Pregnant Women More Likely To Stop Breathing At Night

August 3, 2011

As a follow-up to my post last week on why pregnant women may have an increased risk of stroke, here’s a study published this month in the journal Sleep. Researchers compared 34 women with gestational hypertension vs. 26 healthy women with uncomplicated pregnancies. Significant sleep-disordered breathing was defined as a respiratory disturbance index (RDI) of 5. Pregnant women with high blood pressure had significant sleep-disordered breathing in 53%, whereas 12% of healthy pregnant women had sleep-disordered breathing. Hypertension is a known risk factor for preeclampsia and stroke.

This study is in line with my suspicion that pregnant women, while at risk for obstructive sleep apnea, probably have shorter obstructions and RERAs (respiratory-effort related arousals), rather than frank apneas. Increased progesterone and various other physiologic changes seen in pregnancy can increase your respiratory drive and lower arousal thresholds, leading to more frequent arousals from deep sleep.

Notice how commonly pregnant women snore, and they’re extremely tired. If they weren’t pregnant, doctors would suspect obstructive sleep apnea. Then why do we have this double standard? Why can’t women who suddenly gain weight and snore be routinely screened for obstructive sleep apnea?

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

CPAP Compliance vs. Adherence

June 9, 2010

Throughout all the talks and papers on CPAP usage at this year's SLEEP 2010 Meeting, it seems like the word compliance is being used less and less, and instead, sleep researchers are using the word adherence. Unfortunately, the practical meaning hasn't changed—it describes how long users are able to use CPAP on a nightly basis. Various researchers use different definitions, but one definition that is commonly used (since it's what Medicare uses) is at least 4 hours per night in at least 70% of nights in a 30 day period. So if there are 56 total hours in a week if you sleep for 8 hours, on average you have to sleep at least 20 hours per week on CPAP to be "adherent." That's about 35% of your total sleep time.

Considering that most people aren't able to use CPAP at all (published "adherence" rates range from under 20% to over 80'%), this is a very liberal criteria for what is considered the minimum time that's considered "acceptable" by the sleep community.

Even if you're considered "adherent," it's assuming that you're receiving optimal CPAP pressures with no leaks. So if your final AHI at your "optimal" CPAP pressure is 16, then if you use your CPAP machine enough hours per week, then you're considered "adherent."

There has to be a better way to measure how well and for how long people use their CPAP machines. We should also incorporate the quality of CPAP use, in addition to quantity.

What do you think about these definitions?

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

Q: Severe OSA or UARS?

August 17, 2009

Q:
Hello Dr. Park,

I am a 24 year old male and have been suffering from moderate-severe sleep problems for at least 7 years now. For as long as I can remember, I have had issues waking up in the morning. No matter how hard I try or what methods are used, I couldn’t get up when desired. In the past 2 years I have noticed a big decrease in my level of energy. Oftentimes I feel fatigued to the point where my day is compromised.

In early April I had a sleep study performed which found that I had severe OSA. Apparently I stopped breathing up to 85 times an hour when I was on my back, which was slightly worse than when I was on my side or stomach. I have been using the CPAP for almost 2 months now and honestly don’t feel that much better. I would say that it is a little easier to wake-up in the morning, but that’s about it. I still suffer from fatigue and lack of energy throughout the day. My doctor is saying that the CPAP has returned my AHI to normal levels, but I am not noticing the difference.

In my attempt to locate more information, I came across your journal entry “Tired of Being Tired” to learn more about UARS. My main question, is how possible is it that I have a moderate-severe OSA as well as UARS?

I greatly appreciate your assistance and service and wish you the best!

JPBESpoke

A: Sorry to hear about all that you’re going through. It must be frustrating. If you’re using CPAP regularly and have data from the machine that confirms it (good compliance and no leaks with minimal AHIs), then the best thing to do is to be patient. You’ve had this condition for years, and sometimes it can take months (sometimes 6-12) to begin to feel better.

