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Sleep Disorders

Why do I wake up choking on saliva?

07/23/2008

Question:

I`ve heard of a sleep disorder that causes a person to choke on their saliva during sleep, but I can`t find info on any cause or treatment.

This happens to me often (probably once a month or so), mainly if I fall asleep on the couch while lying on my side watching tv. It`s like I forget to swallow, and the saliva pools up in my mouth until it overflows and runs down my windpipe (or I accidentally inhale it.)

Once in a while I`ll wake up just as it`s starting, so I can stop it in time. But other times I will awaken suddenly in a panic, jumping upright and gasping for air - coughing and trying to get my airway cleared. (This usually takes a good half hour.)

During the day I sometimes find myself in deep concentration and realize I`ve forgotten to swallow for a while. Do I have some kind of faulty swallowing reflex? Could I die from this?

Answer:

Swallowing is affected by a wide variety of disorders and conditions. Below is a brief assessment of the information you have provided and a guarded speculation regarding the potential causes of your problem.

The swallowing function shares several components with the breathing function. Particularly, swallowing and breathing share a common pathway, that is the throat, and thus close coordination is required between the two functions to avoid swallowing into the lungs (aspiration). Swallowing normally occurs at the end of a breath in the awake seated person. When we swallow, there is a cessation of breathing (or we stop breathing and temporarily hold our breath) and the vocal cords, the entrance to the lungs, close to prevent aspiration. This coordination between swallowing and breathing is present during sleep as well as wakefulness. During sleep, secretions in the upper airways stimulate the swallowing reflex by producing brief arousals from sleep (brain activation) that results in closure of the vocal cords to protect against aspiration.

Smoking, alcohol, nasal congestion and post nasal drip, along with gastroesophageal reflux disease (GERD) are all conditions that can damage the mucosa of the upper airway and may result in impaired swallowing. A common sleep condition: obstructive sleep apnea (OSA) is increasingly recognized as having a strong association with impaired swallowing function during sleep.

You describe that your swallowing is more problematic when you are lying down, suggesting a positional component to your problem. This would occur most commonly in individuals who have post-nasal drip, GERD or possible OSA. The build up of saliva in the back of your throat would most commonly suggest either post-nasal drip or GERD as the source of your problems. However, with the limited information and without an examination, it's impossible to say for sure.

I suggest a thorough review of your medical history including medications, habits, and existing conditions. An exam of the upper airway including the nasal mucosa and the throat is also needed. If you have symptoms of snoring and disrupted sleep, or daytime sleepiness, you may need a sleep study. You should probably start with a visit to you primary care doctor. Referral to an Ear Nose and Throat specialist, a Gastroenterologist or a speech therapist are all possible, depending on the results of your initial examination.

Take heart, as the problem you are describing is not likely to be life-threatening and, with proper management, can probably be controlled and/or effectively treated.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University