Before he did
"Sleep apnea syndrome" is an unfamiliar term in the eyes of many people. But mentioning some of its main manifestations, such as loud snoring and daytime drowsiness, seems to be very common.
This is a sleep disorder associated with obstruction of the upper respiratory tract or damage to the respiratory central nervous system. According to The Lancet Respiratory Medicine, more than a billion people worldwide suffer from obstructive sleep apnea. Among the 16 sample countries, including China, the United States, India and Russia, the mainland has the highest number of people affected, or 176 million.
Today is World Sleep Day. "Occasional Cure" found some patients with sleep apnea syndrome who had been dismissive of their poor sleep, and then their families, work, and social interactions were affected, and their lives were out of control for a while. With the help of doctors, they are learning to get along better with the disease.
For 4 years, because of snoring, Yang Ziming could only sleep separately from his wife.
Initially, it was moved from the master bedroom to the second bedroom, when the son had just reached the full moon, Yang Ziming snored, and the little guy woke up. But he soon discovered that even in the two bedrooms, he would still be noisy with the children.
As soon as the child woke up, his wife, who had just been confined, could not sleep. There was a wall between the main and second bedrooms, and she kicked them hard a few times, woke up Yang Ziming, and called to the master bedroom to help. When the child gradually settled down, the tired Yang Ziming returned to the second bedroom and fell asleep. Soon the snoring resumed and the baby was crying again. And so on, several times a night.
Later, the wife simply took the child to the nearby in-laws' house to sleep and came back during the day. This life lasted for more than half a year, until the child was weaned.
After his wife and children moved home, in order to stagger the sleep time, Yang Ziming has been actively applying for night shifts. Occasional holidays, I have to stay up late waiting for my wife and children to fall asleep — "Once I go to bed first, my wife won't be able to sleep."
In those years, not only the increasingly serious snoring reminded Yang Ziming to pay attention to his sleep, but also the experience of waking up frequently due to suffocation, the loss of memory and the irresistible sleepiness. But he didn't know exactly what was wrong with him.
In the 4th year of sleeping separately with his wife, Yang Ziming finally learned that he was suffering from sleep apnea syndrome.
This is a sleep disorder characterized by loud snoring with apnea and daytime sleepiness, which is mainly classified as obstructive and central.
According to a 2019 report released by The Lancet Respiratory Medicine, it is estimated that more than one billion people worldwide suffer from obstructive sleep apnea, and among people aged 30 to 69 years, there are about 936 million mild to moderate patients and about 425 million moderate to severe patients. Among the 16 sample countries, including China, the United States, India and Russia, the mainland has the highest number of people affected, or 176 million.
Studies have shown that patients with untreated severe obstructive sleep apnea have a 3.8-fold higher case fatality rate than the general population.
Even so, "sleep apnea syndrome" is still an unfamiliar term for many people.
Slighted symptoms
Yang Ziming remembers that he began to snore at a very young age, perhaps from the age of six or seven. At that time, the old people said that snoring slept soundly. This sentence influenced him for more than a decade, and he almost never took the breathing problems during sleep seriously.
At the age of 22, Yang Ziming heard his newlywed wife complain that his snoring situation was getting worse. My wife recorded a few audio clips, "That voice, it's really not an exaggeration to say that the snoring sound is like thunder." What surprised him even more was that sometimes there was no breathing sound for tens of seconds.
Yang Ziming works in an industrial park in Jinghai County, Tianjin, and lives in a family dormitory arranged by the company. Sometimes after the night shift, he rested alone in his bedroom, separated by a living room and a security door, and his snoring could be heard by neighbors passing through the hallway.
This is just the beginning of the problem.
He gradually found himself becoming drowsy, reading a book, writing a report or playing with his mobile phone, and he would fall asleep when he stopped slightly. The drive was chaotic, and it was only a twenty-minute drive from his house to the county seat, and he couldn't hold on. "There will be a stop in the middle, and the double flash will be turned on, even if it is squinted for 5 minutes."
When playing mahjong, his friends were chattering, and he went to sleep by himself. When everyone found out, their hands and mouths stopped, and they observed him curiously. Perhaps sensing the reaction of the outside world, Yang Ziming woke up in a silence and asked what had happened. Everyone looked at him and smiled.
