Does Everyone in Your Family Have Sleep Apnea?
February 10, 2010
More and more often, I'm coming across entire family members that are on CPAP for sleep apnea, or undergoing various other treatments for this condition. If one parent has sleep apnea, your children have an increased risk of developing sleep apnea, but if both parents have it, then it's safe to assume that your children will have it too, given that fact that they inherit your facial anatomy.
As I describe in my book, Sleep, Interrupted, all modern humans are on a continuum, where we're all susceptible to breathing problems at night. Only the end extreme is called obstructive sleep apnea. Since sleep apnea is caused by narrow facial structures, young children and even infants can have it too. Many of the various childhood maladies, such as frequent colds, ear infections, bedwetting, night terrors, and even ADHD are probably related to poor breathing and inefficient sleep, aggravating inflammation in the upper airways. There's even speculation that the rate of autism increased after doctors recommended placing infants on their backs during sleep. It's not surprising then, that parents of autistic children are found to have a higher rate of obstructive sleep apnea.
Most young children are treated with tonsillectomy and adenoidectomy for their sleep apnea, and many children do very well. However, about 1/3 who undergo tonsillectomy don't improve significantly. These are the children that probably have smaller jaws. Smaller jaws leads to more reflux and inflammation, leading to enlarged tonsils, causing more frequent obstructions. In these children, rapid palatal expansion was found to be equivalent to tonsillectomy. If you combine both procedures, the results were additive.
Some young children are able to tolerate CPAP, but for most, this is not a practical option. One advantage that children have over adults is the malleability of their jaws. Orthodontics can not only help to straighten teeth, but to expand the jaws as well. Traditional orthodontic dentists tend to remove teeth to make more room for the other teeth, but that ends up making the jaws even smaller. Forward thinking orthodontists make more room for the teeth by enlarging the jaws, both in the front to back and side to side dimensions. The earlier you start, the better the long-term results. Many dentists are beginning treatment as soon as the permanent teeth have come in.
Does everyone in your family have sleep apnea? If not, do you suspect that they all do? Please describe how you're handling this situation in the comments box below.
An Uncomfortable Situation Regarding Sleep Apnea
December 15, 2009
One of the biggest dilemmas in my personal life is how to deal with friends or family members that I’m sure have obstructive sleep apnea or upper airway resistance syndrome. Should I even mention this condition at all, outside of a professional relationship? Is it even ethical, not to mention practical, to give medical advice to close friends or family members?
Once your eyes are opened to how common sleep apnea is, you’ll see that almost every other one of your friends or family will have varying degrees of sleep apnea. Many more won’t have sleep apnea, but a lesser variation called upper airway resistance syndrome. As you get older, I guarantee that a significant number of your friends will have it. Sadly, only 10% of sleep apnea is ever diagnosed and treated by doctors, who instead tend to treat the complications of sleep apnea such as high blood pressure, depression, anxiety, heart disease, heart attack and stroke.
Ultimately, I’ve decided to take these situations on a case by case basis. Invariably, we’ll get on the discussion of what I do at work, and the topic of sleep apnea comes up. Depending on how interested he or she seems, I’ll gently suggest getting evaluated for it. I’ve had various responses to this approach. A number of my close friends have their lives changed radically after being diagnosed and treated for severe obstructive sleep apnea. Others who I know have severe sleep apnea either don’t take it too seriously, and continue their lives thinking that their fatigue, high blood pressure, and weight gain is just a normal part of getting older. In many cases, spouses of these people are frustrated because he or she won’t listen and go see a sleep specialist about this problem.
The other day, I ran into the wife of a couple that I know in my apartment complex. She relayed that her husband is sleeping much better since getting his CPAP machine and wanted to thank me for my advice. A few months before, the topic of her husband’s severe snoring came up during a conversation about what I did for a living.
As long as I can make a difference in my personal, as well as my professional life, I’m still going to do everything that I can to make people aware that sleep-breathing problems are a major cause of illness, fatigue, disability, and even death.
Have you reached out to your friends or family about sleep apnea? What was their response? Please respond with your comments below.
CPAP Success for Sleep Apnea: What You Must Know
November 16, 2009
CPAP, or continuous positive airway pressure, is one of the first-line ways of treating obstructive sleep apnea. Gentle, positive air pressure is passed through a mask into the nose to keep your throat tissues open. For many people, CPAP works very well, but there are many others that have difficulty adjusting to CPAP and end up giving up.
