Expert Interview: Dr. Emerson Wickwire On Cognitive Behavioral Therapy for CPAP

April 15, 2012

Dr. Emerson Wickwire currently serves as Sleep Medicine Program Director at Pulmonary Disease and Critical Care Associates in Columbia, Maryland. He also holds the rank of Assistant Professor, part-time, at the Johns Hopkins School of Medicine, where he completed a two-year postdoctoral fellowship in sleep. Dr. Wickwire is board certified both in behavioral sleep medicine by the American Board of Sleep Medicine and in cognitive and behavioral psychology by the American Board of Professional Psychology. He is a pioneer in interdisciplinary approaches to sleep medicine and maximizing human performance.

In this interview, Dr. Wickwire shares his wisdom about comprehensive approaches to managing sleep apnea, including cognitive-behavioral treatment to maximize success with CPAP .

Some of the questions include:

What are cognitive-behavioral treatments (CBT)?

Have cognitive-behavioral treatments been applied to sleep disorders?

What is the psychology of sleep apnea?

What factors influence PAP use?

What are Wickwire’s Four Pillars of CPAP Success?

What is a PAP adherence risk profile?

What CBT interventions have been tested to improve PAP adherence?

And much more…

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Written by Steven Park · Filed Under Expert Interviews | 4 Comments

Read AJ Jacobs’ Drop Dead Healthy: One Man’s Humble Quest for Bodily Perfection

April 15, 2012

AJ Jacobs, a senior editor for Esquire Magazine, interviewed me last year while working on his latest book project, Drop Dead Healthy: One Man’s Humble Quest for Bodily Perfection. The book is now out and was favorably reviewed by the New York Times. We talked extensively about his snoring and sleep apnea, and he underwent the entire diagnosis and treatment protocol, including CPAP. I just read sections of his book (including parts with me in it) and it’s hilarious!

If you’re not already familiar with Mr. Jacobs, he’s also the author of The Know-It-All: One Man’s Humble Quest to Become the Smartest Person in the World and The Year of Living Biblically: One Man’s Humble Quest to Follow the Bible as Literally as Possible. His current book, Drop Dead Healthy, is already #31 on Amazon’s best-seller list.

His book was endorsed by Dr. Mehmet Oz, and Timothy Ferriss (author of The 4-Hour Body). I strongly recommend that you read Mr. Jacobs’ book. But don’t stay up too late reading it—sleep deprivation can lead to premature aging.

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Obstructive Sleep Apnea And Intracranial Pressure

April 13, 2012

Guest blog by Deborah Wardly, MD

It seems to be a little known fact that obstructive sleep apnea (OSA) can cause an increase in intracranial pressure (ICP). In 1989 Jennum and Borgeson showed that individual apneas lead to an increase in ICP in addition to an increase in arterial pressure, but also that in patients with OSA, more than half of them have elevated ICP while awake in the morning, and the ICP in the morning is higher than it is in the evening. Since that time there have been a few papers addressing this phenomenon, but surprisingly less than one might expect, and probably as a result most doctors do not seem to be aware of the connection.

There is more information in the ophthalmology literature and this specialty seems to be knowledgable about the relationship between OSA and papilledema (swelling of the optic nerve head) as seen in pseudotumor cerebri. There are reports of patients with OSA and intracranial hypertension with papilledema showing improvement in disc edema and visual fields with the use of CPAP.

However there is less awareness of the condition of IIHWOP: idiopathic intracranial hypertension without papilledema. In IIHWOP the headache pattern may be identical to that of migraine, and in the absence of papilledema it may not be possible to diagnose it without a lumbar puncture for opening pressure. The diagnosis of this subset of IIH must be considered in order to detect it.

In IIH the symptoms include most prominently headache, which is worse in the morning, and can be increased by anything which increases ICP, like coughing or sneezing (a Valsalva). The pain can go into the neck and upper back, and may be felt behind the eyes. There can also be nausea and vomiting, as well as dizziness. Many patients have a symptom called pulsatile tinnitus, which is a whooshing sound in the ears synchronous with the pulse. Less frequently there can be numbness of the extremities, generalized weakness, and balance problems. The ICP can affect the cranial nerves, notably the sixth nerve, and as above can lead to swelling of the optic disc which may cause visual changes. IIH can even present with psychiatric symptoms: depression, anxiety, and rarely self injurious behavior and psychosis.

