January 21, 2015
January 15, 2015
January 2, 2015
Now that it’s the day after New Years, many of you likely made a resolution to lose weight. I’m not going to go into any detail about what you should eat or how you should exercise, since that’s not my area of expertise. What I can say is that poor sleep in general will promote weight gain. It’s also known that sleep deprivation will cause cravings for sugary, starchy, salty and fatty foods. Gaining weight will promote obstructive sleep apnea. Lack of energy and exercise will further enhance more weight gain, and the vicious cycle continues.
However, one important aspect of weight gain (or not being able to lose weight) is the importance of prescription medications. I wrote a post a few months ago on 7 common prescription medications that can cause weight gain. I think it’s important to take a look at it again. Check to see if any of the medications that you’re taking is on this list.
If you’ve gained significant weight since taking any of these medications, please tell me your story in the comments section below.
December 31, 2014
Today, I had good news and bad news for Anna, a 28 year old patient regarding her sleep study results. The good news was that she didn’t have obstructive sleep apnea. The bad news was that she stopped breathing 15 times every hour. More bad news: She woke from deep to light sleep 25 times every hour over the course of the entire 7 hours. Lastly, some good news: She has a treatable condition called upper airway resistance syndrome.
Most sleep physicians think of upper airway resistance syndrome (UARS) as a wastebasket diagnosis when you don’t officially have OSA, despite having many of the symptoms of OSA including severe fatigue, unrefreshing sleep, and brain impairment. Snoring is also sometimes lumped into UARS. But when questioned about what can be done, most will tell you the standard sleep hygiene list of bullet points: lose weight, don’t watch TV before bedtime, don’t eat late, and various other important things that everyone must do, even if you don’t have sleep apnea or UARS. Since most people with UARS are not overweight, it’s hard for some doctors to believe that you can have a sleep-breathing problem, especially if your official score on the sleep study is 0.
The problem is that you need at least 5 apneas or hypopneas per hour (AHI) to qualify for a sleep apnea diagnosis based on a sleep study. By definition, apneas are total breathing pauses for more than 10 seconds. Hypopnea are more than 30% obstructed breathing for more than 10 seconds. The total number of apneas and hypopnea per hour is how the AHI is calculated.
But if you stop breathing 25 times every hour, and each episode is anywhere from 1 to 9 seconds, then your AHI will be 0. This was the case for Anna, the woman I saw today. Not having a sleep apnea diagnosis means that you won’t be covered for sleep apnea treatment options by your insurance company—even if you stop breathing 25 times every hour.
Anna’s main complaints were blamed on anemia by her doctors. However, anemia alone can’t explain her daily headaches, anxiety, lightheadedness and dizziness, lower blood pressure, and intense fatigue, no matter how long she sleeps.
Interestingly, she told me that her symptoms got much worse 3 weeks ago when she began to sleep on her back, when she used to sleep on her tummy. When asked what prompted her to make the change, she commented that her dermatologist recommended staying off her tummy since it can cause facial wrinkles. Not too surprisingly, having her switch back to her tummy improved her symptoms back to baseline again.
Most people with UARS have very narrowed jaws and upper airways, rather than being overweight. Due to severe dental crowding, gravity, and muscle relaxation in deep levels of sleep, the tongue, soft palate, or even the epiglottis will fall back and cause you to wake up suddenly, long before the 10 second apnea threshold. In a nutshell, once you obstruct, sleep apnea patients take too long to wake up, whereas UARS patients wake up too quickly. Because the pauses are so short, you won’t have any significant levels of oxygen deprivation.
The problem with so many frequent obstructions and arousals is that your sleep is severely fragmented. You may get the normal amount of deep sleep, but if it’s fragmented, it’s like not getting any deep sleep at all. Not getting deep sleep will cause you to have problems with memory, executive function, and no energy to do anything at all.
