July 30, 2010
Here's a study that confirms that snoring should always be taken seriously: Researchers showed that snoring children had lower IQ/test scores compares with children that didn't snore. Not too surprising, knowing what we know about snoring.
Even if you don't have obstructive sleep apnea, snoring is a sign that you're partially obstructed, and in most cases many people who snore initially go on to develop obstructive sleep apnea many years later. In young children with very actively developing brains, any disruption in sleep quality can disrupt proper brain functioning.
I overheard one sleep researcher a few years ago saying that after tonsillectomy, cognitive and behavioral scores improve dramatically, but never catch up to that of children who didn't need tonsillectomy.
So why should snoring be taken so seriously?
We know that in drivers, snoring alone without having formal obstructive sleep apnea significantly increases your risk of car accidents. Vibrations that come from snoring is thought to alter the sensory nerve endings of the soft palate, somehow damaging the protective reflexes that help to keep the upper airway open. Vibrations from snoring are also found to cause carotid artery wall thickening in rabbits. Damage to the chemical receptors from additional reflux can also aggravate this vicious cycle. These type of studies go on and on.
What all these studies point to is the fact that snoring is on a continuum of sleep-breathing disturbances of which all humans are susceptible. While not all snorers will have obstructive sleep apnea, it's important to look for complications of snoring, as well as to prevent progression later on into true sleep apnea.
How many of your friends or family members snore?
July 28, 2010
I just came across an article in the NY Times that described a condition called SUDEP (sudden unexplained death in epilepsy), where people with seizures can die in their sleep. It’s throughout to be due to loss of protective reflexes and possibly obstruction. This article brought back memories of the time I was on my neurosurgery rotation and a young woman with seizures just died in her sleep. It was a very emotional and distressing situation for everyone involved, especially when I had to tell the family about what happened. In retrospect, she probably died of SUDEP, and come to think of it, I vividly remember that she had a very narrow face.
What I found interesting was the fact that when it happens, people are usually found lying on their stomachs. References were made to SIDS (sudden infant death syndrome) and its’ many similarities. Unfortunately, it goes on to describe the typical genetic causes for this condition, without exploring the upper airway issue at all.
If you Google sleep apnea and seizures, you’ll see tons of papers and references showing a highly significant association between these two conditions. Just to review, here’s my take on this link:
Seizures are thought to develop when abnormal connections form between nerve endings in your brain, leading to a short of “short circuit.” Many of the medications that are used to control seizures essentially calm or lessen the excitability of the brain’s nerve cells. Even the newer vagal nerve stimulation technique works by enhancing the parasympathetic nervous system (which controls the vagus nerve). Anything that helps to calm or relax your nervous system can also help to prevent seizures.
Not too surprisingly, numerous recent studies have shown that untreated obstructive sleep apnea can cause brain damage in a variety of different ways, including multiple mini-strokes, major strokes, decreased brain tissue density, decreased brain volume, diminished brain functioning, and diminished reflexes. All these effects were found to occur in critical areas of of the brain, such as areas that control memory and cognition, executive functioning, breathing, autonomic nervous system control and motor movements.
I’ve also noticed that every patient that I see that has a seizure diagnosis has very narrowed upper airway anatomy, and usually can’t sleep on their backs. More often than not, parents of people who have seizures often snore heavily and likely have untreated obstructive sleep apnea. We also know that untreated obstructive sleep apnea can significantly lower your seizure thresholds, making you more susceptible to experiencing attacks.
What all this implies is that if you have an underlying sleep-breathing problem, whether or not you have obstructive sleep apnea, you’re going to be more prone to various degrees of brain disfunction and miswiring.
What do you think about my theory? Should all epilepsy patients get screened for obstructive sleep apnea? I’d like to hear your opinion.
July 25, 2010
Here's a bizarre anatomic factoid that you may find interesting (or disgusting). One of the most common diagnostic surgical procedures that ENT surgeons are trained for is rigid upper endoscopy, where long, rigid tubes are passed into the esophagus or trachea to not only visualize the anatomy, but also for biopsies or laser treatment.
Dr. Chavalier Jackson was a laryngologist in the early part of this century in Philadelphia who observed that sword swallowers could accomplish their feats with amazing ease. Anatomically, he realized that with your head tilted back, it's literally a straight line from your mouth into your stomach. Most primitive animals and most mammals (other than humans) have relatively straight passageways as well. With humans, our air passageways are curved at a right angle, which is one of the natural consequences of complex speech.
