Ask Dr. Park: Any Question About Sleep Apnea

February 28, 2011

On this Ask Dr. Park teleseminar (3/8/11), I’ll answer your most important questions about obstructive sleep apnea. Here are the questions I answer:

• The benefits of nasal breathing and nasal nitric oxide production

• Can using CPAP cause chills?

• What’s the best mattress option for sleep apnea?

• When would you consider a tracheotomy for sleep apnea?

• How do you know that you’re breathing through your nose when using CPAP?

• What can I do if my AHI is still high despite using CPAP?

• What’s the best sleep position when using CPAP?

• How do you treat complex sleep apnea?

• Is there a linear relationship between BMI an sleep apnea?

• Can sleep apnea be caused or triggered by a car accident?

• Can sleep apnea cause plugged ears to persist over a year?

• Is the MOGA procedure better for severe sleep apnea over CPAP?

• I’ve used APAP for over a year. Why do I still feel tired? I also have low circulation to the brain.

• How is PTSD related to sleep apnea?

• What’s the connection between hormones, progesterone and breathing issues?

• Is long-term use of acid suppressing medications harmful?

• Will a jaw expansion device give you similar results to a UPPP procedure?

• Why do I feel bloated after using CPAP?

• What are your thoughts on Provent?

• What’s a Zeo?

• Can you describe the tongue nerve stimulation devices?

• How does sleep apnea cause car accidents and does CPAP cure it?

• Should I get a tracheotomy?

• Can sleep apnea cause low testosterone?

• What do you think about the Aveo TSD for sleep apnea?

• Can an ENT office exam determine where obstruction is happening?

• How does changes in your monthly cycles affect changes in your mouth?

Click here to order MP3 file download ($17)

Written by Steven Park · Filed Under Expert Interviews | 12 Comments

How Hot Flashes in Women Protects Against Heart Disease

February 26, 2011

Hot flashes and night sweats are common symptoms of menopause. Interestingly, in a study of 60,000 post-menopausal women, those that suffered the worst night sweats and hot flashes at the start of menopause had a 17% lower chance of stroke and 11% lower chance of heart disease when followed for 10 years, compared with those who had no symptoms. Heart attack deaths were 24% lower. The authors could not give a clear explanation for their findings. Here’s my explanation:

I’ve written before that I often see hot flashes and night sweats in young men. They also have irritability, mood swings and insomnia. These symptoms are neurologic events that occur due to a relative change in the status of the involuntary nervous system. These young men are typically gaining weight quickly. This causes a rapid relative change in their sleep-breathing status, due to more frequent breathing pauses at night. Rapid weight gain is known to contribute to obstructive sleep apnea.

In menopausal women, not only do most gain some amount of weight, their progesterone levels begin to drop in their early 40s. Progesterone is a known upper airway muscle dilator, increasing muscle tone to the tongue. As progesterone slowly drops, the tongue relaxes more, especially when in deep sleep. This causes more frequent micro-obstructions and arousals, leading to the typical neurologic (vasomotor) symptoms commonly seen in perimenopausal women. It’s this relative change in the sleep-breathing status that irritates the involuntary nervous system (which regulates temperature, sweating, heart rate, blood pressure, digestion, and various other body functions).

Dr. Guilleminault of Stanford University states that people with obstructive sleep apnea have diminished nervous systems in the throat. Vibrations from snoring or reflux from obstructive events can damage the protective pressure and chemical sensors in the throat. If you already have some degree of obstructive sleep apnea as you approach menopause, it’s plausible that as progesterone levels drop, the additional breathing pauses don’t have as much of an effect on the involuntary nervous system, since it’s been happening already for years or decades. If your nervous system is intact, then the sudden increases in breathing pauses can lead to more severe vasomotor symptoms.

What this study suggests is that the more you’re susceptible to obstructive sleep apnea, the less likely you’ll suffer hot flashes and night sweats early in menopause. This can explain the higher rate of cardiovascular disease in post-menopausal women.

This is another example of interpreting scientific studies based on my sleep-breathing paradigm. If you’re not familiar with this concept, you can read my articles, or for a more in-depth explanation, take a look at my book, Sleep, Interrupted.

What do you think about my line of reasoning? Please enter your feedback below in the comments box.

Written by Steven Park · Filed Under Blog | 3 Comments

Oro-facial & Tongue Exercises for Sleep Apnea

February 24, 2011

I was recently asked about references for orofacial or tongue exercises for sleep apnea. In my experience, all these exercises work to various degrees. There are a number of resources on the internet that I know of:

Janet Bennet has a DVD/training program for snoring. She’s a speech pathologist that accidentally discovered that exercises for tongue thrust helped with snoring significantly.