It does sound like you do have upper airway resistance syndrome, but you also have severe obstructive sleep apnea. What I see is that some people with UARS go on to develop what may look like chronic fatigue syndrome. Your involuntary nervous system is severely unbalanced, and you have to give it time to come back into alignment. Your situation is complicated and and endoscopic exam will only confirm what you already know. But it’s probably a good idea to take one look to make sure there’s nothing else that’s going on. By definition, you’re susceptible to any of the somatic syndromes, since these are intimately linked to sleep-breathing problems.

There are also many studies that show that people with untreated obstructive sleep apnea have significant brain abnormalities with various degrees of injury. Years of hypoxia can cause temporary or permanent injury. You can imagine how multiple areas of damage throughout the brain can give various signs or symptoms such as chronic fatigue, numbness, hormonal imbalances, etc. This is not proven as of yet, but if you look at all the research in this area, it’s a reasonable explanation. This is why sometimes it can take months or over a year to begin to feel better.

Written by Steven Park · Filed Under QnA | 2 Comments

Solutions for Your Bed Partner’s Worst Sleep Problem

March 24, 2009

Anthony Burgess, the novelist, once said: "Laugh and the world laughs with you. Snore and you snore alone". Suffice it to say, there’s nothing worse than trying to sleep next to someone who snores. Snoring is also a common reason why many married couples sleep apart. Besides the whole host of health problems that snoring is associated with, like high blood pressure, heart disease, diabetes, snoring is even linked to erectile dysfunction in men (see our feature article: What the Makers of Viagra Missed). Fortunately, snoring is something you can get rid of. The problem is in knowing how.

Why Snore?

Snoring is probably one of the most frustrating conditions not only for the snorer, but for spouses and bed-partners as well. It’s also one of the least understood medical conditions by most doctors. One of the main reasons for this is that there are a lot of myths perpetuated both by the media and pop culture about snoring. It’s oftentimes seen as something of a farce. The truth is, however, snoring is a sign that the person who snores is most likely struggling to breathe at night, and therefore, is at a much higher risk of having a heart attack or stroke.

Moreover, textbooks and internet resources further mislead people to think that snoring originates at the soft palate, since that’s where most of the vibrations occur. However, the soft palate doesn’t flutter all by itself: the nose as well as the tongue can be involved. Even most doctors focus way too much attention on the soft palate.

The challenging part of eliminating snoring is in figuring out what’s actually causing the snoring. The vibrations of the soft palate is only the end result and not, as many people think, the thing that causes the snoring. Imagine your upper airway as a long, thin tube that has three main areas that can either narrow or collapse when a slight vacuum pressure is applied. Like a flimsy straw that would collapse in the middle if you pinch the tip, or would collapse at one end if you pinched the middle, your airway is also affected by how well you can breathe through your nose not to mention how tone or relaxed your muscles become as you drift off in to deep sleep. Gravity can also play a part in obstructing your airway, since your tongue, as well as the excess tissues around the back of your throat can naturally fall back partially obstructing the airway, as you lie down on your back to go to sleep.

It’s All In Your Jaw Size

Another major factor that determines how well you breathe at night, or how susceptible you are to snoring, is the size of your jaws. It’s been shown that modern human’s jaws are slightly smaller than what we had hundreds of years ago. Various reasons are proposed, but one major reason is thought to be due to a major change in our diets. (For a more complete description of this process, take a look at my book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired.) If your jaw is slightly smaller, then your tongue which grows to its’ normal size, takes up too much space, sitting higher and more backwards in your throat. As a result, when you lay flat on your back, due to gravity, your tongue will fall back partially, and when you breathe in, a mild vacuum effect is created upstream at the palatal level, which constricts the soft palate closed, which then causes the free edge of the soft palate to flutter and vibrate causing the snoring noise. On the other hand, if your nose is stuffy for any reason, then a vacuum effect is created downstream, which forces the palate and the tongue to slide backwards towards the airway making it narrower and therefore creating sounds we call snoring when the air seeps through the small opening. So this is how a simple cold or an allergy attack can aggravate temporary snoring.