We can literally place up to a one inch wide hollow, metallic tubes all the way into the stomach and (using smaller tubes) the far reaches of most of your lungs.
Now with flexible fiberoptic technology, this technology may seem outdated, but there are certain situations where rigid endoscopy may have advantages: With rigid tubes, it's much easier to manipulate the tissues that you're looking at, and you can literally "feel" any lesions, lumps or tumors. In addition, you can add a binocular microscope and "see" the area of interest in 3-D. You can operate with two hands by using a microscope, or use a laser.
So what does this have to do with sleep apnea? Nothing, specifically. But I wanted to point out an anatomic anomaly that all humans have that not only allowed for complex speech and development, but also predisposed us to major sleep-breathing problems.
July 22, 2010
Here's another menopause-related study that may have an alternative explanation. Researchers found that in overweight and obese menopausal women, weight loss significantly improved symptoms of hot flushes. They didn't give any conclusive or plausible explanation for the reason why.
It's clear that if you're overweight or obese, a significantly higher number of women will have undiagnosed obstructive sleep apnea. Losing weight will improved symptoms of obstructive sleep apnea, which include hot flushes, night sweats, mood swings, insomnia, and irritability. We know that even young men can have these same symptoms. These symptoms are not directly caused by hormonal changes per sé—it's the relative change in the person's sleep-breathing status that can cause these vasomotor neurologic symptoms.
For the men out there with obstructive sleep apnea, do you suffer from hot flushes and night sweats?
July 21, 2010
Over that past few months I haven't been getting good sleep, and my wife has noticed that I do stop breathing once in a while. So I decided to give myself a sleep study. I underwent a formal overnight sleep study many years ago just to see what it's like, and at that time, the results were unremarkable. This time, I wanted to try one of the new home sleep tests.
The sleep test was from Sleep Solutions and it's a clamshell laptop-like device with leads that connect to your finger, chest and a nasal cannula, like what you see in patients that receive oxygen in the hospital. The instructions are straight forward, and if there's any problem such as a lead falling off, the computer will tell you. The test is performed for three nights, and the device is mailed back via pre-paid shipping.
About a week later, I finally got my results. Not too surprisingly, I don't have obstructive sleep apnea. However, I did have about 2 apneas or hypopneas every hour. Looking at individual apneas, some were as long as 40 seconds! Once, my oxygen level even dropped to 88%. There are also some mild snoring.
One of the downsides of this particular test is that it doesn't show sleep stages, sleep position, or RERAs (short obstructions and arousals that don't meet the criteria for apnea or hypopnea).
I'm the last person you'd think has obstructive sleep apnea (my BMI is 20). This just goes to show that everyone, no matter what your size, shape or build, is susceptible to breathing problems.
In retrospect, now that I'm sleeping better, my nose has been less stuffy that it has been over the past few months. This only confirms how having a stuffy nose can worsen your sleep quality.
Armed with this information, I'm committed to my current regimen of regular exercise, healthy eating, and good sleep practices.
July 20, 2010
If you have obstructive sleep apnea and can't use CPAP or oral appliances at all, and if you're afraid of all the surgical options out there, here's an innovative procedure that treats sleep apnea in a radically new way: by stimulating your tongue while you sleep.
A small device (similar to a pacemaker) is placed in your chest, and a thin wire is connected to the nerve that goes to your tongue. There's another set of wires that senses when you're breathing in. So whenever you sleep at night, as your muscles begin to relax, it senses that you're breathing and pulses the nerve that goes to your tongue, called the hypoglossal nerve.
An initial trial in Australia is finished with good results so far, and I'm happy to announce that I'm part of the NY City team that will be taking part in the initial mullti-site US clinical trials. Entry criteria include not being able to tolerate CPAP, moderate obstructive sleep apnea (AHI between 20 and 100), BMI < 37, and age 21 to 70, amongst many others. If you're interested, please let me know. Here's a brochure from Apnex, for more information.
July 20, 2010
There are many resources available regarding tips for travel while on vacation, but one thing that can definitely ruin your vacation is poor sleep. You may never think that you will suffer from sleeping problem until it happens, and by then, it’s too late. Besides the various stresses of travel, including delayed flights, misplaced luggage, or traveling with children, the last thing you need is to lay down in your hotel bed, and start tossing and turning, unable to sleep.