There are a number of proven, systematic steps that can be taken to improve CPAP usage, and I’ll cover each of these steps in future posts, but theres’s one important factor that determines whether or not you’ll ultimately benefit from CPAP even before you start. This is your mindset.
CPAP compliance, or the number of people who are able to use and ultimately benefit from CPAP, ranges anywhere from 29 to 83%. (Compliance is only a measure of how many hours patients actually use their machines. It doesn’t actually measure how well they are benefiting from CPAP treatment. You can be 100% complaint, but not sleep any better.) In the real world, compliance is much less than 50%. We know that with intensive education, support, and follow-up, CPAP compliance rates can be very high, but in our fragmented health care system with multiple providers for each patients, results are much less than ideal.
However, over the past 11 years in clinical practice, I’ve noticed a few observations: Bus drivers and airline pilots accept CPAP therapy readily and are usually very successful in adapting to and benefiting from their CPAP machines. In addition, newly diagnosed sleep apnea patients who have either friends or relatives who have good experiences with CPAP also tend to do well. On the other hand, if they hear horror stories about CPAP, they tend not do do as well.
What this goes to show is that your mindset and motivation ultimately affects whether or not you end up accepting or rejecting CPAP. Pilots and bus drivers have their jobs on the line. Until they are treated and cleared by a medical doctor, they can’t return to work. A close friend or family member’s experience using CPAP is also a major factor in how well you’ll be able to tolerate and benefit from CPAP. Imagine having the proper mindset, as well as undergoing intensive education, counseling, support and follow-up. CPAP success rates are sure to go up.
What was your motivating factor in succeeding with CPAP? If you couldn’t tolerate CPAP, what was the main reason? Please enter your comments below.
Sleep Apnea CPAP Compliance Craziness
November 10, 2009
One of my biggest pet peeves is how doctors use the word compliance. If a patient doesn’t comply, it usually implies it was the patient’s fault. In sleep medicine, compliance is often used to measure how well patients use their CPAP machines. But compliance is not the same thing as success.
Various studies report CPAP compliance rates at 29% to 83%. The problem is that the definition of compliance changes from study to study. More recently, we’ve adopted the new Medicare requirement for CPAP compliance, which requires that the patients use CPAP at least 70% of the time over a 30 day period, for at least 4 hours every night. Otherwise, the machine has to be returned.
If you sleep 7 hours every night, it comes to 210 total number of hours per 30 days that you’re sleeping. Seventy percent of 210 hours is 147 hours. If you sleep only 4 hours every night, then this figure drops to 88 hours, which means that you have to use your CPAP machine only 40% of the total time that you’re sleeping to be considered "compliant." This doesn’t take into consideration if you’re actually feeling better or if the machine is being used effectively.
Since CPAP works only if you’re using it, if only 40% of people are still using CPAP regularly 5 years after beginning treatment, then the CPAP success rate is at best 40%. But not all people who use CPAP will benefit, so this figure is likely to be much lower. Many more people are likely to stop using CPAP as the years go by.
There are many patients that are 100% compliant with CPAP, using their machines 100% of the time they are sleeping, with no leaks and a low AHI, and still feel no better. Sometimes they can even feel worse than when they don’t use CPAP.
From what I’ve seen with CPAP compliance studies or even with sleep apnea surgery studies, they all manipulate the numbers to make their results look great. In very tightly controlled research studies with frequent follow-up and intensive intervention, results are likely to be good. But in the real world, with fragmentation of care, poor follow-up and lack of patient education, true success (the patient feels much better AND the numbers show it) is disappointingly low, no matter which option you choose.
Despite all these obstacles, there are proven ways to improve CPAP success. With a systematic and formalized education program, along with intense counseling, follow-up, and long-term support, many more people can benefit from CPAP. Ultimately, a major part of poor CPAP compliance is due to the health care system that’s dropping the ball.
Am I being realistic or too pessimistic? Let me know what you think of this issue in the comments box below.
Can Sleep Apnea Treatment Improve Your Golf Score?
November 5, 2009
UPPP Revisited for Obstructive Sleep Apnea
October 22, 2009
The uvulopalatopharyngoplasty (UPPP) procedure is probably one of the most controversial issues in sleep medicine for sleep apnea treatment. Despite study after study showing limited success rates, surgeons continue performing this procedure. Some in the sleep community are adamant that with such low success rates, it should not be performed anymore. But then there are studies that come out once in a while that show there’s some benefit to this procedure. With all the conflicting information and confusion, who are you to believe?
