Sleep Apnea May Have Caused Metro North Train Crash

April 15, 2014 by  

It’s now official: The train engineer from last year’s deadly train derailment was found to have severe obstructive sleep apnea, where he stopped breathing 65 times per hour. To date, there’s no conclusive proof that the crash was a direct result of his untreated sleep apnea, since he was also taking a sedating antihistamine and had changed shift hours two weeks prior. However, federal transportation officials are convinced that driver fatigue may have played a role in crash that killed four and injured 70 people. 

In an article about this incident, a transportation union official was quoted as saying the crash was a “tragic accident,” and that “there isn’t enough awareness of sleep apnea within the transportation industry.” This is an interesting comment, in light of the fact that recently, the National Transportation Safety Board (NTSB), Federal Motor Carrier Safety Administration (FMCSA), American Trucking Association (ATA), Federal Aviation Administration (FAA), and even Congress have worked tirelessly to bring more awareness about sleep apnea to the public. 

Congress just passed a law (H.R. 3095) requiring investigation, data collection and gathering expert opinion into screening requirements for sleep apnea in various transportation industries. The FAA recently announced that they will be more vigilant about screening for OSA, especially in severely overweight pilots. In this press release, the FAA noted that there are almost 5000 pilots with OSA on treatment that have been issued special issuance certificates. Interestingly, the NTSB database reports 34 accidents, 32 of which were fatal, involving people who had sleep apnea and 294 incidents involving another type of sleep disorder. 

Around 170,000 individuals are injured in trucking accidents each year. About 5,000 semi-trucks per year are involved in fatal traffic accidents in the United States. In a study conducted by the University of Pennsylvania and sponsored by the FMCSA and the American Trucking Association, almost one-third (28%) of commercial truck drivers were found to have OSA.

Given that the incidence of obstructive sleep apnea is so high in these industries, perhaps there should be universal screening. What do you think? Is it invading privacy to force mandatory sleep apnea testing, or does public safety take priority over individual rights?


Can Sleep Apnea Be Cured?

April 7, 2014 by  

During college, one of the most influential coursers that I took was called “Paradigms of Health and Disease.” It was taught by my advisor in the biophysics department. This course looked at how we define what is is to be healthy or sick, and compare and contrast our definitions with other cultures and societies. One important concept that stuck with me from this course is that no disease can ever be truly “cured.” We as physicians can help to alleviate the severity of disease, but we can never completely eradicate conditions like cancer, Alzheimer’s disease, or asthma. The same concept also applies to obstructive sleep apnea. 

Obstructive sleep apnea is a distinct clinical condition that can only be made based on a formal sleep study. However, I’ve argued that all modern humans are susceptible to partial or totally obstructed breathing, leading to various degrees of deep-disordered breathing. Only the more severe extreme is called obstructive sleep apnea. All of us are on a continuum, with various degrees of obstructed breathing that generally worsens with age and various other factors such as menopause, weight gain, and sleep position. This is due to our ability  to talk, which unprotected our upper airways. Modern diets and infant feeding patterns may have accelerated this problem by causing more dental crowding and smaller oral cavity dimensions. 
Unfortunately, as we all age, not only does our skin sag on the outside, but also sags and relaxes on the inside of your upper airway. It’s only natural that as your ability to breathe or sleep gradually goes downwards, the more rapidly your body will get sick or not function properly. The major treatment options we have for sleep apnea only help to alleviate this blockage using air pressure, dental gadgets or surgery, but they never really “cure” the problem. At one extreme, a tracheotomy (making a surgical hole in your windpipe below your voice box) can be described as a “cure”, but not too many people will be happy with this option.
One way of looking CPAP and dental appliances is to think of it as a cane, or a wheelchair. As you get older, many people will require one of these devices to help get around. Similarly, these nonsurgical options for OSA will help you breathe and sleep better, but it’s never an ideal situation. Throat surgery is similar to undergoing a facelift. Sooner or later, your face will continue to sag, and you may require another facelift. The same issues can rise with throat surgery, no matter how good the initial results. This “relapse” happens slowly and may take years or decades to occur. You may then ask, what’s the point of doing surgery if it’s going to come back? 
Even with CPAP or dental appliances, you’ll have to make constant adjustments and modifications every few months to years. The same goes with surgery. Ultimately, it’s a choice between using a device on your face or in your mouth for the rest of your life, or undergo surgery every few decades. Some people will need a combination of CPAP, dental appliance and surgery to achieve optimum results.
Regardless of which option you choose, what’s most important is that you think of OSA as a lifelong condition, like diabetes or even cancer. You’ll have to be vigilant and constantly monitor your condition, or be on the lookout to make sure it’s not slowly coming back. Not only do you have to make significant lifestyle changes but also a mindset shift. It’s not like a broken leg that’s treated and never have to worry about it after it’s been fixed. Unfortunately, there’s no quick “fix” for OSA.
For those of you with obstructive sleep apnea, what kind of lifestyle changes have you made? Has this condition altered the way you look at health or wellness? 