On the other hand, you can go to sleep with no problems, but wake up feeling like you slept for only 3 hours. This can happen due to worrying about your lost luggage, persistent ear pain and hearing loss since getting off the plane, or an uncomfortable mattress or pillow. If you are a poor sleeper to begin with and especially if you normally can’t sleep on your back, then the following travel tips could prevent your vacation from turning into a disaster.
Tip #1. Keep your nose clear.
If you have a history of ear or sinus discomfort while flying, or if you have any degree of nasal congestion due to allergies or colds, then take preventive measures to open up your nasal breathing passageways to prevent ear, nose or sinus problems which can keep you up at night. Your ears and sinuses are connected to your nose through very narrow passageways. If you have any form of nasal congestion or inflammation, these passageways can become more narrow, and the rapid pressure changes during your flight (usually when descending) can aggravate more swelling and a partial blockage of your sinuses or ears. The middle ears are connected to the nose by the Eustachian tubes, which acts to equalize pressure between your nose and your ears every time you swallow. But when there’s swelling (due to colds, allergies, migraines, or acid reflux) around the Eustachian tubes in the back of the nose, this tube doesn’t work properly and your ears won’t equalize. Not breathing well through your nose can also prevent proper breathing at night, leading to poor sleep.
The simplest way of preventing ear, nose and sinus problems while flying is to decongest your nose using generous amounts of nasal saline (which is a mild decongestant), or over-the-counter decongestants, such as Sudafed tablets or Afrin nasal spray. If you have high blood pressure or are sensitive to Sudafed, it’s not a good idea to take. Afrin, on the hand, can only be used for 2-3 days if you have persistent ear fullness after the flight. For most people, taking a decongestant in the middle of the flight (before descending), should be enough. There are various ear “plugs” marketed for flying. They can be helpful for some people; if it works, keep using them.
Now that you've made it safely off the plane without any problems, you finally make it to your hotel at 9 PM and check in. You're really hungry and stop by the restaurant to grab a sandwich.
Tip #2: Don’t eat before bedtime.
Eating late before bedtime, while on vacation or at home, is the single most common habit that could potentially ruin a good night's sleep. On vacation, it’s tempting to eat later or binge at a great restaurant, but you’ll pay for it that night. For many people, if you have food in your stomach when you lay down, some of the stomach juices can regurgitate up into your throat, causing irritation and inflammation. This can wake you up more often, diminishing deep sleep quality. For people who snore or prefer to sleep on their sides or stomachs, they may actively suck up stomach juices into their throats while sleeping, worsening an already tenuous sleep situation. The general rule of thumb is to eat your last meal about 3-4 hours before bedtime. This also means no snacks before bedtime.
Tip #3. Avoid the Night Cap.
You've stopped your late night snacks, and so far so good. You make arrangements to meet your long-time friend at the hotel bar, but the earliest he can meet is at 10 PM. The two of you meet and decide to have a glass of wine. As you take your first sip, you remember the newspaper article that reported that red wine has an ingredient that could keep you young. Afterwards, you to back to your room to rejoin your wife, and you go to bed. The next morning, for some reason, you feel like you only slept for 3-4 hours. What happened?
There are numerous studies that tout red wines' beneficial health effects. But one aspect of red wine, and all other forms of alcohol, that could be detrimental to your health is its' relaxing effects on your throat muscles. If you already have a slightly narrowed upper airway passageways (like most people), sleeping on your back can cause mild collapse of your tongue backwards. But when you add deep sleep, since all your body's muscles relax the most, adding alcohol can tip you over the edge and cause you to stop breathing. You may wake up subconsciously, or completely awake. This is one of the main components of alcohol that promotes hangovers in some people.
The bottom line is that you should avoid drinking alcohol 3-4 hours before bedtime.
Tip #4. Take Your Own Pillow.
You've stopped your late night eating and drinking alcohol, and you are ready to go to sleep. You lie down to sleep, but something doesn't feel right. After a few minutes of tossing and turning and fluffing the pillow, you realize what the problem is: you miss your own pillow. Yours is much firmer, and the hotel's pillow is too soft. Thinking about your pillow is not something that most people consider before taking trips. You can't bring your own mattress, but you can bring your own pillow, if space allows. On car trips, I always bring my own memory foam, contoured pillow. A soft down pillow could easily fit into a decent sized suitcase.
Don't wait until you are ready to go to bed to find that the hotel's pillow isn't "just right." When you first arrive in your room, after you unpack, test drive your pillow. If it doesn't feel right, ask the concierge for a different type of pillow. Some may even have the memory foam contoured pillow that I like, and some Asian travelers may prefer a roll-like buckwheat-filled pillow.
