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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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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Can Snoring As A Baby Predict Behavior Problems?

March 5, 2012

Here’s a new study which reinforces what I’ve been saying about sleep-breathing problems and children: That it’s a major undiagnosed cause of developmental and behavior problems in childhood. Researchers from Albert Einstein College of medicine followed over 11,000 children over a 6 year period. Parents were asked about snoring in sleep surveys from 6 months on, and at 7 years, they filled out a behavioral assessment. Not too surprisingly, children who snored as early as 6 months of age had a 50% increased risk of developing behavior problems by age 7 compared to controls.

We know that children who are sleep deprived become paradoxically hyperactive. In contrast, adults get sleepy (there are always exceptions to this observation). This study supports another study which I mentioned in the past showing that in children with ADHD who undergo tonsillectomy, about 50% can be cured for their ADHD condition. It’s no wonder that stimulants like Ritalin can help to calm a hyperactive child.

It’s important to note that I’m not saying all cases of ADHD are due to sleep-breathing disorders. However, it’s been estimated that a significant number of children (25 to 50%) with an ADHD diagnosis could have a treatable sleep-breathing problem. With these numbers in mind, wouldn’t it make sense to routinely screen for obstructive sleep apnea or a sleep-breathing problem before being given an ADHD diagnosis?

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Ask Dr. Park About Sleep About Sleep Apnea (11/8/11)

November 6, 2011

For this month’s Ask Dr. Park teleseminar, I answer the following questions:

1. Does sleeping with your head propped up help with sleep apnea?

2. Why is UARS so hard to define?

3. What do you think about all the latest publicity about thyroidectomy in helping with sleep apnea?

4. Can using tape over the mouth help with sleep apnea?

5. As we age how can we gauge whether we have sleep-related breathing issues, or circadian rhythm problems?

6. What if you are using a cpap machine and STILL wake up about every 2-3 hours?

7. How low should one seek to lower the AHI and the AI?

8. Is there a place for hyperbaric oxygen in the treatment of OSA?

9. Does a dental positioning device work for mild sleep apnea?

10. How does the future look for sleep apnea patients£ Will something replace CPAP as the gold standard?

11. Is there a clear distinction between central and obstructive sleep apnea? What are the alternatives if your apnea is primarily classified central?

12. If patient’s airway is examined with camera inserted through nose while patient is sitting upright and airway is found to be clear, is this enough to indicate airway would also be clear if patient was lying down? Should patients be checked in both positions?

And many more questions from the live audience.

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Ask Dr. Park: Any Question About Sleep Apnea or UARS

August 4, 2011

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

- Why don’t I feel better on CPAP?

- How long do I have to wait before feeling better on CPAP?

- What’s the best PAP machine for sleep apnea or UARS?

- What’s the difference between flow limitations and RERAs?

- What is the best surgical option for sleep apnea?

- Can nasal surgery cure sleep apnea?

- Is waking up early in the morning everyday around the same time an indication of sleep apnea?

- I was diagnosed with obstructive sleep apnea (AHI 36-40) but do not snore. Might this mean there is some other cause?

- Plus much more….

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Expert Interview: Dr. Christian Guilleminault on UARS

July 21, 2011

This month, I interview Dr. Christian Guilleminault of Stanford University, who is one of the pioneers in sleep apnea diagnosis and treatment. We’re going to focus on Upper Airway Resistance Syndrome (UARS), which he discovered.

Here are some of the questions we covered:

- Describe to us what UARS is and how it’s different from OSA?

- Why is the AHI limited when it comes to picking up UARS.

- How to diagnose UARS: Esophageal manometry vs. nasal cannula.

- How UARS patients have intact nervous systems, whereas sleep apnea (OSA) patients have diminished nervous systems, and what may cause progression from UARS to OSA?

- How do you treat patients with UARS? How is it different from treating sleep apnea?

- What are the dental options for UARS?

- How common is UARS in children and how can they be treated?

- And much more…

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Ask Dr. Park Teleseminar (7/12/11)

June 28, 2011

In this month’s Ask Dr. Park Teleseminar (7/12/11), I answer the following questions:

• Can having a stuffy nose prevent CPAP use?

• What kind of surgical procedures for the nose can help me breathe better?

• Can Viagra make me sleep better if I have sleep apnea?

• What’s the best non-CPAP treatment for severe sleep apnea?

• Is the laser procedure for snoring or sleep apnea effective?

• How does the TAP oral appliance compare with CPAP?

• Can oral appliances be used to treat UARS?

• Is CPAP a commitment for life? Is it ever reversible without surgery?

• What’s the success rate for tongue reduction surgery?

• What can I do about my dry mouth when using CPAP?

• Can wearing a cervical collar help sleep apnea?

• How can air in the stomach due to CPAP be prevented?

• What’s the Pillar procedure?

• Plus many more questions….

Download the 60 minute MP3 recording ($17).