He went to the town hospital to consult about drowsiness, and the doctor said that it might be that the blood lipids were a little high. After taking the medicine for 3 months, the blood lipids came down, "should be sleepy or sleepy", he did not think much more. "Probably related to the frequent night shift, which everyone thinks."
As the head of the throat snoring group at Wuhan Central Hospital, Dr. Cui Qianbo has been treating patients with sleep apnea for 10 years.
He told "occasional cures" that patients who had a medical history of one or two decades before seeking medical treatment were not uncommon a few years earlier. They usually have stubborn hypertension, diabetes, and some are tested for myocardial ischemia, and even transient renal failure after surgery. Because awareness of the disease is weak, doctors need to give a relatively large amount of health education.
In recent years, due to the increase in popular science education and the local impact of improved patients, the number of people who come to seek medical treatment has increased, and most people's medical history before seeking medical treatment has been shortened to one or two years.
However, it is still a common phenomenon that when couples come to the outpatient clinic together, the patient's mobility will be worse, and the family will have a positive attitude. "In the early days, many patients' subjective feelings were not so obvious, and they may have apnea while sleeping, but they did not wake up. Generally speaking, it is the party whose sleep is affected who pushes the doctor to seek medical attention."
Image source: Visual China
The 29-year-old Zheng Yu also did not care about his bad sleep, and from his narration, he could feel that the difference in attitude between him and his wife had existed secretly for at least two or three years.
In 2018, Zheng Yu began to have the experience of waking up. At first, he couldn't tell how he woke up, but his wife said, "You just don't seem to be breathing."
Over time, the frequency of waking up rises to two or three times a night. He himself had a perception, and when he woke up, he felt that "that breath was coming up."
The wife was scared, but Zheng Yuman didn't care. "It doesn't matter if you're young." How can someone in their 20s fall asleep and fall asleep?"
Zheng Yu has a cousin who also suffers from sleep apnea syndrome and has been on a ventilator for many years. The wife consulted with her cousin, but did not consult zheng yu in advance. Later, she synchronized the information she learned to Zheng Yu, including the positive feedback after her cousin's medical treatment.
But he still did not act.
A life that is getting out of control
Yang Ziming began to mind his sleep, when he drove the whole family to the highway.
His hometown is in Dezhou, Shandong, and it takes more than two hours to drive from Tianjin to the highway. Since he got his driver's license, he's been in charge of the road.
Every time, Yang Ziming has a heavy psychological burden. On the way, he was always sleepy uncontrollably, and as soon as his father, who was sitting in the co-driver, found the signs, he sternly reprimanded: "How can you be sleepy when such an important group of family members sit in the car?!"
Accusations followed. Yang Ziming wanted to explain, but he couldn't say it, even he didn't know it, this sleepiness was related to low ventilation during sleep.
"So you must have played too late yesterday." You defend yourself, they won't believe it."
The harshness of the family is not unreasonable, Yang Ziming really had an accident.
In the winter of 2017, my son had several illnesses in a row. For a time, he drove an hour late every night, went to the city's children's hospital to queue up, hung up the number in the morning, went home to pick up his wife and children, and then returned to the hospital. At two or three o'clock in the afternoon, the child finished the infusion, and he was responsible for sending it back. After resting for a long time, Yang Ziming went to the company to report again.
One afternoon, Yang Ziming failed to resist the sleepiness and chased after him.
The child was frightened and held tightly in the arms of his wife. Both the bumper and the front windshield were broken.
The driver of the front car asked Yang Ziming, do you know that you hit me twice? "You must have been sleepy, you didn't even hit the brakes!"
According to Cui Qianbo's observation, patients begin to pay attention to their symptoms, it is likely that it is not for physical health considerations, and the impact on family, work and social interaction will be a relatively large factor.
"Because the impact on health is often subtle, patients may not attribute complications such as hypertension and diabetes to snoring, after all, there are too many causes of these diseases."
Among the patients we have contacted, Wang Xin's experience is the most lamentable.
