More Sleep Apnea Bites the Dust
September 2, 2010
I had a crazy day today with a packed schedule full of patients, but the one thing that made it worthwhile for me was the feedback I got from three different patients about either how well they were sleeping, or how their lives were changed as a result of sleep apnea treatment.
While rounding at the hospital early this morning to see my post op patient, she was doing remarkably well one day after her multiple soft palate and tongue procedures for obstructive sleep apnea. She was already swallowing liquids pretty well, and ready to go home. She also noted that despite the pain and the poor sleep environment of being in a hospital with all the noises and distractions, she felt more refreshed than normal when she woke up this morning.
Another patient that I hadn’t seen in 6 or 7 years came in for ear wax removal, and just happened to thank me for changing his life. I had no idea what he was talking about. He reminded me that I had sent him to a dentist for his sleep apnea and he has been successfully using his dental device all this time.
A third patient came in one month after routine nasal surgery and remarked that his breathing is not only normal, but he’s not snoring anymore, and his sleep is much more refreshing and he’s dreaming more.
These are some of the examples of patients that have found success with either CPAP, oral appliances, or with surgery. Some people find success after their first option, while others go through everything before finding a solution that works.
Admittedly, not everyone that I see has great results like that ones above, but the vast majority do, while the remainder have partial or limited success.
This is what keeps me going, knowing that I’m able to help people breathe better and sleep better, regardless of which option they choose. It’s truly a privilege for me to be able to help people in this way.
What’s your success story? Please share your story with me in the comments box below.
Sleep Apnea Surgery: Sham or Science?
December 17, 2009
As a surgeon, it’s difficult for me to say that most surgical procedures that are performed for sleep apnea don’t work. But like everything else in life, it’s never black or white—there are always various shades of gray.
Many people (and surgeons) think of the upper airway as a simple tube that channels air into the lungs. What’s not appreciated enough is that this passageway from the tip of the nose to the vocal folds is highly dynamic, constantly changing, with multiple levels of partial to total obstruction. There are major areas of potential obstruction (nose, soft palate and tongue), but there are many other factors that can cause inflammation, swelling, or narrowing, in addition to these 3 major areas. These other factors can include weather changes, your emotions, what you just ate, sleep position, drugs and medications, and your weight.
But even if you consider the three major areas only, even then it’s not that well understood. Imagine a simple, long semi-collapsible tube connecting your nose to you windpipe. If there’s one area of obstruction, then opening up this area will help should help in most cases (for example, large tonsils). But let’s say that in addition to the tonsils, you also have nasal congestion due to a deviated nasal septum. Then by undergoing only a tonsillectomy, you may feel better initially, but over time, vacuum forces created in the throat by having a stuffy nose will aggravate soft palate and tongue collapse, leading to sleep apnea later in life. If you start with obstruction in the tongue area, soft palate and the nose, then opening up the soft palate obstruction only may work sometimes, but not all the time.
This is the reason for the 40% success rate of the uvulopalatopharyngoplasty procedure (UPPP). You can argue what the meaning of surgical success, but that’s for another discussion. So this leads to one of the most common questions that I get asked: Does the UPPP procedure work for sleep apnea? The answer is yes, but only in people who have obstruction purely in the soft palate area, especially if you have very large tonsils. This situation occurs only in about 40% of the time in adults.
In young children, undergoing tonsillectomy only without soft palate surgery is found to "cure" sleep apnea in about 2/3 of patients. This makes sense, since tonsils tend to be relatively bigger in children. But what’s the reason for residual sleep apnea in the other 1/3 of children? The answer is for the same reasons as in adults: smaller jaws that lead to tongue collapse and nasal congestion. Even in the children who are considered initially "successful," a certain proportion will go on to slowly re-develop obstructive sleep apnea, due to their smaller jaw anatomy and predisposition for inflammation in the upper airways. The tongue becomes more of an issue later in adulthood as the voice box develops and descends down in the throat.