Furthermore, if your muscles relax more than usual (like after alcohol ingestion), then you may even stop breathing altogether. In this circumstance, if these breathing pauses last longer than 10 seconds, then it’s called an apnea (or loss of breath). In those people who have 5 or more of these apneas every hour on average, then are diagnosed with a serious sleep breathing condition called obstructive sleep apnea. Untreated obstructive sleep apnea can then lead to depression, anxiety, weight gain, diabetes, sexual dysfunction, high blood pressure, heart disease, heart attack and stroke.

The really bad news for snorers is that a significant number of heavy snorers have obstructive sleep apnea (about 30-40%, and much higher as you get older or heavier). It’s true that not all snorers have sleep apnea, and not all people with sleep apnea snore. However, if you’re not snoring, then you may also not be breathing. It’s also been shown that neither you nor your bed-partner can tell if you stop breathing—it can just be silent pauses, without any audible gasping, coking or snorting. When some people say, I used to snore a lot, and now I don’t anymore, but I’m still tired, then there’s cause for alarm since even those that state with certainty, "I know I don’t have sleep apnea" are more often than not, wrong.

What Can I Do To Stop The Snoring?

So, once you’ve found out where the snoring is coming from, the next step to solving your snoring problem is to find the right solutions. Of course you can start by doing the most obvious like:

    • lose weight
    • don’t drink alcohol before bedtime
    • don’t take any medications that are sedating or relaxing
    • sleep on your side
    • sew a sock stuffed with a tennis ball to behind your back to prevent sleeping on your back.
    • use nasal dilator strips.

Sometimes, any of these options may work to various degrees, but for most, the problem will usually come back. The most important issue here, however, is that if you snore heavily, you have to find out if you have obstructive sleep apnea. Even if you are successful in covering up your snoring, you could still have untreated obstructive sleep apnea. And if this is the case, you’re putting yourself at serious risk for heart disease, heart attack and stroke. The best thing to do to avoid this from happening is to see a sleep doctor and undergo an overnight sleep study if you snore.

If you are found to have obstructive sleep apnea, then treating this condition definitively should take care of your snoring. Not only will your snoring improve, you’ll also feel much better in the morning, and have much more energy during the day. In addition, your increased risk for many chronic health problems mentioned above will be improved as well. You may also lose weight. (you may even feel like having sex again-see What the Makers of Viagra Missed).

So lets say that you don’t officially have sleep apnea. What can you do? Before I go into this discussion, sleep apnea is not something that you either have or don’t have. Everyone is on a continuum. As mentioned before, if your AHI is 5.1, you’re told you have it, whereas if your score is 4.9, do don’t have it, and because you don’t officially meet the formal criteria, it’s not a good enough to cause to ignore your snoring. It’s still a problem that should be addressed as it can make you lose sleep, not to mention put a damper on your love life in more ways than one.

All Those Snoring Treatments

There are over 300 patented devices and gadgets for snoring (refer to ). Sometimes they work, but with a few exceptions, most of these devices either cover up your snoring without getting to the root cause of your condition, or keeps you awake so that you don’t snore. Three popular anti-snore aids were recently tested for effectiveness in a prospective study: a throat spray, nasal dilator strips and a pillow. None of these three were found significantly better than controls when tested prospectively. There are even devices that wake you up as you enter deeper levels of sleep to prevent muscle relaxation. Regardless of what treatment options you choose, it’s imperative that you first get a proper evaluation from a sleep specialist or a medical professional about your snoring. Doing so could not only help with the snoring, it can help you foster a healthy relationship with your loved ones.

Written by Steven Park · Filed Under Articles | 1 Comment