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Major Life Changes That Can Trigger Sleep Apnea

Recurrent sinus infections, throat pain, ear fullness and chronic cough are some of the most common conditions that I see every day. You may think that I typically diagnose and treat for routine bacterial infections in these situations, but in most cases, they’re not really infections at all. What I do find, however, is that if you probe and look back at the patients’ history, there’s always some major life change or recent event that acted as a trigger for their symptoms, especially if their upper airway anatomy is already narrowed or predisposed. Here are 5 common examples:

 Sleepless nights from a newborn child

 The birth of a child is always a joyous event, but everyone knows that your life will change drastically all of a sudden. Your normal routines, eating habits, exercise regimens, and especially the timing for all these events will change. The sleep deprivation, lack of exercise, and bad eating habits can promote weight gain, which can narrow your throat even further. This leads to more problems breathing at night, leading to less efficient sleep, leading to more weight gain. This applies to both the mother and the father.

 It’s also a common phenomenon where a woman is never able to lose her pregnancy weight, despite extreme dieting or exercise. This leads to less effective sleep, increased fatigue, and various other health-related conditions. 

 Newfound independence, more depression

 The freshman 15 is more than just an observation—there’s a good reason why college students gain weight all of a sudden during their freshman year. Dorm meals and cafeteria food tends to be starchy and very high in calories, and because of the buffet-style format, there can be problems with portion control. Home-cooked meals by parents, eaten at relatively normal times (5 to 7 PM), turns into eating later in the night: more episodes of pizza, take out food, and late night snacks while pulling all-nighters for exams. 

 Having stomach juices when you go to sleep will allow more acid and other stomach materials to regurgitate into your throat, leading to more frequent arousals and less efficient sleep. This leads to a cascade of metabolic, hormonal, and cardiovascular consequences that promotes weight gain. Drinking alcohol at night relaxes the throat even further, leading to more frequent breathing pauses.

 This relative sudden change in your eating and sleep routines can definitely affect your mood and mental health. It’s not surprising that depression and anxiety peaks during the college years. This is also the time when the larynx (voice box) descends in the neck to its’ lowest position during maturation into adulthood. The lower your voice-box, the more the tongue can fall back, leading to more frequent breathing problems.

 A new job or a promotion

 It’s great to start a new job, or get that promotion that you’ve wanted. But just like any other major change in your life, your routines will change. You’ll stay later to impress your boss, skip meals, come home later and go to bed later. As a result, you’ll gain a few pounds. Some people can eventually adjust their schedules to accommodate a healthy sleep schedule, diet and exercise regimen, but others can’t. This is when things begin to go downhill.

 Injury or surgery

 Most people with sleep-breathing problems prefer to sleep on their sides or stomach. Any kind of injury or undergoing surgery can force you to sleep on your back, which causes more tongue collapse (due to gravity) and more obstructions and arousals (due to muscle relaxation in deep sleep). In fact, many patients have told me that their lack of sleep, physical activity and subsequent weight gain is what triggered a vicious cycle. 

 Menopause

 This applies mainly to women, but hormonal changes can affect men too. Loss of estrogen and progesterone can diminish their protective effects on the upper airway. In particular, progesterone is an upper airway muscle stimulant/dilator. As it begins to diminish in the early 40s, the tongue begins to relax more and more over the years, leading to less efficient sleep, and the typical vasomotor symptoms begin which includes hot flashes, night sweats, weight gain, mood swings, and irritability. Believe it or not, these symptoms can happen in young men, too. These are your body’s nervous system reaction to the changes with your sleep-breathing status.

 

As you can see, all of us will go through some or all of these events at some point in our lives. It’s natural as modern humans to be susceptible to these sleep-breathing related conditions. It may sound a bit depressing, but the good news is that now you’re aware of it, you can take preventive measures once it starts. 

How Sleep Position Can Affect Stillbirth Risk

Researchers from New Zealand discovered that women who did not sleep on their left side the last night before delivering their babies had twice the rate of stillbirth compared with those that slept on their left side. It’s commonly recommended for pregnant women to sleep on their left side, especially later in pregnancy. There are various explanations for why this is preferred, from placing less pressure on the mother’s major blood vessels to worsening the mother’s snoring.

I’ve mentioned before that a woman’s risk of developing obstructive sleep apnea increases as she gains weight during pregnancy, but progesterone counteracts this effect neuromuscularly, by tensing the throat muscles and increasing the drive to breathe. However, back sleeping is a known aggravator of breathing pauses during sleep due to gravity’s effects on the tongue. Whether or not this leads to apneas (10 seconds or longer pauses), the mother will still stop breathing and wake up more often during the night. This can place a major stress not only on the mother’s body, but on the baby as well.