Peripheral Neuropathy and Obstructive Sleep Apnea

March 16, 2014 by  

I just saw a patient 5 weeks after major tongue and soft palate surgery for obstructive sleep apnea, and as expected more often than not, his sleep quality was significantly improved. He did not suffer from brain fog anymore, and was able to think clearly again, something he was not able to do for more than 30 years. He was very happy with the results. As he was leaving the exam room, he wanted to show me something. He took off his shoes, and then his socks, and asked me what I thought.

I was a bit confused by his request, but then I remembered that he showed me his feet many months prior to his procedures. Compared to his right foot at that time, his left foot was more dusky, red and scaly, and not too healthy looking. He had peripheral neuropathy with pain, burring and numbness, for which he was being treated by another doctor. On the post-operative visit, his left foot looked much healthier. He also noted proudly that although he still had some numbness, his burning and pain were completely gone.

Peripheral neuropathy is a common condition seen usually in diabetics, but can also occur in non-diabetics. I wasn’t surprised by his result, but it was a bit unexpected. It not something that’s routinely described as a potential benefit of treating obstructive sleep apnea. We know that sleep apnea causes a stress response that clamps down on blood vessels of the distant extremities. 

I did a quick literature search of the connection between obstructive sleep apnea and peripheral neuropathy and found a handful of studies. One report found that patients with obstructive sleep apnea without any symptoms in the feet had objective measures of diminished nerve function, which improved significantly after CPAP therapy. Another paper described resolution of peripheral neuropathy pain (but not numbness) in a non-diabetic after CPAP. 

Knowing that obstructive sleep apnea and diabetes frequently go hand in hand, and that diabetes and peripheral neuropathy also go together, there’s a good possibility that the first and the last can also be linked as well. The real question that needs to be asked is, how many people with peripheral neuropathy have obstructive sleep apnea, and if treated adequately, how many can be helped or even cured? Another question that follows is, should all diabetics be routinely screened for obstructive sleep apnea? Knowing that obese diabetics can have up to an 80% chance of having obstructive sleep apnea, perhaps the answer should be yes.

If you’ve been diagnosed with obstructive sleep apnea, did your foot pain or numbness get any better after using CPAP, dental appliances or surgery?


Inflammation, PTSD and Sleep Apnea

March 5, 2014 by  

Post traumatic stress disorder, or PTSD, is a commonly seen condition, especially in victims of sexual abuse, or in military personnel after deployment. For the most part, it’s categorized as a mental health disorder that’s treated with medications and/or psychotherapy. Personal or family history of anxiety or depression is though to increase your risk of developing PTSD.
In this new study, the presence of inflammation was found to predict later development of PTSD. In particular, each 10 fold level of C-reactive protein (CRP) was associated with a 51% increased likelihood of showing at least one PTSD symptoms after deployment to Iraq or Afghanistan.
When I came across this study, the first thing that came to mind was the numerous previous studies showing that having obstructive sleep apnea (OSA) is strongly associated with elevated levels of CRP, and that treating OSA with CPAP can lower CRP levels. 
In addition to higher levels of CRP, OSA is also associated with elevated levels of IL-1, IL-6, and TNF-alpha. CRP is a general marker of inflammation and can even be elevated after surgery.
A good analogy is to say that having a fever increase the chances that you have a cold. Your temperature can also go up if you have pneumonia. There’s nothing special about having an elevated temperature, since it’s a general marker of inflammation. In a similar way both obstructive sleep apnea and PTSD are both associated with elevated levels of CRP. 
But what if obstructive sleep apnea increases your chances of developing PTSD? Not too coincidentally, there’s a study showing that veterans with PTSD have up to 50% rate of OSA. Treating OSA can oftentimes improve PTSD symptoms. I’ve had numerous veterans report that their PTSD was completely gone after starting CPAP.
Something to always think about when you’re dealing with PTSD.

