April 28, 2010
As many of you know, I incorporate acupuncture and yoga into my practice when treating sleep apnea and upper airway resistance syndrome. Of course, I don't do it myself—I refer to other trusted practitioners. Despite acupunctures' completely different paradigm of health and wellness compared with Western allopathic medicine, one thing it's great for is to realign any imbalances in your body.
One major imbalance that occurs with sleep apnea is that you'll have too much stimulation of the sympathetic or fight-or-flight part of the involuntary nervous system, and not enough of the parasympathetic (relaxation) nervous system. Not sleeping long enough or not efficiently has been shown to increase sympathetic activity. Acupuncture has been proven scientifically to bring into balance the unevenness between your sympathetic and parasympathetic nervous systems.
Acupuncture won't cure your sleep apnea, but used in conjunction with standard treatment options, it can be helpful for many people. In fact, one recent study showed that it lowered the sleep apnea severity (AHI) by 50% on average. This is presumably due to its' effects on the nervous system, since neurologic dysfunction is a major component of sleep apnea.
I also routinely recommend yoga or yoga-based breathing techniques for my sleep apnea patients. It's not coincidence that by modifying your breathing patterns, you can dramatically alter your sympathetic and parasympathetic activity. A simple concept that you'll appreciate is that when you breathe in, you're activating your sympathetic nervous system, whereas when you breathe out, you're activating your parasympathetic nervous system. This is why when you take longer breathing out (such as with the relaxing breathe, singing, humming or playing a wind instrument), you'll feel more calm and relaxed.
I'm going to be talking about the importance of breathing and how it relates to chronic diseases at the Many Paths One Medicine Traditional Chinese Medicine Conference on May 15th in New York City. Hope you can join me.
April 27, 2010
Gastro-esophageal reflux and laryngopharyngeal reflux disease are commonly seen in patients with obstructive sleep apnea. Many of you will have the typical throat clearing, post-nasal drip, chronic cough or hoarseness that's seen with laryngopharyngeal reflux disease. Sleep apnea causes your normal stomach juices to leak up into the throat, which not only causes you to wake up, but also causes swelling and inflammation in the throat.
We know that any form of breathing obstruction (apnea, hypopnea, RERA) can cause you to wake up. But what's not too commonly known is the fact that any degree of acid in the throat can stimulate certain chemical receptors, which causes you to wake up so you can swallow. It's thought that this is needed to prevent aspiration of stomach juices into your lungs.
A recent Japanese study not only confirmed these concepts, but found an interesting additional observation: While people with severe obstructive sleep apnea have mostly arousals due to breathing pauses, those with mild to moderate sleep apnea have a higher number of spontaneous arousals. Spontaneous arousals are noted on a sleep study when your brain waves go from deep sleep to light sleep or temporary awakening, without any objective evidence of breathing pauses.
What this study doesn't address is the fact that it's not only acid that comes up into the throat when you stop breathing. Your stomach juices also contain bile, digestive enzymes, and bacteria. An obstruction causes a tremendous vacuum effect that's created in the throat, literally suctioning up your normal stomach juices. This initial obstruction will lead to the typical respiratory arousal, but lingering juices will irritate the throat leading to spontaneous arousals. Think of your stomach juices as a sort of sensory form of stimulation, like a loud noise or a bright light. Your throat has a number of very sensitive chemical and pressure receptors that can cause your brain to wake up, without any physical obstruction.
There are also studies that show that chronic exposure to acid can make pressure sensors less sensitive over time, leading to longer and longer pauses with each obstruction.
Furthermore, there's research showing that some of these arousals don't ever show up on routine brain wave leads during a standard sleep study. This is because these protective reflex signals are so minimal that they stay in the deeper levels of the brain, never reaching the outer cortex.
I've always felt that spontaneous arousals are somehow related to breathing pauses. This study only confirms my suspicion that too many spontaneous arousals may be a sign of upper airway resistance syndrome or early obstructive sleep apnea.
What's your opinion on this? Do you have laryngopharyngeal reflux disease?
April 23, 2010
This is something I've written about before, but here's another study that shows how taking a nasal decongestant along with something that helps to empty your stomach faster can help with snoring or obstructive sleep apnea. A recent study published in the Journal of Clinical Sleep Medicine reported that the combination of phenylephrine (a nasal decongestant) and domperidone (a medication that helps to empty the stomach) significantly improved snoring as well as oxygen drops in the middle of the night. Seventeen of 23 subjects reported elimination of snoring and apneic events.
