When people hear that I specialize in the treatment of sleep disorders, especially snoring and obstructive sleep apnea, I become much more popular in conversations at social events outside of work. Because sleep disorders are incredibly common, and because sleep is so important to our enjoyment of life and health, there is no shortage of people who have great questions about sleep and who are as fascinated by sleep as I am. This is especially true for snoring, when it is more the person who has to listen to the snoring, rather than the person who snores, who is most concerned. Although there are countless numbers of websites and magazine articles offering “cures” for sleep problems, unfortunately these pieces often are limited to bullet points without enough of an explanation or guidance as to where to start.
In general terms, snoring is sound produced during sleep, and it can be simply a social nuisance or can be a sign of a potentially serious medical condition called obstructive sleep apnea (OSA). OSA is diagnosed with a test called a sleep study, where it is possible to evaluate people not just for snoring but for the blockages in breathing that separate OSA from snoring. Snoring is much more common than OSA, so many people with snoring do not have OSA. Nevertheless, anyone with disruptive snoring should be evaluated by a medical provider if they also have classic risk factors for significant OSA: obesity, obvious blockage in breathing during sleep, sleepiness or fatigue during the day in spite of getting enough hours of sleep, and/or medical conditions like high blood pressure or diabetes. Formal evaluation by a sleep specialist can lead to proper testing and consideration of potential treatment options. These treatment options are described in some detail on my website, including the general overview. If you are concerned that you may have OSA, you should speak with your medical provider. While these recommendations can help with OSA as well as snoring, there is no substitute for formal evaluation if you have a reasonable chance of significant OSA.
What Should I Try if I Snore but Do Not Have Obvious Signs of Sleep Apnea?
Many people with snoring do not have OSA, and it is safe to start with basic, conservative treatments if you do not have the more-concerning risk factors mentioned above. I never like to answer a question with more questions, but when I am asked what I recommend for snoring, I respond with a series of questions, based on the assessment that I give to all of my new patients. Besides asking about the risk factors above, the critical questions are how often the snoring occurs, anything that makes it better or worse such as sleeping on one’s back or drinking alcohol, nasal blockage, and changes in weight. The answers guide the choices among the first-line conservative treatments for snoring.
Avoiding Alcohol and Other Sedatives—It’s Not Just for Snoring
During sleep, the muscles in our body relax. This is especially true in the two types of deeper, more refreshing sleep: slow-wave sleep and rapid eye movement sleep, or REM. Snoring and OSA are generally worse during these deeper stages of sleep because the throat is basically a tube surrounded by muscles. When the muscles are more relaxed, everything around the throat is able to collapse more easily, resulting in snoring and OSA. Alcohol has a number of effects on sleep, and the most important from the standpoint of snoring and OSA is that it relaxes muscles even more, worsening the problem. There are a number of other sedating or muscle relaxing medications that produce the same effect, such as diazepam (valium), temazepam (Restoril), and even diphenhydramine (Benadryl). I recommend avoiding alcohol within 3 hours before going to bed and avoiding these types of medications if possible. It turns out that alcohol and these other medications can have other negative effects on sleep. Although alcohol can help some people to fall asleep, it actually decreases the amount of deep, restful sleep (both slow wave sleep and REM) and also leads to more awakening from sleep, with difficulty falling back to sleep. I recommend to my patients that they can have a drink with dinner, but they should minimize alcohol after dinner.
Weight Loss—Who, Why, and How Much?
Many of us have a few extra pounds that we are carrying around. Losing that weight is good for our health and can also improve our snoring. However, it is overly simplistic just to tell everyone to lose weight. First, some people do not have weight to lose, so it is an useless recommendation. Second, many people snored even before they lost weight. Third, if weight loss were simple, then there would not be a worldwide obesity pandemic. The real questions I care about are: did you start snoring only when you gained weight; have you tried to lose weight already; and if you lost weight, did your snoring change? The people that obtain the most benefit from weight loss, in terms of helping their snoring, are those who started snoring when they gained weight and have had some success with weight loss and also had some improvement in their snoring at the same time. Then the answer is pretty obvious.
There are likely many reasons as to why weight gain is a major risk factor for snoring and OSA. When we gain weight, we add those extra pounds to our trunk and hips, but there is some evidence that there is fat deposited elsewhere (probably everywhere) in our bodies, including the back of the tongue and around the throat. Because the muscles in our body relax during deep sleep, this fat deposition creates more bulk that can collapse around our throat, narrowing the space for breathing and contributing to snoring. Losing weight can accomplish something of a liposuction treatment, allowing the throat to remain more open for easy breathing during sleep.
The next question is how much weight someone needs to lose. The honest answers are that the amount differs for different people, that more is generally better, and that nobody can tell you a specific number. Obviously, if someone started snoring when they gained a certain amount of weight, usually it will get much better or resolve if they lose that weight (but not always). Weight loss studies have been done on people with OSA, but no large weight loss studies have been on snoring. Because weight loss usually takes time, most of my patients who want quicker results pursue weight loss at the same time that they are using other treatments, including conservative ones.
Avoiding Sleeping on Your Back—Who, Why, and How?
It is very common for people to have dramatic worsening of snoring (and OSA) when sleeping on their back, compared to sleeping on their side or stomach. People usually know if this is the case, as they are generally awakened with sharp elbows or rolled on to their side by others if this is their pattern. For patients with OSA, a sleep study typically will indicate whether the blockage in breathing occurs primarily when someone is on their back, but there is usually not the same assessment for snoring. There are studies of positional therapy (avoiding sleeping on your back) for OSA but no large studies for snoring. It is important that many people need to sleep on their back, often due to neck or back pain that is only comfortable when someone is on their back, broad shoulders that make it impossible for someone to stay on their side, or the development of severe shoulder pain or other issues that only occur after sleeping on one’s side. There are numerous pillows available that claim to help this, but I have not seen any that consistently help those with substantial issues.
Positional snoring (snoring only when sleeping on your back) occurs because when we are sleeping on our back, with our muscles relaxed, gravity allows the roof of our mouth and tongue to fall directly towards the back of our throat. Avoiding sleep on our back reduces this and can be very helpful for some people.
There are a number of tricks that we suggest to help people to sleep on their side, including wearing a T-shirt to bed with a pocket sewn on the back between the shoulder blades, big enough to hold two tennis balls. The idea is that you sleep on your side until your shoulder gets sore, roll onto your back where those tennis balls make things uncomfortable, and then roll onto the other side without waking up. People can wear these T-shirts until they get used to sleeping on their side and then can go without them. Variations on this theme include the use of head pillows or body pillows, specialized straps or bumpers to wear, and a specialized alarm device developed by a company in Holland working with some of my colleagues.
Stopping Smoking—Now Is the Time
There is no room to discuss the many reasons to stop smoking. Studies have shown that people are more likely to quit smoking if a medical provider has recommended it specifically. So although my patients do not come to see me just to get a lecture, I do point out how important this is and how it truly will only reduce snoring if they are able to quit or, at a minimum, dramatically reduce their snoring. Although many patients find this extremely difficult due to the addictive properties of nicotine, I do stress that nicotine causes swelling in the nose and throat, worsening snoring in the process also also creates major problems with falling asleep and staying asleep during the night (the two most common types of insomnia).