If You Sleep Less Than 6 Hours, You Must Read This…

February 26, 2014 by  

I haven’t talked a great deal about sleep deprivation, so when I came across this article on Medscape, I thought the overview of the various epidemiologic findings related to sleeping less than 6 hours was worth reviewing:

“Sleep deprivation has a profound impact on multiple disease states. For example, if you sleep less than 6 hours, epidemiologic studies show the following:

• Stroke is increased by a factor of 4 times.

• Obesity is increased by an increase in ghrelin, which is a hunger hormone.

• Diabetes is increased because sleep deprivation increases insulin resistance.

• Memory loss is accelerated. Epidemiologic studies show that there is not only permanent cognitive loss but also evidence of early brain deterioration.

• Osteoporosis is increased, at least in an animal model, with changes in bone mineral density. Even changes in bone marrow are evident within 3 months of a study in a rat model.

• Cardiac disease is increased. There is a 48% increase in early cardiac death, as well as increased cardiac-related mortality.

• A 4-fold overall increase in mortality.

As it relates to gastrointestinal disease, there is an increased risk for colon cancer, and at least 1 epidemiologic study shows an association between sleep deprivation (or lack of sleep) and an increase in the likelihood of precancerous (adenomatous) polyps.”

The author also summarized the results of this finding that sleep deprived mice had higher rates of tumor growth.

More and more studies are linking sleep deprivation and obstructive sleep apnea with numerous medical conditions, including cancer.

If you sleep less than 6 hours, something else to sleep on…

Poor Sleep Strongly Predicts Chronic Pain

February 19, 2014 by  

It’s been a general consensus amongst physicians that chronic pain can disrupt sleep, leading to insomnia and frequent awakenings during the night. In the sleep research field, it’s been long known that poor sleep quality or quantity can lower your pain thresholds, meaning that you’ll feel pain a lot earlier. Regardless of what causes what, it’s a vicious cycle. 

Here’s a study that only confirms this link: Nonrestorative sleep was found to be a strong predictor of widespread pain in adults over 50.  This has enormous implications as people age and go on to develop aches and pains that are commonly found with arthritis. 

Anecdotally, I’ve had a handful of patients with severe rheumatoid arthritis who stated that the pain went away completely after starting CPAP for newly diagnosed obstructive sleep apnea. One patient tried a number of different biologics that are often prescribed for severe rheumatoid arthritis, but only CPAP helped. This is not surprising, since sleep apnea causes generalized systemic inflammation, in addition to aggravating any already existing pain. 

Statistically, it can be argued that the majority of people over 65 will have at least some degree of obstructive sleep apnea. If this is the case, it’s not surprising that as sleep apnea worsens, arthritis can also worsen.

If you have rheumatoid arthritis, what is the quality of your sleep?


The Missing Link in Insomnia and Sleep Disordered Breathing: Interview With Dr. Krakow

February 12, 2014 by  

Insomnia is treated by sleep specialists as a completely different condition from obstructive sleep apnea. Similar to how sleep problem is now considered a “co-morbid” condition to depression and various other medical conditions, insomnia is now beginning to be considered a “co-morbid” condition alongside obstructive sleep apnea.  I’ve interviewed Dr. Barry Krakow in the past on upper airway resistance syndrome and complex insomnia (click here for the interviews; search for Krakow). Here’s a must-read interview that was just published in Sleep Review Magazine. The magazine interviews Dr. Krakow on complex insomnia and how everyone with severe insomnia should also be considered for a possible sleep-breathing disorder.

Preterm Babies, Wheezing, And Sleep Apnea

February 6, 2014 by  

There’s been a rash of studies on the numerous health consequences of pre-term deliveries. Here’s a study showing that babies born before 37 weeks had significantly higher rates of developing asthma. The more preterm, the higher the risk. Since it was a large-scale epidemiological study combining  42 similar studies, with over 1.5 million total births, it didn’t go too much into possible mechanisms.

Underdevelopment of the lungs is a common potential explanation, but here’s another possible mechanism:  Preterm delivery can raise your risk for obstructive sleep apnea. This study found that very premature delivery and maternal smoking raised the risk of developing obstructive sleep apnea by 2.2 time normal. 