This study was an observational study, so more prospective studies are needed. But it only goes to show that any additional situation that can aggravate sleep-breathing problems during pregnancy can raise your risk of complications, which also includes gestational diabetes and preeclampsia.

I wonder if the researchers asked the women what their preferred pre-pregnancy sleep position was. I suspect that women who can’t sleep on their backs may have more complications during pregnancy due to narrowed upper airway anatomy.

The Connection Between MS And Fatigue

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:

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

SIDS & Sleep Apnea, Revisited

Here’s the response I wrote on KevinMD to blog on the dangers of sleep positioners and SIDS. The author of that blog probably won’t like what I have to say. You’ll see that what I suggest may have huge implications with our children’s health.

The Fountain of Youth, Revealed

Ponce de Leon is well known as the Spanish explorer that searched for the fountain of youth in the early 1500s. Even today, that search continues through the multi-billion dollar cosmetics industry, plastic surgery procedures, and nutritional products. Anti-aging medicine even has a certifying organization for doctors. Some experts are even claiming that they can reverse the aging process.

Knowing what we know about the importance of sleep and the havoc it can cause on your body, I can confidently say that the best way to slow down aging is to optimize your sleep quality. Sleep is known to be vital in tissue healing and regeneration, hormone regulation, as well as in helping to consolidate memories and thought processes. For example, non-REM deep sleep is important for tissue repair, growth hormone release, and other regenerative processes. REM sleep is needed for memory consolidation and creativity.

When most people read or hear about better sleep, they think about going to bed earlier or sleeping longer. People with insomnia are also inundated with “warm milk” recommendations, such as valerian, green tea, turkey, melatonin, meditation, and probably dozens of other vitamins, supplements, or relaxation techniques that help to calm or numb the mind to allow for faster sleep onset. Many of these options can work to various degrees, but won’t be helpful at all if you stop breathing at night. Once your breathing passageways obstruct while sleeping, you have to wake up. You can either wake up violently in a state of panic with sweating and your heart racing, or just get taken out of deep sleep into a lighter stage of sleep.

About 1-2 times per month, I see women who complain of various ear, nose or throat symptoms, let’s say for about 6 weeks. They also usually complains of increased fatigue, headaches, and poor sleep. They usually see their medical doctors and have tried multiple courses of antibiotics or allergy medications. They will typically say that they sleep on their backs when questioned about their preferred sleep position. Looking at their oral cavity exam, I don’t believe them. When questioned further, they all admit that they used to be stomach sleepers, but changed to back sleeping after reading an articles on various magazines, usually by a dermatologist (or sometimes a chiropractor) that recommends avoiding stomach sleeping since it can cause facial wrinkles. Almost every time, their health problems began just after they made the switch in their sleep position. Once they go back to their normal sleep position, their health problems usually resolve.

The cosmetics industry’s fight against facial wrinkles is a classic example our quest to delay aging. In the above example, the reason why some people have to sleep on their stomachs is so that they can breathe properly. Being on their backs causes the tongue to fall back due to gravity, and when in deep sleep, it relaxes completely, leading to obstruction and arousal. Having smaller jaws and dental crowding can aggravate this problem even more. Not getting sufficient amounts of deep sleep causes a generalized state of physiologic stress and adrenaline production, which tends to constrict blood vessels that supply certain parts of the body that are considered “unessential” when you’re under stress. This includes your digestive system, your reproductive organs, as well as your skin. Not receiving proper circulation deprives the tissues of oxygen, preventing proper nutrition and not allowing for healing, regeneration, and waste removal. Hypoxia also creates an environment that’s toxic to the local tissues, leading to further damage and accelerated aging. The bottom line is that not getting good sleep accelerates your aging process.

Another important concept that has profound implications is the fact that underdevelopment of the bony midface and jaw structures leads to wrinkles earlier in life. Having smaller facial bony structures does not stretch the facial skin over the bones as much compared to larger facial structures. Since elastic properties of facial skin tend to degrade over time, having smaller facial bones allows wrinkles to show up earlier, with the same degree of environmental, dietary, or genetic factors.

Two common habits that are thought to accelerate aging and even wrinkles are sun tanning and smoking. Sun tanning may make you look “healthy” temporarily, but sun damage takes a toll on your skin, especially if you’re susceptible to the sleep-breathing problems that I describe. Imagine if you already have diminished circulation to the skin,  with diminished levels of oxygen. By definition, you’ll have more levels of oxidative stress, where free-radical oxygen molecules are formed, which can damage DNA. Add ionizing radiation, and it’s a double whammy.