For many years, he could not fall asleep once he was lying on his back, and only when lying on his side, the airway was slightly opened, and he could barely maintain a half-asleep and half-awake state. During the day, he is always awake, and if it were not for work, he would have fallen asleep at any point in the day.
Gradually, Wang Xin found that his memory was much worse than before. He is a salesman, and he has to sign contracts, ship goods, and collect money every day. "The customer told me which one to send him, and I promised it." After several days, the customer said, why has the goods not arrived yet? Only to find out that I had completely forgotten."
At first, such mistakes occurred once or twice a month, but then they became more and more frequent, "every week, all the time fighting fires". Although the income was not affected, "the whole person was very irritable".
At the end of 2019, Wang Xin resigned. After 6 years in the job, he felt that he was no longer suitable for the job. He became very negative and even had the idea of hurting others.
"A stain"
Because of snoring, Yang Ziming was once a little depressed. "It feels like this is like a stain on my body, and I don't want to show it."
He was very afraid of others talking about his snoring. When the night shift has no task, you can take a nap, and Yang Ziming will sometimes be woken up by colleagues because the other party is sleeping. More times, he was also particularly upset, as if he had activated the defense mechanism, and his speech took on the smell of gunpowder. If I work with a colleague I don't know well, he'll worry, "Will the other person talk to someone about how I went to sleep the next day?"
Later, in order to sleep less, when he was idle, he played games vigorously.
Zheng Yu was also embarrassed by snoring. He was ashamed to let others know about his situation and did not communicate directly with his cousin, for reasons for this.
He would take a nap at the company, but none of his colleagues knew how he slept because he would hide in a small computer room. It gave him a sense of security, "purring louder, no one else could hear it."
In July 2021, Zheng Yu finally took the initiative to seek medical treatment.
Image source: Courtesy of respondents
The stigma is more pronounced in female patients than in men.
Li Xiaonan, a young Zhejiang girl, has been snoring for nearly 10 years. Every time she went out with her friends, she had to sleep in her own room, "preferring to spend more money than bother them."
The only exception was when she and two classmates went to play at Shanghai Disneyland, when the hotel was hot and there was only one empty room left. Li Xiaonan took the initiative to sleep in an extra bed and "keep a little distance" within a limited range. At night, she proposed to put some ghost stories to entertain herself, selfishly trying to cover up her snoring through the sound of the radio.
That night, Li Xiaonan didn't even dare to turn over, and kept lying on his side, so that he could snore less. She slept unsteadily, occasionally waking up when she heard her snoring, and she looked at the other bed nervously, afraid of waking up her friend.
Heavier stigma also affects the diagnosis and treatment of female patients to a certain extent.
For a long time, sleep apnea syndrome was considered a male disease. Studies have shown that the proportion of men and women affected by this problem in the general population is estimated to be between 3:1 and 5:1, but in some large clinical studies, the ratio of male and female patients is as high as 8:1 to 10:1. This means that women are treated less likely than men.
On the one hand, due to the differences in anatomy and hormone levels between men and women, male patients will report more typical symptoms such as snoring and waking up, while women will report more insomnia, headaches, fatigue, depression and other symptoms, which are easily confused with other diseases, so they may be underdiagnosed. On the other hand, there are also some female patients who consider snoring to be "unladylike" and are reluctant to report it.
Cui Qianbo has an intuitive experience of this: when patients report themselves, most men are more comfortable, women are somewhat difficult to talk about, and even some people tell the history of the disease "will be a little discounted".
Generally speaking, if you have already entered the diagnosis and treatment process, this retention will not have much impact. Because the diagnosis and treatment of sleep apnea syndrome is mainly based on objective examinations such as polysomnography monitoring, airway CT, nasoscopy and laryngoscopy, subjective evaluation accounts for a small proportion.
The real question is how many female patients, out of shame, do not actively seek help from the healthcare system.
Today, Li Xiaonan's sleep and breathing condition has been greatly improved. This is thanks to an operation 3 years ago, but it wasn't specifically scheduled to treat sleep apnea.
In the summer of 2019, Li Xiaonan, who took the college entrance examination, decided to undergo resection surgery because of frequent inflammation of the tonsils. Before the operation, she and the chief surgeon accidentally talked about snoring. After polysomnography, she was diagnosed with sleep apnea syndrome.
