Extremely common
and often frightening events -- in many cases, all the more frightening
because whatever provokes them occurred during sleep, such that their
cause may be quite unclear.
BEDPARTNER OBSERVATIONS OF WHAT HAPPENS JUST PRIOR TO THESE
EPISODES
CAN PROVE INVALUABLE IN ARRIVING AT AN ACCURATE DIAGNOSIS.
Possible causes include the following:
-Sleep
apnea. Arousals may be precipitated
either by struggling to overcome upper airway collapse, or by
simple failure to make any effort to breathe. Simultaneously,
it should be realized that many sleep apnea patients stop breathing
hundreds of times per night without ever awakening as a consequence!
Clues
to this diagnosis include:
--The
sensation that one must make repeated efforts to breathe before ‘anything
happens’.
--Shortness
of breath or chest discomfort are immediately relieved after
a few deep breaths
--Awareness
of a throaty, gasping sound, snort or snore with some of
these episodes.
--May
happen more often if sleeping flat -- or if lying on your back.
--
In
some cases, may occur less frequently when sleeping in a chair.
--Worsening after weight gain.
--Occurs more often after drinking alcoholic beverages.
--Occurs more often when experiencing more nasal congestion.
-Gastroesophageal
Reflux Disease (GERD), with backflow of stomach acid up into the esophagus
and throat. Regurgitated acid may spill over the vocal cords
and throw them into spasmodic closure, and inhalation of stomach contents
into the lungs may provoke arousals with coughing and choking. Also,
even if acid does not back up to levels higher than the mid-esophagus,
a nerve reflex can trigger tight wheezing similar to asthma. Chest
pain, virtually identical to that of angina from coronary disease (even
to the point of responding to nitroglycerine) can occur, related to
esophageal spasm.
Clues
to the diagnosis of GERD include:
--Awareness
of bitter, acidic fluid in the throat or nose, or a sour
taste on awakening.
--Associated with
vomiting or near vomiting.
--High
pitched crowing, stridorous sounds unlike the deeper, throaty-sounding
gasps of sleep apnea.
--Wheezing
or coughing.
--Occurrence
more frequent after weight gain.
--Related to
eating late, large meals, alcohol,
spicy foods, or certain other foods like chocolate.
--May improve if sleeping with elevation.
--Immediate
sitting up or jumping to one’s feet, during frantic efforts to
breathe.
--In
some cases, prolonged distress -- sometimes relieved by drinking water
or by taking antacids.
-Sinus
drainage during sleep sometimes can precipitate arousals with choking.
-Asthma frequently
worsens in sleep and in some instances is aggravated by GERD-- particularly
since some asthma medications can make GERD worse.
-Heart
failure often causes attacks of shortness of breath in sleep called “paroxysmal
nocturnal dyspnea” especially when sleeping without elevation. These
usually last more than a few minutes and the patient must sit on the
side of the bed for a time and try to catch his or her breath.
-Coronary
artery disease and other heart problems, including abnormal heart rhythms,
can provoke awakenings with shortness of breath, chest pain, palpitations
and other distressing symptoms.
-Panic
attacks, seizures and other abnormal events precipitating abrupt arousals
also can cause symptoms of breathless and chest discomfort in some
individuals.
We normally become
paralyzed and unable to move anything but our eyes when in rapid eye
movement (REM) sleep -- which prevents us from ‘acting
out’ our dreams. Most people are quite unaware that this
happens, since they are asleep at the time! (See page one of this
handout for a description of REM sleep).
However, that same
paralysis, which normally should occur only in REM sleep, sometimes
intrudes into wakefulness. Such may occur at times
of awakenings (as a brief persistence of paralysis when we awaken from
REM sleep). It also may happen as we are just dozing off but not
fully asleep. It can be thought of as an awake brain in a body
that transiently ‘got stuck’ in REM sleep.
It is not the same
as still being asleep but dreaming that one is struggling to wake up. Instead, the person is wide awake during sleep paralysis
and if unfamiliar with its benign nature, terrified by his or her sudden
helplessness and complete inability to move. It feels like being ‘buried
alive’. Nonetheless, sleep paralysis is harmless. It
usually lasts less than a minute (although it can feel like much longer!). Touching
the person who is experiencing sleep paralysis ‘breaks it’ instantly
-- but such seldom happens, since the person cannot call out for help.
Many people who have
no other sleep disorders experience sleep paralysis on a rare basis. It
can be worsened by sleep deprivation. Sleep paralysis
occurs more frequently in some people with narcolepsy -- a relatively common
disorder causing sleepiness and in some cases, such other symptoms as attacks
of muscle weakness triggered by strong emotions (cataplexy).
Also,
some patients with sleep
apnea may awaken with sleep paralysis, particularly
if sleeping on their back. Both that position and REM sleep
can make breathing worse-- resulting in sleep fragmentation with
repeated arousals. Look
for other signs of sleep apnea especially if you experience sleep
apnea when sleeping on your back and if you have any of its other
symptoms.
