Allergy Solutions for Sleep Apnea Sufferers

April 21, 2010

Spring is in the air, and so are the tree pollens. Millions of people suffer this time of the year from sneezing, scratchy, itchy eyes, nose and throats, nasal congestion and chronic cough. It's also a given that if you have allergies, you won't sleep as well, along with everything from asthma, cough, and sinusitis to diarrhea. So how do allergies cause sleep problems, and in general, and how does it specifically cause or aggravate obstructive sleep apnea?

When Allergies Lead to Something Worse

There are already tomes of articles, books and websites offering tips for allergy sufferers including traditional options like nasal saline irrigation, homeopathic remedies, and using a HEPA filter to prescription medications and allergy shots. But again, how can having a runny nose cause you not to sleep well at night? I've combed through numerous medical and internet resources and to date, I haven't found one good explanation.

However, looking at it from a sleep-breathing standpoint, it makes total sense: any degree of nasal congestion, whether from allergies, colds, or even weather changes, causes a slight vacuum effect downstream in the throat which can aggravate tongue collapse, especially in certain susceptible people. Who then, are susceptible to tongue collapse? Almost every modern human!

It's All In Your Jaws

To be more specific, the smaller your jaws, the more likely you'll sleep poorly when you have allergies. Even if you're completely normal, having a stuffy nose can suddenly cause your tongue to fall back and block your breathing. Plugging your nose has been shown to cause obstructions and arousals during sleep. This is why you'll toss and turn when you have an allergy or a simple cold.

Many people with allergies and small mouths will also have grooves or indentations along the side of their tongues. This is called tongue scalloping. Since the tongue and other soft tissues grow to their genetically predetermined size, and due to crowding from having smaller jaws, the teeth leave their imprints along the side of the tongue. If you have additional inflammation from gastric reflux that's a given with sleep-breathing problems, then this scalloping problem gets worse. Not too surprisingly, tongue scalloping is predictive of having apneas, hypopneas, or oxygen drops in almost 90% of people.

Allergies From Stress?

So then, why do allergies happen in the first place? Again, there are tons of proposed explanations that I don't have the space for, but here's a simple concept from Robert Sapolsky's classic book, Why Zebras Don't Get Ulcers:

Humans can handle big stresses such as a major catastrophe, a death in the family, or running away from a tiger. In these scenarios, your stress response leads to an intense activation of your immune system (in addition to your nervous system's fight or flight response). Once the stress is over, your immune system's activity level drops down to normal, but only after it dips below normal for a short period of time. During this short period, you're also more susceptible to getting sick.

However, modern societies don't have very big stresses such as running from a saber tooth tiger. Rather, we have multiple micro-stresses spread throughout the day such as being honked from the rear on the way to work, your boss yelling at you, or your computer crashing. These little stresses push your immune system's activity higher and higher, with not enough time for it to recover and go back to normal levels. After a certain point, your immune system is on constant overdrive, leading to the typical allergic or autoimmune conditions that are all-too-common today.

When Your Allergy is Not An Allergy

This process also explains why you may also have a chronically runny nose. This is called chronic or nonallergic rhinitis, when the involuntary nervous system in your nose overreacts to irritants, chemical, odors, or weather changes (either pressure, temperature, or humidity changes). Symptoms include runny nose, sneezing, nasal congestion, post-nasal drip and headaches, and is often mistaken for regular allergies. This condition may respond to regular allergy medications, but not as well. Either way, inflammation and swelling can also cause nasal congestion, leading to poor quality sleep.

Overcoming Your Allergies

If you have classic allergies, you must start with the basics: Avoid outdoor activity on high-pollen days, shower before bedtime to get the allergies out of your hair, don't wear shoes indoors, get a HEPA filter, and take over-the-counter medications as needed. Some people benefit from routine use of HEPA filters as well in their bedrooms. You may have to see your doctor if conservative measures don't help.

There are various over-the-counter allergy medications. The newer, nonsedating antihistamines block the effects of histamine, which is what causes watery, itchy, runny eyes and nose. The most common brands are Claritin, Allegra, and Zyrtec. They all work differently in different people, so the only thing you can do is to try each one and see which you prefer. Although they are nonsedating in theory, there are reported cases of drowsiness with all three. Benadryl is an older antihistamine that's very effective for allergies, except that many more people may get drowsy.

If your nose is stuffy, then two options are nasal decongestant sprays (which you can only use for 2-3 days) or decongestant pills. Routine nasal saline irrigation can also help your breathing and sleep.

