One of the most common requests I get is for a referral to a sleep apnea surgeon, particularly if they live in another state. Just like giving a referral for a lawyer or a plumber, there are a number of issues to consider. Some people don’t have access to any surgeons that perform sleep apnea procedures on a regular basis, or the nearest surgeon is located hundreds of miles away. Sleep apnea surgery is not commonly performed by all otolaryngologists, and even the ones that do may not perform these procedures on a regular basis. Here are some factors to consider when looking for a sleep apnea surgeon:
1. Academic or private practice?
There is a general perception that specialized medical and surgical care is better in academic medical settings. Yes, the academic medical centers teach and do more research, but clinicians in private practices can also be well trained and be more than competent. Ultimately, it is the individual surgeon’s passion and desire to constantly learn and apply these techniques that makes for a good doctor.
2. Do you do tongue base procedures?
Many otolaryngologists will do the nasal procedures and the UPPP procedure well, but not do any other procedures for the tongue base. If this surgeon is the only one that available for miles around, then you may not have a choice. My personal bias is that if you are going to be doing sleep apnea surgery at all, you should be well versed in all areas of the upper airway, especially in the tongue base area. Regardless, a good sleep apnea surgeon will know when an additional tongue base procedure is needed, but also what specific type of palatal procedure is needed.
3. How many have you done?
This is a requisite question that everyone is supposed to ask any surgeon, but there are inherent problems with asking such a question. First of all, it puts the surgeon in a defensive state, having to justify his or her qualifications on something that they do for a living. Do you ever ask a plumber how many drains he is unplugged? You may argue that unclogging a drain is not the same as major throat surgery, but there are certain similarities. Both the surgeon and the plumber has to know when and when not to do a procedure, which tools to use, how to explain to the patient/customer what’s to be expected, and how to deal with any potential complications.
Both surgeons and plumbers can be new on the job, but if trained properly, both can get the job done quickly and effectively. This is the point of residency, where residents perform high volumes of surgical procedures over many years. Ultimately, what is more important than the number of procedures is how well it’s performed. Doing a tonsillectomy 2000 times does not make you a good tonsillectomy surgeon. Learning how to do it properly, and constantly striving to improve the technique and the outcomes is what makes for a good surgeon.
The challenge in sleep apnea surgery is not so much the technique, but choosing the right patients to operate on, as well as knowing where in the airway to perform the operations. You could be the best UPPP surgeon in the world, but if you do not do any tongue base procedures, then your overall success rates will never be above 40%.
Honestly, the technical aspect of sleep apnea surgery is relatively straight forward. It is like an elevator operator that has worked for 25 years but was never asked to go to the penthouse floor. Would you ask him how many times he has pressed the penthouse button in his career?
Similarly, once a surgeon is properly trained, minor variations of surgical techniques in the throat are not difficult to master. If you were to ask me to do an appendectomy, I’ve done a dozen or so in my surgical internship year. But that’s not what I do on a regular basis, so I’m not going to offer to take out your appendix. If I read about a new UPPP technique, I can apply it right away and get good results from the start. Of course I’m honest with my patients that I have never done this variation before. But if you build up a good relationship with your surgeon, being the whether or not he’s performed the procedure is a moot point.
4. What are your results?
What is more important than how many procedures have been done is how effective are your results? If the surgeon has published a paper on success rates for UPPP, then you already know the answer. Most busy surgeons do not write papers all the time, but should know what their success rates and should be able to tell you.
5. What is your complication rate?
A good surgeon should know what his or her complication rate is. If a surgeons states that he’s had no complications, go to the next surgeon. Every surgeon, by definition, has had complications. There is a saying in general surgery, “If you do not have any complications, then you’re not being aggressive enough during surgery.
6. Who else do you work with?
A sleep surgeon should not be a one-man show. A good sleep surgeon will work intensively with various other physicians and medical health professionals. It has to be a team approach, like what is seen in comprehensive cancer centers. Proper follow-up and care are critical with any type of sleep apnea treatment, especially before and after any type of surgical procedure.