One interesting consequence of UARS is how your heart responds to repeated obstructions. Every time you obstruct, tremendous vacuum forces are created in your chest cavity. This causes your heart muscle to becomes stretched, and your body thinks that there’s too much fluid. The heart then makes a hormone called atrial natriuretic peptide (ANP), which goes to your kidneys to make you produce more urine than usual. This is one of many factors that can cause people with sleep-related breathing disorders to go to the bathroom at night. Usually, you’ll wake up a the same time intervals, about 90 to 120 minutes apart, which happens to be one sleep cycle. Every time you go into deeper levels of sleep, due to muscle relaxation in your throat, you’ll have a more severe obstruction and arousal, and you’ll think you have to go to the bathroom. But oftentimes, it’s not a lot of urine.
Other interesting properties of ANP include low blood pressure, weight loss, digestive problems, low magnesium levels, anemia, and neuro-excitability. Essentially, your entire nervous system is overactive, especially to emotions, weather changes, smoke, chemical, and odors. It’s estimated that about 5 to 10% of people with UARS progress to OSA every year, especially if you gain weight. I often see overweight, snoring women in their 50 and 60s who have high blood pressure, with classic OSA, but when in their 20s, were stick thin and with low blood pressure. Even the cold hands and feet that they had when younger tends to go away after menopause.
Now that you’re more familiar with UARS, you may be asking what you can do about it. In general, you have to treat it just like for obstructive sleep apnea. The challenge is that since insurance won’t pay for treatment, you’ll have to pay for a CPAP machine or dental appliance. I’ve covered OSA treatment options in great detail in other articles, teleseminars and my book, starting with conservative options to standard devices and gadgets, dental appliances, and lastly, surgical options. However, for nasal congestion, it’s generally covered, since that’s a different diagnosis.
Most people with undiagnosed UARS can’t be helped by traditional medical options. Oftentimes, you may be diagnosed with anemia, hypothyroidism, anxiety, depression, headaches, irritable bowel syndrome, nutritional or vitamin deficiencies, allergies, for even food sensitivities. I have had every one of these conditions resolve partially or completely when UARS is addressed fully. Some do well with only lifestyle adjustments like not eating late and using Breathe Right Strips. Others do well with CPAP or a mandibular advancement device. Some need aggressive surgery to feel relief. Unfortunately, not too many people ever end up going up the ladder for UARS treatment, since it takes time, resources and having access to the right health care practitioners that are even aware that this exists.
By now, you’re probably more knowledgeable about UARS than most physicians in this country. Hopefully, you can use this information to search out the root cause of many of your symptoms, which is an extremely narrowed airway preventing you from getting deep sleep.
If you have some, or even all of the symptoms of UARS, which options have worked for you? How did your doctor respond to your concerns? Please enter your responses in the text area below.
I interviewed two of the foremost sleep physicians on UARS in my past teleseminars: Drs. Barry Krakow and Avram Gold. Click here to go to iTunes podcast page. Search for Episodes 27 and 31. After listening, please subscribe and rate my podcast. The more feedback you give me and topics that you want to hear about, the more programs I can develop to address your particular needs.
December 18, 2014
Did you know that the holiday season is the deadliest time of the year? With the added stresses of the season, more eating and drinking, more sleep deprivation, less sunlight, and less exercise, it’s no surprise. Here are three past posts that are important to read, especially if you have obstructive sleep apnea:
December 16, 2014
It seems that everyone is tired these days. Not just plain tired, but exhausted to the point to not being able to function at all tired. This is what Barbara told me when she came to see me for her stuffy nose problem. She was in her late 40s, had gained about 15 pounds over the past year, and she’s beginning to snore.
Your first thought may be that I’m thinking obstructive sleep apnea, but you’re wrong. If you came to see me for this problem, the most important things to consider are your diet, exercise levels, sleep duration, lifestyle factors, and recent life stress issues. That may seem a little out of my area of expertise as an ENT surgeon, but as a physician, my duty and responsibility is to first address your health in total, in the context of your environment and surroundings.