During that operation, in addition to cutting off her tonsils as originally planned, doctors also treated areas such as the uvula (commonly known as "small tongue"). This procedure is called uvula palatal pharyngeal plasty and is the most widely used surgical approach to the treatment of obstructive sleep apnea in adults.
Previously, Li Xiaonan had considered specifically treating snoring, but due to the influence of stereotypes, she delayed for a long time.
"When it comes to snoring, the impression is that of a middle-aged man, fat and fat." Li Xiaonan felt that it was normal for this to happen to her father, but it became difficult to accept when it happened to a teenage girl. "At that time, the weight was still a little overweight, and I didn't want to face it."
Everything has an explanation
In 2018, Yang Ziming first heard the term "sleep apnea syndrome".
That summer, he returned to his hometown to mourn for his grandmother. At night, he and his cousin took turns guarding the spirits. My cousin was a doctor at a third-class hospital in the northeast, and one morning, he said to Yang Ziming, who had just woken up: "It's too terrible, don't you go and see it?"
"What do you see?" Yang Ziming was confused.
"Sleep apnea syndrome."
"Speaking human language!"
"You snored so badly, held your breath so many times, I don't even know if I want to wake you up." Cousin is on the right side. "Your blood oxygen must be particularly low, are you usually very sleepy and have a bad memory?" Go back and find a big hospital!"
Yang Ziming knew that his various performances were related to breathing problems during sleep. Everything has an explanation.
Back in Tianjin, he immediately hung up. An entolaryngologist suggested that he go to Tianjin People's Hospital, which has a dedicated snoring center. While waiting for the doctor, he found that everyone around him was sleeping, and they were all snoring. "Surely not wrong, this is the place."
According to the doctor's analysis, his tonsils were hypertrophied and his jaw was somewhat retracted. Also consider the thickening of soft tissues brought about by obesity, yang Ziming, who was 1 meter 66 tall at the time, weighed about 170 pounds. Various factors make his airway quite narrow, and his breathing is blocked during sleep.
Yang Ziming's endoscopic imaging diagnostic report sheet.
Obstructive sleep apnea has a variety of etiology and risk factors, including tonsillar hypertrophy, excessive or thick uvula, retarded tongue roots, tumors in the nose or pharynx, and other anatomical abnormalities, which are also related to obesity, smoking, alcohol consumption and other factors, as well as certain familial clusters.
It has a multisystem clinical manifestation, in addition to the above-mentioned hypertension, diabetes, but also includes enuresis, liver function damage, increased blood viscosity and nasopharyngitis.
At the snoring diagnosis and treatment center, Yang Ziming learned that the "simple stomach disease" that he had been conditioning for 4 years was also related to sleep apnea.
Since 2014, he has often woken up to a burning sensation in his stomach when he falls asleep. At its worst, the stomach acid seems to be about to rush into the mouth.
At the town hospital, he was diagnosed with reflux esophagitis. Several commonly used acid-suppressing drugs were tried, but there was no obvious effect. Eventually, he discovered that a gastric mucosal protector could slightly reduce pain. For the next 4 years, he kept this medicine, and he couldn't stand it, so he took one.
Yang Ziming did not want to rely on drugs, and the doctor said, "Eating less or not eating at night may be better." He did so, but the inflammation continued.
Later, instead of sleeping on his back, he folded a quilt and leaned behind him, or at least two pillows. This is his own thinking, "maybe in this way, the stomach acid will not jump up under the action of gravity." The price is that when you wake up, your tailbone hurts.
The doctor at the snoring clinic explained to him how this all happened: due to the hypopnea during sleep, his negative pressure in the chest cavity and the negative pressure in the esophagus increased significantly, exceeding the tone of the sphincter, and the gastric contents were therefore sucked into the esophagus.
"Cure sleep apnea, and there will be no problem."
Choice
In October 2018, taking advantage of the company's off-season, Yang Ziming took a leave of absence to the Municipal People's Hospital for polysomnography monitoring.