7. What are your options if the procedure does not work?
You should never undergo a procedure “just to see” whether or not it will work. Your surgeon should be able to give you a reasonable predicted success rate based on research findings, his or her experience, and your particular anatomy. There should be a discussion about the steps that may be necessary in the small chance that the procedure does not work. What are the expected potential reasons why the procedure may not work? This is a discussion that should occur before, and not after surgery.
8. Are you board certified?
It is a given that the for the most part, your surgeon will be board-certified in their main specialty, such as otolaryngology, oral surgery and general or plastic surgery. It takes one to two years to pass the written and/or oral exams after finishing residency, so a newly practicing surgeon may be a top notch surgeon, but not yet board certified. Your new surgeon may have trained with a prominent sleep surgeon during residency, be up to date on the latest research and surgical techniques, so if you go only by board-certification, you’re ruling out working with a potentially great surgeon. Not passing the boards usually reflects more on test taking ability, and not one’s clinical or surgical abilities.
Recently, more otolaryngologists are becoming double board certified (like myself) in sleep medicine. Honestly, I do not think being certified in sleep medicine makes me a better surgeon. I think the field of sleep medicine is fascinating, and only wanted to further my education and provide a more balanced form of care to my patients. However, you can still not be certified in sleep and be an excellent sleep surgeon, as evidenced by the fact that many of the pioneers of sleep apnea surgery are not board certified in sleep medicine. Sleep surgery is definitely within the realm of otolaryngology, and not sleep medicine, although there is beginning to be more cross-collaboration between the two specialties.
The vast majority of sleep surgeons will be otolaryngologists, but some oral surgeons also perform overlapping procedures, since they deal with the facial skeleton. There may be some general and plastic surgeons who have an interest in sleep apnea surgery as well.
Ultimately, what is more important than how may procedures I have done, or the training programs that I attended, is whether or not you and I develop a quality patient-physician relationship, where there is mutual trust and understanding. Obviously, this takes time and effort by both parties.
This is an excerpt from my forthcoming book, “The Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need for the Life You Want.”
In my last post, I listed 7 Reasons Not to Undergo Sleep Apnea Surgery. For this post, I will give you 7 good reasons why you should consider sleep apnea surgery. There is a heated debate about sleep apnea surgery within the sleep medicine community. Some sleep physicians are adamant that you should never do surgery, whereas some surgeons downplay CPAP or dental appliances entirely. My belief is that you should do everything possible before considering surgery. However, there’s no “one size fits all” surgery for everyone (except for a tracheotomy), and any kind of surgery must be custom-tailored for every individual, since everyone is different.
1. I hate CPAP
This is the most common reason for wanting to consider surgery. In general, what I find is that most patients give up too soon with CPAP, without proper troubleshooting with the sleep doctors and equipment company. For the vast majority of issues that come up with CPAP, there are simple solutions. On the other hand, some of you have tried religiously for 9 months, going through 4 different masks and 3 different machines. Some find that CPAP makes things much worse, no matter what you try. At a certain point, you have to say enough is enough and consider trying another option. Einstein once said that the definition of insanity is doing something over and over again and expecting different results. Check out the CPAP pro and con posts. I will talk about CPAP in much more detail in later posts.
2. Oral appliance is not helping
In general you want to try every mainstream non-surgical option before considering surgery. Practically speaking, insurance companies also want documentation about what’s been tried in the past. Sometimes, pushing the jaw forward won’t move the tongue forward very much. This can be seen with endoscopy in the office. Some people won’t have enough teeth, or may have TMJ issues.
3. You have a stuffy nose
For both CPAP And oral appliances, you need to make sure that you’re able to breathe well through your nose. One recent study found that “non-compliant” CPAP users went from 30 minutes to over 5 hours after nasal surgery alone. Similar results have been found for oral appliances as well. This is why I have a very low threshold to offer nasal surgery. Once thing to note is that in general, nasal surgery doesn’t cure sleep apnea.
4. You have large tonsils or adenoids
In children, removing tonsils and adenoids is the first-line recommended way of treating obstructive sleep apnea. But even with adults, removing huge tonsils or adenoids can make a big difference. One staging criteria called the Friedman classification found the if you have huge tonsils and a low positioned tongue, and your BMI is less than 40, then you chances of surgical success from UPPP alone is 80%.
