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Is Snoring a Risk Factor?

1981; Elsevier BV; Volume: 80; Issue: 5 Linguagem: Inglês

10.1378/chest.80.5.525

1931-3543

A. Jay Block,

Neonatal Respiratory Health Research

The pickwickian syndrome is characterized by obesity, daytime hypersomnolence, and alveolar hypoventilation causing hypercapnia and hypoxemia. Common consequences of the syndrome include secondary polycythemia and heart failure.1Burwell CS Robin ED Whaley RD Bickelman AG Extreme obesity associated with alveolar hypoventilation: a pickwickian syndrome.Am J Med. 1956; 21: 811-818Abstract Full Text PDF PubMed Scopus (557) Google Scholar, 2Rochester DF Enson Y Current concepts in the pathogenesis of the obesity-hypoventilation syndrome.Am J Med. 1974; 57: 402-420Abstract Full Text PDF PubMed Scopus (211) Google Scholar Authors have called attention to the propensity of such patients to die suddenly, often during sleep.3MacGregor MI Block AJ Ball Jr, WC Serious complications and sudden death in the pickwickian syndrome.Johns Hopkins Med J. 1970; 126: 279-295PubMed Google Scholar, 4Miller A Granada M In-hospital mortality in the pickwickian syndrome.Am J Med. 1974; 56: 144-150Abstract Full Text PDF PubMed Scopus (49) Google Scholar The explanation for the high nocturnal mortality in this syndrome is now clear and relates to severe obstructive sleep apnea and nocturnal oxygen desaturation. When respiration is monitored during sleep, patients with the pickwickian syndrome show hundreds of episodes of severe oxygen desaturation accompanied by episodic pulmonary hypertension, severe bradycardia, and multiple cardiac arrhythmias.5Walsh RE Michaelson ED Harkleroad LE Zighleboim A Sackner MA Upper airway obstruction in obese patients with sleep disturbance and somnolence.Ann Intern Med. 1972; 76: 185-192Crossref PubMed Scopus (88) Google Scholar, 6Sackner MA Landa L Forrest T Greeneltch D Periodic sleep apnea: chronic sleep deprivation related to intermittent upper airway obstruction and central nervous system disturbance.Chest. 1975; 67: 164-171Crossref PubMed Scopus (58) Google Scholar, 7Guilleminault C Tilkian A Dement WC The sleep apnea syndromes.Ann Rev Med. 1976; 27: 465-484Crossref PubMed Scopus (1190) Google Scholar, 8Guilleminault C Eldridge FL Tilkian AG Simmons FB Dement WC Sleep apnea syndrome due to upper airway obstruction.A review of 25 cases. Arch Intern Med. 1977; 137: 296-300Crossref PubMed Scopus (241) Google Scholar Bypass of the pharynx by tracheostomy relieves the obstructive sleep apnea and nocturnal oxygen desaturation and eliminates the cardiovascular consequences.9Tilkian AG Guilleminault C Schroeder JS Lehrman KL Simmons FB Dement WC Sleep-induced apnea syndrome.Prevalence of cardiac arrhythmias and their reversal after tracheostomy. Am J Med. 1977; 63: 348-358Google Scholar, 10Tilkian AG Guilleminault C Schroeder JS Lehrman KL Simmons FB Dement WC Hemodynamics in sleep-induced apnea. Studies during wakefulness and sleep.Ann Intern Med. 1976; 85: 714-719Crossref PubMed Scopus (379) Google Scholar, 11Motta J Gilleminault C Schroeder JS Dement WC Tracheostomy and hemodynamic changes in sleep-induced apnea.Ann Intern Med. 1978; 89: 454-458Crossref PubMed Scopus (148) Google Scholar In addition to the relationship between nocturnal events and early death in pickwickian patients, the evidence for such a relationship may also extend to the general population. Recent studies have clearly shown that asymptomatic, obese, severe snorers may also have nocturnal apnea, oxygen desaturation, increased carbon dioxide tension, and nocturnal pulmonary and systemic hypertension.12Lugaresi E Coccagna G Farneti P Montovani M Cirignotta F Snoring.Electroencephalogr Clin Neurophysiol. 1975; 39: 59-64Abstract Full Text PDF PubMed Scopus (129) Google Scholar, 13Lugaresi E Coccagna G Cirignotta F Snoring and its clinical implications.in: Guilleminault C Dement WC Sleep apnea syndromes. Alan R. Liss, New York1978: 13-21Google Scholar, 14Block AJ Boysen PG Wynne JW Hunt LA Sleep apnea, hypopnea, and oxygen desaturation in normal subjects. A strong male predominance.N Engl J Med. 1979; 300: 513-517Crossref PubMed Scopus (499) Google Scholar, 15Harman E Wynne JW Block AJ Malloy-Fisher L Sleep-disordered breathing and oxygen desaturation in obese patients.Chest. 1981; 79: 256-260Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar In several studies of asymptomatic subjects, we have shown that sleep apnea, hypopnea, and nocturnal oxygen desaturation correlate positively with the male sex, female menopause, older age, excess weight, and alcohol ingestion.14Block AJ Boysen PG Wynne JW Hunt LA Sleep apnea, hypopnea, and oxygen desaturation in normal subjects. A strong male predominance.N Engl J Med. 1979; 300: 513-517Crossref PubMed Scopus (499) Google Scholar, 15Harman E Wynne JW Block AJ Malloy-Fisher L Sleep-disordered breathing and oxygen desaturation in obese patients.Chest. 