Understanding Your Sleep Study Report

Expert Interview with Dr. Anita Bhola

The sleep study report may look like a jumble of numbers and cryptic medical terms that’s impossible to decipher. However, with a bit of guidance from Dr. Anita Bhola, a board-certified sleep medicine physician in New York City, you’ll be able to understand the basics in how to read and interpret your sleep study.

During this information packed hour, you’ll learn:

• What your sleep study measures

• The difference between sleep efficiency and latency

• How apneas are different from hypopneas and how you’d measure this on

your sleep study

• How to tell if you may have obstructive and central sleep apnea  why knowing    this can help you and your doctor decide on the right course of treatment

• How to see the various sleep stages on your report and notice hypnograms

• Answers to most frequently asked questions regarding sleep studies

Buy your copy of this audio recording today, available in two easy-to-access formats:

MP3 audio recording, $17

PDF digital transcript, $7

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MP3 recording + PDF transcript, $20

Start Breathing, Sleeping, and Living Better with Dr. Park’s Expert Interview Series!

An Insider’s Guide to Septoplasty

The septoplasty operation is one of the most misunderstood surgical procedures that lay people, and even many physicians have. Some people even equate septoplasty with having a nose job, which is not true. Although, some people use having a crooked septum as 

an excuse to undergo a rhinoplasty, septoplasty, done correctly, can help patients breathe better, and more importantly, sleep better.

Understanding the Anatomy

In order to fully appreciate if septoplasty is the right procedure for you, you must understand the anatomy of how it’s done.

The nasal septum is the midline cartilaginous structure that divides the two halves of your nasal cavity. The part in the back of the septum is made of bone. Whenever the septum is crooked to a significant degree, your nose can be stuffy, and a septoplasty can be offered if medical therapy doesn't work.

However, having a crooked septum doesn't mean that you'll have a stuffy nose, or that you'll need a septoplasty. No one has a perfectly straight septum. There are other parts of your nasal anatomy that contributes to your ability to breathe, which includes your nasal turbinates and your nostrils. The turbinates are wing-like structures that jut in from the side-walls of your nose that look like wings. They normally warm, filter, smooth and humidify the air that you breathe. Inside this structure is the bone and the outside is a mucous membrane lining. The middle part is made of very vascular tissues that can swell tremendously when filled with blood. This is regulated by your involuntary nervous system. This nervous system normally swells and shrinks the turbinates, alternating from side to side, every few hours (called the nasal cycle).

Do You Have Flimsy Nostrils?

The other structure that is often overlooked is your nostrils. For most people, breathing in causes a mild vacuum effect that causes a mild collapse and a constriction of the nostrils. But in some people with either flimsy or weakened nostrils (from a prior rhinoplasty), they collapse very easily, even with a slight bit of inspiration. If you are one of these people, you may benefit from nasal dilator strips (Breathe-rite is one brand). Sometimes these strips are not strong enough, or it can irritate the skin. Another option is to use internal nasal dilators which work much better. Some of the more common brands are Breathewitheez, Nasal Cones, and Nozovent.

What's Involved with Septal Surgery? 

The septoplasty procedure can be done in conjunction with a turbinate procedure. There are many ways to perform a septoplasty, but the most important point is that it should be done well. The septum is covered on both sides by a mucous membrane. After an incision is made inside the nose on the mucous membrane, this layer is peeled away from the septal cartilage. The other side is also entered, which creates two tunnels on either side of the septal cartilage. The crooked part of the septal cartilage is next removed. Some surgeons either soften the cartilage or flatten it out and place it back, and others leave it out completely. In many cases, a small portion of bony spur that juts out at the base of the septal cartilage is also removed. The last part of the operation is where different surgeons use different techniques. Traditionally, thin plastic sheets with or without soft sponge-like packs are placed against the septum on both sides to keep the mucous membrane together for proper healing. If a large clot of blood forms between the two mucous membrane layers, the remaining cartilage may lose it's blood supply and literally melt away. 

Because the entire procedure in done inside the nose (or endoscopically), there is no swelling, bruising or changes to the outside of the nose or face (unless a rhinoplasty is done simultaneously).