This makes sense, since snoring and obstructive sleep apnea involves a combination of inflammation and obstruction. It's been shown that stomach juices can literally be suctioned up into the throat (and nose) during any obstructive event, whether or not it qualifies as an apnea. Digestive enzymes, bile, bacteria, and acid can cause inflammation and swelling in the upper breathing passageways, including the nose and throat.
By definition, all people who snore or have sleep apnea will have some degree of nasal congestion, since there's structural anatomic narrowing due to smaller jaws, as well as inflammation from allergic as well as neurologic causes. If your nose is stuffy, a vacuum effect is created downstream as you breathe in, causing the tongue to fall back and obstruct your breathing more easily.
This is why whenever you do anything to open up your nose (decongestants or Breathe Right strips), some people sleep much better (about 10%).
Quite often, whenever people are given azithromycin (Z-Pak) antibiotic for routine conditions like a throat infection or sinusitis, they feel dramatically better, even if they never had an infection. One interesting property of azithromycin is it's known anti-inflammatory effects: it stimulate smooth muscles in your stomach and empties the contents downstream. But this only works in some people. You can imagine this is the same effect that domperidone has, but not as strong.
So if you combine a nasal decongestant and use something to empty your stomach faster, then this could lead to less inflammation in your throat and less of a vacuum effects that's created due to nasal congestion. This is also why not eating late or drinking alcohol is so important in this matter, along with optimizing nasal breathing through whatever means possible. Sometimes, taking a stomach acid reducer (like Prilosec or Nexium) can also help with sleep, since less acidic juices can cause less inflammation.
There are two problems with this study. The first is that they didn't do formal sleep studies. It was based on subjective questionnaires and oxygen monitoring. However, they do mention that they are working another study that will address this issue. I'm guessing that they will find significantly improved objective results with regard to the apnea hypopnea index and other measures.
Secondly, the drug droperidone is not available in the US. There are other alternatives, but they all have significant side effects, since they all cross the blood-brain barrier (droperidone does not).
This combination of treatment options will probably be another option for people who snore or have obstructive sleep apnea, but currently, it won't achieve mainstream status until more studies are done, along with availability droperidone in this country (or something similar).
Did your sleep quality ever improve significantly after opening up your nose (using a decongestant or nasal dilator strips), or after taking a Z-Pak?
April 21, 2010
Almost every time I see or hear about a man or woman who suffered from a stroke, the first thing that comes to my mind is, did this person have sleep apnea? We have numerous studies that show that untreated obstructive sleep apnea is an independent risk factor for significantly increasing your risk for stroke (up to 3 times higher). A new study combined 29 different past studies that looked at people with stroke or TIA (transient ischemic attack), and found that 72% of people had obstructive sleep apnea.
Knowing that up to 57% of men and 35% of women ages 30 to 70, and up to 81% in the elderly (above 65 years) have sleep apnea, this study's findings are not surprising. Untreated sleep apnea has been shown to cause systemic inflammation, thicker blood, slowing of blood flow and many other stroke-promoting factors. Furthermore, patients with sleep apnea are found to have significantly higher rates of brain lacunar infarcts, as well as diminished blood flow and brain neuron density in various critical areas of the brain, including parts that control memory, executive function, breathing and respiration, and autonomic function.
The real question is, does everyone over 60 (or even younger) need a sleep study to prevent strokes and heart attacks?
What's your opinion on this?
April 21, 2010
Spring is in the air, and so are the tree pollens. Millions of people suffer this time of the year from sneezing, scratchy, itchy eyes, nose and throats, nasal congestion and chronic cough. It's also a given that if you have allergies, you won't sleep as well, along with everything from asthma, cough, and sinusitis to diarrhea. So how do allergies cause sleep problems, and in general, and how does it specifically cause or aggravate obstructive sleep apnea?
When Allergies Lead to Something Worse
There are already tomes of articles, books and websites offering tips for allergy sufferers including traditional options like nasal saline irrigation, homeopathic remedies, and using a HEPA filter to prescription medications and allergy shots. But again, how can having a runny nose cause you not to sleep well at night? I've combed through numerous medical and internet resources and to date, I haven't found one good explanation.
However, looking at it from a sleep-breathing standpoint, it makes total sense: any degree of nasal congestion, whether from allergies, colds, or even weather changes, causes a slight vacuum effect downstream in the throat which can aggravate tongue collapse, especially in certain susceptible people. Who then, are susceptible to tongue collapse? Almost every modern human!
