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Viagra, Raynaud’s & Sleep Apnea

Viagra is still a popular drug that’s used to treat erectile dysfunction (ED) in men. It works by relaxing smooth muscle in blood vessels, allowing blood to enter the penis. A recent study showed that it can also help people with Raynaud’s phenomenon, where small blood vessels in the hands or feet go into spasm and cause cold or numb extremities, sometimes to the point of infection or even gangrene. This condition is commonly seen with autoimmune conditions, especially in lupus. It makes sense that relaxing smooth muscles that constrict blood vessels may increase circulation. Unfortunately, people taking this medication had a number of side effects.

In my book, Sleep, Interrupted, I describe a young woman who had classic Raynaud’s symptoms, needing to wear socks and mittens to bed even in the summer. After undergoing multilevel upper airway surgery for her mild obstructive sleep apnea, her Raynaud’s disappeared completely! Her depression, low blood pressure, irritable bowel symptoms, and daily headaches improved significantly as well.

There are also numerous studies showing the ED is a common complication of obstructive sleep apnea. One of the more common signs that sleep apnea treatment is working (through CPAP, dental devices or surgery) is that men are having erections again upon awakening in the morning. In many cases, ED resolves completely after sleep apnea treatment.

Not getting deep, high quality sleep is known to cause a physiologic state of stress, leading to too much of an adrenaline response. This results in an inability to relax vascular smooth muscles in various parts of the body, including the hands, as well as the digestive or reproductive organs.

If you have obstructive sleep apnea or upper airway resistance syndrome, it’s a given that your body will be under a constant state of stress. This why why after properly treating these conditions, ED and Raynaud’s often improve. These common conditions are not problems specific to the respective body parts—they are the end result of a systemic problem aggravated by not breathing and not sleeping properly.

These sleep-breathing problems are often treated successfully by alternative and complementary practitioners, since they tend to focus on the whole person, including his or her surroundings, rather than the one specific neurotransmitter, hormone, or body part.

However, taking a pill, whether it’s a prescription medication, vitamin or natural herb, or breathing exercises during the day, won’t solve the problem completely if you’re not able to breathe properly at night.

How many of you have had partial or total resolution of your ED or Raynaud’s after treating your sleep-breathing condition?

 

Brain Damage in Chronic Fatigue Syndrome and Sleep Apnea

There are a lot of controversial theories about the origins of chronic fatigue syndrome (CFS), and even more recommendations on how it can be treated. One particular explanation is that people with CFS have some sort of brain dysfunction, which disrupts how it regulates the body’s nervous, metabolic, and hormonal systems. A recent study confirmed that white matter and grey matter volume was diminished in various parts of the brain and brainstem.

These findings are very similar to numerous studies showing that untreated obstructive sleep apnea can lead to brain volume loss or lower tissue density in various parts of the brain, including areas that control memory, executive function, and especially autonomic control. This brings up the classic chicken or the egg question: Did brain damage come first and CFS afterwards, or does CFS cause brain damage? Knowing how common sleep-breathing problems are at any age, and knowing how even mild levels of breathing difficulty during sleep can significantly affect brain functioning, perhaps brain damage from suddenly worsened sleep apnea could be a more logical reason for most (but not all) cases of CFS.

Many patients with CFS will have documented obstructive sleep apnea, but not all. However, the upper airway anatomy in most CFS patients are more like people who have upper airway resistance syndrome. Their upper airways are so narrow that their nervous system become overly sensitive to any degree of airway obstruction. As I’ve stated before, UARS patients wake up to a light stage of sleep, even with very subtle degrees of breathing obstruction. These pauses are not long enough to be called apneas. This causes a chronic low-grade physiologic state of stress, which by itself is known to be detrimental to brain health.

So it’s not surprising that most people with CFS have very small mouths and narrow jaws. Many have had excessive dental extractions for various reasons, or have various degree of jaw underdevelopment. The vast majority definitely can’t sleep on their backs.

This also explains why a simple cold or viral infection (Mono, Lyme, etc.), sudden weight gain, or physical injury that forces you to sleep on your back, can trigger the vicious cycle that leads into the classic symptoms of CFS. All these events suddenly narrow the already narrowed upper airway.