The classic presentation of a person with IIH is an obese woman in her 40s, prior to menopause. The IIH is found to improve if the woman loses weight.

However there is a recent association noted in men with IIH: they are more likely to have OSA and testosterone deficiency. Therefore in addition to OSA, hormones seem to play a role in whether a person develops IIH. There is also a suggestion in the literature that IIH may in some cases be related to a hypercoagulable state. This may explain its prominence in people with higher estrogen levels. We know that OSA promotes hypercoagulability, is made worse by obesity, and may cause morning headache. OSA also will improve with weight loss.

I hope the reader can see the correlation and overlap between the symptoms of intracranial hypertension and those of OSA. It is my impression that there is likely a significant amount of IIH that is unrecognized among patients with OSA, because the relationship between apnea and ICP is not well known. Could it be that the severe fatigue and other debilitating symptoms in UARS are actually a result of unrecognized intracranial hypertension? I also suspect that problems in making the diagnosis of OSA may lead to underdiagnosis of OSA as the cause of many recognized cases of IIH.

What is your experience? As physicians were you aware that OSA may cause ICP? Do you have patients with both OSA and IIH? Do you have OSA patients with many of the IIH symptoms who might need further evaluation? As a patient with OSA, do you see yourself in the description of IIH?

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A Surprising Finding: Sleep Apnea Is Linked With Depression!

April 5, 2012

If you have sleep apnea, you’re more likely to suffer from depression. I can’t help but to be amazed that theses type of studies are still performed. I know that in the name of science, you have to show that there are statistical associations between two conditions that are thought to be related. But it’s like doing a study that shows that if you cut your hand, you’re more likely to bleed, or if you trip over an uneven sidewalk, you’re more likely to fall.

You don’t have to be a doctor to know that not sleeping well for extended periods can definitely cause you to feel depressed. The skeptics will then point out that there’s only a strong association between depression and sleep apnea, and that it doesn’t show that sleep apnea actually causes depression. Knowing how prevalent sleep apnea is in our society (most of it undiagnosed), it makes sense to at least think about obstructive sleep apnea before you make a diagnosis of depression and prescribe antidepressants. Unfortunately, even if a randomized placebo-controlled prospective study of thousands of patents showed that having untreated sleep apnea leads to higher rates of clinical depression, it’s unlikely that physicians will change the way they diagnose and treat depression.

Interestingly, most antidepressants suppress REM sleep. Coincidentally, REM sleep is when you’re most likely to have obstructions and apneas, due to complete muscle relaxation in your throat. So anything that lowers REM sleep will by definition lower your rate of apneas. In fact, there are published studies showing that REM sleep deprivation can be helpful for depression. Not having as many apneas could make you feel better during the day. I realize this may be an overly simplistic explanation, but it’s definitely something that the scientific community should think more about.

Come to think of it, there are no prospective randomized double-blinded placebo-controlled trials showing that drinking water cures dehydration. Millions of mothers are giving their children water every day to treat dehydration without FDA approval.

Written by Steven Park · Filed Under Blog | 2 Comments

Ask Dr. Park Teleseminar on Obstructive Sleep Apnea

April 4, 2012

In this Ask Dr. Park Teleseminar, I answer the following questions:

- I’ve had my CPAP machine for 5 years. Should I undergo another sleep study to see if anything has changed?

- Does palatal expansion work for people over 60?

- What do you think about Provent therapy?

- Is it possible to have a dental device lose its’ effectiveness without any weight gain?

- What’s your vision in the multidisciplinary approach to OSA treatment and comorbididies?

- Will restorative breathing correct OSA cases previously recommended for surgery?

- Can sleeping on your side be OK for sleep apnea?

- A recent Chinese study reported OSA in 27% of 5 to 12 year olds. In view of the obesity epidemic here in the US, is the incidence here in the US at least as high, if not higher?

- Should a person’s stuffy nose be addressed before OSA therapy?

- Does CPAP create “dependence,” so that surgical options later on may not work as well due to a weakened diaphragm or other muscles for breathing?