There are a number of prescription medications, including topical nasal steroid or topical steroid sprays. Leukotriene phosphate inhibitors, such as Singulair, and various others also available. Oral steroids can also be useful in emergency situations. As a last resort, an allergy evaluation with shots are a consideration.

Regardless of which way you treat your allergies, it's important to follow all my recommendations for better breathing while sleeping, such as avoiding eating or drinking alcohol within 3-4 hours of bedtime, sleeping on your side or stomach. Having a stuffy nose for whatever reason can trigger breathing pauses downstream, ultimately giving you a bad night's sleep.

Written by Steven Park · Filed Under Articles | 2 Comments

The Hidden Truth About Allergies Revealed

October 27, 2009

Everyone knows that allergies cause sneezing, itchy, watery eyes, and nasal congestion and that for some people these symptoms can be more severe than for others. For these people allergies can feel like a curse, making them feel sleepy, irritable and downright miserable. There are many medical explanations for allergies, including the theory that the body is overreacting to the typical allergens.

But there’s one other reason why some people with allergies are more affected than others, and this has to do with their jaw size. If you had normal-sized jaw anatomy, then it’s less likely an allergy attack would bother you; in fact, it’s less likely you’ll even have allergies in the first place. Let me explain.

Why Your Jaw Size Matters

If you have smaller than normal jaws, it means that there’s less space for your tongue, so it takes up relatively too much space, especially when you’re on your back due to gravity. Even worse, whenever you’re in deep sleep, due to muscle relaxation, you’ll stop breathing to wake up and turn over. During these breathing pauses, a vacuum effect is created temporarily, which literally suctions up your normal stomach juices into your throat and nose. It’s been shown that stomach bacteria and digestive enzymes can be found in sinus and lung washings. This leads to inefficient sleep, which eventually makes your nervous system and immune system overactive.

This is why it’s important to avoid eating too close to bedtime. The more juices you have in your stomach, the more it’ll come up and cause nasal inflammation. And since alcohol is a strong muscle relaxant, indulging in a glass of wine before bedtime can make you stop breathing more often and cause more stomach juices to come up into your throat, in addition to heightening your immune and nervous systems.

What You May Not Know Will Surprise You

Sometimes, what seems to be allergy symptoms may not be related to allergies at all. Whether or not your allergy testing is positive, you may be suffering from non-allergic rhinitis or chronic rhinitis, which is linked to sleep breathing problems or silent acid reflux (LPRD). With non-allergenic rhinitis, your nose becomes sensitive to temperature, pressure, humidity changes, chemicals, odors, and emotions. Non-allergic rhinitis responds somewhat to allergy medications, so you may think you have an allergy problem.

One of the most under-appreciated things that most allergy sufferers (and doctors) don’t think about is getting a good night’s sleep. It’s been shown that lack of quality (or quantity of) sleep can adversely affect your immune system through the following mechanism: a low-grade physiologic stress response is created which heightens your immune system, making it over-react to common pollens or other allergens. (The same process occurs with your nervous system, too). So how does this relate to allergies?

Hay Fever Defined

Hay fever (or allergic rhinitis) results in congestion, sneezing, runny nose, irritated eyes and other annoying symptoms for more than 35 million Americans every year. It occurs when your body has an allergic reaction to something in your environment. During this time of the year, ragweed is the most common cause of hay fever, though mold, pet dander, dust mites and cockroaches can also cause allergies year-round.

When your body comes in contact with these allergens, your immune system kicks into overdrive. At the initial allergen exposure, the body creates an antibody called immunoglobulin (IgE), which rests on a type of white blood cells called mast cells. After repeated exposure to the same allergen, a massive release of histamines and other inflammatory mediators occurs. The end result—runny nose, watery eyes and sneezing.

When Allergies Cause You Misery

Obviously, a little sneezing and congestion never hurt anyone. For most people, these symptoms are no more than a mere nuisance and most can get by without any medications or for others, simple over-the-counter medications (see chart). However, some people with allergies feel completely miserable, with poor sleep and severe daytime fatigue.

As I alluded to in my book Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, anything that causes swelling or inflammation in your nose or throat can set off a vicious cycle where due to narrowing of the upper air passageways, the soft tissues of the throat (palate and/or the tongue) start to obstruct your breathing, which creates a vacuum effect in your throat that suctions up normal stomach juices into your throat. This causes more swelling and inflammation in your throat and nose, aggravating this self-perpetuating cycle.