If you have CFS, what was your precipitating event?

Autism, Vaccines, & Sleep Apnea: My Multi-Hit Theory

I remember during M&M (morbidity and mortality) rounds as a resident, our chairman felt strongly that an error never occurs in isolation. He insisted that a bad outcome happens from a series of mistakes, oversights and lack of communication. Even in engineering or aviation, whenever something goes wrong, there’s usually a series of events that led to the final adverse outcome. The same analogy also applies with cancer.

Although vaccines were essentially exonerated by recent large-scale studies (showing that the rate of autism was no different before and after Thimerisol was removed), there are still many proponents of the vaccine theory. I think that there’s some merit to this possible connection, but not for the reasons that you may think. Let me explain.

You may remember in one of my previous posts, I described reading about a theory that proposes that since the Back to Sleep campaign for infants in the early 90s, the incidence of autism went up significantly afterwards. This campaign led to a 40% reduction in sudden infant death syndrome (SIDS). However, one of the consequences of keeping infants on their backs is to keep them in a lighter state of sleep. This can prevent proper memory consolidation and brain development.

Although it sounds like a feasible explanation, it’s going to be difficult to prove. Medically and politically, doctors are not going to retract this recommendation, even if it is found to be plausible. However, if you add to this the fact that modern jaws are smaller due to a more bottle-feeding and poor nutrition, sleeping on your back can definitely lessen your deep sleep efficiency.

In another recent post, I alluded to allergy shots aggravating obstructive sleep apnea, by increasing nasal congestion. Anything that causes inflammation in the nose or throat, including allergies, colds, migraines, reflux or weather changes, can aggravate more frequent pauses in your breathing, especially when in deep sleep.

The human voice box is unique in that it’s located below the tongue. This migration downwards begins at birth and continues until your 60 or 70s. Around 4 to 6 months, a space is created between your soft palate and your voice box, called the oropharynx. Only humans have a true oropharynx. Descent of the larynx is needed for complex speech and language. But this also predisposes humans to breathing problems, especially when on our backs. This is when the tongue and voice box falls back the most, due to gravity. When you add muscle relaxation during deep sleep, you’re more likely to stop breathing and wake up.

Not breathing at night while sleeping, from a brief second to 30 seconds or more, can be detrimental to your brain. The end extreme of this spectrum is called obstructive sleep apnea, but even multiple short episodes of breathing pauses due to upper airway obstruction can lead to various pathways that can lead to significant neurological impairment.

If you put all these mechanisms together, then it creates a situation where you can suffer serious brain damage. In most cases, you won’t be able to see any anatomic changes using traditional imaging studies, such as with a CT scan or an MRI. These are sub-radiologic changes that occur within the brain tissues itself.

Vaccines and flu shots, just like anything else that creates a mild infection, can cause swelling and inflammation in your nose and throat. If your anatomy is already predisposed, and you add additional variables such as back sleeping and bottle-feeding, then even an allergy attack could in theory cause changes in your brain that can mimic autism. Given that the total number of child immunizations has increased tremendously only adds to my argument. Not too surprisingly, there are also known reports of children who develop autism after a simple cold or flu infection.

Ultimately, it may not be the specific type of vaccine or flu shot, or even the specific materials that they’re made with, but rather the general inflammation causing properties of these immunizations that may be the trigger that tips children over the edge to progress into any of the autism spectrum disorders. I may be going out on a limb here, but in the big scheme of things, autism may even be a childhood manifestation of the same process that causes Alzheimer’s.

What’s your opinion on my thought experiment? Will you agree with me that autism has multifactorial causes and not just one trigger?

Can Allergy Shots Cause Obstructive Sleep Apnea?

During a routine visit, a patient of mine commented that he noticed an interesting phenomenon whenever he checks his wife’s CPAP compliance data. Normally, her RDI hovers around 3-4, and she’s fine, but whenever it goes up to 7-8 or above, she’s more cranky, tired and irritable. In particular, these spikes correlate with the days immediately after she undergoes allergy shots.

Immunotherapy, or allergy shots, is meant to cause a reaction by your immune system, and in the process, produces inflammation. If this inflammation and swelling occurs in her nose, then it’s conceivable that additionally nasal resistance can increased your CPAP pressure needs.