If you like to sleep on your back, and feel less than refreshed in the morning, try sleeping on your side. If that's not possible, experiment with the roll-like pillow that I mentioned previously, or roll up a towel to just the right thickness. The reason this may help you sleep is that when your head is cocked back slightly when sleeping (unlike softer, down pillows that end up bending your head forward), the space behind the tongue opens up significantly, preventing frequent awakenings at night.
Tip #5. Don't Sleep In.
When you're on vacation, it's tempting to stay up late and sleep in in the morning. RESIST THE URGE. I've already covered in the past few lessons why it's important not to eat late, and why you must go to bed at a reasonable time to allot for your normal sleep duration. If you go to bed late and wake up later in the morning, you've shifted your sleep clock, which will make you want to go to bed later. Once you're back home, along with the clock shift from changing time zones, you'll be doubly affected: time zone shift and a sleep clock shift. This is why it's so hard to get anything done when you get back to work.
To make the most of your vacation, plan your sleep times accordingly so that you can maximize your fun during your waking hours. Spend time outside in the sun, walk, jog, cycle, swim, and relax! If possible, remember to give yourself a day or two to wind down after you come back before you go back to work.
Even if you don't suffer from any problems during your trip, many ear and sinus problems occur AFTER your return trip, usually aggravated by the return flight. You've had a great vacation, but now you're paying for it when you come home. If you had followed my advice during your vacation, you wouldn't have to see a doctor about your ear problem.
July 20, 2010
One of the most common excuses for not wanting to use CPAP is that “I travel a lot.” Even after I explain that many people travel just fine with their CPAP machines, some people are stll reluctant. With advances in technology and increased awareness by the lay public, government officials and medical professionals about the importance of using CPAP for obstructive sleep apnea, traveling with CPAP, although initially a challenge, can be done with relative ease. People use CPAP on planes, and even go camping with it. With the FAA’s recent ruling and instructions on carrying and using CPAP on airlines, it’s become even easier to travel with CPAP machine. I know there are various types of PAP devices, but for the sake of simplicity, I’ll call these devices the generic name, CPAP.
Flying with Your CPAP
The Federal Aviation Administration (FAA) recently ruled that airline passengers must be allowed to use respiratory assistive devices, such as a CPAP machine (Nondiscrimination on the Basis of Disability in Air Travel – May 13, 2009). However, don’t think that you’ll just breeze by security checkpoints at the airport. Here are some common tips that are recommended when you fly with your CPAP machine:
1. Never check your CPAP machine.
2. Always have with you a prescription for your CPAP machine and your latest sleep study. You never know if your unit gets lost or stolen, or breaks down.
3. Attach a medical equipment tag, identifying the contents as such.
4. Let the TSA security agent know that you have a CPAP machine. Remove it from the back and have it scanned separately.
5. Request that security agents change gloves and wipe down the table before inspecting your machine. Wrap your device in a clear bag while being scanned to prevent contamination with germs and other chemicals.
6. Keep a record of the model and serial number in hand, just in case.
7. If you’re going to use your CPAP machine in-flight, check beforehand if there’s an outlet next to your seat, and if you have the right adaptor.
8. If the flight attendant says something about your CPAP being another carry-on, let him or her know that it’s a CPAP machine and under the Americans with Disability Act, it’s not counted as an added carry-on.
9. Consider having your doctor give you a letter describing the need for your CPAP machine.
10. Most CPAP units will automatically convert to the correct local voltage. Check with your instruction manual or manufacturer to confirm this. You may, however, need a plug adaptor, as well as an extension cord, in case your outlet is far away.
Tips On Water
Many people are so focused on the logistics of their machines, that sometimes they forget about distilled water. Make sure you have plenty of distilled water available if you’re going to use it on the plane, or at your final destination.
If you’re not going to use your CPAP device on the plane, then make sure you empty and dry the water chamber before flying (check out expedia for available flights!). If you’re planning on using your CPAP device on-board, there are two options to be able to pass large amounts of fluids past TSA security checkpoints: Have your doctor prescribe distilled water in a pharmaceutical grade bottle. A 500 mL bottle should hold about 16 oz. Another option is to purchase papFLASK, which is designed to pass through security checkpoints with ease.
For whatever reason you don’t have distilled water available, using bottled or even tap water is OK, but try to find distilled water as soon as reasonably possible. Mineral deposits in tap water can build up within the PAP machine and can cause damage if it continues long-term.