5. Previous surgery didn’t work
Just because your previous surgery didn’t work, doesn’t mean that you’re not a candidate anymore. In most cases surgical failure happens because you didn’t address other areas of obstruction. The other possibility is that the areas that you addressed surgically wasn’t aggressive enough to make a difference.
6. If you can’t breathe out through your nose
Notice that I said breathe out through your nose. I’ve described a phenomenon where the soft palate and uvula flops back into the nose, causing you to keep waking up due to your nose becoming clogged with each exhale.
7. You’ve tried everything
Some of you have tried literally everything. CPAP, APAP, oral appliances, nasal strips, tongue exercises, acupuncture, nasal surgery, and even playing a didgeridoo. Still no relief.
If you think that you fit the bill for sleep apnea surgery, please read my past post on why you shouldn’t consider surgery for sleep apnea. If you don’t meet any of the criteria from this post, talk to your surgeon about what he or she recommends. Please share your experiences with sleep apnea surgery on Facebook, Twitter, or Linkedin below.
For many of you, the idea of sleeping with a mask or something inside your mouth makes you cringe. Sleep apnea is taking a toll on your personal and professional life, and you’re willing to consider surgery. You do your research, but find that there are so many different opinions about sleep apnea surgery, it’s impossible to make any sense in deciding on the options. For a summary of how to decide if surgery is right for you, read my report, “The Truth About Sleep Apnea Surgery.”
In this post, I will reveal 7 reasons why you should avoid sleep apnea surgery. In my next post, I’ll go over 7 good reasons to think about surgery for sleep apnea.
1. You’re severely overweight
Studies have shown that the more overweight you are, the less likely any surgery for sleep apnea will succeed. In general losing significant weight will lower your sleep apnea severity by only one level (severe to moderate, moderate to mid, etc.). However, once you do lose a lot of weight, you can be a better candidate for surgery.
One type of surgery that I recommend often is nasal surgery. In general, it’s not going to cure you of your sleep apnea. However, being able to breathe better through your nose can make CPAP or dental appliances (or even future surgery) work much better.
2. You have severe OSA
In general, the more overweight you are, the less likely you’ll respond to sleep apnea surgery. If you can lose a significant amount of weight, then the better your chances for surgical success.
3. Your surgeon recommended a UPPP only
There are exceptions to this situation, but in general, a uvulopalatopharyngoplasty (UPPP) along has less than a 40% chance of surgical success. “Let’s do the UPPP to see if it works” is not a good answer. Your surgeon should make recommendations based on the published data, personal experience and your unique situation.
4. Many hospitals and surgeon are not experienced with OSA surgery
Most ENT surgeons will be familiar with basic sleep apnea procedures, but there are very few that do a variety of different surgical procedures at different levels of the throat. Since undergoing anesthesia with sleep apnea also places you at a higher risk, it’s important that the anesthesiologist and hospital is well experienced in treating patients with obstructive sleep apnea.
5. You haven’t tried CPAP or dental devices
From a practical standpoint, it’s unlikely that your insurance company will approve any kind of surgery if you have not tried a CPAP or dental appliance first. Medically speaking, it’s generally recommended trying non-surgical options before considering surgery.
6. Your nose is stuffy
The more stuffy your nose is, the less likely throat surgery will help. This concept applies to CPAP and dental appliances, and it applies to surgery as well.
7. You don’t have family or friend’s support
Undergoing any type of surgery is a big commitment. You’ll need help making errands, doing chores around the house and to help you cook and eat meals. Most importantly, it’s vital that your family members are supportive of your decision.
If you’re considering undergoing surgery for sleep apnea, how many of the above reasons do you have not to undergo the procedure? Please participate in the discussion in your favorite social media link below.
This is a continuation of my love/hate series on treatment options for obstructive sleep apnea.
In my last post, I described 7 reasons why I like using CPAP for my patients with obstructive sleep apnea. In this post, I will go ever 7 reasons why I hate CPAP. As you can see from this post and past posts, I have a love/hate relationship with all the diagnosis and treatment options for obstructive sleep apnea.