Nicotine is a known stimulant which also has been proven to constrict blood vessels, especially in the skin. It also has a calming effect the way Ritalin helps to calm children with ADHD: Stimulants help to counteract the effects of sleep deprivation from not breathing well at night. It’s also been shown that it takes nicotine about 45 seconds to reach the brain once you inhale smoke into your lungs. This doesn’t make any sense, since most smokers will tell you that they feel more relaxed after the first one or two breaths. What’s making smokes relaxed is the relaxing properties of deep breathing, along with the stimulating effects of nicotine. But by relaxing more using deep breathing techniques to inhale a stimulant, you’re cutting off blood flow to your skin, which if already sun damaged, is more likely to suffer from wrinkles.

The basic thesis of my sleep-breathing paradigm states that all modern humans stop breathing once is a while. But as we get older, not only do we sag on the outside, but also on the inside. If you think about it, the rate at which we age is directly proportional to how narrow your upper airway gets. Add to this additional gravity and the typical weight gain that tends to occur during middle age, it’s no wonder so many people have sleep-breathing problems as we all get older. We’ll never run out of more pills, gadgets, devices and diets that tout their anti-aging properties, but without addressing how well you breathe while sleeping, you’ll continue to suffer from accelerated aging.

 

Struggling with an addiction? Check into a Long term drug rehab facility and get the help you deserve!

 

Treatment Resistant Depression: Could It Be Sleep Apnea?

Here’s a blog on KevinMD that talks about why there’s no such thing as treatment resistant depression. This is my response to the article:

Depression is assumed to be a biochemical or neurologic problem of the brain. It’s also a given that people with depression will have sleep problems, which is thought to be due to the depression. What this also assumes is that you’re able to breathe properly at night when you’re able to sleep, which is absolutely not true. Everyone stops breathing to various degrees, but only the end extreme is called obstructive sleep apnea. Modern humans, due to our unique upper airway anatomy, are all susceptible to breathing pauses at night.

You can stop breathing 20 to 30 times per hour and not officially have sleep apnea on a sleep study. Even if you had obstructive sleep apnea, 90% is estimated to be undiagnosed.

Not being able to achieve quality deep sleep can wreak havoc on your brain function. Even worse, not getting enough oxygen to your brain can cause major biochemical changes and even structural damage.

If someone has “treatment resistant” depression, it’s important to consider an underlying sleep-breathing problem. Medications or even ECT won’t help you recover if you’re not breathing properly at night. You can even make an argument to screen for a sleep-breathing problem at the first sign of depression.

I may sound like a hammer looking at depression as a nail, but if you accept the basic premise that everyone stops breathing at night to various degrees, and in light of the fact that most people with sleep-breathing problems are not diagnosed, it’s a simple condition that can be treated with gratifying results.

If you’re still not convinced, why is it that the vast majority of people with depression can’t (or prefer not to) sleep on their backs? It’s due to smaller jaw anatomy, where the tongue takes up relatively too much space, and can obstruct breathing easier when supine, especially when in deep sleep due to muscle relaxation. Parents of people with severe depression will snore heavily, and will have various degrees of cardiovascular disease (from untreated obstructive sleep apnea).

High-Tech Elbow To Prevent Snoring

Here’s an interesting device that reportedly helps prevent snoring. It’s called the    and it works by analyzing your snoring levels and through wireless technology, helps to increase your throat’s muscle tone, lessening the chances that you’ll snore. It’s made of two components: There’s a device under your mattress, and there’s a wrist band. Presumably, whenever it detects that you’re snoring, it sends a signal to your wrist device, causing some sort of mild stimulation, which will wake you just enough to lighten your sleep stage, but not enough to wake you up completely. It’s known that lighter stages of sleep can promote throat muscle tension.

In theory, it sounds great. But there’s a downside to this: it prevents you from staying in deep sleep. It’s just a high-tech version of getting your bedpartner’s elbow shoved in your ribs every time you snore.

Like most-anti-snoring gadgets out there, all it does is to cover up the snoring, with various degrees of success. In most cases, it ends up only delaying the diagnosis and treatment of obstructive sleep apnea.

Do you suffer from the “bruised rib syndrome”?

Why Do Toddlers Sleep Better In Strollers Or Car Seats?

I’m so proud of my wife—she’s beginning to think like me when it comes to my sleep-breathing paradigm. She just told me that a fellow mommy had just mentioned that her toddler son has major sleep problems at night, but when in his stroller or car seat, he sleeps fine. That brought up memories of taking our first son Jonas out for a drive, just to get him to sleep. Even now with my third son Brennan, he refuses to take naps in his crib, but falls asleep fine in his stroller. I experimented once by reclining his stroller back completely horizontal, and he woke up very quickly. This has huge implications which I’ll get to at the end of this post.