Inflammation or swelling caused by colds, allergies or infections of the nose can aggravate OSA by increasing vacuum pressures downstream, allowing the tongue to fall back more easily. This is one simple reason why you don’t sleep well when you have allergies or a cold.

Do you have similar experiences? Do you not sleep well after undergoing allergy shots?

Another Strong Link Between PTSD and Sleep Apnea

Here’s a not too surprising study about post-traumatic stress syndrome (PTSD) in veterans: 54% of PTSD patients who underwent formal sleep studies were found to have obstructive sleep apnea. This is much higher than what’s normally expected (about 20%). There are numerous reports of veterans with severe PTSD that are eventually found to have obstructive sleep apnea later in life, and once treated, the PTSD goes away.

It’s likely that they always had some degree of obstructive sleep apnea to begin with, and once the emotional or physical trauma took place, memories or thoughts of that event can trigger a hyperintense reaction, since your nervous system is going to be hypersensitive in general.

I’m also guessing that there will be a significant number of veterans that don’t meet the official criteria for obstructive sleep apnea, but still suffer from significant breathing pauses and arousals.

Based on these findings, do you think everyone with a formal diagnosis of PTSD should be screened for obstructive sleep apnea? Please enter your comments in the text box below.

ADHD & Sleep Apnea: The Controversial Connection

As the new school year begins, it’s only natural that there’s more awareness about learning and behavior issues. One of the most controversial topics that came up frequently is ADHD, or Attention Deficit Hyperactivity Disorder. It’s thought that 2-4% of children have this condition, and a shocking 50% of children with this condition are on some form of prescription medication. Not only is it seen in children, but adults can have it as well. Symptoms include inability to focus or pay attention, being easily distracted, and various behavioral problems in the classroom.

There are a number of proposed explanations for why ADHD occurs, including brain biochemical imbalances, environmental and dietary toxins, and allergic conditions. One possible explanation that never receives very much attention is from lack of deep quality sleep.

Poor Sleep Can Ruin Your Child’s Brain Health

It may be coincidence, but it’s estimated that about 2-4% of all children have obstructive sleep apnea. And we know from numerous studies that poor sleep, whether not enough sleep, or poor quality sleep, can adversely affect the brain in a number of different ways.

For one thing, lack of oxygen to the brain has been shown to cause lowered blood flow and metabolism in critical areas of the brain, including parts that involve memory and executive function.

There’s no doubt that hypoxia can cause significant alterations in the levels of neurotransmitters that regulate memory, focus, concentration, and other cognitive skills. If you pick any one out of dozens or hundreds of biochemical markers, you’ll find that there will be a deficiency or an elevation. Whether it’s dopamine, acetylcholine, or serotonin, if you look for abnormalities, you’ll find it. Not too surprisingly, the same can be said for depression, anxiety, and other mood disorders.

Admittedly, ADHD is a multifaceted condition. Sometimes, it’s mainly due to one condition, and in other cases, from a combination of different causes. Not breathing well at night while sleeping can present with the same clinical symptoms as toxic contamination such as lead poisoning. So it’s important to have the pediatrician or other health care professional to look at all possibilities before considering psychotherapy or prescription medications. Only after every treatable condition has been ruled out should the diagnosis of ADHD be given, since ultimately, it’s a diagnosis of exclusion.

First Check For Sleep Apnea, Then ADHD

One recent study found that 28% of children scheduled to undergo routine tonsillectomy had official ADHD. Once their tonsils were removed, the rate of ADHD dropped by about 50%. Since these children were selected from a pool of patients that are already predisposed to sleep-breathing problem, it’s only natural that sleep apnea is so common. In another contrasting study, there was no difference in the rate of obstructive sleep apnea between controls and children with ADHD.

One thing that’s for certain, many children with ADHD, even if they don’t officially have sleep apnea, will have major sleep breathing or sleep hygiene issues. This situation is similar to patients who don’t have obstructive sleep apnea but have upper airway resistance syndrome, where they still stop breathing multiple times during the night.

