• The benefits of nasal breathing and nasal nitric oxide production

• Can using CPAP cause chills?

• What’s the best mattress option for sleep apnea?

• When would you consider a tracheotomy for sleep apnea?

• How do you know that you’re breathing through your nose when using CPAP?

• What can I do if my AHI is still high despite using CPAP?

• What’s the best sleep position when using CPAP?

• How do you treat complex sleep apnea?

• Is there a linear relationship between BMI an sleep apnea?

• Can sleep apnea be caused or triggered by a car accident?

• Can sleep apnea cause plugged ears to persist over a year?

• Is the MOGA procedure better for severe sleep apnea over CPAP?

• I’ve used APAP for over a year. Why do I still feel tired? I also have low circulation to the brain.

• How is PTSD related to sleep apnea?

• What’s the connection between hormones, progesterone and breathing issues?

• Is long-term use of acid suppressing medications harmful?

• Will a jaw expansion device give you similar results to a UPPP procedure?

• Why do I feel bloated after using CPAP?

• What are your thoughts on Provent?

• What’s a Zeo?

• Can you describe the tongue nerve stimulation devices?

• How does sleep apnea cause car accidents and does CPAP cure it?

• Should I get a tracheotomy?

• Can sleep apnea cause low testosterone?

• What do you think about the Aveo TSD for sleep apnea?

• Can an ENT office exam determine where obstruction is happening?

• How does changes in your monthly cycles affect changes in your mouth?

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One of the more common conditions you’ll see in such a clinic is Pierre Robin sequence, where due to improper maturation of the lower jaw, the lower chin is recessed severely. You’ll see milder variations of this all the time, but if severe enough, these people can’t breathe, especially at night.

Treating Only The Extremes

One of the problems with modern medicine is that we name and treat only the extreme end of a continuum, or only when significant problems result. Having a slightly recessed chin may be thought of a the person’s normal facial feature, and his or her ability to breathe is never even considered.

The entire basis for my sleep-breathing paradigm is that all modern humans have constricted facial structures, not due to a congenital or genetic problem, but due to our eating and lifestyle habits. Genetically, we’re all programmed to have relatively wide jaws, with room for all your wisdom teeth. Now, that rarely ever happens. This is why obstructive sleep apnea can be described as a mild craniofacial condition that can significantly affect your upper breathing passageways.

Small Jaws, Small Airway

It seems that almost everyone these days will need braces to fix crooked teeth or narrow dental arches. Dental crowding by definition means that your upper and lower jaws are underdeveloped. This creates less total volume inside your mouth, leading to overcrowding of your tongue. Your tongue can then fall back easier when on your back, and when in deep sleep, due to muscle relaxation, you’ll stop breathing more often at night.

Even your nose can be affected by this problem. Since your nasal sidewalls follow your upper molars, the side to side distance in your nose will be more narrow, and as the roof of your mouth (nasal floor) gets pushed up, it’ll also cause your septum to buckle.

If you add additional inflammation and swelling in your nose (due to colds, allergies or nonallergic rhinitis), your nose will become stuffier faster, and even worse, your nostrils will cave in easier.

Having underdeveloped upper jaws prevents proper cheekbone fullness, giving your mid-face a sinked-in look. This type of facial appearance is so common these days that it’s almost accepted as normal. I remember reading in the New York Times a few years back where they reported that women’s preferences for male actors has changed from the classic square-faced, angular facial features, to softer, more feminine, rounded faces.

Despite having some good first line options such as CPAP or oral appliances, these approaches don’t really address the root cause. If your child’s jaw was severely underdeveloped and your choice was either lifetime CPAP or jaw enlargement, which would you choose? What if, rather than cutting the jaws and pulling it forward, you can apply distraction plates that can be pulled slowly, little by little, to normalize the jaws and improve the airway significantly? What about advanced dental appliances that can expand your upper and lower jaws in three dimensions, making more room for your tongue? With current technology, we can modify your jaws significantly. But for adults with obstructive sleep apnea, any kind of surgical or dental modification of the jaws is only considered as a last resort.

I describe obstructive sleep apnea as the end extreme of a continuum of sleep-breathing disorders. Similarly, if you look at obstructive sleep apnea as being a craniofacial problem, everyone will have various degrees of jaw underdevelopment. If you have impacted molars, or had to have your wisdom teeth taken out, then your breathing passageways are compromised.

Not only are your jaws more narrow, but the soft tissues that line your breathing passageways will be much more likely to become inflamed and cause even further obstruction. Frequent obstructions can cause a vacuum effect in your throat which literally suctions up your normal stomach juices into your throat, promoting more inflammation and swelling. These juices (which include acid, bile, digestive enzymes and bacteria) can then also reach your nose, sinuses, ears and even your lungs, causing additional inflammation and swelling. If your nose is stuffy, then a vacuum effect is created downstream in your throat and the tongue can fall back much easier, whenever you’re in deep sleep (due to muscle relaxation).

Our Airways Are Like Plumbing

In the medical community, craniofacial problems are generally treated surgically. Even with plumbing, if you only open up one area of multiple clogged areas, the pipes will still be clogged (like doing a UPPP). Sometimes you can put in drano to soften the clogging and open up the passageways (like allergy medications), but after years of buildup and accumulation, you have to physically open up all the blocked areas. You can also use a plunger to force the water down the drain (like CPAP), but you know that sooner or later, it’ll get clogged again. The older the pipes, the worse it becomes (old age).