It's All In Your Jaws
To be more specific, the smaller your jaws, the more likely you'll sleep poorly when you have allergies. Even if you're completely normal, having a stuffy nose can suddenly cause your tongue to fall back and block your breathing. Plugging your nose has been shown to cause obstructions and arousals during sleep. This is why you'll toss and turn when you have an allergy or a simple cold.
Many people with allergies and small mouths will also have grooves or indentations along the side of their tongues. This is called tongue scalloping. Since the tongue and other soft tissues grow to their genetically predetermined size, and due to crowding from having smaller jaws, the teeth leave their imprints along the side of the tongue. If you have additional inflammation from gastric reflux that's a given with sleep-breathing problems, then this scalloping problem gets worse. Not too surprisingly, tongue scalloping is predictive of having apneas, hypopneas, or oxygen drops in almost 90% of people.
Allergies From Stress?
So then, why do allergies happen in the first place? Again, there are tons of proposed explanations that I don't have the space for, but here's a simple concept from Robert Sapolsky's classic book, Why Zebras Don't Get Ulcers:
Humans can handle big stresses such as a major catastrophe, a death in the family, or running away from a tiger. In these scenarios, your stress response leads to an intense activation of your immune system (in addition to your nervous system's fight or flight response). Once the stress is over, your immune system's activity level drops down to normal, but only after it dips below normal for a short period of time. During this short period, you're also more susceptible to getting sick.
However, modern societies don't have very big stresses such as running from a saber tooth tiger. Rather, we have multiple micro-stresses spread throughout the day such as being honked from the rear on the way to work, your boss yelling at you, or your computer crashing. These little stresses push your immune system's activity higher and higher, with not enough time for it to recover and go back to normal levels. After a certain point, your immune system is on constant overdrive, leading to the typical allergic or autoimmune conditions that are all-too-common today.
When Your Allergy is Not An Allergy
This process also explains why you may also have a chronically runny nose. This is called chronic or nonallergic rhinitis, when the involuntary nervous system in your nose overreacts to irritants, chemical, odors, or weather changes (either pressure, temperature, or humidity changes). Symptoms include runny nose, sneezing, nasal congestion, post-nasal drip and headaches, and is often mistaken for regular allergies. This condition may respond to regular allergy medications, but not as well. Either way, inflammation and swelling can also cause nasal congestion, leading to poor quality sleep.
Overcoming Your Allergies
If you have classic allergies, you must start with the basics: Avoid outdoor activity on high-pollen days, shower before bedtime to get the allergies out of your hair, don't wear shoes indoors, get a HEPA filter, and take over-the-counter medications as needed. Some people benefit from routine use of HEPA filters as well in their bedrooms. You may have to see your doctor if conservative measures don't help.
There are various over-the-counter allergy medications. The newer, nonsedating antihistamines block the effects of histamine, which is what causes watery, itchy, runny eyes and nose. The most common brands are Claritin, Allegra, and Zyrtec. They all work differently in different people, so the only thing you can do is to try each one and see which you prefer. Although they are nonsedating in theory, there are reported cases of drowsiness with all three. Benadryl is an older antihistamine that's very effective for allergies, except that many more people may get drowsy.
If your nose is stuffy, then two options are nasal decongestant sprays (which you can only use for 2-3 days) or decongestant pills. Routine nasal saline irrigation can also help your breathing and sleep.
There are a number of prescription medications, including topical nasal steroid or topical steroid sprays. Leukotriene phosphate inhibitors, such as Singulair, and various others also available. Oral steroids can also be useful in emergency situations. As a last resort, an allergy evaluation with shots are a consideration.
Regardless of which way you treat your allergies, it's important to follow all my recommendations for better breathing while sleeping, such as avoiding eating or drinking alcohol within 3-4 hours of bedtime, sleeping on your side or stomach. Having a stuffy nose for whatever reason can trigger breathing pauses downstream, ultimately giving you a bad night's sleep.
April 21, 2010
Looking back at my teen years at Stuyvesant High School in the mid 1980s, it's amazing what I was able to accomplish: Beside the rigors of academics, I was in the symphonic band, orchestra, jazz band, captain of the track team, and a major science geek, entering and placing in various prestigious competitions, including reaching the semi-finals of the Westinghouse Science Talent Search (now renamed Intel). I also remember having the hardest time getting up in the mornings, since I had to commute over an hour by public transportation to get to school. Many of my friends had to travel much further and had even more impressive activities.