Here are 7 things to try to combat fatigue before considering medications, stimulants:
1. Are you eating late? This is a common problem that can aggravate reflux, but this habit can severely aggravate sleep-breathing problems If you’re already susceptible to a sleep-breathing disorder (everyone), even brief pauses in breathing can vacuum up your normal stomach juices into your throat. This causes frequent arousals and fragmented sleep. Try to avoid eating anything within 3-4 hours of bedtime. The same applies to alcohol.
2. Is your nose stuffy? Having a stuffy noses is like sucking in through a flimsy straw: As you pinch the tip (nose), the middle part (palate or tongue) begins to collapse. This is why it’s important to breathe optimally through your nose. You can start with frequent nasal saline irrigation, with or without breathe right strips.
3. Was there any recent weight gain? Even 3 to 5 pounds of weight gain can aggravate more reflux and obstructed breathing, leading to a vicious cycle of frequent arousals. Going on an exercise plan to lose weight can help.
4. Was there any recent change in your sleep position? If you were a natural side or stomach sleeper, but you recently had to change to your back because of an injury or even surgery, it’s likely that your sleep quality is now much worse on your back. Back sleep is most prone to your tongue or soft palate falling back, and
5. Orofacial myology. Exercises for your tongue, lips, mouth and throat can help to strengthen your muscles and re-educate proper position, leading to proper function. It’s estimated that regular exercises alone can lower apnea severity by about 50%. Check out my interview with Joy Moeller about this important field.
6. Deep breathing relaxation exercises. You can find these activities through yoga, tai chi, or various other forms of proper breathing, including Buteyko breathing. Slowing down your breathing can help to calm your nervous system.
7. Check for a vitamin D deficiency. Most modern, Western adults are deficient in this vitamin. Actually, it’s a hormone that affects every part of your body including your brain, heart, muscles, digestive system, bones, and kidneys. Although the lower limit of normal is 20, some doctors are recommending levels between 60 to 80.
Once you’ve considered all the above situations and you’re still not any better, check for obstructive sleep apnea or upper airway resistance syndrome. It’s estimated that up to 1/3 of all adults may have at least mild levels of obstructive sleep apnea. A large number of people will have upper airway resistance syndrome. Many of these people with get diagnosed with a vitamin deficiency, hormone imbalance, or anxiety/depression. Obstructed breathing which can lead to frequent arousals and lack of quality deep sleep can definitely make you tired, irritable, cranky, and exhausted.
Have you tried any of the above options and if so, how well did it work?
December 1, 2014
Guest blog by Deborah Wardly, MD
Previously I blogged about the relationship between intracranial hypertension and obstructive sleep apnea, and pointed out the similarity between the signs and symptoms of upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA) and those of intracranial hypertension. Intracranial hypertension is characterized by headaches, fatigue, dizziness/vertigo, ringing in the ears (which can be pulsatile), and visual disturbances to include papilledema (swelling of the optic disc). It can be present without papilledema (idiopathic intracranial hypertension without papilledema, or IIHWOP), which many doctors don’t seem to realize, and in these scenarios a lumbar puncture (spinal tap) is the only way to diagnose it. It is associated with obesity in many cases, as is OSA.
Recently a study was published showing that in a group of patients with chronic fatigue syndrome (CFS), 20% of them met criteria for idiopathic intracranial hypertension (IIH), and 85% of them had improvement in their chronic fatigue syndrome symptoms after reduction of their intracranial pressure after lumbar puncture. The only thing missing from this study was the sleep study results on these patients! But we know how closely UARS can appear to resemble CFS, and this study begs further evaluation of UARS patients’ intracranial pressures, especially given the knowledge that apneas increase intracranial pressure.