This paper showed that orofacial exercises can significantly reduce snoring and symptoms of sleep apnea. There’s even a free short video that shows the various exercises.

A paid exercise program for sleep apnea. A more condensed, free version can be found here.

This is not an oral or tongue exercise, but playing the didgeridoo has been to be found helpful.

There are even singing exercises for snoring.

Have you tried any of these options, and if so, how well did it work?

Written by Steven Park · Filed Under Blog | 5 Comments

Can Sleep Apnea Cause Hiatal Hernias?

February 23, 2011

Someone emailed me in response to my comment that hiatal hernias may be related to sleep apnea. He basically said that my ideas were nonsense. Here’s what I wrote back:

“Thanks for taking time to comment. I did mention that it’s a hypothesis, and yet to be proven. In my opinion, a hiatal hernia is similar to having a deviated nasal septum. Everyone has some degree of it (due to jaw narrowing and dental crowding), but only some people have symptoms. One thing I’m learning as I study the effects of sleep apnea is that it can cause or aggravate almost every chronic medical condition that we know of, from a metabolic, hormonal, neurologic and immunologic standpoint. I know about the classic medical explanations of hiatal hernia as well as many of the alternative/complementary explanations. But I don’t find any of these explanations satisfying. If you look at all the various studies on the effects of sleep apnea (which is due to a craniofacial underdevelopment of the jaws that most modern humans have, that leads to crowding of the upper airway), it was only logical that sleep apnea (which is so common and undiagnosed) may lead to a hiatal hernia.

For example, pressure readings using catheters in the esophagus during apneic episodes show tremendous negative pressures in the chest cavity, with loosening of the phreno-esophageal ligament, which opens up the lower esophageal sphincter temporarily. These pressures are also strong enough to prevent blood flow to the heart during these episodes. The junction of the stomach and the lower esophagus (the lower esophageal sphincter) sits in an opening in the diaphragm, like a sleeve. If you’re pulling down on the diaphragm with excessive positive abdominal pressure, while creating tremendous negative pressure in the chest cavity, along with loosening of the phreno-esophageal sphincter, it’s plausible that the lower part of the stomach can slide up into the chest cavity. Continued vacuum effects in the throat, along with upper and lower esophageal sphincter dysmotility, can lead to pharyngeal reflux, which has been shown to reach the lungs, sinuses and ears. This also includes digestive enzymes, bile, and H. pylori.

Lack or oxygen to the brain and the body, as well as a massive physiologic stress response, can alter your involuntary nervous system, creating a relative overactivation of your sympathetic nervous system (increased adrenaline), and an underfunctioning parasympathetic nervous system (vagus nerve).

Sleep apnea is only a small aspect of my sleep-breathing paradigm, which states that all modern humans stop breathing occasionally, due to various factors. Even healthy people can stop breathing during a simple cold. Thin, young people can stop breathing 20 to 30 times per hour and not have official sleep apnea on a sleep study. It’s taken for granted that most people breathe properly at night, but this is absolutely not true—due to our ability to talk/communicate, as well as a shrinking of our facial skeletons. Looking at health and disease from this perspective, it goes against most traditional dogma, whether within allopathic medicine or alternative/complementary fields.

When I was a medical student, my mentors at Columbia University were laughing at the hypothesis that a simple bacteria could cause stomach ulcers. The person that proposed this hypothesis went on to receive the Nobel Prize in medicine. I’m not saying that my research is of that magnitude, but we have to be willing to think outside the box if we’re going to make any significant progress.”

What do you think about my hypothesis?

Written by Steven Park · Filed Under Blog | 5 Comments

Women & Heart Disease: A Travesty, Part II

February 22, 2011

Carolyn Thomas over at her blog Heart Sisters just wrote about my comments to a KevinMD post on heart attack symptoms in women. It’s an issue that needs much more awareness by physicians and the lay public.

Written by Steven Park · Filed Under Blog | Leave a Comment

Women And Heart Disease: A Travesty

February 18, 2011

February is American Heart Month, and one thing that’s being stressed more this year is the fact that many women’s heart problems go undiagnosed, especially if they have atypical symptoms. The American Heart Association just recently came out with revised guidelines of cardiovascular disease prevention for women. The two interesting points they make is that women have a higher proportion of strokes to heart attacks compared with men. The other point they at emphasize is the fact that if you had a complication during pregnancy, your risk of heart disease later in life is significantly higher.

What was surprising to me is that we have lots of studies showing that most cases of pregnancy-related complications such as preeclampsia and gestational diabetes may be caused by untreated obstructive sleep apnea. Since weight gain is a major risk for sleep apnea, why should pregnant women be excluded from having a sleep-breathing disorder? By definition, pregnancy will cause you to have temporary sleep-breathing problems, whether or not it’s officially obstructive sleep apnea.

