Snoring

What is Snoring?

Snoring is the sound made when the soft tissues of the nose and throat vibrate as you breathe during sleep. It can be harmless (primary or simple snoring), or it can be a symptom of sleep-disordered breathing such as obstructive sleep apnea.^[1] It is common, and about half of adults over 60 snore.^[2]

Common symptoms

The main symptom is a loud breathing noise during sleep, often noticed first by a bed partner. Snoring affects the people who share your bedroom as well as you.^[2]

• Loud, regular snoring that disturbs a partner^[2]
• Mouth breathing, which can point to a blocked nose^[1]
• Pauses in breathing seen by a partner, gasping, and unrefreshing sleep, which suggest sleep apnea^[3]
• Excessive daytime sleepiness^[3]

Causes and risk factors

Snoring happens when the airway narrows during sleep, and the cause may lie in the structure of the nose, mouth and throat or in how the muscles behave.^[1] Researchers separate snoring into anatomic and non-anatomic types, and personalized treatment depends on which applies.^[1]

Simple snoring and sleep apnea sit on a continuum, and snoring can be a risk factor for the later development of sleep apnea.^[4] Researchers still lack an agreed definition of simple snoring, and the apnea-hypopnea index cut-offs used to separate it from sleep apnea vary between studies.^[5]

How it is diagnosed and treated conventionally

A physician evaluates snoring by reviewing sleep habits, other health conditions and the upper airway, and may order an overnight sleep study to check for sleep apnea.^[1] This matters because snoring can be a sign of obstructive sleep apnea, which affects cardiovascular health, quality of life and driving safety.^[3]

For snoring without sleep apnea, a sleep physician can prescribe a dental oral appliance, and guidelines recommend oral appliances over no treatment for adults who ask for treatment.^[6] For sleep apnea, positive airway pressure (CPAP) performed best in a large network meta-analysis, and oral appliances may be an alternative for people who cannot tolerate it.^[7]

Why Snoring calls for a whole-person approach

Snoring is rarely caused by one thing. Nasal blockage, body weight, sleep position, age, alcohol and the muscle tone of the throat can each contribute.

Care that looks at these linked factors is a reasonable addition to a medical evaluation. The factors below describe what has been reported, and they are not a promise that changing one will stop snoring.

Nasal airway

A blocked nose can push people to breathe through the mouth, and mouth breathing is linked with snoring and with the progression of sleep-disordered breathing.^[1] Nasal problems should be assessed by a physician.

Weight and sleep position

Physicians commonly look at body weight, sleep position and alcohol use when planning care. The causes and consequences of simple snoring are incompletely understood.^[4]

Sleep quality and daytime function

Snoring can disturb sleep for both the snorer and the partner.^[2] Whether simple snoring on its own causes daytime sleepiness or cardiovascular and metabolic disease is still debated, so those symptoms deserve a check for sleep apnea.^[4]

Throat muscle function

Exercises for the mouth and throat muscles, called myofunctional therapy, have been studied. In sleep apnea trials, myofunctional therapy probably reduced snoring intensity slightly, and its effect on snoring frequency was very uncertain.^[8] In a trial of 40 obese people who snored, myofunctional therapy did not significantly change measured snoring.^[9]

Acupuncture for Snoring

What the research shows

No clinical trials of acupuncture for snoring itself were found, so its effect on snoring is unknown. The research that exists is in obstructive sleep apnea, and it is limited.