My recent published paper discusses what is currently known about how OSA can increase intracranial pressure (ICP), and then further discusses other possibilities for this phenomenon that could be investigated. We know that individual apneas can increase ICP, and that an increase in carbon dioxide effecting an increase in cerebral blood flow may be causal, as well as perhaps an increase in intrathoracic pressure at the termination of the apnea. In my paper I discuss how OSA can increase glutamate excito-toxicity in the brain, and the evidence for glutamate being able to cause brain edema. I discuss how OSA may open the blood-brain barrier, which would also cause brain swelling.
Alperin, et al. has demonstrated that in obese women with idiopathic intracranial hypertension, they have evidence of both brain swelling and poor jugular venous drainage. I suggest in my paper how the anatomical relationship of the recessed jaw to the narrowed airway, something we recognize is present in many cases of OSA, may also be involved in a compression of the internal jugular veins. This would contribute to the poor jugular venous flow observed in IIH by Alperin, and would increase resistance to CSF outflow. We know that obesity increases the risk of OSA in part by fat compression of the airway in the neck. Perhaps obesity increases the risk of IIH by fat compression of the jugular veins in the neck? Such that it is not entirely a direct causal relationship between OSA and IIH, but that they are conditions which go hand in hand when there is a recession of the mandible or increased fat content of the neck.
An important point that I discuss in my paper is the fact that a Valsalva maneuver will increase ICP. A Valsalva maneuver is created upon “bearing down”, something we do when coughing, sneezing, grunting, crying or shouting, yet even upon laughing, singing or talking. Many people with intracranial hypertension do not tolerate any Valsalva activity, as it will increase their headaches. Think about what it feels like to exhale with your CPAP on—it is a Valsalva as well. Could this be the reason that some people with OSA/UARS do not tolerate CPAP, but must use BiPAP, or cannot use PAP at all? Do these individuals have undiagnosed IIH?
If you do not tolerate CPAP, or even BiPAP, do you have headaches or any of the other symptoms of IIH?
Do you find you must have perfect control of your airway problem in sleep, in order to prevent or reduce the headaches, dizziness, and fatigue?
If you have CFS symptoms or IIH symptoms in conjunction with your OSA/UARS, would you consider a spinal tap to further elucidate your symptoms?
November 12, 2014
A psychologist colleague of mine once told me that at the hospital where he works, many of his patients are on antipsychotic and antidepressant medications. A significant number of these patients will go on to gain significant weight, snore heavily, and end up dying of heart attacks or strokes. While this is purely anecdotal, based on what we know about the side effects of commonly prescribed prescription medications, it’s not too far fetched for the following reason: Any medication that causes weight gain can potentially aggravate or uncover obstructive sleep apnea.
I’ve written extensively in the past how obstructive sleep apnea is mainly a structural problem with narrow jaws and upper airways, but if you add fat in the throat due to being overweight, it just makes things much worse. Here are 7 commonly prescribed prescription medications that can aggravate obstructive sleep apnea due to their ability to put on weight:
1. Many of the antidepressants, especially the tricyclic antidepressants (TCAs) are known to stimulate appetite. Two examples of brand names are Pamelor and Elavil. The newer class of antidepressants called selective serotonin repute inhibitors (SSRIs) don’t generally cause weight gain, except for Paxil. One interesting known side effect of these type of medications is that they suppress REM sleep. Perhaps by limiting REM sleep, you’re prevented from having as much apneas since you’re kept out of REM sleep. This can be one way that these medications may help with depression. However, there’s a cost to not getting enough REM sleep: Your nervous system gets more excitable, with lowered pain thresholds, and you’ll have more problems with learning and memory.
2. Depakote (valproic acid) is a common mood stabilizer to treat bipolar disease and seizures. It’s also used to prevent migraines. One study found that 44% of women and 24% of men gained about 11 pounds on average over one year.