Steps You Can Take

During allergy seasons (trees during the spring, ragweed during the fall, molds all year round), there are a number of conservative step you can take to lessen your symptoms, to more formal medical treatments:

● Stay indoors during high pollen counts with air conditioning (check pollen counts on pollen.com)

● Wash your hair before going to bed if you’ve been outdoors during the day. You don’t want to rub your face on your pollen-contaminated pillow all night long

● Most plants release pollens in the early morning, so if possible stay indoors until after 10AM. Pollen and molds can also be high in the late afternoon and early evening hours

● Wash your bedding every week in very hot water

●Invest in allergy-free bedding (if you’re allergic to dust mites)

● Try the Asian custom of taking off your shoes before entering your living spaces. Think about all the microscopic dust, pollen, molds and dirt that get tracked into your house, where your toddler is crawling on.

● Invest in a HEPA filter for your bedroom

● Keep pets out of the bedroom

● Remove rug or carpeting from the bedroom

● Finish eating at least 3-4 hours before bedtime

● Avoid alcohol within 3-4 hours of bedtime

● Regularly practice yoga, breathing, tai chi, or some form rhythmic meditative breathing (which also includes swimming).

A few natural and/or herbal remedies include:

● Regular irrigation with nasal saline. There are many options, including a Neti-pot, saline sprays, mists, pumps and squeeze bottles. The key is to find something you’re comfortable with that you’ll use every day. ●

Butterbur and stinging nettle extracts are two herbs that have anti-allergy properties. You can find them at any health food store or order them online. If the above conservative options are not good enough, you can try any of these over-the-counter allergy medications:

● Loratadine (brand name Claritin, Allavert, etc.) or Zyrtec. Zyrtec is stronger, but has a slightly higher chance of making you drowsy. If you take it regularly at night before you got to bed, this any potential drowsiness won’t be an issue and this effect wears off after a few days. ● Diphenhydramine (Benadryl). This is an older, stronger antihistamine, which can definitely make you drowsy. It’s also used to severe allergic reactions and rashes.

● Oxymetazoline (Afrin) can be used for severe nasal congestion only occasionally and should be used no more than 2-3 days at a time.

If you also have nasal congestion, then you can get the "-D" version of the various antihistamines. The D stands for decongestant, which is usually an oral version of phenylephrine or pseudo-ephedrine. This can sometimes be stimulating, so if you’re sensitive to these medications, don’t take it just before bedtime. If you have high blood pressure or a heart condition, talk to your medical doctor before taking these specific medications.

There are a number of prescription medications for allergy: Allegra (which should be coming out over-the-counter soon), nasal steroid sprays (Flonase, Nasonex, Rhinocort, Nasacort, Veramyst), and Singulair. Astelin is an antihistamine nasal spray. Different people respond differently to each of these medications, so it’s important to talk to your doctor about which one may be right for you. My preference for moderate to severe allergies is to use one of the topical nasal steroid sprays on a regular basis, since it works much better at preventing allergies, as well as treating it. In general, these sprays are not absorbed into the body in significant amounts and can be used for long periods.

Allergy shots (immunotherapy) are another option that you may want to consider if your allergies don’t respond to medications or if you don’t want to depend on medications as much. With immunotherapy, the sufferer receives regular injections of purified allergen extracts for between two to five years. The goal of immunotherapy is to rewire the immune system so it no longer overacts to allergens and causes hay fever.

Putting It All Together

If you have an underlying sleep-breathing problem such as obstructive sleep apnea or upper airway resistance syndrome (most people to some degree—I explain why in my book, Sleep, Interrupted), then it’s likely that you’ll have some kind of allergies or nonallergic rhinitis, whether mild or severe. Not only will your nose be overly sensitive to allergens or weather changes, it can also be irritated by your stomach juices.

This process supports observations that children who were bottle-fed as infants have higher rates of allergies later as children. It’s been suggested that bottle-feeding promotes jaw narrowing and dental crowding, which leads to smaller airways. This occurs despite the protective effects of the mother’s antibodies in breast milk, since it may be given in a bottle. So the next time you suffer from seasonal allergies or even year-round allergies, resist the temptation to simply take a pill. Go down the list of conservative options I’ve outlined, and most importantly, optimize your sleep quality. Any activity that’s calming and relaxing to your nervous system (yoga, breathing exercises, tai chi, swimming) can also help to alleviate your symptoms. Many of you will be surprised to find that conservative and simple lifestyle changes can lead to many more allergy-free, symptom-free days.

