The Biggest Throat Problem for Sleep Apnea Sufferers

August 21, 2010

If you wake up every morning needing to hack up lots of thick mucous, or have throat pain, hoarseness, or a chronic cough, you’re not alone. You may think it’s the beginning of a cold, but a cold doesn’t continue for weeks to months without progressing into the full-blown viral symptoms.

Instead, these symptoms are the beginnings of the most common throat problem sleep apnea sufferers face. And as I explain below, without understanding why this occurs, it can be one of the hardest problems to treat.

Beware of the “Vacuum Effect”

People with obstructive sleep apnea are more prone to breathing problems at night due to partial or total collapse of one or more areas of the entire upper airway, from the nose to the tongue. It’s usually worse when on your back, since the tongue can fall back more in this position. During deep sleep, your muscles naturally relax and you’ll be more susceptible to breathing stoppages.

Pressure sensors placed inside sleep apnea patients reveal that every time an apnea occurs, a tremendous vacuum effect is created inside the chest and throat, which literally suctions up your normal stomach juices into your esophagus and throat. This can happen occasionally, even for normal people, but if you happen to have a late meal or a snack just before bedtime, there will be even more stomach juices lingering in your stomach to come up into the throat. If you happened to drink a nightcap, the situation is even worse since alcohol is a strong muscle relaxant.

What comes up into your throat is not only acid, but also bile, digestive enzymes, and even bacteria. Washings of lung, sinus and ear contents have shown H. pylori, a common stomach bacteria, and pepsin, a major stomach digestive enzyme. So what comes up can cause severe irritation in your throat, provoking the mucous secreting glands of your throat to try to dilute these substances.

Although people generally attribute throat mucous to post-nasal drip, in most cases there’s nothing dripping down the back of the throat. It’s actually coming from your stomach. However, in some cases, since your stomach juices can reach your nose, it can cause nasal congestion and inflammation, which can aggravate tongue and soft palate collapse by creating a vacuum effect downstream. Ultimately, it’s a vicious cycle.

Chronic acid and other irritating substances lingering in your throat can have other detrimental effects. One recent study showed that chronic acid exposure can numb or deaden the protective chemoreceptors in your throat. These are sensors that detect any acid in the throat to prevent aspiration of your stomach contents into your lungs. If these chemoreceptors sense any acid in your throat, a feedback signal is sent to the brain, causing you to wake up so that you can swallow. This is what’s called a reflux arousal.

Treating Reflux For Good

So besides not eating late and avoiding alcohol close to bedtime, what else can you do?

I’m assuming that many of you that are reading this article are already being treated for obstructive sleep apnea, via either CPAP, oral appliances, or even with surgery. The problem is that no matter which option you choose, there will always be some degree of reflux. Taking acid reflux medications can help sometimes, but for the most part, these reflux medications don’t really do anything for reflux. All they do is to lower the acid content content before it comes up into your throat.

Other options include stimulating your stomach via natural remedies or prescription medications to empty your stomach much faster. One fascinating study showed that using a combination of pseudoephedrine (Sudafed) and a pro-motility agent (domperidone) eliminated snoring in most people. Unfortunately, we don’t have the equivalent of domperidone here in the US. Other similar medications are available, but have more serious side effects.

This is why eating early at least 3-4 hours of bedtime is so important whether or not you have obstructive sleep apnea. The same also applies to alcohol. If your nose is stuffy, talk with your doctor to find a way to breathe better through your nose. Make sure you’re sleeping in your preferred or optimal sleep position. Lastly, work with your sleep physician to fully optimize your sleep apnea treatment, no matter which option you choose.

Written by Steven Park · Filed Under Articles, Sleep Health, obstructive sleep apnea | 1 Comment

Reflux And Spontaneous Arousals In Mild Sleep Apnea

April 27, 2010

Gastro-esophageal reflux and laryngopharyngeal reflux disease are commonly seen in patients with obstructive sleep apnea. Many of you will have the typical throat clearing, post-nasal drip, chronic cough or hoarseness that's seen with laryngopharyngeal reflux disease. Sleep apnea causes your normal stomach juices to leak up into the throat, which not only causes you to wake up, but also causes swelling and inflammation in the throat.

We know that any form of breathing obstruction (apnea, hypopnea, RERA) can cause you to wake up. But what's not too commonly known is the fact that any degree of acid in the throat can stimulate certain chemical receptors, which causes you to wake up so you can swallow. It's thought that this is needed to prevent aspiration of stomach juices into your lungs.

A recent Japanese study not only confirmed these concepts, but found an interesting additional observation: While people with severe obstructive sleep apnea have mostly arousals due to breathing pauses, those with mild to moderate sleep apnea have a higher number of spontaneous arousals. Spontaneous arousals are noted on a sleep study when your brain waves go from deep sleep to light sleep or temporary awakening, without any objective evidence of breathing pauses.

What this study doesn't address is the fact that it's not only acid that comes up into the throat when you stop breathing. Your stomach juices also contain bile, digestive enzymes, and bacteria. An obstruction causes a tremendous vacuum effect that's created in the throat, literally suctioning up your normal stomach juices. This initial obstruction will lead to the typical respiratory arousal, but lingering juices will irritate the throat leading to spontaneous arousals. Think of your stomach juices as a sort of sensory form of stimulation, like a loud noise or a bright light. Your throat has a number of very sensitive chemical and pressure receptors that can cause your brain to wake up, without any physical obstruction.

There are also studies that show that chronic exposure to acid can make pressure sensors less sensitive over time, leading to longer and longer pauses with each obstruction.

Furthermore, there's research showing that some of these arousals don't ever show up on routine brain wave leads during a standard sleep study. This is because these protective reflex signals are so minimal that they stay in the deeper levels of the brain, never reaching the outer cortex.

I've always felt that spontaneous arousals are somehow related to breathing pauses. This study only confirms my suspicion that too many spontaneous arousals may be a sign of upper airway resistance syndrome or early obstructive sleep apnea.

What's your opinion on this? Do you have laryngopharyngeal reflux disease?

Written by Steven Park · Filed Under Blog | 2 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