3. Atypical anti-psychotics (Risperdal, Seroquel, Zyprexa, Abilify, and others) are known to cause significant weight gain (7% or more in original body weight) in up to 30% of patients. There’s also some evidence that these medications may also cause insulin resistance and potentially lead to diabetes. A study published in Obesity found that men who took Zyprexa for only 2 weeks increased their food intake by 17%. Another study published in the Journal of the American Medical Association reported that 10 to 36% of children and teens became overweight or obese after 12 weeks taking atypical antipsychotics for the first time.
4. Prednisone, one of many corticosteroids to control inflammation, is one of the most commonly prescribed medications. Chronic, long-term use is given for asthma, inflammatory bowel disease, rheumatoid arthritis, and various other autoimmune conditions. One study found that 70% of people on chronic steroid use reported significant weight gain.
5. Antihistamines such as Allegra and Zyrtec, are also associated with being overweight. This study found that patients on these medications were 55% more likely to be overweight compared to those not taking the medications.
6. Insulin. You’d think that with better sugar control, there would be weight loss, but the findings are the reverse. Here’s a study showing that insulin alone promotes weight gain.
7. The older beta-blockers such as atenolol, metoprolol and propranolol are also associated with significant weight gain. One possible mechanism is that any drug that lowers sympathetic activity will block the brain pathway that stimulates melatonin. Light stimulates receptors in the eye that stimulate nerves in the suprachiasmatic nucleus (near the optic nerve), which then connects to the thalamus then drops down to the spinal cord, connecting with the superior cervical ganglion, and then back up to the pineal gland, which makes melatonin. Light suppresses melatonin, whereas darkness enhances melatonin. Since the superior cervical ganglion is part of the sympathetic nervous system, taking beta-blockers can potentially alter melatonin production.
As I was doing research for this blog post, I kept getting led down more rabbit holes with studies detailing potentially serious side effects with all these medications. I only listed 7 medications, but there are many more. It’s clear that most if not all prescription medications will have various side effects, with many causing sleep or weight disturbances. This is something that all physician must think about when prescribing any of these medications.
If you started taking any of the above mentioned medications, did you notice any significant weight gain?
November 5, 2014
Asthma is the third most common chronic disease amongst children, and the third most common reason for admission to the hospital. The CDC estimates that 7.1 million children suffer from this condition, costing over $50 billion a year. A new study from the University of Chicago found that children who undergo tonsillectomy had 37% reduced hospitalizations and 26% less visits to the emergency room. They compared about 13,000 children with asthma who underwent adenotonsillectomy to 27,000 who didn’t undergo the procedure. This finding builds on previous smaller-scale studies finding similar results. A Fox News article summarizing the findings concludes with a standard disclaimer that since this was a retrospective study, causation can’t be linked, and that large-scale prospective studies are needed.
What the paper doesn’t address is the possible reason why removing tonsils may help asthma. I’ve described in the past about the strong association between large tonsils, obstructive sleep apnea and reflux. Every time a child stops breathing, a vacuum force is created in the chest and throat, with normal stomach juices coming up into the throat. What comes up not only includes acid, but also bile, digestive enzymes, and bacteria. In fact, one recent study found pepsin (a stomach enzyme) in the lungs in the vast majority of children and teens with chronic lung disease. There are also numerous reports of pepsin being found in chronic ear and sinus infection fluid.
While tonsillectomy is not a completely benign surgical procedure, this study adds to the multiple potential benefits that improved breathing and sleep can have on your child’s health.
For the parents out there, did you notice any improvements in your child’s asthma symptoms after tonsil surgery?
October 16, 2014
One of the most common complaints by my patients with obstructive sleep apnea (OSA) is memory loss. Judith is a 55 year old woman who used to have a sharp memory, but now is having trouble with names and losing her keys all the time. Things got much worse when she gained more weight, which worsened her snoring. She was eventually placed on CPAP for her moderate obstructive sleep apnea, and is now happy to report that while her memory is not back to normal, it is much improved.