CPAP and oral appliances are both important and necessary tools to treat the vast majority of people with sleep apnea, but we also need to open our minds to the idea that we shouldn’t have to sleep with gadgets or devices for the rest of our lives.

A Modern, Western Dilemma

It’s commonly known that our brains are getting bigger over time. As modern human’s mid and lower faces get smaller and smaller, I predict that in a few hundred to a few thousand years, everyone will be tethered to a hose while sleeping, like in the science fiction movies. Maybe vocal speech and communication will not be needed anymore, and we’ll be able to communicate with mental telepathy. We’ll all begin to look like that alien in the old Star Trek episode with the huge brain and a tiny face.

Sadly, it’s already started. If you look at the younger generations, you’ll see how narrow their dental arches are, along with flat cheekbones and narrow nasal widths. Recently, I happened to see an Amish chorus singing songs in the Grand Central subway station. I was amazed how most had very prominent cheekbones, well-formed jaws, and good looking smiles. It’s not surprising that cultures that eat organically and off the land will have more fully developed jaws.

So the next time you’re sitting in an auditorium and a public place with lots of people, think about that classic first day of college speech by the dean or president:

“Look to your left…and look to your right. At the end of this year, one of the two that you see will not be here with you.”

Similarly, every other person sitting next to you will most likely have smallish jaws, and have an undiagnosed sleep-breathing problem. From a craniofacial standpoint, they won’t be able to sleep well due to narrowed breathing passageways. If you end up befriending or marrying one of these people, now you’ll understand what makes them tick, or sick.

This month, I’ll be answering the top 10 questions I get asked about obstructive sleep apnea. Of course, I’ll also leave plenty of time for me to answer your other questions at the end of the program.

1. What’s the difference between snoring and apnea, and where is each coming from?

2. What’s the best CPAP – mask combination?

3. Is snoring itself harmful or do you need to have sleep apnea to have adverse health effects?

4. How effective are mouthpieces for sleep apnea?

5. How can the source of airway blockages be determined?

6. What’s the best operative solution after UPPP fails and what is it’s success rate?

7. Does sleep apnea cause permanent brain damage?

8. Can CPAP convert OSA into UARS?

9. Do you have any suggestions for what to do for patients who just cannot sleep in a sleep lab?

10. What’s the best sleep apnea treatment?

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Theses are only rough estimates, but if you take 100 people who are newly diagnosed with obstructive sleep apnea, only about 1/2 are willing to even try it. Of the people who give it a try, maybe about 1/2 end up using it regularly, and of those who use it regularly, perhaps 1/2 continue to use it for more than 1-2 years. Even if you’re using it regularly, not everyone feels any significant improvement in their symptoms.

As you can see, out of all the possible people who are candidates for CPAP, only a small fraction ever end up benefitting at all. It’s shocking how many CPAP machines sit in the closet after only a few weeks use. In controlled research studies, compliance can be quite high, even up to 60 or 80%, but in the real world, it’s probably more like 20-30% long-term.

Despite the grim statistics, CPAP is still the best option that we have. Millions of people benefit from its’ use significantly, and in many cases, it’s a life-saver. There’s also so much more that can be done to educate and support new CPAP users so that more people are able to use and benefit from it.

The frustrating thing is that there are alternative forms of treatment that can be just as good, if not better than CPAP. But in most cases, they’re simply dismissed as being not effective.

The first treatment option that’s available that should be considered the real “gold standard” is tracheotomy. This is where a hole is surgically made just below your voice box into your windpipe, essentially bypassing your entire upper airway. This has essentially a 100% cure for obstructive sleep apnea.

The two other major options for sleep apnea are oral appliances and surgery. The criticism by certain sleep doctors against these two options is that it never gets the AHI down to normal levels. But even a 50% drop in the severity of your breathing pauses is much better than not using your CPAP at all. This was borne out in one Veterans Administration study that showed that the UPPP procedure (with a historical 40% success rate) had a higher overall survival rate years later compared to people placed on CPAP. Surgical “success” is a controversial topic, and I’ve talked in detail about my logic for offering surgery at all.

It’s clear that there are certain camps that are strong proponents for each of the three major treatment options (CPAP, dental devices, and surgery). Each has it’s advantages and disadvantages. CPAP should always be considered first, but the two other treatments should at least be offered once you’ve exhausted all your CPAP options. Advanced orthodontics is another emerging treatment option but we’ll have to see results from more studies.

One interesting observation is that for people who are happy with their surgery, they forget about the fact that they have obstructive sleep apnea. They just go on with their their normal (and more productive) lives. They’re not reminded every night that they have sleep apnea, as what happens with oral appliances or CPAP. For others, CPAP is a normal part of life, like brushing your teeth before bedtime, and are not bothered at all. Notice how different people deal with their treatment options differently.

In my mind, it’s not about which option is better, but customizing your treatment plan based on a systematic process that starts with CPAP, and making sure to go on to other options if CPAP is not working. Unfortunately, too many people give up after trying only CPAP. Ultimately, there is no gold standard.

What’s your feeling on this admittedly controversial topic?

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.

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.

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

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PDF digital transcript, $7

 

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MP3 recording + PDF transcript, $20

 

 

Start Breathing, Sleeping, and Living Better with Dr. Park’s Expert Interview Series!

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.

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.

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?