Her brilliant idea was that with strollers and car seats, you’re propped up partially, and not fully horizontal, as with a crib. For may children, they don’t like to sleep on their backs. Even if they’re able to sleep on their backs, they can’t stay asleep, and will wake up rather easily. When your back, the tongue and voice box falls back partially due to gravity, but if your jaws are more narrow than normal (most modern humans), then the tongue takes up relatively too much space and will obstruct your breathing much easier, especially when on your back (due to gravity) and when in deep sleep (due to muscle relaxation).

Infants are born with the epiglottis (the top of the voice box) overlapping the soft palate. After birth, it slowly descends, and creates a gap between these two structures called the orophayrnx. Only humans have a true oropharynx. The problem is that the tongue can fall back more easily into this space, potentially occluding your airway. This is also why only humans have choking and swallowing problems. The benefit to having all the floppy and pliable soft tissues is that it allowed for complex speech and communication.

Imagine if you are a natural side or stomach sleeper and you were forced to sleep on your back. How would you feel? Would you consider this a form of torture?

Think about what we’re doing to our infants by forcing them to sleep on their backs. The experts’ explanation for why it cuts down on the rate of SIDS (only 40%) is that it keeps babies in a lighter stage of sleep!!! Knowing what we know about quality deep sleep and brain development, it’s not surprising that there’s an epidemic of neuro-cognitive-behavrioral problems in our society. I read in one sleep blog that the rate of autism began to rise significantly just after the back to sleep campaign was started in 1993. I’m not saying that we should ignore pediatricians’ recommendations of infant sleep position, but doctors should at least acknowledge that there may be a real problem here.

Stay tuned for Part II of my post on infant sleep position and SIDS.

How do you feel about this issue? I’d like to hear your opinions in the comments box below.

Breast Implants, Autoimmune Disease, & Sleep Position

I wrote about breast implants and sleep problems a few weeks before, but I wanted to address an additional aspect of breast implants that deserves even more attention. In past years, there was a push to move towards saline-based over silicone-based implants, since there were reports autoimmune diseases with silicone implants. Studies performed at that time were inconclusive, but for the most part, most surgeons now recommend saline implants, although patients still seem to prefer silicone.

If you’re a stomach sleeper, and you elect to undergo breast implants, there’s a good chance that you’ll have to sleep on your back after your procedure. If you have smaller jaws than normal (almost everyone these days), then your sleep efficiency will go downhill the longer you stay on your back. Poor sleep quality not only increases your adrenaline levels and stress hormones, it also will over-activate your immune system. Once this happens, your immune system won’t be able to differentiate your own body’s tissues vs. foreign bodies or invaders. As a result, various areas of your body can be damaged, including your joints, kidneys, skin, your bowels, and even your brain.

This may be a big leap, but could it be possible that poor sleep quality due to poor breathing makes you sleep on your side or stomach to begin with, but when made even worse by forcing you to sleep on your back, is it enough to cause your body’s immune system to go onto overdrive and attack it’s own tissues?

What do you think about my theory? Please enter opinions in the comments box below.

Can Sleep Apnea Cause Nerve Deafness?

More than a handful of times, whenever someone comes to me with sudden hearing loss on one ear, there’s usually a precipitating event, such as an infection, stressful event, or trauma. Here’s a sequence of events where an underlying sleep-breathing problem clearly caused hearing loss.

A middle aged man with known severe hearing loss in both ears came to see me with sudden worsened hearing loss in his left ear 4 weeks ago. He normally uses hearing aids, but now he can’t understands people as well, even with his hearing aid. It turns out that exactly 4 weeks ago, while lifting something from his driveway, he pulled his back, with resulting severe back pain. He went to see his doctor, who prescribed a strong narcotic, which didn’t help that much. He’s usually a stomach sleeper, but due to his back pain, he had to sleep on his back. The night after he took his pain medication, he woke up and noticed his hearing loss on his left ear. His recent hearing test showed significantly diminished hearing in his left ear.

When I examined him, he had the classic anatomy of someone who has obstructive sleep apnea: small jaws, high arched hard palate, and very narrow posterior airway space (space behind the tongue), especially when on his back. All throughout his life, he naturally preferred to sleep on his stomach, but when suddenly forced to sleep on his back, wasn’t able to sleep efficiently (due to gravity’s effect on his tongue). But when he took his pain medication, his muscles relaxed even further, and he probably stopped breathing much more often. This caused a major and sudden stress response which probably caused either major inflammation or a mini-stroke in his inner ear blood vessels. Studies have shown that the area in the brainstem that controls the ear, as well as blood vessels that supply the inner ear are much more susceptible to damage. In particular, the area that’s responsible for the high frequencies is more prone to injury.

His exam only reinforced my observation that people who suffer from sudden nerve deafness all have very similar upper airway breathing passageways.

The traditional thing to do in this situation is to give oral steroids, but since it’s been about 4 weeks, the evidence for improving his condition is poor. Instead, I ordered a formal sleep study.

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