What to Expect After Surgery

Nasal packing, if placed, are removed anywhere from 1-3 days after the procedure. Many patients report that this is one of the most uncomfortable parts of undergoing this procedure. Some surgeons, like myself, don't use any packs or splints using the following method: compressing the two mucous membrane layers by sewing the two layers together using an absorbable suture, like a quilting stitch. This way, nothing needs to be removed, and you're breathing much better right after the surgery. It's expected with this procedure that your nose will get clogged up after a day or two with accumulation of blood, mucous and debris.

This operation is usually performed as an outpatient procedure, so you'll go home a few hours after surgery. It's usually performed under general anesthesia, but can also de done under local anesthesia with sedation for certain situations. Most people can go back to work after a day or two. Heavy straining or lifting should be restricted for about one week. In my practice, I see the patients about 2 days after the surgery, when the nose is cleaned of all the accumulated debris. Some people need a second cleaning 1-2 weeks later.

Typically, it may take a few weeks to months to feel the full benefits of this operation. During the first few weeks, crusts will build up and fall out as wounds heal. This is also the time when the swelling from the surgery goes away. Afterwards, scarring and tightening of the soft tissues can take weeks to months. You may have your ups and downs in the first few weeks, but you should see consistent improvement by 3-4 weeks. 

Most people don't use any pain medications, but one is prescribed just in case. You'll probably be more bothered by the sore throat from having a breathing tube placed during intubation.

What Are The Risks?

Complications are rare, but with any surgical procedure, there is a small chance of infection or bleeding. There is also a small risk any time someone undergoes general anesthesia, which includes, allergic or medication reactions or airway problems. In terms of overall risk, it's riskier when you cross the street. Other very rare complications such as smell loss or a hole in your septum have been reported. 

A septoplasty, if done properly, is one of the most gratifying procedures for both the patient and the surgeon. Success rates are very high. However, there are a few percent of patients where nasal congestion still persists, or it comes back after a few weeks to months. In this situation, there are two main possible reasons: there is persistent turbinate swelling due to inflammation, or you have flimsy nostrils. There are treatment options for both theses conditions.

Everything You Ever Wanted to Know About CPAP Masks

Are you having problems with your CPAP mask? Are you newly diagnosed with sleep apnea, and want to find out which options you have? If so, hear me interview Chip Smith and Brian Werther of Restoration Medical on "Everything You Ever Wanted to Know About CPAP Masks."

During this information packed hour, you'll learn:

• The key to getting the right fit
  
• An insider's guide to finding the right mask for you
  
• How to overcome the most common mistake people make when they're choosing a mask
  
• Most common problems people have with their CPAP mask and how to avoid them
  

Title: Everything You Ever Wanted to Know About CPAP Masks

Format: MP3 download

Price: $17

Click here to order.

7 Simple Ways To Get Rid of Your Snoring For Good

If your spouse or bed-partner snores and keeps you up at night, then you're not alone. Most people snore at least occasionally, while about 25% snore all the time. Snoring is a major problem that not only can affect your relationship, but your health as well (snorer and snoree).

Snoring may be a sign that you have obstructive sleep apnea, a condition where you literally stop breathing repeatedly while sleeping. Untreated obstructive sleep apnea can cause or aggravate depression, anxiety, hypertension, diabetes, heart disease, heart attack, and stroke.

Even if you don't have sleep apnea officially, studies have shown that snorers have a much higher risk for relationship problems, car accidents, and cognitive impairment.

One important thing to note is that you don't have to snore to have sleep apnea. Even young, thin women who don't snore can have significant sleep apnea.

Here's a checklist of the 7 “musts” of snoring cessation. Try these simple strategies before you resort to more invasive and expensive options:

1. Don't eat within 3-4 hours of bedtime.
If you snore, chances are, you'll stop breathing once in a while. When you do stop breathing, you'll create a vacuum effect in your throat which suctions up your normal stomach juices into your throat, causing you to wake up partially or fully. This also causes more swelling and inflammation which narrows your throat and nose even further. This leads to less efficient sleep, leading to weight gain, which narrows your throat even further.