So does sleep apnea surgery work? Like everything else in life, it depends.
If you want more detailed information on the truth about sleep apnea surgery, sign up for my free report on the box to the right.
Did you ever undergo surgery for sleep apnea? Was it addressing one level or multiple levels? Please enter your response in the comments box below.
The ABCs of Oral Appliance Therapy
November 12, 2009
How to Treat Sleep Apnea with Oral Appliances, Revealed
Dr. Park Interviews Dr. David Lawler, a dentist with extensive knowledge and expertise in treating sleep apnea using oral appliances. During this 60 minute call, Dr. Lawler explains in detail what oral appliance therapy is and how it can be used to treat sleep disorders. Find out:
- Why customized dental devices are good alternatives to CPAP in treating obstructive sleep apnea
- How oral appliances can help you stop snoring
- The major mistakes people make when getting dental devices for their sleep apnea and what you can do to avoid them
- How to lessen the discomfort of using any dental device
- Tips on finding the right dentist in your area to fit you with these devices
Buy your copy of this audio recording today, available in two easy-to-access formats:
Start Breathing, Sleeping, and Living Better with Dr. Park’s Expert Interview Series!
Tongue Retaining Device for Obstructive Sleep Apnea: Does It Work?
October 19, 2009
There are many variations of oral appliances to treat snoring and obstructive sleep apnea, but one variation that you may not have heard of is the tongue retaining device (TRD). There are also different variations of TRDs, from suction bulbs to hybrid mandibular advancement device-TRDs. Here’s one example and here’s another. Here’s a good review of the science behind tongue retaining devices.
In this month’s issue to Journal of Clinical Sleep Medicine, French researchers reported complete or partial responses in 71% of cases, with the mean AHI dropping from 38 to 14. Snoring dropped by 68%, and subjective sleepiness dropped significantly as well.
What I had in mind when I saw the paper’s title was the suction cup-like device that sits between your teeth and lips, with a bulb protruding out your mouth. Your tongue sits inside the suction cup, keeping it from falling back. A simple and novel idea. However, when I looked more closely at the study it turns out that what they call a tongue retaining device is actually a hybrid mandibular advancement device and TRD. We know that mandibular advancement devices, by pushing your jaw forward can significantly push your tongue base forward, improves the space behind your tongue. The researchers set the mandibular protrusion at 50 to 75% of maximal protrusion, which can definitely improve your sleep quality.
Although my experience is limited, I’ve had mixed results in people who have tried tongue retaining devices. In general, they’re not as expensive as the formal mandibular advancement devices, so there’s less of a barrier for people to try it out.
Just out of curiosity, I have patients stick out their tongue whenever I examine the space behind the tongue while they’re lying flat on their backs. This is a rough estimate, but only in about one out of 4 times, do I see any significant improvement in the posterior airway space. This may explain why many patients don’t see any benefits. Drooling, discomfort and an inability to swallow are some of the more common complaints.
Have you tried tongue retaining devices and if so, what’s been your experience? Please enter your responses below.
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?
Pregnant Women On CPAP For Pre-eclampsia
August 19, 2009
Ask Dr. Park – A Live Teleconference
May 3, 2009
Join me on the next "Ask Dr. Park" call. We’ll talk about lots of things, but the focus of this teleseminar will be sleep apnea. Everything about the quality of your sleep will be discussed: from tips on improving your sleep quality to a discussion on the best treatments for OSA. And, you get to set the actual agenda! I would like to hear from YOU about what your biggest questions and topic areas of concern are. The aim is to arm you with lots of information about sleep apnea that you want to know. This is a rare treat for any of you or your loved ones who suffer from sleep apnea.
This event will be held live on 5/12 at 8PM Eastern. You’ll be able to either call in using your telephone line, or listen in on your computer’s browser. You can ask your question during registration or during the call.
Click here to register and receive the call-in information.
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