A recent paper published in the Mayo Clinic Proceedings concluded that there’s still a role for the UPPP in some sleep apnea patients. While not "curative" in all patients, a significant number of people had improvements not only in their sleep apnea scores, but also in quality of life measures. (Take a look at my response to Sleep Apnea Ed’s blog here.)
With the UPPP, the overall "success" rate is found to be around 40% in numerous studies. You could say that it doesn’t work most of the time (60%), or that it worked 40% of the time. Is there a way to predict who’ll respond and who won’t? A common screening system developed by Dr. Friedman showed that if you have very large tonsils and a relatively low-sitting tongue, and you’re not very overweight, then you’ll have about an 80% chance of surgical "success." Unfortunately, not too many people fit into this category.
ENT surgeons tend to overly focus on the soft palate, mainly because that’s where the snoring is coming from, and it’s the traditional operation that we do for snoring and sleep apnea. Now we know that the soft palate is only a small part of the condition that causes sleep apnea. Once you address the entire upper airway (from the tip of the nose to the voice box), then surgical success rates can go as high as 80%. If you make the jaws much larger (the maxilla-mandibular advancement, or the MMA), success rates are well above 90%. The thinner you are, the better these procedures will work.
One study that I recall showed that even the 40% success rate was better in the long term than CPAP. Patients were recruited from a VA hospital with newly diagnosed sleep apnea and two groups were followed: CPAP users and UPPP patients. What why found a few years later was that you had a higher chance of being alive if you underwent a UPPP than if you were assigned to the CPAP group. Even though the overall success rate for UPPP is only 40%, these 40% stayed "successful", at least for the first few years. CPAP users, on the other hand, probably began to drop off in using their CPAP machines, at after a few years, compliance was poor. Based on research that shows that your overall risk of dying from cardiovascular disease in much higher if your have untreated sleep apnea, these results make sense.
Of course there’s still a lot more we as physicians can do for sleep apnea patients before they even consider surgery (counseling for CPAP, oral appliances, etc.), but once they run out of all other options, it’s important to know the facts and see the big picture. With good patient selection, intensive counseling, and setting realistic long-term goals, surgery can be a good option for some people. Usually, a UPPP alone is never the answer.
How many of you have undergone a UPPP operation and it didn’t help? How much counseling, follow-up and support did you receive with CPAP or oral appliances? Was multi-level surgery offered besides just a UPPP? Please enter your response in the text area below.
Sleep Apnea Success: What Does It Mean?
October 20, 2009
If you have sleep apnea, success has many meanings. In the ideal situation, it means that you feel great, you don’t have to use any gadget or device when you go to bed, and your sleep apnea score (AHI) is 0.
Unfortunately, the definition of success in the sleep apnea research fields keeps changing depending on who’s reporting it. In general, the surgical definition of success is a drop in the final AHI (apnea hypopnea index) of greater than 50%, and the final number is less than 20. Some use an AI (apnea index) being less than 10. Rarely, some people use 5. Some studies report two or three definitions simultaneously. Studies report anything from 40% to 95%, depending on different types and combinations of procedures.
For CPAP users, there are multiple definitions of success. One common definition is when CPAP is used at least 50% of each night for at least 4 out of 7 nights. Actually, this is a measure of compliance, meaning, how well did the patient stick to using the machine? Reported compliance rates using different criteria range widely from 20% to 90%.
Surgical success and CPAP compliance doesn’t measure the effectiveness of the form of therapy. In other words, do you actually feel much better? Is it lowering your blood pressure, or are you feeling less depressed? You can be using CPAP 100% of the time 7 days a week, or your AHI after surgery can drop from 45 to 3, and you may not feel any better. These same concepts apply to oral appliances as well.
What you may find is that although you’re using CPAP every night, your "effective" AHI each night is still relatively high, and not anywhere near the near 0 levels that were obtained during the CPAP titration study. Since the vast majority of CPAP machines that are prescribed will only measure "compliance" data, you’ll never actually know how effective the treatment is when you’re actually using it. Some of the more advanced models are able to tell you what the effective AHI is every night. For only a few hundred dollars more, it’s probably worth giving every patient models with these features.
Even if you’re "successful" in the beginning, how will you feel 20 to 30 years from now? Will you still be using your CPAP machine 100% of the time, or will your AHI remain at the same levels just after surgery? Probably not.