A meta-analysis of 9 trials with 584 participants found lower apnea-hypopnea index and sleepiness scores with acupuncture, but the quality of evidence was mainly low to very low, and the sleepiness result reversed in a sensitivity analysis.^[10] A later meta-analysis of 19 trials with 1,365 participants reported similar improvements.^[11] A large network meta-analysis concluded that acupuncture might improve apnea-related outcomes, but that the evidence was weak and that CPAP performed best.^[7]

Individual trials disagree. A pilot trial of 36 people with moderate sleep apnea (26 completed it) found fewer breathing events with acupuncture than with sham.^[12] A small trial of 44 hypertensive people with mild to moderate sleep apnea found no difference from sham after 10 sessions.^[13]

How acupuncture may work

How acupuncture might act on snoring or sleep apnea has not been established. One meta-analysis reported lower inflammatory markers after acupuncture, but this is an association in the reported studies and not proof of how it works.^[11]

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the head, face, hands and legs, usually left in place for about 20 to 40 minutes. Two of the sleep apnea trials above gave about 10 sessions.^{[12, 13]} A course usually involves several visits with reassessment.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[14] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Snoring

The Ayurvedic view

Ayurveda traditionally links heavy, noisy breathing in sleep to excess Kapha, the principle associated with heaviness and mucus, which can congest the nose and throat. These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to reduce Kapha, such as lighter evening meals, regular sleep hours and avoiding heavy, cold or oily foods late in the day
• Steam inhalation and nasal care, including Nasya (herbal oil placed in the nose) and Jala Neti (salt-water nasal rinse)^[15]
• Breathing practices from the yoga tradition, taught by a qualified instructor

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty. Nasal therapies should wait until a physician has evaluated the cause of the snoring.

What the research shows

There are no clinical trials of Ayurvedic treatment for snoring or sleep apnea. A PubMed search found none, so any benefit is unknown. A review of Jala Neti said that most studies support its use in sinus and allergic conditions, and called for randomized trials. The review does not report any results for snoring.^[15]

Herbal medicine for Snoring

Herbs and formulas that have been studied

No herbs have been studied for simple snoring. Chinese herbal formulas have been studied in obstructive sleep apnea, and the formulas vary and are chosen by pattern.^[16]

What the research shows

The evidence is limited and is for sleep apnea, not snoring. A systematic review of 58 trials with 4,590 participants found that Chinese herbal medicine lowered the apnea-hypopnea index more than placebo in 7 studies, and that herbs combined with CPAP reduced it more than CPAP alone in 28 studies. The authors concluded herbs may be an option for sleep apnea.^[16] The placebo comparison rested on only 7 studies with 583 participants, so it should be read cautiously.

Treatment of sleep apnea should be directed by a sleep physician, and herbs should never replace CPAP or other prescribed treatment.^[7]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe serious bleeding or clotting events when warfarin was combined with herbs including dan shen, dang gui, ginger, ginseng and Boswellia.^[17] Sedating herbs or supplements may be unsuitable for people with sleep apnea, so tell your practitioner about any sleep medicines you use.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[18] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, take blood thinners, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes snoring and noisy breathing in terms of phlegm and dampness blocking the airway, sometimes with spleen qi weakness. Researchers might loosely compare this with nasal congestion, excess tissue bulk and low muscle tone around the airway.^[1]

Ayurveda's excess Kapha likewise describes heaviness and congestion. No study has shown that a dosha or a qi pattern corresponds to a specific biological process in snoring.

How this care fits with your medical care

Integrative care for snoring is complementary. Snoring should be evaluated by a physician to check for sleep apnea, and anyone who is prescribed CPAP or an oral appliance should keep using it as directed.^{[3, 7]} Do not stop or change prescribed treatment without your prescriber. We do not diagnose sleep apnea.

Please bring your diagnosis, any sleep study report, a full list of medicines and supplements, and notes from your bed partner about your sleep. A child who snores regularly should be seen by a pediatrician.

When to seek urgent medical care

Loud snoring is not an emergency by itself, but some signs point to sleep apnea or another serious problem.^[3]

• Pauses in breathing, choking or gasping during sleep
• Falling asleep while driving or at work
• Excessive daytime sleepiness, morning headaches or confusion
• Chest pain, an irregular heartbeat or severe shortness of breath at night
• Sudden swelling of the face or throat, or severe trouble breathing

If any of these occur, call 911 or go to the nearest emergency department.