The one thing that protects against sleep apnea during pregnancy is the rise in progesterone, which acts as an upper airway muscle stimulant, but this can only help so much. As progesterone drops after delivery, what do you think will happen to women who still have most their pregnancy weight? I’m willing to bet that if you do the same study looking at post-partum complications such as postpartum depression, you’ll see the same increased rate of heart disease later in life.

The shocking thing was that nowhere in these general guidelines do they even mention looking for obstructive sleep apnea. I won’t begin to talk about the link between stroke and sleep apnea–there are just too many studies to mention. I encourage you to take a look at the recommendations of the American Heart Association’s website. Tell me what you think about this glaring omission.

Written by Steven Park · Filed Under Blog | 5 Comments

Deafness and Dementia Linked, Through Sleep Apnea?

February 16, 2011

There are a number of studies that associate an increased risk of deafness to sleep apnea, and an increased rate of dementia with sleep apnea, so why can’t deafness and dementia be linked, with sleep apnea being the main cause for both conditions? A study that was recently published in Neurology showed that for every 10 dBL hearing loss, after 12 years, the risk of dementia from all causes rose 27%. I’ve written numerous times about how sleep apnea can cause damage to the auditory cortex areas of the brain, as well as to the inner ear. The same process from sleep apnea that causes brain damage can injure areas that control memory, executive function, autonomic function, and hearing.

The next time someone you love can’t seem to hear you, it could be because he or she can’t process your words properly? Do you know someone who’s severely hard of hearing, and has possible dementia?

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Why Stroke Rates Are Increasing in Younger People

February 10, 2011

Researchers have shown that rates of hospitalization for ischemic strokes in young people, even in children and teens, is rising. The largest jump was a 51% increase in male ages 15 to 34. Rising rates were also seen in male ages 5 to 14 (36%), female ages 5 to 14 (31%), and female ages 15 to 34 (17%). Stroke rates actually decreased in people above 45 by 25 to 29%.

The study authors don’t give convincing explanations for the increase, but do speculate that it could be from increased awareness and earlier diagnosis, better imaging technology, and rising obesity rates. But one clear and documented condition that’s not mentioned is that untreated obstructive sleep apnea can significantly increase your risk of stroke. It’s been shown to be an independent risk factor for stroke, increasing your odds by 2-3 times normal.

Just this morning, I had a patient tell me that his wife had a stroke in her early 40s. Not too surprisingly, she snores heavily. No one ever suspected diagnosing and treating obstructive sleep apnea.

Untreated sleep apnea can significantly increase your chances of having a stroke through various different mechanisms. One way is through creating a hyper-coagulable state—blood tends to be thicker, and when stagnant, it can clot more easily. Various inflammatory factors are elevated in sleep apnea, again making you more likely to clot a blood vessel in your brain. Chronic hypoxia can also create oxidative stress, massive inflammation and clotting of smaller brain vessels.

I predict this problem will only get worse over the next few decades. Knowing what we know, it’s shocking how little we in the medical profession do to prevent this problem from happening.

Do you personally know a young person that has suffered a stroke? Does that person snore?

Written by Steven Park · Filed Under Blog | Leave a Comment

Sleep Apnea Is A Craniofacial Problem

February 10, 2011

As a resident during otolaryngology training, I rotated in the medical center’s craniofacial clinic, seeing various disorders that lead to underdeveloped or malformed facial or skull structures. These syndromic children clearly had severely asymmetric faces or underformed jaws. In many cases they had breathing problems requiring surgery.

One of the more common conditions you’ll see in such a clinic is Pierre Robin sequence, where due to improper maturation of the lower jaw, the lower chin is recessed severely. You’ll see milder variations of this all the time, but if severe enough, these people can’t breathe, especially at night.

Treating Only The Extremes

One of the problems with modern medicine is that we name and treat only the extreme end of a continuum, or only when significant problems result. Having a slightly recessed chin may be thought of a the person’s normal facial feature, and his or her ability to breathe is never even considered.

The entire basis for my sleep-breathing paradigm is that all modern humans have constricted facial structures, not due to a congenital or genetic problem, but due to our eating and lifestyle habits. Genetically, we’re all programmed to have relatively wide jaws, with room for all your wisdom teeth. Now, that rarely ever happens. This is why obstructive sleep apnea can be described as a mild craniofacial condition that can significantly affect your upper breathing passageways.

