Snoring must have been a staple joke of primitive life. Surely even snoring troglodyte men must have seemed comical -- up to the point when their mates rose from their straw pallets and brained them with mastodon bones -- because the comparison to animal sounds is so obvious. My snore, for example, has been likened to the roar of a hibernating bear, to the grunting of a warthog and to the snarl of a chainsaw on a Sunday morning. It has also been said to "lack the sweet, tea-kettle-y whistle of cartoon snoring." It has occasioned the use of elbows, the reconfiguration of pillows as artillery and the remark, "I ought to get a cattle prod." A person who shared my bed once said, "I want to sleep with you, but I don't like your snoring." That person was my 2-year-old son.
But, like the stoning of cats and the baiting of bears, snoring is less funny than it seems. It can be a symptom of obstructive sleep apnea -- a state of nocturnal oxygen deprivation that is as potentially risky to health as obesity or alcoholism. About a third of all American adults are believed to snore. Several million are sleep apneics, who are robbed of breath in the night. The majority are men, apparently because of hormones. Maturing women thicken at the bosom and hips; men fatten at the neck and belly. Fatter necks, like rooster wattles, rattle, especially when you're lying on your back.
According to data presented at a recent American Thoracic Society conference, sleep apneics have a 40-percent higher risk of developing heart disease than do non-apneics. They are also seven times more likely to be in car crashes (they're always sleepy). This is a pretty quiet epidemic, and some people believe it is exaggerated. A 1997 survey article in the British Medical Journal claimed that apnea's hazard to public health was overblown. But leading sleep researchers pointed out that the study was conducted for Britain's National Health Service and may have been biased by a desire to limit treatment. In any case, few individuals take apnea seriously enough to get help.
In my own case, the corticosteroid sprays I use to treat the allergies that inflame my nose seem to have dampened my own nocturnal decibel levels. So much so that I was recently able to observe with an attitude of bemused sympathy, in a laboratory setting, as other people snored.
At Georgetown Hospital's sleep laboratory in Washington, a 42-year-old named Antonio Go is kind enough to let me watch him sleep while hooked up to electrodes. At 9 p.m., three other patients show up to have their sleep monitored. Everyone has bags under their eyes.
To get in the mood we watch a videotape called "Rise and Shine," in which an amiable slob named Todd keeps falling asleep at board meetings and bridge games. Everyone thinks it's a hoot except his wife. Why is he so sleepy? Unbeknownst to him, Todd sleeps poorly in bed -- he snores and chokes and rumbles and turns through the night while his long-suffering wife clenches her teeth.
Finally his wife drags him to a Marcus Welby lookalike who puts him on a device called a CPAP -- continuous positive airway pressure -- a compressor attached to a mask worn over the nose that forces a stream of air into the respiratory canal. It works, and in no time Todd is vigorously trimming the hedges in the afternoon, instead of napping.
The video was produced by Respironics, a CPAP manufacturer that touts its own products. But the hospital's dip into commercialism does not seem to bother Antonio. On the other hand, the fact that the required mask is reminiscent of "Silence of the Lambs" is not lost on him. "It looks horrible," said Antonio. "I guess I would only use it at home."
The cosmetic angle is important to Antonio, a medical technologist who happens to work in Georgetown's hematology lab. He's a fitness buff who doesn't drink or smoke and looks about 30. Two years ago he had laser surgery to correct his eyesight. Then he thought he could lose the snoring as well, which was first brought to his attention at youth hostels in Europe two decades ago. "After doing surgery, my eyesight is 20-20. I'm enjoying life not having glasses. So I thought this is another aspect of my life -- I thought maybe I could get rid of my snoring. It's embarrassing. When I'm with my friends, they always say it's terrible if I fall asleep first because it's like thunder."
He has also noticed he has to sleep nine hours a night and gets drowsy driving on the freeway. But it was only after his sister, a nurse in San Jose, brought sleep apnea to his attention that he figured there was a medical justification for getting his snoring treated.