1. Always the wrong pressure
Traditionally, your CPAP pressure is calibrated to cover the worse-case scenario—REM sleep on your back. We know that apneas happen most often in this situation. You’ll get the same pressure the entire night no matter which sleep stage you’re in and which position you’re sleeping in.
Automatic machines are designed for limitations of CPAP, but despite advances in APAP technology and algorithms, it’s still not able to predict when you will enter REM sleep or switch onto your back.
2. The Heisenberg uncertainty principle
One of the principles of physics is that whenever you observe an atom using light, you’re changing the position of the atom. In the same way, having a mask strapped to your face with positive pressure will by definition change the quantity and quality of your sleep. For many people, the benefits will far outweigh with side-effects, but for others, CPAP causes more arousals than it helps.
3. Often used with stuffy noses
Many people with obstructive sleep apnea have stuffy noses, and we know from studies that having nasal congestion can significantly lower CPAP effectiveness. Allergy medications or nasal saline irrigation may help some people, but even if you’re able to benefit from CPAP, it’s probably not working as well it could work due to a stuffy nose. To adjust for these issues, a full face mask can be used, which cover both your nose and mouth. In theory, this can work better, but full face masks are generally more uncomfortable.
4. CPAP doesn’t address milder forms of obstruction
When you undergo a CPAP titration, the pressure is usually calibrated to get rid of apneas and hypopnea, especially when you’re on your back and in REM sleep, when your muscles are most relaxed. However, more subtle degrees of obstruction that don’t meet the 10 second threshold criteria and not addressed. This is why many people can have CPAP adherence data showing an AHI of .1, no leaks, and using 100% of total sleep time, but they don’t feel any better.
5. Potentially makes your teeth crooked
Dentists say that about 50 grams of force is enough to move your teeth. That’s about 2 ounces. Nasal and full-face masks place constant pressure on your front teeth. There are documented reports of patients using CPAP where the upper incisors were found to be shifted back.
6. The system is broken
Studies have shown that with proper education and good follow-up, most people can do well with CPAP. However, due to a broken health care system, many patients slip through the cracks, with minimal to no education and not enough follow-up visits that are needed for troubleshooting. In the academic published literature, “adherence” rates range from 40% to 80%. In the real world, only about 20 to 30% people who start using CPAP are still using it effectively at 1 year.
7. Not a permanent solution for most people
Even if you’re able to use CPAP, life situations change. You may gain more weight. Or you may be in a new relationship. Although I see many people who are very happy using CPAP over decades, some people will want other options at a later time.
8. Flawed CPAP “Adherence” requirements
Medicare and some insurance companies will require that you use CPAP for about 50% of your total sleep time. Otherwise, your machine is taken away. If you start with an AHI of 50 and use your CPAP 50% of the time (4 hours every night), technically, you’re “adherent.” But your average AHI level during your total sleep time is still 25, since you didn’t use CPAP during the other 4 hours during the night. CPAP may be very effective in lowering your AHI to minimal levels, but it’s completely useless if you’re not using it at all.
9. Periodic cleaning and maintenance is needed
This may not matter for people who are regimented and find it important to maintain their CPAP devices on a regular basis, but many others find it cumbersome. Additionally, your body’s CPAP pressure needs will change over the course of months to years, so it’s important to check the pressure at least every 6 to 12 months.
Despite these 9 reasons why I don’t like CPAP, it’s the best that we have, so I do recommend it for most people with moderate to severe. obstructive sleep apnea.
Here are three ways to maximize the chances that your CPAP will work for you:
1. Find the right mask
Many people don’t know that you can ask for a different mask within 30 days. The combination of the right mask and headgear can make a major difference in your comfort levels and whether or not CPAP will work for you.
2. Unstuffy your stuffy nose
Having nasal congestion wil significantly lower the chances CPAP will work. Higher nasal resistance will raise up your CPAP pressures, and it’s also more likely that you’ll open your mouth, causing a mouth leak, which can cause you to wake up. Do everything to make sure that you’re breathing optimally through your nose. This can involve nasal saline, nasal dilator devices, allergy medications, or even surgery.