Reports show that he has a minimum oxygen saturation of only 57 percent and a maximum apnea of 67 seconds. Doctors seriously emphasize that blood oxygen is too low, and normal people have at least 94%, but Yang Ziming has no concept. But the longest pause in breathing startled him —"I've been holding my breath while swimming, and I probably can't hold my breath for so long."
Yang Ziming's polysomnography monitoring report.
He had two options in front of him: to undergo surgery or to sleep on a ventilator for a long time.
Yang Ziming was a little embarrassed. On the one hand, due to stereotypes, he was less afraid to undergo anesthesia surgery. And the doctor also said that the postoperative may not be able to completely solve the problem; on the other hand, thinking that he is not yet 30 years old, and he will have to sleep with a ventilator for the rest of his life, he feels that life has been an additional burden since then. "And the ventilator at that time was not as small as it is now, and it was inconvenient to carry such a machine when going out."
Cui Qianbo introduced that the current treatment of sleep apnea syndrome is mainly divided into three directions, one is to lose weight, quit smoking and alcohol, change position and other behavioral changes, the second is to use ventilators, oral appliances and other medical equipment, and the third is surgery. Among them, behavior change is through-the-process, and patients need to choose between the latter two.
Doctors usually recommend ventilators first. It is safer and works for a wider population, both central and obstructive patients can try it, while surgery is only available for a subset of obstructive patients.
"We will first recommend that patients receive 5 to 7 days of ventilator treatment, if they cannot tolerate air pressure, noise and other problems, or if the patient's jawbone is not well developed, wearing a nasal mask will leak air, and then consider surgery."
However, most patients see a ventilator for the first time, "in fact, some resistance."
Before receiving meticulous health education, they will prefer surgery. "People might think that this procedure, like other surgeries, directly removes the lesion, which is more in line with their understanding of the cause of the removal." But in fact, surgery does not currently play a radical role.
Doctors are operating on people with sleep apnea syndrome.
Before seeking medical treatment, Zheng Yu had almost identified his choice - surgery. Every time he made up his cousin sleeping on a ventilator, he felt that "it was too tiring to live like that."
The doctor at the first hospital told him that surgery was OK, but the blood oxygen was so low that he needed to wear a ventilator for a month to improve, and he needed regular re-examinations.
Zheng Yu was not very happy. He didn't want to take frequent leave, that year, he changed to a new car, built a house for his family, two children waiting for him to raise, his parents' health is not good, "still a little financial pressure."
He wants to solve the problem in the fastest way possible. So I went to another hospital and touched the wall once or twice before I found a doctor who agreed to arrange the operation as soon as possible.
This is actually a risky choice.
Coexistence with disease
Yang Ziming finally chose surgery.
For the first year or two after the operation, he was no longer plagued by sleep problems. From the first stitch removal, he felt a noticeable improvement: "I used to breathe heavily when I slept, and when I woke up, my mouth was very dry, and now I can close my mouth when I sleep." He asked his wife, do I still snore? The wife said that there was one more point, but compared with before, it was a world of difference.
Yang Ziming moved back to the master bedroom, and his wife never pushed him awake again.
But the hidden dangers have not been completely eliminated. After the postoperative review, the doctor repeatedly told him to lose weight, but he did not do it.
He changed jobs, stopped working night shifts, and now has a job that requires him to sit in front of a computer for a long time. As my son grew older, he had less and less personal time. After work, I have to help my wife cook first, help my children write homework after eating, and brush dishes and wash clothes. When the child finishes his homework, it is time to rest, "You can no longer do something that affects the child."
For a while, he got up early to run, from 5:30 to 6:30, and ran five or six kilometers in a row. After running for more than a month, his weight has not increased or decreased, and he feels very frustrated. As soon as the work was busy, the time was not very convenient, so I did not insist on it.
Later, the outbreak of the epidemic and frequent isolation caused anxiety, his work and schedule became chaotic, and the amount of activity was much less. The weight soared, once exceeding 200 pounds.
In the Spring Festival of 2021, his wife told Yang Ziming that she would occasionally be woken up by him again.
Yang Ziming went to re-examine, and the doctor still remembered him - "How did you not lose any weight, and even rose?"
"Hurry up and buy a ventilator."
