December 18, 2014 by Steven Park
Did you know that the holiday season is the deadliest time of the year? With the added stresses of the season, more eating and drinking, more sleep deprivation, less sunlight, and less exercise, it’s no surprise. Here are three past posts that are important to read, especially if you have obstructive sleep apnea:
December 18, 2014 by Steven Park
Thanks to everyone who voted to help me choose the new logo for my upcoming website revamping. We have our webmaster working on a completely new theme, which should be ready for launching within the next month or so.
Also, I’m right in the middle of the editing process for my upcoming book, “The Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting The Sleep You Need And The Life You Want.” My plan is to launch the book in mid to late spring of 2005. Thanks for being patient.
December 16, 2014 by Steven Park
It seems that everyone is tired these days. Not just plain tired, but exhausted to the point to not being able to function at all tired. This is what Barbara told me when she came to see me for her stuffy nose problem. She was in her late 40s, had gained about 15 pounds over the past year, and she’s beginning to snore.
Your first thought may be that I’m thinking obstructive sleep apnea, but you’re wrong. If you came to see me for this problem, the most important things to consider are your diet, exercise levels, sleep duration, lifestyle factors, and recent life stress issues. That may seem a little out of my area of expertise as an ENT surgeon, but as a physician, my duty and responsibility is to first address your health in total, in the context of your environment and surroundings.
Here are 7 things to try to combat fatigue before considering medications, stimulants:
1. Are you eating late? This is a common problem that can aggravate reflux, but this habit can severely aggravate sleep-breathing problems If you’re already susceptible to a sleep-breathing disorder (everyone), even brief pauses in breathing can vacuum up your normal stomach juices into your throat. This causes frequent arousals and fragmented sleep. Try to avoid eating anything within 3-4 hours of bedtime. The same applies to alcohol.
2. Is your nose stuffy? Having a stuffy noses is like sucking in through a flimsy straw: As you pinch the tip (nose), the middle part (palate or tongue) begins to collapse. This is why it’s important to breathe optimally through your nose. You can start with frequent nasal saline irrigation, with or without breathe right strips.
3. Was there any recent weight gain? Even 3 to 5 pounds of weight gain can aggravate more reflux and obstructed breathing, leading to a vicious cycle of frequent arousals. Going on an exercise plan to lose weight can help.
4. Was there any recent change in your sleep position? If you were a natural side or stomach sleeper, but you recently had to change to your back because of an injury or even surgery, it’s likely that your sleep quality is now much worse on your back. Back sleep is most prone to your tongue or soft palate falling back, and
5. Orofacial myology. Exercises for your tongue, lips, mouth and throat can help to strengthen your muscles and re-educate proper position, leading to proper function. It’s estimated that regular exercises alone can lower apnea severity by about 50%. Check out my interview with Joy Moeller about this important field.
6. Deep breathing relaxation exercises. You can find these activities through yoga, tai chi, or various other forms of proper breathing, including Buteyko breathing. Slowing down your breathing can help to calm your nervous system.
7. Check for a vitamin D deficiency. Most modern, Western adults are deficient in this vitamin. Actually, it’s a hormone that affects every part of your body including your brain, heart, muscles, digestive system, bones, and kidneys. Although the lower limit of normal is 20, some doctors are recommending levels between 60 to 80.
Once you’ve considered all the above situations and you’re still not any better, check for obstructive sleep apnea or upper airway resistance syndrome. It’s estimated that up to 1/3 of all adults may have at least mild levels of obstructive sleep apnea. A large number of people will have upper airway resistance syndrome. Many of these people with get diagnosed with a vitamin deficiency, hormone imbalance, or anxiety/depression. Obstructed breathing which can lead to frequent arousals and lack of quality deep sleep can definitely make you tired, irritable, cranky, and exhausted.
Have you tried any of the above options and if so, how well did it work?
December 1, 2014 by Steven Park
Guest blog by Deborah Wardly, MD
Previously I blogged about the relationship between intracranial hypertension and obstructive sleep apnea, and pointed out the similarity between the signs and symptoms of upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA) and those of intracranial hypertension. Intracranial hypertension is characterized by headaches, fatigue, dizziness/vertigo, ringing in the ears (which can be pulsatile), and visual disturbances to include papilledema (swelling of the optic disc). It can be present without papilledema (idiopathic intracranial hypertension without papilledema, or IIHWOP), which many doctors don’t seem to realize, and in these scenarios a lumbar puncture (spinal tap) is the only way to diagnose it. It is associated with obesity in many cases, as is OSA.