3. Talk to your health care professionals
Communicate with your sleep physician and equipment company often, especially in the first few weeks. They can troubleshoot only if you give feedback.
In the following posts, I will go over reasons why CPAP may not work, and why I like and dislike surgical options for obstructive sleep apnea.
What has been your experience using CPAP? Was it good or bad? How were you able to overcome challenges to be able to get to the point of sleeping better?
This is a continuation of my love/hate series on treatment options for obstructive sleep apnea.
For those of you with severe obstructive sleep apnea, it can be a potentially deadly disease. Your chances of heart attack, stroke, cancer, car accidents and sudden death are significantly higher compared to those of you with mild to no sleep apnea. Before the 1980s, there was no way of treating this condition unless you opted for a tracheotomy (placing a tube through a hole in your neck).
Continuous positive airway pressure (CPAP) is now the most common recommendation for most people with obstructive sleep apnea. Without a doubt, CPAP has definitely saved millions of lives so far. However, there are many more millions who would love to be able to use CPAP but find that they just can’t use it no matter how much they try.
Here are the 7 reasons why I like CPAP, and will recommend it as first-line therapy for most people with moderate to severe obstructive sleep apnea:
1. CPAP has the most evidence
Since being developed by Dr. Colin Sullivan 35 years ago, most of the research and data on the benefits of treatment has been using CPAP. It’s now commonly accepted that CPAP can significantly lower blood pressure, sugar levels, death rates, car accidents, and various other medical conditions.
2. It’s readily available
Because it’s been around so long, it’s the most widely available. Sleep physicians are most knowledgeable and comfortable prescribing CPAP. Our health care system is set up to prescribe CPAP once you’re diagnosed with sleep apnea through your local medical equipment company. Insurance companies approve CPAP with minimal hassles.
3. It can report helpful information
Most of the modern CPAP machines can report important information every night, including the total number of hours used, any significant leaks in the system, and the average apnea-hypopnea index (AHI). In essence, it’s like doing a basic sleep study every night. This data can be used to track progress and do any necessary troubleshooting.
4. Studies have shown that CPAP is consistently better than dental devices or surgery
This is true, but only if you’re able to use CPAP regularly.
5. It’s possible to get immediate benefit without waiting months or years
In an ideal world, it’s possible to get your sleep test within 1-2 weeks and be set up with a CPAP machine within 2-3 weeks total. Dental devices can take longer, and surgery is usually recommended only after you’re not able to use or benefit from CPAP.
6. It’s now much more convenient
CPAP sizes are shrinking, much quieter, and much more user friendly. They also have portable battery packs and for the adventurous, portable solar panels for the battery. Airport security personnels are much more knowledgeable about these devices as well.
7. It saves lives, especially for severe OSA.
Despite all the positive features of CPAP, it’s only as good as the degree it’s used. Many others are able to use it religiously but don’t find that it helps them feel better at all. I will address more these issues in my future posts.
If you’ve had success in using CPAP, tell us your story below.
In my last two posts, I described 7 positive and 5 negative aspects of mandibular advancement devices for obstructive sleep apnea.
If you’re thinking about trying an oral appliance for your sleep apnea, here are 5 things you must consider to maximize the chances it will work for you:
1. Make sure you’re able to breathe well through your nose. For most people, it’s pretty obvious if your nose is stuffy, but for some others, you won’t know if you have a stuffy nose since you’ve had it all your life. By definition, people with obstructive sleep apnea have smaller facial dimensions so the nose will tend to be stuffier than normal. Whether you use nasal saline, Breathe Rite strips, allergy medications, or even surgery, do everything possible to make sure you’re breathing optimally through your nose before starting your oral appliance treatment. Research has shown that having better nasal breathing will significantly increase your chances of benefiting from oral appliances (and CPAP as well).
2. Research has shown that people with severe obstructive sleep apnea (AHI over 30) don’t do as well with mandibular advancement devices. It doesn’t mean that it won’t work with you, since everyone is different. This makes sense since having years and years of repeated obstructions will cause your throat tissues to cave in and becme floppy, so moving your tongue forward won’t open up other areas in your throat.