The long-term effect of surgery is not very ideal, and it has become the consensus of the medical community. According to the "Guidelines for the Multidisciplinary Diagnosis and Treatment of Obstructive Sleep Apnea in Adults" issued by the Sleep Medicine Professional Committee of the Chinese Medical Doctor Association, the long-term effectiveness of plevulobopharyngioplasty is 40% to 50%, and for adult patients with tonsil II. degree and above hypertrophy, the short-term (1-6 months) effectiveness of tonsillectomy alone is 85% and the short-term cure rate is 57%.
Cui Qianbo introduced that according to the guidelines, the efficacy is mainly measured by the low ventilation index of apnea, and the cure standard is <5 times / h. He estimates that only one or two percent of the patients in the department actually meet the criteria for cure. "They have a relatively simple location for airway obstruction, possibly on a flat surface, without abnormal bone development. And the general parting will not be very heavy, it may be about moderate."
"Overall, however, the patient's condition has improved." At the same time, the medical community is also looking for more effective treatments.
Yang Ziming finally picked a lightweight ventilator that weighed only 1.25kg. Now, he wears a ventilator to sleep every day, and he also takes it with him when he goes out.
It does take some tongue and explanation from others. The same age is fine, a little question will pass, the older generation will be suspicious, "may think that you will not live long, or run outside and say, the old Yang family's sons are on the ventilator."
Yang Ziming remembered that the first time he put on the nose mask, there was no feeling of air rushing in at once. The ventilator has a sleep monitoring function, which will determine the time to fall asleep and delay the rise to the appropriate pressure. Before the user goes to sleep, it will automatically adjust to a smaller gear, so Yang Ziming does not feel pressured. Just can't talk casually, otherwise the air will run out of the mouth.
The temperature and humidity of the air flow are also intelligently adjusted, sometimes Yang Ziming will feel a little dry, he tried to increase the humidity manually, and found that the condensed water droplets could be seen in the connection tube, and he used the automatic mode again.
The most difficult to adapt to is the foreign body feeling, after all, there is a thing covering the nose, the binding will leak air, there is no effect, the tightness of the stranglehold makes the back of the head hurt, and it may be taken off unconsciously in the middle of the night. In the first few months of use, his wife woke him up from time to time and asked him to put on his nose mask again.
He is still groping for a more comfortable way to use it.
Wang Xin has been with the ventilator for 3 months.
His diagnosis was somewhat misplaced. Last July, he went to see chronic pharyngitis and mentioned snoring in the clinic. Doctors consulted him and arranged a nasal microscopy and found that his pharyngeal cavity was narrowed by up to 70%.
After getting the diagnosis, Wang Xin still did not regard it as a disease.
Doctors suggested he wear a ventilator, which he thought was too exaggerated and joked with friends. "In our cognition, ventilators are worn during rescue, I am jumping around, why should I wear them?" 」
Until one night 5 months later, he couldn't sleep and his side lying down didn't work. I felt like a fish out of the water, keeping its mouth open but unable to breathe in.
At this time, he turned over the previous doctor's instructions again. Then he began to search for the nearest ventilator experience center from home, and rushed to the next morning. After trying it on, without hesitation, I bought one for 16800 yuan.
The ventilator that Wang Xin currently uses.
He felt like he was adapting well. On day 3 of wearing it, he noticed that his blood pressure was back to normal (120/78). Previously, he had been taking antihypertensive drugs for 4 years, but his blood pressure could only be controlled at around 150/95.
Under the guidance of the Nutrition Department, he began to lose weight. The results were remarkable, 20 pounds lighter in two months, but there was still a gap of 70 pounds from the target weight.
At the end of the conversation, he said he was ready to start looking for a job. Admittedly, there are economic reasons, on the other hand, he is quite satisfied with his current physical and mental state, and he thinks that he can do a job.
He has an optimistic vision of the future. Maybe in less than a year and a half, if you lose weight successfully, you can take off the ventilator.
This article was reviewed by Pan Chunchen, Department of Otolaryngology, First Affiliated Hospital of the University of Science and Technology of China
(In order to protect personal privacy, the patients in this article are pseudonyms.) ）
Author: Chen Yihan Shi Jie
Producer: Li Chen
First image source: Visual China
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