2. Don't drink alcohol within 3-4 hours of bedtime.
Alcohol is a strong muscle relaxant, so it will make your throat muscles more slack and more apt to collapse and obstruct. And any obstruction around your airway as you sleep means more snoring.

3. Don't sleep on your back.
Due to gravity, everyone's tongues can fall back when on our backs. This narrows the space behind the tongue and along with muscle relaxation during deep sleep, you'll snore more and stop breathing more often. The traditional recommendation for pinning a tennis ball to the back of your pajama shirt ma work for a few people, but there are a lot more sophisticated ways to keep you off your back.

4. Clear up your nose.
Make sure that you're able to breathe properly through your nose, since having a stuffy nose will create a slight vacuum effect in your throat, aggravating partial to total collapse of the soft palate and the tongue. Whether through over-the-counter remedies, prescription medications, or with surgery, get this taken care of first. Unfortunately, this works only sometimes and in many cases, nothing changes. Regardless, if you need further treatment, you need to be able to breathe through your nose for the other options to work. It's been shown that definitively optimizing nasal breathing through surgery cures obstructive sleep apnea in only 10% of cases.

An interesting study published about 10 years ago showed that when given a nasal decongestant as well as a medicine that helps to empty the stomach faster, about 80% of snoring was significantly improved.

5. Lose weight.
Needless to say, this is easier said than done. One of the reasons why you may be overweight is because you don't sleep well. Less efficient sleep promotes weight gain, which not only cause you to expand on the outside, but also narrow in on the inside of your upper airways. But how about some of you who are not overweight, or even very skinny? Snoring and sleep-breathing problems occur due to a structural narrowing of the entire upper airway, from the tip of your nose to your voice box.

6. Try any of the various over-the-counter anti-snore gadgets, devices, and pills.
But don't expect dramatic results. Yes, sometimes, it'll help with your snoring, but even if it works, the effects don't usually last. The reason why you snore is due to your jaw anatomy and additional inflammation. Covering it up with any of these options is only a temporary solution. A study showed that compared with controls, the throat spray, nasal dilator strips, and anti-snore pillow was not any better.

7. Seek medical help.
If all the above don't work, it's time to see an ear, nose and throat doctor. A comprehensive exam is needed to find out which areas of your upper airway (from the tip of the nose to the voice box). We know that for most people it's the soft palate that flutters, making the annoying, chainsaw sounds. Usually, snorers will have a combination of areas that contribute to snoring, with the tongue being the most common culprit, due to having small jaws.

In most cases, a sleep study is needed to check to see if you have obstructive sleep apnea. If you do have sleep apnea, then treating this condition will help your snoring. Even if you don't have obstructive sleep apnea, all the different treatment options for sleep apnea can be used. As I mentioned in Step #4, you must first optimize nasal breathing and then deal with your tongue. The timing for eating and drinking alcohol is something that you should continue for a lifetime.

Unfortunately, things only tend to get worse as you age. The soft tissues in your throat tend to sag and collapse, especially after decades of repeated strong inspiration. This is why it's important to get your snoring taken care of, first using the conservative steps outlined in his article, and later by seeing a physician that can help you with this condition.
 

Provent Nose Plugs for Sleep Apnea

I have to admit, the idea that you could treat sleep apnea with nose plugs was very interesting. Ventus Medical's Provent is a totally different type of sleep apnea treatment using adhesive plugs that works by making breathing out slightly more difficult through your nose. When you inhale, your breathing is normal, but as you exhale, a slight bit of resistance is created, creating a gentle amount of positive pressure downstream in the throat, preventing the tongue and soft palate from collapsing.

The scientific explanation is a little complicated (even for me), but the gist of it is that at the end of exhalation, that's when your throat muscles are most prone to collapse. So by slightly increasing the pressure, a stent-like effect is created, just like with CPAP.

Their study involved 28 people who used the device over 3 nights in the lab. On average, the AHI dropped about 50% (19.1 to 8.2) and after 30 days at home, it stayed low at 10.6. Other studies have also shown an average drop of about 50%. As expected, patents with severe sleep apnea didn't respond as well. You can find out more about the results at the companies' website.