3. If possible have your ENT (otolaryngologist) take a look at your throat using a flexible camera with you lying flat on your back. This position maximizes tongue collapse. Note the air space behind your tongue and then thrust your lower jaw forward, beyond your upper teeth. Make sure you’re not opening your mouth too much, since that will push your tongue backwards. Most people will have significant tongue movement when pushing the jaw forward, but there are some people where the tongue doesn’t move very much, or not at all. I’ve had a number of patients who paid $3000 for an oral appliance which didn’t help, and we found that the tongue doesn’t move at all. Rarely, the tongue can move backwards with the jaw thrust forward.
You also want the soft palate to open up at least somewhat along with the tongue moving forward. The side of the tongue connects with the soft palate via the palatoglossus muscle. For people with severe obstructive sleep apnea, no matter how much the tongue moves, the soft palate still collapses completely.
4. It’s also important to remember that routine dental x-rays and CAT scans of the throat are usually performed sitting up, so the airway can seem wide open. In many cases, the degree of obstruction can be dramatically more severe when lying down on your back. This is why many of you can’t sleep on your back.
5. Not all advancement devices are equal. I get asked all the time which is the best device. There are literally dozens of different FDA approved mandibular advancement devices. All have their pros and cons. Most experienced dentists will have a handful of favorite options that are used for appropriate patients. Ultimately, it’s the dentist’s experience and follow-up care which is more important than which device is used. Similarly, how and why a surgeon uses a laser is more important than which type of laser he for she uses.
In my practice, if you have mild to moderate sleep apnea, can breathe well through your nose, and can open up the space behind the tongue and soft palate by moving your jaw forward, you have a much higher chance of benefiting from mandibular advancement devices.
If you’ve been successful with an oral appliance to treat your sleep apnea, please describe your experience below.
In my last post, I described 5 reasons why I like oral appliances to treat obstructive sleep apnea. This is a continuation of my love/hate, pro/con blog posts about various sleep apnea tests and treatment options.
Here are my 5 reasons why I don’t like oral appliances:
1. It’s challenging to find a qualified dentist for every patient. For most people who live in metropolitan areas, there are lots of options. If you live in rural areas or if you have insurance that’s not common accepted (like medicaid plans) it’s much more challenging.
2. It can change your bite. This is an expected, and common side effect. If you work with a good dentist, this can be minimized or reversed. Some people don’t care, since they’re sleeping so much better.
3. It’s much more expensive than CPAP. If you don’t have insurance, it can cost a few thousand dollars, whereas CPAP is well below $1000.
4. It can be lost or damaged. Because it’s so small, it’s easier to lose. I’ve also had a handful of patients that told me that their dog chewed up their devices.
5. Although these devices will pull the tongue forward, it also takes up space within the mouth, leaving less room for the tongue.
For the most part, I find that mandibular advancement devices are helpful and in general, better liked by patients. This is in line with published studies.
In my next post, I’ll describe the 5 things you need to know before you see a dentist, to maximize the chances that an oral appliance will work for you.
When given a choice for treating obstructive sleep apnea, many people hate the idea of using a mask attached to a hose every night. Fortunately, there are a number of good alternatives.
Mandibular advancement devices (also called oral appliances) for obstructive sleep apnea come in various models, but they all have one thing in common: The lower jaw is pushed forward against the upper jaw, moving your tongue forward, opening up your airway. Different models have different bells and whistles, and all have their pros and cons. This is why it’s important for a dentist to be experienced with a number for different models, since everyone has different needs.
Continuing on my love/hate themes for various treatment options for obstructive sleep apnea, in this post I’m going to describe 7 reasons why I think dental appliances are a great alternative to CPAP for obstructive sleep apnea.
1. No headgear or straps around your face. Most oral appliances fit completely inside the mouth.
2. It’s silent. Because it’s not a pump, it’s completely silent.
3. It’s small and convenient. It’s also easy to take with you on trips, compared to CPAP machines.
4. Compared to even a few years ago, more dentists are available to make these devices, and are usually covered through most major insurances.