Camping or Backing Up with CPAP
For travel to areas that don’t have electricity, or in case you have a blackout, there are numerous battery options available. Each manufacturer will usually have a back up battery recommendations and adaptors.
For more extended periods, various people have written about using a 12 volt deep cycle marine battery with a sine wave inverter. There are numerous other battery options so do your research. Different manufacturers have different voltage needs, so also check with your manufacturer. Since a humidifier uses a lot of energy, most people recommend not using the humidifier if you’re only camping for a few days. There’s lots more information about batteries in CPAP support sites such as sleepguide.com, cpaptalk.com, talkaboutsleep.com, or apneasupport.com.
Have A Back Up Plan
Some patients carry around their oral appliances with them whenever they travel, either using it in place of their CPAP machines or just in case the device breaks. Some people use both the oral appliance and their CPAP machines simultaneously. If you’ve never tried an oral appliance and you’re interested in an alternative option, it may be worth giving it a try now before you need to travel for long extended periods.
No More Excuses
With advances in technology and more acceptance by the medical community as well as the lay public, there’s basically no reason (unless it’s psychological) you can’t travel with a CPAP machine. With knowledge and some flexibility and creativity, anyone can travel with CPAP, even in the more remote areas of the world. There have even been descriptions of solar power being used to recharge batteries used for CPAP. If you travel frequently to the same location, consider purchasing a second unit. Prices for middle of the road CPAP models are in the $300 to $700 range.
The first major challenge is in finding a way to make CPAP work for you. The second major challenge is in un-tethering your machine from your bedroom. Many people are living vibrant and normal lives, despite having to use their CPAP machines while traveling. Or is it because they are using their CPAP machines regularly while traveling? You decide.
July 19, 2010
A few days ago, I did an experiment.
Many months ago, when I had a bad cold with severe coughing, I slept out in the living room sofa so that I didn't bother my wife. That night, I slept really well. I suspect that the reason for this is the angle that the armrest creates with my head position, similar to what a good contour pillow does—by tilting your head slightly back, it opens up your airway.
Recently, I haven't been sleeping well, and I after working late on my computer, I decided to try sleeping on the same sofa to see if I could recreate that great sleep experience. The experiment failed miserably. My sleep quality was pretty bad, especially since it was a bit hot and humid.
The next morning, I mentioned to my wife why I slept on the sofa that night. I told her that I wanted to recreate that really good nights' sleep that I had previously. She looked at me for a few seconds, and said something in passing, that really didn't hit me until now: "Honey, I know you're really passionate about sleep, but if your main goal is always to get that perfect night's sleep, you'll never get it."
I only recently realized just now how profound her statement is. She was just trying to be helpful and give me some practical advice, but I think she hit on a major life lesson: Don't focus on absolute goals when you should be focusing on bigger things in life.
For example, running and finishing a marathon is a worthwhile goal, but what's more important is, why even run the marathon? Is it to become healthier, or develop an exercise regimen that's part of an overall healthy lifestyle?
Is your goal of eating healthier to see how healthy you can eat? Could it be that by staying healthy, you'll have the energy to spend quality time with your children, as well as to be around to see your children grow up past their teens?
Why even bother getting a good nights' sleep? Is it to boast to everyone that you're such a great sleeper?
Rather than trying to sleep well, think about the reasons why getting a good nights' sleep is so important in your life: You can be much more refreshed tomorrow and be at your best during your presentation or 5K run.
What I realized was that a good sleep should not be your ultimate goal. Rather, it should be a part of your overall plan for bigger, grander life goals, such as enhancing and enjoying your relationships, succeeding and advancing with your career goals, and living the life of your dreams.
Numerous successful people have stated that once you have a grand vision or life goal, the steps that you need to take will come naturally. Once you know they why, the intermediate steps and the how will become obvious.
July 18, 2010
I was going through the NY Time's excellent Patient Voices blog and multimedia piece on migraine (see my comments #30, and #584), and was reminded that people who have migraines are at a higher risk of cardiovascular disease later in life. In this 2006 study from JAMA, women who have classic migraines had significantly higher risks for major cardiovascular disease, ischemic stroke, heart attack, coronary revascularization, angina, and ischemic cardiovascular disease death.
This is not too surprising since most migraineurs have upper airway resistance syndrome or obstructive sleep apnea, and we know that obstructive sleep apnea can significantly increase your chances of suffering from heart disease, heart attack, or stroke.
If you have migraines, does your mother or father snore or have cardiovascular disease?