Late To Bed, Early To Rise
It's almost a given that if you have a teenager, he or she will be sleepy, especially in the morning. Various experts describe teens' hectic schedules as a major cause of their sleepiness. One particular explanation is that teens' sleep cycles are shifted later into the night, going to bed later and waking up later. But because most of our schools begin at 8AM, teens have to get up hours before their normal wake times. But can there be an alternative explanation to why their sleep times are shifted and why they have trouble getting up in the morning? Is their delayed sleep time a natural part of their development, or is it an artificial product of modern society?
My sleep-breathing paradigm proposes that all modern humans are susceptible to breathing problems while sleeping due to our smaller jaws. Coupled with this paradigm, there are also various developmental and anatomic changes that teens undergo that can explain why teens are so sleep deprived, and why paradoxically, they can be extremely active and productive during the day.
In my book, Sleep, Interrupted, I describe a phenomenon where due to a major change in modern humans' diets along with the invention of bottle-feeding, our jaws are getting smaller with more dental crowding. Another variable that compounds this problem is that we're able to talk and communicate—this make our tongue prone to collapse, especially when on our backs and in deep sleep (due to muscle relaxation).
Growing Up Can Cause Sleep Problems
Throughout life, there are various accelerated periods of growth or change with our voice boxes as it relates to our upper airways. This first period occurs between 4-6 months, when the voice box separates away from the soft palate, creating a uniquely human area in the throat called the oropharynx. The oropharynx is the space that's behind your tongue, between the tonsils and below the soft palate. Humans infants, who are born able to breathe and suckle at the same time, have to relearn this process during this timeframe. Interestingly, this is also the period of time when SIDS (sudden infant death syndrome) peaks.
The Tonsil Dilemma
During ages 3 to 6, childrens' tonsils grow significantly larger, and not too surprisingly, this is also the time period in which tonsils are most frequently removed, especially for snoring and obstructive sleep apnea. Once tonsils (and adenoids) are removed, most children do well, but recently, we're realizing that this is not necessarily the case.
The problem is that removing tonsils and adenoids only addresses part of the problem—it doesn't address the smaller jaws that these children have. Having smaller jaws means that the tongue can fall back easier and cause more of a vacuum effect in the throat that suctions up normal stomach juices into the throat, causing the tonsils to become even larger. This creates more obstructions, preventing the jaws from widening and developing more fully. This is why rapid palatal expansion alone was found to be equivalent to tonsillectomy, and doing both gave additive results.
Let's say that your child's large tonsils were removed, but the jaws never fully developed properly. Most young teens will eventually need braces to correct for crowded teeth. Unfortunately, most orthodontics is focused on straightening teeth, rather than enlarging the airway.
As your child goes through puberty, an obvious thing also happens: his or her voice becomes lower. One major consequence of a deepening voice is that the voice box has to drop in the neck. This opens up the oropharynx even further, creating even more space for the tongue to fall back. This process continues into early adulthood, where the voice box settles in its' final location (it's been shown that the voice box continues to drop an additional 1/2 vertebral body length slowly even up to age 70).
Delayed Sleep or Deficient Sleep?
As your teen undergoes this transition, by definition, sleep quality diminishes, with various consequences, both good and bad. Because they're not able to sleep efficiently, it's hard to get out of bed in the morning. To compensate for their fatigue, they tend to participate in numerous activities throughout the day, including sometimes very physical sports. I've also commented in my book about a possible connection between mild sleep deprivation and creativity promotion, since your senses are heightened. After a full days worth of school and after-school activities, they'll have dinner and then have another few hours of homework to tackle.
With this schedule, it's not surprising that most teens don't get to bed before 11 or 12 PM, if not later. If you add to this all the media distractions like the computer, phones and television, they'll get even less sleep. Eventually, they crash, and are forced to wake up earlier than they want to to begin the next day. When I was is high school, I didn't have that much homework, so I usually went to bed at a reasonable time, around 9 to 10 PM. These days, I'm sure that teens probably go to bed much later than this. Their minds are so wired at night that it's difficult to go to bed earlier. In essence bad sleep hygiene such as this can lead to delayed sleep times, similar to many adults with delayed sleep phase syndrome.
An Explanation For The Freshman 10
If one or both parents snore or have documented obstructive sleep apnea, the teen has a higher risk of having sleep apnea as well, or developing it later in life. For some reason, sleep apnea in teens is not seen too often. But I'm willing to bet that it's a major problem that's not being addressed. Similar to the natural anatomic changes that occur during menopause, adolescence is a period of change in the sleep-breathing status that can cause paradoxical patterns of moodiness and irritability, along with intense creativity and productivity.