5. Recent studies have shown that oral appliances are equivalent to CPAP for people with mild to moderate obstructive sleep apnea. The American Academy of Sleep Medicine has stated that oral appliances can be considered a first line treatment option in addition to CPAP.
6. An oral appliance can be made as a holder for CPAP using a nasal pillow-type mask. This way, there are no straps or headgear for CPAP. The appliance can be set at a neutral position just to hold the CPAP in place, or it can used as an advancement device in addition to allowing for nasal pillows.
7. It can be used effectively for snoring, even if you don’t have obstructive sleep apnea.
Oral appliances are very helpful for many patients in my practice. However, these devices do have some drawbacks. For my next post, I will give 5 reasons why I don’t like oral appliances.
If you are successful at using an oral appliance to treat your sleep apnea, how did it compare to using CPAP? How were the different options explained to you by your sleep physician? What was your experience like getting the device made by your dentist? Please describe your experiences below.
In-between nasal surgery cases today in the operating room, my resident asked me why the standard over-the-counter isotonic nasal saline preparation said .65% saline, rather than .9% saline.
The normal salt concentration in our bodies is 0.9%, which can also be mimicked by adding 9 grams of salt into 1 liter of water. This is called isotonic saline.
Nasal saline rinses are a helpful way of helping you to clear out your nose and open up your sinuses. There are a number of different concentrations, formulations, and ways of getting saline into your nose. Most physicians recommend isotonic saline, which is the same salt concentration as what’s in your body. There are certain reasons for use more or less concentrated versions.
Hypertonic saline is saltier than your body’s salt concentration, so irrigating your nose will cause water to leave your nasal membranes into the saline to equalize the salt concentrations. It’s like what happens when you add salt to a cucumber. Water leaves the cucumber and it shrivels up, like what happens to your nasal membranes. Swimming in ocean water also does the same thing. This process is called osmosis. Using hypotonic (less saltier) saline will cause water to enter your nasal membranes, causing more swelling and congestion.
In theory, you should use isotonic saline to flush out nasal mucous and cause some mild shrinkage of your nasal membranes. This is why nasal saline irrigation can make you feel and breathe much better. Then why do many products say that .65% is “isotonic”?
After doing some research, it turns out that one of the common brand names (Ayr®) is isotonic at .9%, but only .65% is salt. The rest is made up of a buffering agent (sodium hydroxide) to make it less irritating, with two other preservatives. The first one is EDTA, which acts to bind to heavy metals, and also has antibacterial and anti fungal properties. It’s also used in a number of other applications, as a food stabilizer to cosmetics and even for lead poisoning. The other one is benzalkonium chloride, which is used in many eye drops and nasal sprays as a preservative. It also has antimicrobial properties.
Neilmed®, on the other hand, comes in dry packets which you use to make your own isotonic saline. It contains only sodium chloride and sodium bicarbonate.
If you also look at the list of ingredients for Ayr gel, it contains a lot more ingredients that you may normally see in hand lotions:
- methyl gluceth-10
- propylene glycol
- aloe barbadensis leaf juice (aloe vera gel)
- PEG/PPG-18/18 dimethicone
- sodium chloride
- xanthan gum
- glyceryl polymethacrylate
- sodium hydroxide
- poloxamer 184
- diazolidinyl urea
- glycine soja (soybean) oil
- geranium maculatum oil
- tocopheryl acetate
- blue 1.
This may explain why I personally can’t tolerate any kind of nasal saline, since it burns too much, even with added buffering agents. However, most people do well with nasal saline irrigation.
There’s also some concern about long-term use of nasal saline, but for short bursts or intermittent use, it should be safe.
The least expensive way is to make your own saline. Mix 2 cups of distilled water or boiled tap water that’s been cooled to lukewarm temperature with one teaspoon of sea salt or Kosher salt and one teaspoon of baking soda. Don’t use regular table salt, as it may contain iodine. You can recycle one of the over-the-counter bottles or containers, or even use a very large medical syringe or even a turkey basting syringe. Baby suction bulbs can also work. You can store homemade saline at room temperature for 3 days.