- Your opinion on the new implants (Pillar and hypoglossal nerve stimulation)

- Does sleeping on a 45 degree incline help with obstructive sleep apnea?

- What can be done to reduce the number of “getups” each night?

- What percentage of OSA is due to tongue collapse (vs. soft palate)?

And much, much more.

Click here to purchase the 60 minute MP3 recording.

Written by Steven Park · Filed Under Expert Interviews | 6 Comments

Expert Interview: Lois Laynee on “Restoring Breathing for a Good Night Sleep”

March 26, 2012

This month, I have as my guest Ms. Lois Laynee, CEO of AZ Sleep Apnea Center, and founder of Restorative Breathing Method. She will give a talk titled:

“Restoring Breathing for a Good Night Sleep”

In this program, Lois reveals:

- The physiology and biomechanics of optimal breathing
- Why exclusive nasal breathing is a must
- Ways to open up your nose without prescription medications
- How to receive a free brochure on Restorative Breathing techniques
- And much more…

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Written by Steven Park · Filed Under Expert Interviews | 8 Comments

A Final Farewell to Dr. Brian Palmer

March 19, 2012

I was shocked and saddened to find out that my friend and colleague, Dr. Brian Palmer, recently passed away. Dr. Palmer was responsible for opening my eyes to the importance of breastfeeding and good dental hygiene when it comes to your risk of developing obstructive sleep apnea. His decades of research and teaching has educated thousands of health care professionals. I had him as a guest on my Expert Interview program twice, the last time being December, 2011. Prophetically, I do remember him telling me that his 2 hour presentation was his gift to society. You can listen to his talk on the Evolution of Malocclusion and Sleep Apnea here. His website is a valuable resource for the lay public and professionals alike.

Rest in peace, Brian.

Written by Steven Park · Filed Under Blog | 3 Comments

Today Is World Sleep Day

March 16, 2012

In celebration of World Sleep Day, let’s give others the gift of sleep. If you have a loved one, a friend, or even a colleague that snores heavily or has problems sleeping, refer that person to a sleep medicine doctor. Most common sleep conditions are easily treatable. Here’s a press release by the World Sleep Federation describing their mission.

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Another Link Between Heart Disease, Depression, & Sleep Apnea

March 9, 2012

Here’s a study showing that having both heart disease and depression can significantly increase your chances of cognitive decline later in life. This makes absolute sense if you have obstructive sleep apnea to begin with, since this is what can aggravate or cause both heart disease and depression. There are also many studies showing how damaging untreated obstructive sleep apnea is on the brain.

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The Benefits of Breastfeeding on Breathing

March 7, 2012

The American Academy of Pediatrics just published a policy statement reiterating their recommendation that infants should be breastfed exclusively for 6 months. They also made this recommendation in their 2005 paper, but this time they actually quantify the health benefits.

The authors wrote that others have suggested that more than 900 infant deaths per year in the United States could be prevented if 90% of mothers breastfeed exclusively for six months. They also cited evidence that breastfeeding improves neurodevelopmental outcomes and enhances development of host defenses in infants born preterm. Other benefits include the following:

72% reduction in hospitalization for respiratory infections
64% reduction in the incidence of gastrointestinal infections
58% to 77% reduction in the incidence of necrotizing enterocolitis
36% to 45% reduction in the risk of sudden infant death syndrome
27% to 42% reduction in the incidence of asthma, atopic dermatitis, and eczema
52% reduction in the risk of celiac disease
31% reduction in the risk of inflammatory bowel disease
15% to 30% reduction in the incidence of obesity in adolescences and adulthood
15% to 20% reduction in the risk of childhood leukemia and lymphoma.

I’ve also proposed arguments made by dentists that bottle-feeding increases your risk of dental crowding and malocclusion. The smaller your jaws, the less airway you’ll have to breathe through properly during the day and especially at night. Notice that sleep-related breathing problems can directly or indirectly influence most, if not all the bullets listed above.

It’s also important to note that the physical act of breastfeeding itself is what protects against dental crowding and an increased risk of developing obstructive sleep apnea later in life. Obviously, exclusive breastfeeding without pumping is not practical or realistic in our society. However, you have to think about these implications.

Do you think Pediatricians are going a good job promoting breastfeeding?

Written by Steven Park · Filed Under Blog | 3 Comments

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