. Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health.