The bottom line is that not all saline is the same. If you walk down the aisle in the pharmacy, you’ll see many more options. Take a look at all the ingredients. Not only are the ingredients different, the way you get the salt water into your nose is also different. This ranges from squeeze bottles, to Neti-pots, and syringes, and even aerosol cans. There are even pressurized irrigation systems.
What you’re experience with nasal saline washes? Are you sensitive to various added ingredients? If you make your own, what helpful tips can you offer? Please enter your experiences and suggestions in the text box below.
Robert was clearly anxious about spending a night in a sleep lab, since he never liked sleeping in hotel rooms. He always followed a specific bedtime routine, and was concerned that he would not be able to sleep at all in the sleep lab. Due to the very high likelihood of having obstructive sleep apnea, and with a history of leg movements, I recommended an in-lab study.
An in-lab comprehensive sleep study is considered the “gold standard” for sleep apnea testing. A number of different wires are attached to your body to measure the following: brain waves, nose and mouth channels for airflow, chin and leg movements, oxygen levels, snoring microphone, and chest and stomach belts to detect movement.
Because it’s so comprehensive, it can also be somewhat intrusive. Being hooked up from head to toe (actually ankle) can prevent you from getting a good night’s sleep. Here are 7 reasons why an in-lab study is not the most ideal way of measuring your sleep quality:
1. It’s not your normal sleep environment.
It’s bad enough traveling and having to sleep in a hotel room with an unfamiliar bed and surroundings. How about adding wires to your scalp, eyes, chin, chest finger and legs? Many of you have asked me, “How can you expect me to sleep in a strange room with all those wires and with someone watching me?
The good news is that despite people’s fears, the vast majority of people are able to sleep long enough to be able to calculate a sleep apnea score, or the apnea-hypopnea index (AHI).
2. Not your normal sleep times.
No matter how well you try go to bed at a set time, it’s almost impossible to time it just right, especially if you’re in a new environment. Many patients have told me that they were expected to go to sleep much later or much earlier than their normal sleep times. This is like trying to sleep in a different time zone. Make sure you call ahead to see approximately when you’ll be able to go to sleep.
3. All wired up and tethered.
Having all those wires on your entire body can definitely make it uncomfortable for you to sleep. It can also tether you to some degree, preventing you from rolling side to side.
4. Not your normal sleep position.
Having wires attached to your body will also prevent you from sleeping in your normal sleep position. Many labs will tell you to sleep on your back. For some of you, this can be a form of torture, since you won’t be able to sleep at all on your back.
5. Not your usual pillow.
Most likely, you’ll forget to bring your favorite pillow. Many people are very particular about their pillows. It’s also important to realize that a pillow can significantly affect your head position and your airway size.
6. Stuffy nose from nasal cannula.
In-lab and home sleep studies all use a plastic nasal channel with two prongs that fit inside your nostrils. This measures nasal airflow. But in some cases, having something in your nose can create more vacuum forces that causes your nostrils to cave in more, which can keep waking you up. One exception to this situation is the Itamar WatchPAT unit, which doesn’t use a nasal cannula.
7. Overkill for most routine OSA.
For most run-of-the-mill cases of obstructive sleep apnea, a home study should be more than adequate. There are very specific situations where an in-lab study may be needed, such as in patients with neuralgic conditions, heart failure, or patients with special needs. However, for the vast majority of patients with sleep apnea, in-lab studies can be overkill.
Despite all these limitations, it’s the best that we currently have. Home testing is getting better, and there may come a time when most routine testing for sleep apnea can be handled through home testing, with the medically complicated patients reserved for in-lab studies. With better technology and perhaps with advances in smartphone features, screening for sleep apnea will definitely undergo rapid changes in the near future.
In case you’re wondering, Robert was found not to have any significant sleep apnea, but did have lots of leg movements (called periodic limb movements). Upon further questioning, he reported that he had to shake his legs and walk around just before bedtime, which was consistent with Restless Leg Syndrome (Willis-Ekbom disease). He also had low iron levels. After being given iron supplements for 3 months, his sleep quality improved.
In my next post, I will reveal the 7 Reasons Why I Don’t Like Home Sleep Studies.
If you agree of disagree with any of my 7 points, I’d like to know. Please enter your comments below.
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