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

When Your Cold is Not a Cold

June 12, 2009

In our current age of economic recession and flu epidemics, experiencing hoarseness or a sore throat can conjure up worst-case scenarios. What I’ve noticed in more recent months is that more and more people with these two symptoms are coming in concerned about throat or lung cancer. If you feel a lump in your throat, the word lump itself can cause feelings of stress or anxiety. If you’re a smoker or a past smoker, the situation is even worse.

The other day a man came in complaining of an itchy, scratchy throat 4 days prior, with loss of his voice the next day. He didn’t have any other viral symptoms such as fever, chills, or muscle aches. Upon further questioning, he normally eats dinner early, but the night before all this happened, he went out to eat dinner late and also had some drinks.

Here’s the explanation to the sequence: Because of his upper airway anatomy, he was predisposed to acid reflux at night due to occasional obstructions and arousals. I talk about who may be predisposed and why this occurs in my book, Sleep, Interrupted. During an obstruction, vacuum forces can suction up small amounts of stomach juices into the throat, leading to various throat symptoms such as scratchiness, pain, hoarseness, post-nasal drip, lump sensation, and chronic cough. More often than not, doctors will give oral antibiotics in this situation, "just in case."

Many typical "colds" start of with a scratchy or sore throat, with no other viral symptoms. Later, it can "travel" up into the nose and sinuses, leading to nasal congestion and sinusitis. What’s happening here is that there was an initial episode of acid reflux, which first irritates the throat, leading to more swelling and congestion, aggravating the vicious cycle. It’s also been shown that your normal stomach contents (acid, bile, digestive enzymes, bacteria) can travel up into your nose and ears. Chronic inflammation can predispose any part of the body to true viral or bacterial infections.

The typical fevers, chills and sweats that are seen in this situation may suggest a viral infection, but you can also have all these symptoms from an involuntary nervous system reaction, which is called vasomotor symptoms. This happens when your involuntary nervous system becomes imbalanced due to a sudden change in your sleep-breathing status.

Even if you start off with allergies or a runny nose from a cold, eventually, the tongue will collapse more and perpetuate this vicious cycle.

So the next time you have a sore throat and are convinced that you have an infection, think again. In many cases, you’ll find that either you must have eaten late or drank alcohol the previous night. If not, then you may have a true cold. But since it’s been shown that having colored nasal mucous of throat phlegm does not necessarily mean you have a bacterial infection, things are not always what it seems.

How do your typical "colds" begin? I’d like to know.

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

Spring Is In The Air — And So Are The Pollens

April 28, 2009

Allergy season is here again, evidenced by the waves of patients coming in to see me complaining of sneezing, nasal congestion, chronic cough, and watery, itchy eyes. Most people have accepted the fact that allergies are one the rise, and that it’s a normal part of living life in the 21st century. Numerous clinical studies confirming this remind us of this fact every day.

But it doesn’t have to this way. Listed below are simple tips to help you lessen the severity of your allergy symptoms, or even prevent it altogether. The more tips you follow, the better your results will be. Not all the tips will apply to everyone, so use common sense in choosing which options to choose from.

Also, before you whole heartedly invest your time and money with these allergy prevention tips, it’s a good idea to make sure you’re actually allergic to seasonal pollens. If you’re not sure, consider seeing an allergist to get tested.

10 Tips For An Allergy Free Season

1. Stay indoors during allergy season or high pollution days, minimizing time spent outdoors. Use air conditioning when indoors.

2. Don’t wear shoes indoors. Allergies, dust, molds and dirt can be brought into your living space. (See my article, An Allergist’s Nightmare: The Micro-Poop Theory).

3. Keep pets out of the bedroom. They can track in dirt, dust, and allergens.

4. Wash your hair or take a shower after you come home or before bedtime. Pollens can settle on your head, which rubs off on your pillow, which you then inhale while sleeping.

5. Try to spend more time at the beach, where there are less pollens.

6. Invest in a HEPA filter for your bedroom (and other rooms as well if you can afford it).

7. When traveling, ask for an allergy-free room. Click here to search for allergy-free rooms.

8. Use saline nasal sprays regularly. Saline flushes out pollens and contaminants, and acts as a mild nasal decongestant. A Neti-pot is one variation. Do this once before bedtime and once in the morning.

9. Consider investing in allergy-free bed sheets (if you’re allergic to dust).

10. Follow the 10 Solutions for Better Sleep I’ve mentioned in this month’s newsletter. Good quality sleep can lower your immune system’s overactivity to allergens.