Snoring is caused by loose tissue vibrating in the flexible canal between mouth and lungs, sort of like shingles whining in a gale. Being overweight or thick-necked aggravates the problem by increasing pressure on the canal, narrowing it and adding volume to the vibrations. If the airway becomes tight or inflamed enough, it closes entirely. The cutoff of oxygen is bad enough; if oxygen levels in the blood get low enough, the brain sends signals to kick the sleeper awake. This may happen hundreds of times a night, all of it forgotten in the morning. Not surprisingly, apneics often wake up sleepy with headaches.
Cumbersome as it is, CPAP is the most effective treatment to stop apnea, if decongestants and a diet don't work. But Antonio is kind of hoping his HMO will authorize laser surgery, a $2,000 procedure to whittle away flab from the soft palate and uvula (the stalactite of flesh hanging above the tongue). Lisa Anarado, the technician who is busy pasting electrodes to Antonio's head, suggests that laser surgery often doesn't work. Not only that, but it hurts and can change the timbre of your voice. (James P. Kiley, director of NIH's National Center for Sleep Disorders Research, tells me that laser-assisted uvulopalatoplasty has "done more harm than good.") A new surgery called somnoplasty, in which radio waves are used to melt away flabby tissue, is promising but relatively untested and more expensive.
After the sensors are attached, the wires are taped together in a ponytail-like bundle behind Antonio's head and jacked into the console. Anarado turns out the light and within minutes Antonio is very cooperatively rocking the house. He's like a child mugging for the camera, only he's doing it unconsciously. And noisily. Like thunder.
In the room next door, Anarado and another polysomnographist, Kelly Knight, watch the needles jiggle across scrolls of graph paper -- monitoring brainwaves, eye movements, breathing, blood oxygen, chest, chin and leg movements. They stifle yawns. Their jobs keep them up all night watching others labor through sleep. Like all overnight workers, they have their own circadian issues. "I always say that a sleep technician is an apneic in the making," Knight says brightly. She lives in Annapolis, Md., and has spent the previous day tossing and turning in bed while Blue Angels roared overhead practicing stunts for the West Point commencement .
Through their work, sleep experts come to understand better than most how the quality of our waking life depends upon the quality of our sleep. "You're more aware of how much bad sleeping there is," says Anarado, who has tried unsuccessfully to get her own mother to see a sleep doctor. "Most people don't take good care of their sleep. Unless they're totally exhausted, they don't come in -- unless their spouses drag them."
"Either that or a court order," interjects Knight.
One patient of the lab was a bus driver whose license was suspended until her doctors certified that her apnea had been treated. Truckers and air traffic controllers have slept here. One man came in after falling asleep at the wheel and running over two little girls. The average lab visitor is an obese 40-year-old with a thick neck.
Antonio's profile seems benign by comparison. But the polysomnograph shows he's no slouch. Vibrations from the microphone attached to his neck are transmitted to a polysomnograph needle that groans metallically as it spits out a series of seismic blots. At around midnight, as his pitch builds and the snore blots get larger, the line that graphs output from an airflow sensor in Antonio's nose goes flat for 15 seconds. A flat line means Antonio has stopped breathing. Eventually, the oxygen saturation level of his blood begins to sink. The lack of oxygen sends a warning signal to his nervous system and arouses him, for seconds, from sleep. This happens 13 times between 1:03 and 1:33 a.m. -- in the normal sleeper it might happen twice. "He's borderline serious apneic," Anarado says. At 2:16 a.m., she awakens Antonio and he puts on the CPAP mask. The remainder of the morning his outputs improve. He wakes up feeling lousy, as usual, but of course he's only slept six hours.
"I'm still sleepy," he says. "But maybe I'm going to try this CPAP at home." Or maybe he'll do the surgery, if insurance will pay for it. Or maybe he'll just keep snoring, he says. "My dog doesn't mind."