As I’ve describe with my sleep-breathing paradigm, all modern humans are susceptible to sleep-breathing problems to various degrees. It’s a normal part of being human, mainly due to our ability to talk. So thinking of any of these treatment options as a cure is a mistake, since the forces that create collapses in your throat will only get worse as you get older. (Find out more about these important concepts in my book, Sleep, Interrupted.)
Just like any chronic condition, managing sleep apnea has to be considered a life-long process of constant adjusting and fine-tuning, rather than thinking of these treatments as a one time "cure."
Are you a successful sleep apnea patent? How has your mindset changed regarding "success" since you first started treatment? Please enter your responses below in the comments box.
The Best Sleep Apnea Treatment
October 13, 2009
Sleep apnea, just like any other chronic medical condition, has many different forms of treatment. In addition to how you choose to take care of your problem, you also have to integrate many other various methods as well, including a sensible diet and exercise regimen. Unfortunately, there’s no pill to solve this anatomic problem.
I’m assuming that you’ve tried all the conservative options like losing weight or improving your nasal breathing. Once you and your doctor have decided that you need to move on to one of the more definitive treatment options, you have three to choose from: CPAP, oral appliances, or surgery.
If you’ve done your research (I’m assuming you have since you’re reading my blog), you’ll see vastly differing opinions on success rates and patient experiences. Some discussions are very heated. Unfortunately, as expected, the internet forums are filled disproportionately unsatisfied patients that have tried each of the three treatment options. You won’t see a website called, "ILoveCPAP.com", or "IHadSuccessfulSleepApneaSurgery.com". Most people who are happy with their results go on to live normal and productive lives. The ones that are still searching for better answers tend to fill the blogs and forums with their individual experiences.
In the medical world, we’re no better. Our research studies are full of conflicting data that the press ends up distorting in their quest to bring you the latest in breaking news. Even though a news story tries to present two sides to the coin, it can’t do it in 800 words. There are books on sleep apnea with over 100,000 words that don’t ever make strong conclusions that one is better than the other. Because science can only prove association between one variable and another (and never cause and effect), we’re only getting an overly simplified picture of peoples’ medical conditions.
In medical studies, we always try to exclude other variables besides what we’re studying. If one person doesn’t exercise whereas another does, then we have to "adjust" for this fact, so that it doesn’t skew our data for CPAP’s effects on blood sugar levels.
This brings me to sleep apnea treatment options. Yes, we have hundreds, if not thousands of studies supporting various aspects of sleep apnea treatment. They all report their answers in averages, essentially negating a single individual’s experiences. If you’re an outlier, then you’re considered "deviated." You should be average, but for some reason, you’re an aberration because the dental device didn’t work for you.
If you look at the big picture, all three treatment options (CPAP, oral appliances and surgery) all work to similar degrees. In carefully controlled research studies, "success rates" are as high as 80 to 90% in some cases for all three options. However, in the real world, true success is probably way less than 50%. I’ll even hazard a guess at 10 to 20% long term (20 to 30 years).
So what does success mean? For the sleep physician, it’s lowering your sleep apnea number no sleep study down below 10, or some variation. But what it your number goes from 35 to7, but you don’t feel any better? What if you start at 7 and go down to 4? We doctors just shrug our shoulders in this situation.
For the patient, success means different things for different people. As examples, for people who choose CPAP, it’s waking up in the morning completely refreshed and having the energy to perform during the day without feeling very tired or fatigued. For others, it’s being able to go to a movie with a loved one and not fall sleep. For oral appliance users, it’s getting to the point of not having to use CPAP or undergo surgery. For surgery patients, it’s getting to the point where you don’t have to use a device of any kind. Different people have different wants and needs from treatment, as well as different expectations.
But just like you would never prescribe a pill for high blood pressure without stressing other issues such as proper diet, weight loss, adequate exercise and stress reduction, you can’t prescribe sleep apnea treatment without addressing all the other issues as well. Sometimes, these "other issues" can help more than the treatment itself in the long run. Occasionally significant weight loss can even "cure" someone with mild sleep apnea.
We can leave the debate over the specific pros and cons of different sleep apnea treatments for another time. For now, what I want to stress is that it’s important to stress your ultimate goals before treatment, and have an integrated plan of action along with your sleep doctor. With sleep apnea, there’s no magic bullet.
What was your ultimate goal when you started sleep apnea treatment? Please write your comments below.