Another study showed that 94% of patients continued using the device for a significant number of hours on a regular nightly basis.

Without a doubt, Provent does work to various degrees in various people. But just like every other new sleep apnea treatment option, it's not a "magic bullet" that cures sleep apnea for 100% of patients. Looking at the numbers, It seems like it's no better than other minimally invasive options (except that it's not invasive).

Practically speaking, I've had limited experience using this device in a handful of patients with mixed results. Some patients like it and others can't use it at all.

It's not covered by insurance yet, and it'll cost about $135 per month. They also have a rebate program for a 50% discount for the first few months. If you're interested in trying out Provent, an examination in the office is needed to make sure that you're a right candidate.

To learn more about Provent Therapy, click here.

Breathing Lessons for Sleep Apnea Sufferers

Proper breathing is fundamental to good health and vitality. It's also the most basic physiologic function that we must do to survive. Improper breathing can lead to illness, disease, and ultimately, death. Ancient Hindu cultures recognized this basic principle and developed very sophisticated breathing techniques that we now realize are scientifically sound when it comes to promoting optimal health, energy and life balance. These breathing concepts have spread across various continents to different cultures, but the basic fundamental principles remain the same. What Most Holistic Doctors Already Know Breathing means spirit in many languages (Hebrew, Latin, Greek, and Sanscrit), but not in English. In Latin, the word for breath and the word for soul are the masculine and feminine roots of the same root. In Greek, the two words are the same. Breathing is a natural physiologic function which continues, regardless of whether or not you notice it. It's controlled by two parts of the autonomic nervous system: the sympathetic and parasympathetic nervous systems. The sympathetic nervous system is the classic fight-or-flight half that's needed if you're in a fight or running from a tiger. The parasympathetic nervous system is the relaxation half, promoting sleep, digestion and reproduction. Inhalation is activated by the sympathetic nervous system and exhalation is activated by the parasympathetic part. When you slow down your breathing, your heart rate slows down. If you take a little longer exhaling relative to inhaling, then you're spending more time activating your parasympathetic nervous system. This is the physiologic reason why breathing techniques such as the relaxing breath is literally relaxing. These same concepts also apply to singing, humming or whistling. Notice that when you sing, you're spending up to 10 to 20 times longer exhaling relative to inhaling. By activating your vagus (parasympathetic) nerve, this is why you feel good when you sing. What Some Doctors Don't Know We all take it for granted that the physical air passageways that we breathe through is more than sufficient as conduits for air to travel into and out of our lungs. However, our upper air passageways are dynamically changing all the time, depending on your head position, weather status, allergies, emotions, moods, stress levels and even what you just had for lunch. Your nose is exquisitely sensitive to pressure or humidity changes, swelling or shrinking your internal nasal turbinates to significant degrees. Air passing through the nasal cavity is being filtered, humidified, and warmed before passing into the lungs. Any temporary or permanent blockage to proper breathing in this area can prevent optimal airflow into the lungs. In addition, the nose and sinus cavities make a gas called nitric oxide, which has two important beneficial properties. The first property is that nitric oxide is antimicrobial, both in the nose as well as in the lungs. This gas, when inhaled even in small amounts into the lungs, can increase oxygen absorption up to 20%. Not breathing through your nose for whatever reason has potentially detrimental effects on your health. What Most Doctors Don't Know Everyone in the Western, alternative and complementary fields of healing naturally assume that we are able to breathe properly at night. We now know that there are certain medical conditions such as sleep apnea where you have complete obstruction and repeated bouts of oxygen deprivation. Most practitioners still think that this typically occurs in some people who are overweight, snore, and have big necks. But now we know that even young, thin women who don't snore can have significant obstructive sleep apnea. Even more, many people who don't officially meet the criteria for obstructive sleep apnea still can have significant breathing pauses but wake up too quickly to be classified as an apnea. These are the patients that are commonly diagnosed with idiopathic hypersomnia. However, the bigger issue is that by definition, all modern humans are susceptible to breathing problems at night for the following reason: Due to jaw narrowing and dental crowding from a radical change in our diets, our tongues take up relatively too much space, and as a result, we're more susceptible to obstructing the airway when sleeping on our backs (supine) and in deep sleep due to muscle relaxation. In his classic nutritional text, Nutrition and Physical Degeneration, Dr. Weston Price documented these physical changes. Our ability to talk also positioned our voice boxes below the tongue, which can aggravate this process. Many modern humans can't sleep on our backs anymore since the tongue and voice box falls back the most in the back position. As a result, we compensate by sleeping only on our sides or stomachs. The problem is that it's not good enough. A simple cold or an allergy attack, or with even 5 to 10 pounds of weight gain, can cause more frequent obstructions occur, leading to less efficient sleep. Less efficient sleep leads to a physiologic stress response that can cause or aggravate a number of various medical conditions such as anxiety, depression, insomnia, cold hands, digestive problems, high blood pressure, etc. What I describe in my sleep-breathing paradigm is that all modern humans are on a continuum, where the one extreme end is called obstructive sleep apnea. The rest of us are lower down, but we creep up during various life stages, such as puberty, pregnancy, and menopause. A simple cold, by causing nasal congestion in a young, healthy woman, can cause her to toss and turn at night, due to repeated tongue collapse. Once the cold improves, sleep improves as well. What We All Must Know Breathing should never be taken for granted. We must do everything to make sure that proper breathing occurs not only during the day, but also at night. Many younger, thinner patients who complain of being tired all the time will also be found to have hypothyroidism, anemia, cold hands and feet, low blood pressure, anxiety, depression, or other various disorders. Later in life, as they slowly gain weight, they move up the continuum, and eventually will go into obstructive sleep apnea. Almost invariably, one or both parents will snore and have known or unknown cardiovascular disease. If you see a high-arched hard palate, an extra small mouth or a recessed jaw, or scalloping on the side of the tongue, ask about sleep position, fatigue issues, and sleep. You'll be surprised how often all these features come together to explain your chronic fatigue and various health problems.