Recently a study was published showing that in a group of patients with chronic fatigue syndrome (CFS), 20% of them met criteria for idiopathic intracranial hypertension (IIH), and 85% of them had improvement in their chronic fatigue syndrome symptoms after reduction of their intracranial pressure after lumbar puncture. The only thing missing from this study was the sleep study results on these patients! But we know how closely UARS can appear to resemble CFS, and this study begs further evaluation of UARS patients’ intracranial pressures, especially given the knowledge that apneas increase intracranial pressure.
My recent published paper discusses what is currently known about how OSA can increase intracranial pressure (ICP), and then further discusses other possibilities for this phenomenon that could be investigated. We know that individual apneas can increase ICP, and that an increase in carbon dioxide effecting an increase in cerebral blood flow may be causal, as well as perhaps an increase in intrathoracic pressure at the termination of the apnea. In my paper I discuss how OSA can increase glutamate excito-toxicity in the brain, and the evidence for glutamate being able to cause brain edema. I discuss how OSA may open the blood-brain barrier, which would also cause brain swelling.
Alperin, et al. has demonstrated that in obese women with idiopathic intracranial hypertension, they have evidence of both brain swelling and poor jugular venous drainage. I suggest in my paper how the anatomical relationship of the recessed jaw to the narrowed airway, something we recognize is present in many cases of OSA, may also be involved in a compression of the internal jugular veins. This would contribute to the poor jugular venous flow observed in IIH by Alperin, and would increase resistance to CSF outflow. We know that obesity increases the risk of OSA in part by fat compression of the airway in the neck. Perhaps obesity increases the risk of IIH by fat compression of the jugular veins in the neck? Such that it is not entirely a direct causal relationship between OSA and IIH, but that they are conditions which go hand in hand when there is a recession of the mandible or increased fat content of the neck.
An important point that I discuss in my paper is the fact that a Valsalva maneuver will increase ICP. A Valsalva maneuver is created upon “bearing down”, something we do when coughing, sneezing, grunting, crying or shouting, yet even upon laughing, singing or talking. Many people with intracranial hypertension do not tolerate any Valsalva activity, as it will increase their headaches. Think about what it feels like to exhale with your CPAP on—it is a Valsalva as well. Could this be the reason that some people with OSA/UARS do not tolerate CPAP, but must use BiPAP, or cannot use PAP at all? Do these individuals have undiagnosed IIH?
If you do not tolerate CPAP, or even BiPAP, do you have headaches or any of the other symptoms of IIH?
Do you find you must have perfect control of your airway problem in sleep, in order to prevent or reduce the headaches, dizziness, and fatigue?
If you have CFS symptoms or IIH symptoms in conjunction with your OSA/UARS, would you consider a spinal tap to further elucidate your symptoms?
November 17, 2014 by Steven Park
I’m in the process of completely overhauling my website, and I need your help with the logo design. I’ve whittled the design down to 6 candidates. Will you please help me choose your favorite design? I would also appreciate your feedback and comments as to why you like or dislike the designs. This poll is being undertaken by my publisher, who will report the results to me. I will then publish the final results.
The logo and Web site redesign is just the start. I’m just about to begin working with an editor to go through the manuscript for my second book, “The Total Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You Want.” This is still a working title, so I’ll send out another poll about the title as the book publishing process continues.
Thanks for taking time to help me with the start of a very important project.
Please click here to take the poll to choose your favorite logo.
November 12, 2014 by Steven Park
A psychologist colleague of mine once told me that at the hospital where he works, many of his patients are on antipsychotic and antidepressant medications. A significant number of these patients will go on to gain significant weight, snore heavily, and end up dying of heart attacks or strokes. While this is purely anecdotal, based on what we know about the side effects of commonly prescribed prescription medications, it’s not too far fetched for the following reason: Any medication that causes weight gain can potentially aggravate or uncover obstructive sleep apnea.