Deciphering Your OTC (Over the Counter) Meds

If you’ve followed the above and are still suffering, here are some helpful hints regarding over the counter (OTC) and prescription medications. For those of you who are more visual, you can get a print out of an OTC chart organized by symptoms by clicking here.

For simple sneezing, watery, itchy eyes and a runny nose, an antihistamine is your best bet. Three of the newer OTC antihistamines are loratadine (Claritin), fexofenadine (Allegra), and ceftirizine (Zyrtec). In general, ceftirizine is the most potent, as well as having the most potential for drowsiness (about 10% chance). In general, the drowsiness effects wears off after a few doses. It probably safer taken at night. Different people have different rates of effectiveness as well as side effects, so you may have to try all three to see which one works the best for you.

If you have any nasal congestion or sinus pressure, taking one of the above medications that includes the letter "D" can help. The "D" stands for decongestant, which is actually a stimulant that constricts your blood vessels. For some people who are sensitive to oral decongestants (usually stimuoation), it’s not a good idea to take them. If you have high blood pressure or an enlarged prostate, decongestants can sometimes worsen these conditions. Diphenhydramine (Benadryl) is an older antihistamine that’s relatively strong, but has a much higher chance that it can make you drowsy. It’s also the main ingredient in many OTC sleep aids.

If the above OTC medications are not effective, then prescription medications are available. There are a number of topical nasal allergy sprays that contain an anti-inflamatory steroid. These nasal sprays are designed not to enter the bloodstream in significant amounts. The more common brand names are Flonase, Nasonex, Veramyst, Rhinocort, and Nasacort. They’re all essentially the same, but different people with have different reactions, whether it’s how well the allergy symptoms are controlled, to what kind of side effects are seen. Irritation or nosebleeds are two of the most common side effects, but overall, most people tolerate these sprays very well. Your choice is usually made by what’s on your prescription plan’s formulary, and the prescribing doctor’s preferences.

These sprays are meant to be used on a regular basis, which prevents allergy attacks from happening. For example, if you know you have severe spring allergies, then you can start using this on a daily basis a few weeks before the season starts and continue on throughout the season.

Aselastine (Astelin) is a topical nasal antihistamine spray that’s good for acute nasal allergy symptoms. Ipratropium (Atrovent) is also a nasal spray that acts by blocking your nasal nervous system’s signal to cause your nose to produce mucous and congestion. It’s more often given for chronic rhinitis or non-allergic rhinitis, where your nose is overly sensitive to weather changes, chemicals, scents or odors.

If you have severe watery, itchy eyes, and if over the counter eye drops don’t help, then olopatadine (Patanol) eye drops are useful. These are antihistamine eye drops. Studies have also shown that regular use of nasal steroid sprays are almost as effective as topical antihistamine eye drops, but in addition, addresses your nasal symptoms.

Oral steroids are sometimes given for severe allergies or life-threatening allergy attacks. These medications are similar to what your body makes when you’re under stress, and side-effects like weight gain and stomach problems occur more commonly with long-term, high-dose use (such as for asthma or rheumatoid arthritis). A convenient way of taking this is found in a Medrol Dose Pack, which is a moderate dose of steroids that tapers down quickly over 6 days.

If your allergy symptoms are very severe, or you suffer for much longer periods than you desire, then a formal allergy evaluation with testing may be a good option. It’s a good idea to know exactly what you’re allergic to. Your allergist can discuss with you various treatment options, from conservative measures like what I already discussed, to immunotherapy (sublingual or traditional shots).

Some Unconventional Allergy Solutions

If you’re interested in natural options, stinging nettle is a well-known herb that has been shown to help with common allergies. Butterbur is another herbal antihistamine. Both can be found in most health food stores.

Needless to say, a healthy diet rich in fruits, vegetables, omega-3 oils (found in fish), and fiber will help your immune system to function more optimally.

Lastly, eating locally produced honey has been suggested to help with allergies. It’s thought that the honey contains the local pollens that can cause your allergy symptoms. Being exposed to small amounts of pollen on a regular basis is similar to what the allergist does through shots. Use honey as a sweetener on a daily basis before the onset of the allergy season.

If you follow some of the conservative steps I’ve outlined earlier, most of you won’t need to take any medications. However, if you feel the need to take something, hopefully this article can guide you towards making the right choices. You should always talk to your doctor before trying new OTC or prescription medications, as there can be interactions with certain prescription medications.

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