The Single Most Important Advice I Give To Patients

September 5, 2011

The New York Times confirmed what I’ve been telling patients for years—that eating within 3-4 hours of bedtime can promote acid reflux. What the journalist didn’t mention was the fact that acid reflux and obstructive sleep apnea go hand in hand. Here’s what I wrote in reply to his article:

Having heartburn at night also means that you’re at risk of stomach juices reaching your throat, which not only has acid, but bile, digestive enzymes, and bile. In light of the fact that about 10 to 25% of the population has at least some sleep apnea (the majority in the elderly in some studies), any pauses in breathing will literally suction up your stomach juices into your throat, causing not only arousals, but also swelling and inflammation, leading to post-nasal drip, chronic throat clearing, chronic cough, and even Eustachian tube dysfunction.

The more often you stop breathing at night, the more you’re likely to suction up stomach juices into your throat, which can also lead to desensitization of your pressure and sensory nerve endings. Over time, this can lead to loss of protective upper airway reflexes, predisposing one to obstructive sleep apnea. In addition, vibratory trauma from snoring is thought to not only desensitize sensory nerve endings, but also cause carotid artery wall thickening.

Not eating late will also increase your sleep efficiency, which can promote weight loss. On the contrary, any degree of sleep deprivation or sleep inefficiency will promote weight gain. Gaining weight promotes more reflux and sleep apnea.

Counseling New Yorkers to avoid eating (and drinking alcohol) within 3-4 hours of bedtime is the simple most important recommendation I make, in addition to my routine treatment options.

Written by Steven Park · Filed Under Blog | 3 Comments

Heart Attack Symptoms in Women – A Must Read

January 1, 2011

I came across a post in KevinMD with stories from women (many in their 30s and 40s) who suffered from serious heart attacks. I commented on this post in #5. I strongly urge you to read the entire article. I’ve also posted my reply below:

Wow! I was riveted while I read through the entire post. We know that younger women can have heart attacks, and it’s acknowledged that doctors are not good at picking up heart attack symptoms in younger women.

Here are a few observations that I had:

1. Many of the women had heart attacks from 3-5 AM. One study showed that people with obstructive sleep apnea have heart attacks during this timeframe, as compared to earlier in the morning in people who don’t have sleep apnea and have heart attacks.

2. Many women also described severe heartburn as a major symptom. If these women were having a sudden increase in the number and severity of apneas, then it’s expected to have more severe reflux, due to the negative pressures in the chest. One woman, Lidia, had too much to eat and drink for her birthday. Alcohol relaxes your throat muscles, and additional reflux from stomach juices can cause more obstructions and arousals.

3. One woman described recent 10 pounds weight gain—an additional risk for obstructive sleep apnea.

4. Also notice how many women either were pregnant or post-partum. Weight gain during pregnancy is a major risk for obstructive sleep apnea, which can lead to pre-eclampsia and gestational diabetes. That’s also why pregnancy complications are linked to a higher rate of heart disease—because you’re at risk for having obstructive sleep apnea. Post-partum, the protective effect of progesterone is gone (progesterone tenses your upper airway dilators), and more frequent breathing pauses can tip you over the edge.

5. I’m willing to bet that many of these women snored, but it’s also been shown that you can be young, thin and not snore to have significant obstructive sleep apnea. What I’m sure of is that one or both parents of these women snores heavily, with major cardiovascular disease. Typically, these women won’t be able to sleep on their backs, due to smaller oral cavity jaw structures, which narrows the posterior airway space. Deep sleep will relax the muscles, making them more prone to breathing pauses.

6. Some of the women also mentioned casually that they were sleep deprived. Not sleeping enough can be a major trigger to cause major sympathetic stimulation when normally, you’re not ever able to get efficient sleep at all.

7. I bet that most of these women, even when younger, never felt refreshed, no matter how long they slept. Typically, these women will attribute their fatigue to anemia, stress, TMJ, sinus infections, migraines, hypothyroidism, insomnia or chronic fatigue. Many will also have cold hands or feet, and oftentimes, blood pressure will be one the low side, especially when younger (later on, the BP normalizes and then goes high). This is called upper airway resistance syndrome, a variation of obstructive sleep apnea, where you can stop breathing 10 to 20 times per hours and not have official sleep apnea on a sleep study.

It’s important to pick up the atypical symptoms of heart attack in women, but what’s just as important is to treat what’s actually aggravating, if not causing the heart disease. If this had been done months or years prior to their heart attacks, many of these cardiac events could have been prevented.

In these women, there was usually some trigger that tipped them over the edge, whether it’s weight gain, eating late, severe stress, drinking alcohol, pregnancy, or even weather changes. There’s so much proven evidence showing that most people with heart disease have (or will have) significant obstructive sleep apnea. Physicians have to erase the image of the traditional sleep apnea patient as being overweight, snoring, male, with a big neck. Sleep apnea is a craniofacial, anatomic problem due to smaller jaws. Obesity comes later, which only makes the problem worse.

Learning the benefits of the Coronary Artery Bypass Surgery versus traditional surgery may be a good option for women who currently suffer from heart problems.

Written by Steven Park · Filed Under Blog | 6 Comments

The Truth About Acid Reflux Medications

July 3, 2009

One of the biggest myths about acid reflux medications is that they help with acid reflux. In fact, they do nothing to prevent reflux of acid into your esophagus or throat. What they really do is to lower acid secretion in your stomach so that whatever comes up doesn’t cause as much irritation.

The problem is that whatever comes up, although less acidic, still have small amounts of bile, digestive enzymes, and stomach bacteria that can continue to irritate the throat. In fact, studies have found pepsin (a digestive enzyme) and H. pylori (a common stomach bacteria) in ear, sinus and lung washings. This is why aggressive long-term acid reflux therapy only works sometimes. One you stop it, it usually comes back. Ultimately, dietary and lifestyle changes are what keeps the symptoms away for good.

Laryngopharyngeal reflux disease (LPRD) is one of the most common conditions seen in a typical ENT practice. Symptoms include chronic cough, post-nasal drip, hoarseness, lump sensation, throat pain burning, with or without any stomach symptoms. Published studies in our field recommend long-term (2-3 months) of twice daily treatment with one of the PPIs (proton pump inhibitors such as Prilosec, Nexium, Protonix, Aciphex, etc.). A recent study showed that these medications can have a significant rate of rebound acid secretion after stopping, so people may need to continue for a long time.

So why do so many people continue to have acid coming up into the throat? This is where my sleep-breathing paradigm can explain this all-too-common problem. Most modern humans, by definition, stop breathing once in a while when sleeping. This is due to a combination of our smaller jaws, and a predisposition to inflammation and swelling of the already narrowed airways. When in deep sleep, due to our muscles relaxing to various degrees, the smaller your jaw size, the more likely you’ll stop breathing and wake up partially or completely. During this process, a vacuum effect is created, actively suctioning up small amounts of your stomach juices into your lower esophagus or your throat.

This is why I’ve cut back my recommendation for PPI therapy dramatically to only 1-2 week short bursts, while emphasizing dietary and lifestyle modifications. Many people with chronic acid reflux issues will have an underlying sleep-breathing problem, and further testing usually confirms this.

Written by Steven Park · Filed Under Blog | 1 Comment