During the initial evaluation process, one of the first things to always consider is the possibility of a sleep-breathing problem. Snoring or breathing problems at night are always a good thing to look for, but you don’t have to snore to have significant obstructive sleep apnea. If your child has very large tonsils, or has frequent throat infections, then consider seeing an ENT surgeon. Chronic nasal congestion or a runny nose can suggest a problem with the upper breathing passageways as well. If one or both parents snore, then even more reason to suspect a possible sleep-breathing problem.

But before you take your child to see a sleep doctor or an ENT surgeon, first try these simple steps to improve their sleep quality.

1.  Take care of any allergies, whether food related or environmental. Allergies can cause inflammation of the upper air passageways that can cause swelling and further narrowing, leading to more obstructions and arousals. If conservative options fail, then see an allergist.

2.  Don’t eat or snack within 3-4 hours of bedtime. Eating close to bedtime allows more stomach juices to be suctioned up into the throat when you stop breathing.

3.  Deal with any nasal congestion. Having a stuffy nose for any reason causes a vacuum effect that allows your tongue to fall back easier when in deep sleep.

4.  Set a regular bedtime routine, with no media (TV, computers or phones) within one hour of going to bed.

5.  Make sure the bedroom is completely dark. Many bedroom appliances, clocks or other devices have exceptionally bright LED bulbs that can prevent proper sleep onset.

If you suspect that your child may have ADHD, the first thing to consider is to consider poor sleep quality as a major aggravator, if not the cause. Yes, you still need to address all the other issues that can aggravate ADHD, such as diet, stimulus control or allergies, but sleep should never be excluded from the list. Even if sleeping better doesn’t’ help with the ADHD, it can definitely help with various other health issues, such as obesity prevention, or lower incidence of asthma, depression, and anxiety. It could even help your child raise his or her test scores.

The Biggest Throat Problem for Sleep Apnea Sufferers

If you wake up every morning needing to hack up lots of thick mucous, or have throat pain, hoarseness, or a chronic cough, you’re not alone. You may think it’s the beginning of a cold, but a cold doesn’t continue for weeks to months without progressing into the full-blown viral symptoms.

Instead, these symptoms are the beginnings of the most common throat problem sleep apnea sufferers face. And as I explain below, without understanding why this occurs, it can be one of the hardest problems to treat.

Beware of the “Vacuum Effect”

People with obstructive sleep apnea are more prone to breathing problems at night due to partial or total collapse of one or more areas of the entire upper airway, from the nose to the tongue. It’s usually worse when on your back, since the tongue can fall back more in this position. During deep sleep, your muscles naturally relax and you’ll be more susceptible to breathing stoppages.

Pressure sensors placed inside sleep apnea patients reveal that every time an apnea occurs, a tremendous vacuum effect is created inside the chest and throat, which literally suctions up your normal stomach juices into your esophagus and throat. This can happen occasionally, even for normal people, but if you happen to have a late meal or a snack just before bedtime, there will be even more stomach juices lingering in your stomach to come up into the throat. If you happened to drink a nightcap, the situation is even worse since alcohol is a strong muscle relaxant.

What comes up into your throat is not only acid, but also bile, digestive enzymes, and even bacteria. Washings of lung, sinus and ear contents have shown H. pylori, a common stomach bacteria, and pepsin, a major stomach digestive enzyme. So what comes up can cause severe irritation in your throat, provoking the mucous secreting glands of your throat to try to dilute these substances.

Although people generally attribute throat mucous to post-nasal drip, in most cases there’s nothing dripping down the back of the throat. It’s actually coming from your stomach. However, in some cases, since your stomach juices can reach your nose, it can cause nasal congestion and inflammation, which can aggravate tongue and soft palate collapse by creating a vacuum effect downstream. Ultimately, it’s a vicious cycle.

Chronic acid and other irritating substances lingering in your throat can have other detrimental effects. One recent study showed that chronic acid exposure can numb or deaden the protective chemoreceptors in your throat. These are sensors that detect any acid in the throat to prevent aspiration of your stomach contents into your lungs. If these chemoreceptors sense any acid in your throat, a feedback signal is sent to the brain, causing you to wake up so that you can swallow. This is what’s called a reflux arousal.

Treating Reflux For Good

So besides not eating late and avoiding alcohol close to bedtime, what else can you do?