To hear Dr. Park's interview with master Yoga teacher and Feldenkrais expert on the proper principles of breathing for better health and better sleep, click here.

5 Things You MUST Know About Sleep Apnea Surgery

Sleep apnea surgery is one of the most controversial subjects in sleep medicine. There are heated debates within the sleep community as well as in online forums and support groups. Sleep apnea surgery is definitely not for everyone, for some, it can be a life-changing experience. Here are 5 important issues that you must be aware of before considering any form of sleep apnea surgery:

1. Does sleep apnea surgery work?

Yes, but only when done properly. Just like with CPAP or dental devices, if you don't use it properly or use it at all, it won't work.

One of the most common misconceptions about sleep apnea surgery is the relatively low success rate of the uvulopalatopharyngoplasty (UPPP) procedure, which is often quoted at 40%. But performing this operation is like bypassing only one blocked heart vessel when you have 3 other vessels that are blocked. For some strange reason, ENTs are overly obsessed with the soft palate, since this is where snoring usually comes from and we have the most research and procedures for the soft palate.

We now know that if you address the entire upper airway together (nose, soft palate, tongue), then your success rates are much better, approaching 80%. Why only 80%? There's only so much you can do with the soft tissues within the small space within smaller jaws (which is the main anatomic reason for sleep apnea). The more aggressive you are, the higher the success rate, but the more chance of pain and complications.

If you go to the next level and enlarge your jaws (upper and lower), then success rates can reach 90 to 95%.

To put things into perspective, if you bypassed everything with a tracheotomy (placing a breathing tube below your voice box), then you'll have a 100% "cure", but obviously, this is not a very practical option.

One question you must ask then, is, what's the meaning of success? In surgery, one common definition is that the final AHI (apnea hypopnea index) on a formal sleep study drops greater than 50% of the original and the final number has to be less than 20. One of the main criticisms of sleep apnea surgery is that even if "successful", you may still have mild sleep apnea. Surgeons will argue that it's better than not using CPAP at all.