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The Connection Between MS And Fatigue

June 8, 2011

It’s a given that if you have multiple sclerosis (MS), you’ll be tired all the time. It’s thought to be a normal part of having this condition, just like many other chronic medical conditions. But here’s an interesting study that suggests that fatigue can precede MS by up to 3 years. The researchers found that many MS patients complained of fatigue to their doctors months or even years before the first clinical signs of MS.

Here’s my take on this: I’ve written in the past about how the vast majority of people with MS that I see in my office have small jaws and narrowed upper airway anatomy. In an informal poll I conducted on Medhelp.com’s MS forum, a very high number of people had an excessive number of dental extractions, couldn’t sleep on their backs, and many of their parents snored heavily. Having excessive dental extractions causes the oral cavity to become much smaller, making the tongue take up too much space.

I’m not discounting current thinking about the origins of MS, but it’s extremely interesting that most patients with MS have very narrowed upper airway breathing anatomy which prevents achieving deep sleep. Lack of quality deep sleep can lead to various neurologic, hormonal, metabolic and digestive problems. Many patients with MS also have obstructive sleep apnea, but most will most likely have upper airway resistance syndrome, which I’ve described extensively here and in my book.

For those of you who happen to have MS:

What’s your favorite sleep position (back, side or stomach)?
Did you have any teeth removed besides your wisdom teeth, and if so, which ones and how many?
Do either of your parents snore heavily?

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Ask Dr. Park Teleseminar on Obstructive Sleep Apnea (4/12/11)

March 23, 2011

In this month’s (April 12, 2011) Ask Dr. Park Teleseminar I answer your questions on anything related to obstructive sleep apnea:

1. Do UARS patients progress into obstructive sleep apnea?

2. Given how common sleep apnea is, why hasn’t universal screening been implemented?

3. Despite using CPAP 5 to 8 hours every night, why am I still tired?

4. What do you think about the Pillar implants for snoring and sleep apnea?

5. How do I know when I can come off my CPAP machine as my sleep apnea improves?

6. What comes first, depression or sleep apnea?

7. How do you know if your sleep apnea machine is set for you correctly for you?

8. What surgery is recommended for nasal congestion?

9. Is it possible to underdiagnose sleep apnea in a sleep study?

10. What tips do you have for us dentists regarding UARS?

11. Can nasal congestion alter other areas of the upper airway?

12. Do you do turbinate reduction with the microdebrider?

13. What is UARS?

14. How much does lack of understanding of OSA and its’ consequences play in poor compliance? Are sleep doctors to blame?

15. Where are the best doctors or medical centers to go to on the West coast for fibromyalgia and UARS?

16. Why not add a hyoid procedure to the UPPP?

17. Can white matter lesions on DTI scans be responsible for sleep apnea patients’ symptoms?

18. Can hyperbaric oxygen therapy have a role in treating complications of sleep apnea?

19. What is expiatory sleep apnea?

20. Is bi-level use becoming more common?

21. Does high altitude make sleep apnea worse?

22. Is it worth trying the oral appliance for sleep apnea?

23. Is there any connection between cervical stenosis and sleep apnea?

24. What’s an SV Unit?

Click here to order the MP3 recording ($17).

Click here to order the PDF transcript ($7).

Written by Steven Park · Filed Under Expert Interviews | 7 Comments

Tim Ferris, Michael Phelps, ADHD, & Sleep Apnea

March 21, 2011

I wrote in my last post about how creativity can be linked to ADHD, mainly due to inefficient sleep from breathing problems at night. ADHD can also be linked to tremendous achievements in sports or physical activities. People who don’t sleep efficiently will take measures during the day to compensate for their inability to stay focused or stay awake. Some people drink lots of coffee. Others exercise like crazy. Some even become olympic swimming or ballroom dancing champions.

I’ve written before about how Michael Phelps, the olympic swimming champion, has a major malocclusion, and seems to be a mouth breather. It’s well documented in the papers that he had ADHD as a child. Swimming is a great way to not only stay active, but also has a calming, relaxing property that’s almost like doing deep-breathing meditation exercises. Swimming forces you to take slow, rhythmic breaths. His mother has known hypertension, and being clearly overweight, it’s likely that she has obstructive sleep apnea. Many long distance runners feel alive only when they’re running. It’s shocking how often people who are addicted to endurance sports can’t or prefer not to sleep on their backs.

Even with Tim Ferris, best-selling author of The 4-Hour Work-Week, in his new book, The 4-Hour Body, he describes how he and his entire family have major insomnia. He even recommends sleeping on your stomach, which is what he most likely prefers due to his jaw anatomy. He’s excelled in almost every physical activity, from running to swimming, to body-buiding, and even ballroom dancing. I do enjoy reading his books, but I have to admit that his writing style is definitely scattered, in the stereotypical style that’s typical for ADHD.

Problems can arise if you get injured or are forced to sleep on your back for some reason (an injury or surgery). Poor sleep quality can promote rapid weight gain, and then it’s really difficult to take off, especially since you’re not sleeping well, and you’re not able to exercise at your normal levels. Time and time again, people with these issues tell me that they get really down and depressed even if they miss a few workouts.

I know many of you reading this have this condition. Do you agree or disagree?

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