1981; 79: 256-260Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 16Block AJ Wynne JW Boysen PG Sleep-disordered breathing and nocturnal oxygen desaturation in postmenopausal women.Am J Med. 1980; 69: 75-79Abstract Full Text PDF PubMed Scopus (137) Google Scholar, 17Block AJ Wynne JW Boysen PG Lindsey S Martin C Cantor B Menopause, medroxyprogesterone and breathing during sleep.Am J Med. 1981; 7: 506-510Abstract Full Text PDF Scopus (114) Google Scholar, 18Taasan VC Block AJ Boysen PG Wynne JW Alcohol increases sleep apnea and oxygen desaturation in asymptomatic males (abstract).Am Rev Respir Dis. 1981; 123: 64PubMed Google Scholar, 19Taasan VC, Block AJ, Boysen PG, Wynne JW. Alcohol increases sleep apnea and oxygen desaturation in asymptomatic men. Am J Med (in press)Google Scholar Those subjects with sleep-disordered breathing and nocturnal oxygen desaturation were also noted to snore. Kripke et al20Kripke DF Simmons RN Garfinkel L Hammand C Short and long sleep and sleeping pills. Is increased mortality associated?.Arch Gen Psychiatry. 1979; 36: 103-116Crossref PubMed Scopus (547) Google Scholar have also reported that use of sleeping pills may double the death rate in the elderly. In addition, Smolensky21Smolensky M Halbreg F Sargent II, F Chronobiology of the life sequence.in: Itoh S Ogata K Yoshimura H Advances in climatic physiology. Springer-Verlag, New York1972: 281-318Crossref Google Scholar has studied 432,000 reported deaths with reference to chronobiology and reports that the most frequent time of death is between 5:00 and 6:00 am. The factors that correlate positively with sleep apnea and nocturnal oxygen desaturation are disturbingly reminiscent of the factors associated with shortened longevity.22Singer RB Levinson L Medical risks: patterns of mortality and survival. Lexington Books, Lexington, Mass1976Google Scholar, 23Society of Actuaries, Association of Life Insurance Medical Directors of America. Build study. March 1980, U.S.AGoogle Scholar, 24U.S. Department of Health and Human Services. Vital Statistics of the United States. Life Tables, Vol II, Section V. Publication No. 81-1104. Washington, D.C.: Public Health Service, 1978Google Scholar, 25Sorlie P Gordon T Kannel WB Body build and mortality. The Framingham study.JAMA. 1980; 243: 1828-1831Crossref PubMed Scopus (95) Google Scholar Although obesity may be a risk factor because of associated conditions such as diabetes, hypercholesterolemia, and hypertension, it is nevertheless strongly correlated with reduced longevity, particularly among the very obese.26Drenick EJ Bale GS Seltzer F Johnson DG Excessive mortality and causes of death in morbidly obese men.JAMA. 1980; 243: 443-445Crossref PubMed Scopus (350) Google Scholar Excellent statistical evidence is available to relate male sex, menopause, older age, excess alcohol, and sleeping pill ingestion to reduced life span.20Kripke DF Simmons RN Garfinkel L Hammand C Short and long sleep and sleeping pills. Is increased mortality associated?.Arch Gen Psychiatry. 1979; 36: 103-116Crossref PubMed Scopus (547) Google Scholar, 22Singer RB Levinson L Medical risks: patterns of mortality and survival. Lexington Books, Lexington, Mass1976Google Scholar, 23Society of Actuaries, Association of Life Insurance Medical Directors of America. Build study. March 1980, U.S.AGoogle Scholar, 24U.S. Department of Health and Human Services. Vital Statistics of the United States. Life Tables, Vol II, Section V. Publication No. 81-1104. Washington, D.C.: Public Health Service, 1978Google Scholar, 25Sorlie P Gordon T Kannel WB Body build and mortality. The Framingham study.JAMA. 1980; 243: 1828-1831Crossref PubMed Scopus (95) Google Scholar Until recently, no thought has been given to the possibility that these factors may reduce longevity by a common mechanism–ie, the predisposition to snoring, sleep-disordered breathing, and nocturnal hypoxia. In fact, studies of asymptomatic subjects have shown few episodes of severe nocturnal oxygen desaturation, and then only in occasional subjects; and no nocturnal arrhythmias were observed.14Block AJ Boysen PG Wynne JW Hunt LA Sleep apnea, hypopnea, and oxygen desaturation in normal subjects. A strong male predominance.N Engl J Med. 1979; 300: 513-517Crossref PubMed Scopus (499) Google Scholar Nevertheless, although the subjects were monitored for only one or two nights, in each study several of them had a few episodes of profound oxygen desaturation and apnea usually associated with snoring.14Block AJ Boysen PG Wynne JW Hunt LA Sleep apnea, hypopnea, and oxygen desaturation in normal subjects. A strong male predominance.N Engl J Med. 1979; 300: 513-517Crossref PubMed Scopus (499) Google Scholar, 16Block AJ Wynne JW Boysen PG Sleep-disordered breathing and nocturnal oxygen desaturation in postmenopausal women.Am J Med. 1980; 69: 75-79Abstract Full Text PDF PubMed Scopus (137) Google Scholar, 17Block AJ Wynne JW Boysen PG Lindsey S Martin C Cantor B Menopause, medroxyprogesterone and breathing during sleep.Am J Med. 1981; 7: 506-510Abstract Full Text PDF Scopus (114) Google Scholar Presumably, such phenomena also occur every night at home and are exacerbated by ethanol ingestion. Throughout a lifetime, ample opportunity exists for occasional arrhythmia or other cardiovascular events induced by nocturnal hypoxia. Perhaps the predisposition to snoring and the consequent sleep-disordered breathing and oxygen desaturation have been neglected too long in considering the important risk factors for mortality.