I’ve written extensively in the past how obstructive sleep apnea is mainly a structural problem with narrow jaws and upper airways, but if you add fat in the throat due to being overweight, it just makes things much worse. Here are 7 commonly prescribed prescription medications that can aggravate obstructive sleep apnea due to their ability to put on weight:
1. Many of the antidepressants, especially the tricyclic antidepressants (TCAs) are known to stimulate appetite. Two examples of brand names are Pamelor and Elavil. The newer class of antidepressants called selective serotonin repute inhibitors (SSRIs) don’t generally cause weight gain, except for Paxil. One interesting known side effect of these type of medications is that they suppress REM sleep. Perhaps by limiting REM sleep, you’re prevented from having as much apneas since you’re kept out of REM sleep. This can be one way that these medications may help with depression. However, there’s a cost to not getting enough REM sleep: Your nervous system gets more excitable, with lowered pain thresholds, and you’ll have more problems with learning and memory.
2. Depakote (valproic acid) is a common mood stabilizer to treat bipolar disease and seizures. It’s also used to prevent migraines. One study found that 44% of women and 24% of men gained about 11 pounds on average over one year.
3. Atypical anti-psychotics (Risperdal, Seroquel, Zyprexa, Abilify, and others) are known to cause significant weight gain (7% or more in original body weight) in up to 30% of patients. There’s also some evidence that these medications may also cause insulin resistance and potentially lead to diabetes. A study published in Obesity found that men who took Zyprexa for only 2 weeks increased their food intake by 17%. Another study published in the Journal of the American Medical Association reported that 10 to 36% of children and teens became overweight or obese after 12 weeks taking atypical antipsychotics for the first time.
4. Prednisone, one of many corticosteroids to control inflammation, is one of the most commonly prescribed medications. Chronic, long-term use is given for asthma, inflammatory bowel disease, rheumatoid arthritis, and various other autoimmune conditions. One study found that 70% of people on chronic steroid use reported significant weight gain.
5. Antihistamines such as Allegra and Zyrtec, are also associated with being overweight. This study found that patients on these medications were 55% more likely to be overweight compared to those not taking the medications.
6. Insulin. You’d think that with better sugar control, there would be weight loss, but the findings are the reverse. Here’s a study showing that insulin alone promotes weight gain.
7. The older beta-blockers such as atenolol, metoprolol and propranolol are also associated with significant weight gain. One possible mechanism is that any drug that lowers sympathetic activity will block the brain pathway that stimulates melatonin. Light stimulates receptors in the eye that stimulate nerves in the suprachiasmatic nucleus (near the optic nerve), which then connects to the thalamus then drops down to the spinal cord, connecting with the superior cervical ganglion, and then back up to the pineal gland, which makes melatonin. Light suppresses melatonin, whereas darkness enhances melatonin. Since the superior cervical ganglion is part of the sympathetic nervous system, taking beta-blockers can potentially alter melatonin production.
As I was doing research for this blog post, I kept getting led down more rabbit holes with studies detailing potentially serious side effects with all these medications. I only listed 7 medications, but there are many more. It’s clear that most if not all prescription medications will have various side effects, with many causing sleep or weight disturbances. This is something that all physician must think about when prescribing any of these medications.
If you started taking any of the above mentioned medications, did you notice any significant weight gain?
November 5, 2014 by Steven Park
Asthma is the third most common chronic disease amongst children, and the third most common reason for admission to the hospital. The CDC estimates that 7.1 million children suffer from this condition, costing over $50 billion a year. A new study from the University of Chicago found that children who undergo tonsillectomy had 37% reduced hospitalizations and 26% less visits to the emergency room. They compared about 13,000 children with asthma who underwent adenotonsillectomy to 27,000 who didn’t undergo the procedure. This finding builds on previous smaller-scale studies finding similar results. A Fox News article summarizing the findings concludes with a standard disclaimer that since this was a retrospective study, causation can’t be linked, and that large-scale prospective studies are needed.
What the paper doesn’t address is the possible reason why removing tonsils may help asthma. I’ve described in the past about the strong association between large tonsils, obstructive sleep apnea and reflux. Every time a child stops breathing, a vacuum force is created in the chest and throat, with normal stomach juices coming up into the throat. What comes up not only includes acid, but also bile, digestive enzymes, and bacteria. In fact, one recent study found pepsin (a stomach enzyme) in the lungs in the vast majority of children and teens with chronic lung disease. There are also numerous reports of pepsin being found in chronic ear and sinus infection fluid.