Notice that the incidence of depression and anxiety also begins to spike in the late teens and early adulthood. Imagine taking a teen out of his protected home environment with regular, healthy meals and place him suddenly in college where he'll binge in the cafeteria, stay up late, and even drink alcohol.
All this can lead to, or aggravate underlying sleep-breathing problems. Since inefficient sleep causes weight gain, and weight gain can narrow the throat, all this is not surprising. Perhaps the freshman 10 weight gain is an expected consequence of this expected life transition (an anatomic transition) that can unmask any underlying sleep-breathing problems.
April 21, 2010
Sleepy teens are one of the most ignored groups by the sleep community. Teens are not bigger children, nor are they smaller adults. To dispel some of the common myths and misconceptions about teens and why they are so sleepy, I’ve invited back Stanford University’s internationally renown sleep physician and surgeon Dr. Kasey Li to talk to us about this very important issue.
In this month’s Expert Interview, Dr. Li will reveal:
- Why your teen is so tired and sleepy
- Why tonsillectomies don’t work all the time
- What happens when children with sleep apnea become teenagers
- What other common sleep conditions besides sleep apnea do teens have?
- What are the treatment options for teens with sleep apnea?
Topic: “Why Your Teen is Sleepy”
Date: April 27, 2010 Time: 8PM Eastern / 5PM Pacific
Click here to register.
April 16, 2010
There are many people who sleep with their pets in bed. If you have sleep apnea, however, you may need to reconsider this practice. Yes, there's definitely the emotional-comfort aspect of sleeping next to your pet, but almost invariably, your pet is likely to prevent you from getting the best sleep possible. Either you won't be able to turn in bed to your preferred sleep position, or you'll be awakened often by your pet's movements or sounds.
If you have obstructive sleep apnea, you're not able to achieve deep sleep, so any sound or movement is more likely to wake you up. Even if you don't have sleep apnea, anything that can potentially lessen your sleep efficiency can aggravate any other underlying medical condition that you may suffer from. I commented on this issue in a newly released book, Leashes And Lovers (search for my name under Look Inside), by Sheryl Matthys. If you're a dog lover, you must read this book.
As expected, whenever I make the suggestion that pets (and children) be removed from the bedroom, most people are highly reluctant.
What's your opinion on this issue? Do you sleep with your pet in bed? Please enter your comments in the text box below.
April 15, 2010
It's common knowledge that breastfeeding is better for your baby compared with formula, and this new study estimated a figure on dollars saved if 90% of new moms breastfed exclusively for 6 months: $13 Billion. The results are not too surprising. One criticism that was mentioned was the fact that there are costs involved in breastfeeding, including unpaid time off work and lost productivity. This is an important issue that our society has to grapple with: What's more important—job productivity and wages that pay for food, or having a healthier baby?
What they found was that 3/4 start out breastfeeding initially, but at 3 months, less than 1/3 are breastfeeding. The excess annual cost associated with poor levels of breastfeeding compared to the ideal 90% compliance rate was: $9.1 Billion (991 estimated preventible deaths due to SIDS, necrotizing enterocolitis, and lower respiratory tract infections). The remaining amounts were due to otitis media, atopic dermatitis and childhood obesity.
What I discovered after reading the full article was interesting—to define breastfeeding, they asked survey respondents if they have “ever breastfed or fed breast milk.” Exclusivity was defined as the following: "…not having fed anything other than breast milk, including water, in- fant food, juice, formula, cow’s milk, or sugar water." What's clear is that either natural feeding from the mother's breast, or pumped milk from the mother is defined as breast feeding.
There are many dentists and lactation experts that would argue that there's a big difference between the two. Dr. Brian Palmer has argued convincingly that feeding from the mother's breast protects against developing obstructive sleep apnea. In other words, bottle-feeding can aggravate malocclusion and dental crowding. If you notice the various related illnesses in the study, they are all potential complications of untreated obstructive sleep apnea. Something to think about.
What's your take on this issue? Please enter your comments in the text area below.
April 11, 2010
- #1 reason why parents should never ignore your teenager’s sleepiness (their packed schedule has nothing to do with it!)
- Why many tonsillectomies don’t work unless you do “THIS” first
- How parents can inadvertently pass on their “sleepy gene” to their teens and what you can do avoid doing so
- Which treatment options work and which fail and how you can help your child to get the right treatment