I’m assuming that many of you that are reading this article are already being treated for obstructive sleep apnea, via either CPAP, oral appliances, or even with surgery. The problem is that no matter which option you choose, there will always be some degree of reflux. Taking acid reflux medications can help sometimes, but for the most part, these reflux medications don’t really do anything for reflux. All they do is to lower the acid content content before it comes up into your throat.

Other options include stimulating your stomach via natural remedies or prescription medications to empty your stomach much faster. One fascinating study showed that using a combination of pseudoephedrine (Sudafed) and a pro-motility agent (domperidone) eliminated snoring in most people. Unfortunately, we don’t have the equivalent of domperidone here in the US. Other similar medications are available, but have more serious side effects.

This is why eating early at least 3-4 hours of bedtime is so important whether or not you have obstructive sleep apnea. The same also applies to alcohol. If your nose is stuffy, talk with your doctor to find a way to breathe better through your nose. Make sure you’re sleeping in your preferred or optimal sleep position. Lastly, work with your sleep physician to fully optimize your sleep apnea treatment, no matter which option you choose.

Can Antidepressants Cause Obstructive Sleep Apnea?

I do believe that untreated obstructive sleep apnea (OSA) is a major cause, if not the most common cause of depression.  We know from numerous studies that OSA, via massive hypoxia and inflammation, causes brain biochemical and structural changes that can alter almost every aspect of your physiology and psychology.

Almost weekly, I see patients that suddenly gained significant weight after starting an antidepressant medication. We know that certain antidepressants are more likely to cause weight gain. Weight gain can aggravate obstructive sleep apnea, and obstructive sleep apnea can worsen depression. We also know that depression is linked with a higher incidence of insomnia, cardiovascular disease, and even death.

Did you gain weight after starting an antidepressant medication? If so, which one did you take?

Can Sleep Apnea Cause Psoriasis?

How is psoriasis connected to obstructive sleep apnea? You may think I'm crazy for even making the suggestion, but if you look at the studies, the results don't lie—you just have to connect the dots.

I've always wondered about this link, since almost every known medical condition is proven to be or possibly associated with obstructive sleep apnea. I was reminded about this connection when I read about golfer Phil Mickelson's psoriatic arthritis. I already commented on the association between sleep apnea and arthritis, and this time, I'm going to show you that psoriasis may be connected as well.

First of all, numerous studies have shown that people with psoriasis have a much higher chance of having cardiovascular disease. There are other reports that psoriasis is associated with an increased incidence of cancer, lymphoma, obesity, metabolic syndrome (also known as "Syndrome X"), autoimmune diseases (Crohn's disease and diabetes, etc.), psychiatric diseases (such as depression and sexual dysfunction), psoriatic arthritis, sleep apnea, personal behavior issues, chronic obstructive pulmonary disease (COPD).  If you have severe psoriasis, the likelihood that you'll have a heart attack is 3 times normal. Your chance of dying overall is almost doubled than if you didn't suffer from this condition. Average life expectancy is about 3 to 5 years shorter for someone with psoriasis.

We also know that obstructive sleep apnea can cause metabolic syndrome, hypertension, diabetes, high cholesterol, inflammation, heart disease, heart attack, and stroke. Your risk of dying early increases 45% if you have severe obstructive sleep apnea.

There's even a case report of someone with severe psoriasis who was completely cured after undergoing gastric bypass surgery for obesity.

Here's my take on the connection between obstructive sleep apnea and psoriasis: The chronic stress response and repeated episodes of hypoxia deprives the skin of vital blood flow and nutrients. Sympathetic activity overload preferentially shuts down certain parts of the body that are considered unessential, such as the digestive system, reproductive system, and the skin. In addition, chronic low-grade stress also causes your immune system to overreact and cause inflammation, inducing various self-destroying tendencies that are common with autoimmune conditions.

What do you think about this possible connection? I'd like to hear your opinion.

Phil Mickelson, Arthritis, and Obstructive Sleep Apnea

I've always wondered about a possible link between arthritis and obstructive sleep apnea. We know that people with arthritis also have a higher rate of cardiovascular disease and metabolic syndrome. I recently found out that Phil Mickelson has a debilitating condition called psoriatic arthritis. A few days before the last US Open, he could barely walk. 

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