At a recent Airway Dentistry conference I went to last month, the most memorable topic was given by Dr. Ronald Harper, Distinguished Professor of Neurobiology at the David Geffen School of Medicine at UCLA. I’ve been following his work over many years, but his presentation only confirmed my suspicion that there can be significant brain damage with untreated obstructive sleep apnea. Based on various high-tech MRI technology, specific known areas of the brain can be damaged with repeated episodes of apneas and low oxygen levels. Note that the word “damage” can mean low functioning, or dead brain cells. Here are 5 particular areas of brain damage from untreated obstructive sleep apnea with their specific symptoms:
1. The right insular cortex. This is the area of the brain that regulates sympathetic control of the autonomic nervous system. If the insular cortex is damaged, baroreflex control is affected. The insula also controls nerve endings that relate to pain. Both OSA and sleep apnea patients are found to have insular cortex injury.
2. The vetrolateral medulla (VLM). This area of the brain controls breathing and blood pressure regulation. Injury to this area blunts and delays heart rate responses to sudden pressure changes. One sided VLM injury leads to an asymmetric response to blood pressure challenge, which can potentially cause heart rhythm problems.
3. The cerebellum is the area of the brain that helps adjust blood pressure control and motor coordination, including breathing. Damage to this area prevents the ability to coordinate vascular and motor activity.
4. The hippocampus is found to be significantly smaller in people with obstructive sleep apnea. This area of the brain processes short and long-term memory and spatial navigation. One study found that hippocampal damage can be partially reversed after a period of CPAP. The hippocampus is also one of the first areas to be damaged in Alzheimer’s disease.
5. Mammary bodies are important for memory recall, as well as for memory for certain smells. These structures are much smaller in patients with OSA, and almost nonexistent in patients with heart failure. The hippocampus and mammary bodies are also found to be damaged in chronic alcoholism.
If OSA can damage critical areas of the brain that regulates breathing, balance, memory, and the autonomic nervous system, the implications are enormous. For example, heart failure is thought to lead to central sleep apnea. Is it possible that untreated obstructive sleep apnea can damage breathing and reflex centers in the brain that can lead to heart failure? What proportion of Alzheimer’s disease is actually undiagnosed OSA? The possibilities are endless. As they say at the end of every scientific journal article, more studies are needed.
If you have both OSA and memory problems, did your memory improve at all after being treated? Please tell your story below.
(Take a look at the references below to take a look at the various photos and figures. The figure above is from the Macey 2002 paper)
Canessa, N., Castronovo, V., Cappa, S. F., Aloia, M. S., Marelli, S., Falini, A., et al. (2011). Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function before and after Treatment. American Journal of Respiratory and Critical Care Medicine, 183(10), 1419–1426
Henderson, L. A., Woo, M. A., Macey, P. M., Macey, K. E., Frysinger, R. C., Alger, J. R., et al. (2003). Neural responses during Valsalva maneuvers in obstructive sleep apnea syndrome. Journal of Applied Physiology (Bethesda, Md. : 1985), 94(3), 1063–1074.
Kumar, R., Chavez, A. S., Macey, P. M., Woo, M. A., Yan-Go, F. L., & Harper, R. M. (2012). Altered global and regional brain mean diffusivity in patients with obstructive sleep apnea. Journal of Neuroscience Research, 90(10), 2043–2052.
Macey, P. M., Henderson, L. A., Macey, K. E., Alger, J. R., Frysinger, R. C., Woo, M. A., et al. (2002). Brain Morphology Associated with Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 166(10), 1382–1387.
Macey, P. M., Kumar, R., Woo, M. A., Valladares, E. M., Yan-Go, F. L., & Harper, R. M. (2008). Brain structural changes in obstructive sleep apnea. Sleep, 31(7), 967–977.
Lal, C., Strange, C., & Bachman, D. (2012). Neurocognitive impairment in obstructive sleep apnea. CHEST Journal, 141(6), 1601–1610.