While tonsillectomy is not a completely benign surgical procedure, this study adds to the multiple potential benefits that improved breathing and sleep can have on your child’s health.
For the parents out there, did you notice any improvements in your child’s asthma symptoms after tonsil surgery?
October 16, 2014 by Steven Park
One of the most common complaints by my patients with obstructive sleep apnea (OSA) is memory loss. Judith is a 55 year old woman who used to have a sharp memory, but now is having trouble with names and losing her keys all the time. Things got much worse when she gained more weight, which worsened her snoring. She was eventually placed on CPAP for her moderate obstructive sleep apnea, and is now happy to report that while her memory is not back to normal, it is much improved.
At a recent Airway Dentistry conference I went to last month, the most memorable topic was given by Dr. Ronald Harper, Distinguished Professor of Neurobiology at the David Geffen School of Medicine at UCLA. I’ve been following his work over many years, but his presentation only confirmed my suspicion that there can be significant brain damage with untreated obstructive sleep apnea. Based on various high-tech MRI technology, specific known areas of the brain can be damaged with repeated episodes of apneas and low oxygen levels. Note that the word “damage” can mean low functioning, or dead brain cells. Here are 5 particular areas of brain damage from untreated obstructive sleep apnea with their specific symptoms:
1. The right insular cortex. This is the area of the brain that regulates sympathetic control of the autonomic nervous system. If the insular cortex is damaged, baroreflex control is affected. The insula also controls nerve endings that relate to pain. Both OSA and sleep apnea patients are found to have insular cortex injury.
2. The vetrolateral medulla (VLM). This area of the brain controls breathing and blood pressure regulation. Injury to this area blunts and delays heart rate responses to sudden pressure changes. One sided VLM injury leads to an asymmetric response to blood pressure challenge, which can potentially cause heart rhythm problems.
3. The cerebellum is the area of the brain that helps adjust blood pressure control and motor coordination, including breathing. Damage to this area prevents the ability to coordinate vascular and motor activity.
4. The hippocampus is found to be significantly smaller in people with obstructive sleep apnea. This area of the brain processes short and long-term memory and spatial navigation. One study found that hippocampal damage can be partially reversed after a period of CPAP. The hippocampus is also one of the first areas to be damaged in Alzheimer’s disease.
5. Mammary bodies are important for memory recall, as well as for memory for certain smells. These structures are much smaller in patients with OSA, and almost nonexistent in patients with heart failure. The hippocampus and mammary bodies are also found to be damaged in chronic alcoholism.
If OSA can damage critical areas of the brain that regulates breathing, balance, memory, and the autonomic nervous system, the implications are enormous. For example, heart failure is thought to lead to central sleep apnea. Is it possible that untreated obstructive sleep apnea can damage breathing and reflex centers in the brain that can lead to heart failure? What proportion of Alzheimer’s disease is actually undiagnosed OSA? The possibilities are endless. As they say at the end of every scientific journal article, more studies are needed.
If you have both OSA and memory problems, did your memory improve at all after being treated? Please tell your story below.
(Take a look at the references below to take a look at the various photos and figures. The figure above is from the Macey 2002 paper)
Canessa, N., Castronovo, V., Cappa, S. F., Aloia, M. S., Marelli, S., Falini, A., et al. (2011). Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function before and after Treatment. American Journal of Respiratory and Critical Care Medicine, 183(10), 1419–1426
Henderson, L. A., Woo, M. A., Macey, P. M., Macey, K. E., Frysinger, R. C., Alger, J. R., et al. (2003). Neural responses during Valsalva maneuvers in obstructive sleep apnea syndrome. Journal of Applied Physiology (Bethesda, Md. : 1985), 94(3), 1063–1074.
Kumar, R., Chavez, A. S., Macey, P. M., Woo, M. A., Yan-Go, F. L., & Harper, R. M. (2012). Altered global and regional brain mean diffusivity in patients with obstructive sleep apnea. Journal of Neuroscience Research, 90(10), 2043–2052.
Macey, P. M., Henderson, L. A., Macey, K. E., Alger, J. R., Frysinger, R. C., Woo, M. A., et al. (2002). Brain Morphology Associated with Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 166(10), 1382–1387.