Small Jaws, Small Airway

It seems that almost everyone these days will need braces to fix crooked teeth or narrow dental arches. Dental crowding by definition means that your upper and lower jaws are underdeveloped. This creates less total volume inside your mouth, leading to overcrowding of your tongue. Your tongue can then fall back easier when on your back, and when in deep sleep, due to muscle relaxation, you’ll stop breathing more often at night.

Even your nose can be affected by this problem. Since your nasal sidewalls follow your upper molars, the side to side distance in your nose will be more narrow, and as the roof of your mouth (nasal floor) gets pushed up, it’ll also cause your septum to buckle.

If you add additional inflammation and swelling in your nose (due to colds, allergies or nonallergic rhinitis), your nose will become stuffier faster, and even worse, your nostrils will cave in easier.

Having underdeveloped upper jaws prevents proper cheekbone fullness, giving your mid-face a sinked-in look. This type of facial appearance is so common these days that it’s almost accepted as normal. I remember reading in the New York Times a few years back where they reported that women’s preferences for male actors has changed from the classic square-faced, angular facial features, to softer, more feminine, rounded faces.

Despite having some good first line options such as CPAP or oral appliances, these approaches don’t really address the root cause. If your child’s jaw was severely underdeveloped and your choice was either lifetime CPAP or jaw enlargement, which would you choose? What if, rather than cutting the jaws and pulling it forward, you can apply distraction plates that can be pulled slowly, little by little, to normalize the jaws and improve the airway significantly? What about advanced dental appliances that can expand your upper and lower jaws in three dimensions, making more room for your tongue? With current technology, we can modify your jaws significantly. But for adults with obstructive sleep apnea, any kind of surgical or dental modification of the jaws is only considered as a last resort.

I describe obstructive sleep apnea as the end extreme of a continuum of sleep-breathing disorders. Similarly, if you look at obstructive sleep apnea as being a craniofacial problem, everyone will have various degrees of jaw underdevelopment. If you have impacted molars, or had to have your wisdom teeth taken out, then your breathing passageways are compromised.

Not only are your jaws more narrow, but the soft tissues that line your breathing passageways will be much more likely to become inflamed and cause even further obstruction. Frequent obstructions can cause a vacuum effect in your throat which literally suctions up your normal stomach juices into your throat, promoting more inflammation and swelling. These juices (which include acid, bile, digestive enzymes and bacteria) can then also reach your nose, sinuses, ears and even your lungs, causing additional inflammation and swelling. If your nose is stuffy, then a vacuum effect is created downstream in your throat and the tongue can fall back much easier, whenever you’re in deep sleep (due to muscle relaxation).

Our Airways Are Like Plumbing

In the medical community, craniofacial problems are generally treated surgically. Even with plumbing, if you only open up one area of multiple clogged areas, the pipes will still be clogged (like doing a UPPP). Sometimes you can put in drano to soften the clogging and open up the passageways (like allergy medications), but after years of buildup and accumulation, you have to physically open up all the blocked areas. You can also use a plunger to force the water down the drain (like CPAP), but you know that sooner or later, it’ll get clogged again. The older the pipes, the worse it becomes (old age).

CPAP and oral appliances are both important and necessary tools to treat the vast majority of people with sleep apnea, but we also need to open our minds to the idea that we shouldn’t have to sleep with gadgets or devices for the rest of our lives.

A Modern, Western Dilemma

It’s commonly known that our brains are getting bigger over time. As modern human’s mid and lower faces get smaller and smaller, I predict that in a few hundred to a few thousand years, everyone will be tethered to a hose while sleeping, like in the science fiction movies. Maybe vocal speech and communication will not be needed anymore, and we’ll be able to communicate with mental telepathy. We’ll all begin to look like that alien in the old Star Trek episode with the huge brain and a tiny face.

Sadly, it’s already started. If you look at the younger generations, you’ll see how narrow their dental arches are, along with flat cheekbones and narrow nasal widths. Recently, I happened to see an Amish chorus singing songs in the Grand Central subway station. I was amazed how most had very prominent cheekbones, well-formed jaws, and good looking smiles. It’s not surprising that cultures that eat organically and off the land will have more fully developed jaws.

So the next time you’re sitting in an auditorium and a public place with lots of people, think about that classic first day of college speech by the dean or president:

“Look to your left…and look to your right. At the end of this year, one of the two that you see will not be here with you.”

Similarly, every other person sitting next to you will most likely have smallish jaws, and have an undiagnosed sleep-breathing problem. From a craniofacial standpoint, they won’t be able to sleep well due to narrowed breathing passageways. If you end up befriending or marrying one of these people, now you’ll understand what makes them tick, or sick.

Written by Steven Park · Filed Under Articles, CPAP, obstructive sleep apnea | 3 Comments