We know that obstructive sleep apnea can predispose your stomach juices to come up into the throat, mainly due to vacuum forces in the throat. If you accept the possibility that stomach juices can reach the throat, then it can easily reach the lungs or even the ears. Here’s one study showing that children with chronic lung diseases had much higher rates of pepsin (a stomach enzyme) in lung washings. 

There’s a reason why 40 weeks is needed for full-term delivery. Not having enough time to fully develop the airway and jaw structures can lead to narrowed upper airways which can predispose to obstructive sleep apnea, asthma, reflux, and a variety of  other future health problems.

If your child was delivered pre-term, does he or she have asthma?



How Lack of Sleep Can Lower Economic Productivity

February 3, 2014 by  

I’m willing to bet that many of you reading this blog stayed up last night watching TV or surfing the net, going to bed much later than your normal bedtime. Some of you never sleep for more than 6 hours. Life can oftentimes prevent optimal sleep times, such as having a new baby, work obligations, or staying up to watch the Grammy or Academy awards. 

I’ve written in the past about the enormous medical consequences of poor sleep quality or quantity. But here’s another good reason to regularly get at least 7 hours of sleep: Our country’s gross domestic product. The New York Times printed a revealing article about the negative impact of sleep deprivation on our country’s economy. One telling statistic mentioned is that the number or people who sleep less than 6 hours rose 22% from 1975 to 2006.

If you listen to the topic of conversations during work or amongst friends, being tired or having problems with sleep are very common. Not getting the 7 to 8 hours of sleep is almost normal in this day and age. This is not including people who have medical sleep conditions such as obstructive sleep apnea. In one month in 2008, 29% of workers had fallen asleep or felt sleepy at work. One Australian study estimated the cost of sleepiness on the country’s gross domestic product at 0.8%. If you include medical complications of poor sleep, car accidents and industrial accidents, this figure is sure to be much higher.

This is why companies that values quality sleep can be much more productive and fosters more creativity (think Google’s sleep pods). 

What’s your reason for not getting enough sleep? Is it under your control, or do your personal or work situations prevent you from getting a good night’s sleep?

Flat-Head Syndrome Linked to Developmental Delays

January 27, 2014 by  

Children with deformational plagiocephaly (DP), or “flat-head syndrome,” have been more commonly seen ever since pediatricians recommended placing infants on their backs during sleep. It’s an accepted consequence of a maneuver that has been found to lower crib death (sudden infant death syndrome, or SIDS) by about 40 to 50%. So far it’s been thought of as merely a cosmetic problem, and various conservative repositioning measures are generally recommended.
However, in a recent study, children with DP at 36 months were found to be around 2 to 8 times more likely to receive “at-risk” scores compared to children without DP. Differences were largest in cognition, cognition and parent-reported maladaptive behavior, and smallest in motor development. As you may see, there can be a significant overlap in these developmental problems and common conditions like ADHD and autism.
In the conclusion, the authors point out that this study doesn’t prove that having DP leads to developmental problems. One possible explanation proposed was that children with developmental delays may be less likely to reposition themselves, thus leading to DP. 
Here’s another possible explanation: It’s been shown that back sleep lowers sleep quality in infants. One study from 1993 showed that prone body position was associated with a significant increase in sleep duration (+ 6%) and in non-REM sleep (+25%) and a significant decrease in number of arousals (–40%) and in their duration (-43%).
This is one possible way that being placed on backs during sleep can lower the rate of SIDS. By keeping children in a lighter stage of sleep, they are more easily arousable, if they obstruct. One obvious consequence of poor quality sleep is that it can negatively affect young children’s brain development. Proper amounts of REM and deep sleep is important for memory consolidation and optimal brain development.
Perhaps having poor sleep and slower brain development can lead to less optimal motor reflexes that allows the infant to roll over. In some infants that naturally want to roll over onto their tummies, parents are told to turn their infants on to their backs, or to use positioning devices to promote back sleep.
I’m not recommending that parents ignore pediatrician’s back sleep recommendation. This can be a very sensitive issue that needs further research and discussion. With advances in technology and current know-how, it would be relatively easy to do a study to answer these questions. 
Did your child have flat-head syndrome? If so, did he or she have any developmental issues later in life?

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