Macey, P. M., Kumar, R., Woo, M. A., Valladares, E. M., Yan-Go, F. L., & Harper, R. M. (2008). Brain structural changes in obstructive sleep apnea. Sleep, 31(7), 967–977.
Lal, C., Strange, C., & Bachman, D. (2012). Neurocognitive impairment in obstructive sleep apnea. CHEST Journal, 141(6), 1601–1610.
October 7, 2014 by Steven Park
Over the years, I’ve witnessed countless stories about patients with obstructive sleep apnea who undergo nightmare experiences while undergoing treatment. Oftentimes, the insurance issues can be worse than any medical issues. In his book, The Midnight Stranglers: A Personal Quest For Healthcare Transparency, Aiden Hill chronicles his painful journey from first being diagnosed with obstructive sleep apnea to his ordeal as a consultant helping California residents obtain health care coverage.
- Basic concepts of obstructive sleep apnea and consequence of non-treatment are covered. It’s not taken to be medical advice, but is well-written from a lay-person’s perspective.
- He describes the current flawed state of affairs with our health care system, likening it to Dr. Jekyll and Mr. Hyde. There can be a dark consequence to any good intention.
- With ongoing changes to our health care system, he emphasizes the importance of taking a pro-active approach before undergoing any type of treatment. Even then, you’re likely to get hit with an unexpected bill, despite putting in your due diligence. Expect to spend hours, days or even years dealing with the aftermath. I’ve experienced this personally numerous times.
- The problems that he encountered with insurances companies, doctors, hospitals, and government entities are all governed by the basic rule: “Protect the asset.”
- I completely agree that full financial transparency is needed before undergoing any medical transaction.
October 3, 2014 by Steven Park
When I first wrote my book, Sleep, Interrupted in 2008, I had a question mark in my diagram linking obstructive sleep apnea to possible cancer. Since that time, there have been a number of studies making that link stronger, and I am now more comfortable in removing that question mark. One of the basic hallmarks of obstructive sleep apnea is repeated episodes of low oxygen levels (intermittent hypoxia) due to obstructed breathing at night. If you google “intermittent hypoxia and cancer” you’ll see about 460,000 search results, of which 33,000 are scholarly articles. Low oxygen levels are strongly associated with cancer progression.
In a recent review article on this subject, Dr. David Gozal and colleagues published a paper titled, Sleep apnea awakens cancer: A unifying immunological hypothesis. They hypothesized that intermittent hypoxia and sleep fragmentation can promote changes in the tumor microenvironment, leading to a weakened immune system and tumor growth enhancement.
It’s important to remember that intermittent hypoxia not only can enhance cancer development, it can also in theory enhance benign tumor growth as well. One of many possible explanation is the concept of increased levels of vascular endothelial growth factor, which enhances more blood vessel growth, so that more nutrients (via blood) can reach the oxygen starved tissues. Initially, it may only cause localized enlargement of the soft tissues. Imagine if you continue to have intermittent hypoxia, and let’s say that you have a gene that makes you more susceptible to cancer. If you add additional lifestyle habits such as smoking and drinking alcohol, then one mutation can potentially lead cancer.
To date there hasn’t been any particular cancer that’s strongly associated with obstructive sleep apnea. However, one large-scale population study found that your chances of dying from cancer increases almost 5 times if you have untreated severe obstructive sleep apnea. Another study found a 2.5 times increased risk of having cancer and 3.4 times higher risk of dying from cancer with untreated moderate to severe obstructive sleep apnea.
Notice that the most common types of cancer happen in the “low priority” organs when you’re under stress. These areas include the gastrointestinal system, the reproductive organs, hands, feet, and the skin. In general, the core, central areas take priority. Any form of physiologic or emotional stress diverts blood flow and nervous system activation away from low priority to high priority areas. Rarely do you hear about cancer in the brain, heart or muscles, which are considered high priority.
This is another example of how sleep connects the dots between almost every known chronic health condition. Unfortunately, cutting edge cancer research focuses mainly on the molecular, genetic, and biochemical aspects without looking at the big picture. Without addressing proper sleep and breathing, even the best cancer treatments can give possibly suboptimal results.
If you have a diagnosis of obstructive sleep apnea, do you have a cancer history in your family?