2. Not All Surgeries Are The Same

There are probably dozens of procedures for sleep apnea from various nasal, soft palate and tongue operations to skeletal framework procedures. These can range from minimally invasive to major surgery. The problem is that by definition, they'll all work to a certain degree. For example, procedures for a stuffy nose have been shown to "cure" sleep apnea in 10% of patients. But for the most part, none of these options by themselves have very good success rates.

The key is to examine the upper airway for each individual and figure out where the obstruction is and take care of it simultaneously. Most people have more than one area of obstruction. Surgeons at Stanford have about a 75 to 80% success rate with soft palate and tongue base procedures. This is called multi-level surgery for sleep apnea. You have to look at the airway from the tip of the nose all the way to the voice box.

3. There's No Cure for Sleep Apnea

Unless we all undergo tracheotomies, there's no way to prevent breathing pauses at night. Modern humans' upper airway anatomy is thought to be predisposed to breathing problems at night, which only gets worse as we age. I talk about why this problem has gotten much worse in recent years in my book, Sleep, Interrupted. All of us are on a continuum, where various factors (anatomy, age, weight, inflammation, etc.) contribute to forces that make our tongues and palates to collapse. The older we get, we'll either gain weight, which narrows our breathing passageways, or our throat tissues will sag and collapse easier.

Surgery will shift the line of this continuum downwards, but it won't bring it down completely. This is why it's important to incorporate a healthy diet and lifestyle and exercise regimen into any sleep apnea treatment regimen.

For most people, lowering the numbers significantly will make you feel much better. But sometimes, the numbers will go down dramatically, but you may not feel any better. This just goes to show that there may be other issues besides sleep apnea that have to be addressed. You've had sleep apnea for years or decades. Just by fixing your sleep apnea won't immediately fix problems that can arise from sleep apnea, such as hormonal problems, weight gain, or memory problems and brain fog.

4. Surgery is the Last Resort, But Don't Rule It Out

Admittedly, there are many people who rush to surgery prematurely, but there are also many others that aren't even offered surgery due to misconceptions by physicians. There are also many patients that are turned off by all the conflicting information that's available on the internet.

Before you even think about surgery, make sure you've tried or considered all the other options thoroughly. Most people who fail CPAP do so because of poor counseling, support and follow-up by the medical system. Just like everything else with life, your chances of success depends on which doctors you see. The follow-up and support offered by your CPAP equipment vendor can also play an important role in whether or not you'll benefit from CPAP. The same issues also apply with dental devices for sleep apnea.

This is why it's important to educate yourself about all the treatment options, and not to give up too easily. Too many people give up at this point, and don't consider any further treatments. Surround yourself with a group of trusted doctors and professionals that forms a team. Use their expertise and guidance to find a way to make things work. If nothing works for you, don't rule out surgery just for the sake of avoiding surgery. Learn and educate yourself about surgery before rejecting it.

5. How to Find the Right Surgeon

Finding the right surgeon for your sleep apnea condition can be challenging. Everyone claims to specialize in snoring and sleep apnea surgery. Who are you to believe?

First of all, find someone who's comfortable performing a wide range of procedures in all the three areas of the upper airway (nose, soft palate and tongue). Are they familiar with the minimally invasive procedures as well as the standard options? No everyone will be an expert at all the procedures, but it's important to know about all the other options as well as well as to make appropriate referrals when necessary.

There are a variety of "minimally invasive" procedures out there, especially for the soft palate, but these procedures have to be offered very selectively. Even if successful initially, is your surgeon prepared for relapsed that are likely years later? Is the goal of surgery only to cover up the snoring, or will it treat the underlying anatomic causes?

If your surgeon recommends palatal surgery "just to see," without addressing the entire upper airway from the nose to the tongue, go for a second opinion. If you do decide to undergo a palatal procedure (with or without tonsillectomy), be prepared for a 60% failure rate, which means that the tongue needed to be addressed as well. Sometimes, more needs to be done to the soft palate or the nose has to be addressed. Everyone is different, and the treatment recommendations have to be tailored to the individual.

For a more detailed free report on The Truth About Sleep Apnea Surgery, click here.

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