When CPAP Doesn’t Help Your Sleep Apnea
September 25, 2009
Every few days, I hear from a frustrated patient with sleep apnea how they’re at wit’s end with their CPAP machine. Either they just can’t seem to get used to it, or they’re using it faithfully, but find no improvement in their quality of sleep. Some are almost in tears, to the point of giving up. Many of these people have tried various masks, different machines, participated in online and live CPAP support groups, or had multiple interactions with their sleep medicine doctor and their DME vendor. All to no avail.
Granted, there are a number of reasons why you may not find CPAP helpful, but with good support and going through a standard checklist of issues, many of you can usually find a solution. You’re not the only one going through this process. Most people just starting out with CPAP fit into this category.
However, there are others that have tried everything, and still don’t notice any improvement. Even the compliance data from the machine is saying that everything is good, with no leaks and a very low AHIs. What can be done for you at this point?
Unfortunately, many of you fall into the trap of feeling like it’s your fault, that there’s something wrong with you or that you’re doing something wrong. You may ask, many others are able to use CPAP just fine, so what’s wrong with me?
This is a very common situation where typically, most sleep doctors just shrug their shoulders and offer a stimulant like Provigil to take during the day and sleeping pills at night.
From my perspective, there are three issues/options to consider if you ever get to this point. The first is to make sure that you’re able to breathe well through your nose. If your nose is stuffy (and most sleep apnea patients have stuffy noses by definition due to their anatomy), then CPAP pressure have to be higher, and it can become more uncomfortable with more chance of leaks. Many of my patients are able to better tolerate and benefit from CPAP after treatment.
The second consideration is, do you have full compliance data? Most people are given bare-bones CPAP machines that only measure how long you’re using the machine for every night. There’s no information to tell you if there’s any leak within the system, or if you’re having significant apneas or hypopneas. Having a fully data capable model is important to get objective feedback on what’s going on.
Third, at a certain point, after exhausting all the possibilities, you have to look at other options including oral appliances and even surgery. For a recording of an interview I did with a dentist about oral appliances, click here. For a free report called, "The Truth About Sleep Apnea Surgery," click here.
One last thing to consider is that your sleep apnea may be adequately treated (by whatever means), but you still feel lousy. Dr. Jacob Teitelbaum, a world renown expert in chronic fatigue syndrome, explains that due to the massive neurological and hormonal imbalances that occur in these situations, some people don’t feel better with CPAP, oral appliances, or even with surgery, despite optimal treatment based on sleep studies. Go to his website at vitality101.com to find out more information. He has a free online symptom analysis program that will guide you toward various treatment options.
Are you struggling with CPAP? If so, what steps have you taken with CPAP, and what other options have you tried so far?
Elite Runners, Jaw Size, And Insomnia
August 25, 2009
I came across this article in Runner’s World about an up and coming marathoner, Tera Moody, who suffers from chronic insomnia. She was found to have obstructive sleep apnea, but could not tolerate CPAP or a dental device. She eventually found some help by undergoing CBT, or cognitive behavioral therapy. She still suffers from insomnia occasionally, and take sleeping pills for emergencies. It’s clear that she’s not treating her sleep apnea. This puts her at significantly increased risk later in life for depression, diabetes, high blood pressure, heart disease, heart attack and stroke.
While the article was well written, the writer brings up the same old stereotypical thinking that sleep apnea patients must be older, male, heavy set, snores, and with a big neck. We now know that even young thin women that don’t snore can have significant sleep apnea.
One thing that’s striking about her picture is the smallness of her jaw. It’s significantly recessed. Coincidentally, while I was searching for other profile pictures of her, I came across a profile picture of Joan Benoit Samuelson, the 1984 Olympic marathon winner. Not too surprisingly, her jaw is pretty recessed as well.
One thing I’ve noticed is that certain elite distance runners (and even the most avid distance runners in my track club), all have various sleep problems. They can never get deep refreshing sleep, and they prefer not to sleep on their backs. I’m guessing that continuous running is what makes them feel alive, so they thrive on it, leading to their elite statuses. Some athletes (in running and in other sports) are literally addicted to exercise. Not exercising for a day or two can lead to depression and lethargy. Sleep-breathing problems can definitely aggravate, if not cause insomnia. One recent study showed that surgery for sleep apnea cured chronic insomnia in many cases.
Do you know any intense athlete that also has a major sleep problem?
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