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Ask Dr. Park: Minimally Invasive Options for Snoring & Sleep Apnea

Please join me for my next Ask Dr. Park program when I’ll be talking about all the different minimally invasive treatment options for snoring and obstructive sleep apnea. I’ll talk about Somnoplasty, Pillar, Repose, Snoreplasty, and many others.

Date: September 14

Time 8 PM Eastern

Registration details to follow…..

UARS: The Hidden Sleep Condition

You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?

The Real Reason for Your Chronic Fatigue

Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.

Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?

In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.

It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.

Blame It On Your Parents (And Your Jaws)

The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.

Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”

Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.

Is It Hormones or Your Breathing?

A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.

With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.

Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.

Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.

If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.

Sleep Apnea in Asians vs. Caucasians

I've always suspected that Asians are much more susceptible to obstructive sleep apnea due to having smaller facial structures, and here's a study that supports my theory. Researchers in Hong Kong compared skeletal facial measurements between these two groups and found that although the average age and BMI were similar, Chinese subjects had much more severe obstructive sleep apnea (35% vs. 25%), and had significantly smaller facial bony measurements. However, Caucasians were significantly more overweight. For the same degree of obstructive sleep apnea, Caucasians were more overweight, and Chinese had more craniofacial bony restriction.

 

This explains why when Asian immigrants come to the US and begin eating Western foods, their rates of obesity, diabetes and heart disease goes up significantly higher than rates for the general population. I remember reading a while ago that the ethnic Chinese population in Queens, NY has an epidemic of young children being overweight with much higher degrees of diabetes as they get older.

 

For those of you from Asian descent, do your parents snore? If so, do they have high blood pressure, diabetes, or heart disease? Please enter your response in the comments box below.

Sleep Apnea And Pulmonary Embolism

Here's another link that solidifies the connections in my sleep-breathing paradigm: Researchers found that people who have pulmonary embolism (PE) have a much higher change of having undiagnosed obstructive sleep apnea. Pulmonary embolism is a condition where blood clots from your lower legs or other parts of your body travel into your lungs and get stuck, preventing you from breathing properly. In their study of hospitalized patients suspected of having pulmonary embolism, those that were found to have pulmonary embolism were more likely to snore (75% vs, 50%) and have obstructive sleep apnea (65% vs. 36%) compared with those that did not have pulmonary embolism. PE was found to be independently associated with the risk of obstructive sleep apnea (odds ratio = 2.78).

All this makes sense, since we know that obstructive sleep apnea creates conditions in your bloodstream that promotes stagnation, inflammation, and clotting. In addition, we also know that the blood itself in sleep apnea patients are much thicker (viscous), making it easier to clot when stagnant. 

With sleep apnea, there are various levels of potential clotting, from larger vessels like the carotid artery and deep veins in the legs, to to small vessels in the gut or in the brain. 

If you know anyone who suffered from a pulmonary embolus, does that person snore?

Snoring: Not So Benign

Here's a study that confirms that snoring should always be taken seriously: Researchers showed that snoring children had lower IQ/test scores compares with children that didn't snore. Not too surprising, knowing what we know about snoring. 

Even if you don't have obstructive sleep apnea, snoring is a sign that you're partially obstructed, and in most cases many people who snore initially go on to develop obstructive sleep apnea many years later. In young children with very actively developing brains, any disruption in sleep quality can disrupt proper brain functioning. 

I overheard one sleep researcher a few years ago saying that after tonsillectomy, cognitive and behavioral scores improve dramatically, but never catch up to that of children who didn't need tonsillectomy.

So why should snoring be taken so seriously?

We know that in drivers, snoring alone without having formal obstructive sleep apnea significantly increases your risk of car accidents. Vibrations that come from snoring is thought to alter the sensory nerve endings of the soft palate, somehow damaging the protective reflexes that help to keep the upper airway open. Vibrations from snoring are also found to cause carotid artery wall thickening in rabbits. Damage to the chemical receptors from additional reflux can also aggravate this vicious cycle. These type of studies go on and on. 

What all these studies point to is the fact that snoring is on a continuum of sleep-breathing disturbances of which all humans are susceptible. While not all snorers will have obstructive sleep apnea, it's important to look for complications of snoring, as well as to prevent progression later on into true sleep apnea. 

How many of your friends or family members snore?

My Sleep Study Results Are In!

Over that past few months I haven't been getting good sleep, and my wife has noticed that I do stop breathing once in a while. So I decided to give myself a sleep study. I underwent a formal overnight sleep study many years ago just to see what it's like, and at that time, the results were unremarkable. This time, I wanted to try one of the new home sleep tests. 

The sleep test was from Sleep Solutions and it's a clamshell laptop-like device with leads that connect to your finger, chest and a nasal cannula, like what you see in patients that receive oxygen in the hospital. The instructions are straight forward, and if there's any problem such as a lead falling off, the computer will tell you. The test is performed for three nights, and the device is mailed back via pre-paid shipping. 

About a week later, I finally got my results. Not too surprisingly, I don't have obstructive sleep apnea. However, I did have about 2 apneas or hypopneas every hour. Looking at individual apneas, some were as long as 40 seconds! Once, my oxygen level even dropped to 88%. There are also some mild snoring. 

One of the downsides of this particular test is that it doesn't show sleep stages, sleep position, or RERAs (short obstructions and arousals that don't meet the criteria for apnea or hypopnea).

I'm the last person you'd think has obstructive sleep apnea (my BMI is 20). This just goes to show that everyone, no matter what your size, shape or build, is susceptible to breathing problems. 

In retrospect, now that I'm sleeping better, my nose has been less stuffy that it has been over the past few months. This only confirms how having a stuffy nose can worsen your sleep quality.

Armed with this information, I'm committed to my current regimen of regular exercise, healthy eating, and good sleep practices. 

Migraines, Heart Disease & Sleep Apnea

I was going through the NY Time's excellent Patient Voices blog and multimedia piece on migraine (see my comments #30, and #584), and was reminded that people who have migraines are at a higher risk of cardiovascular disease later in life. In this 2006 study from JAMA, women who have classic migraines had significantly higher risks for major cardiovascular disease, ischemic stroke, heart attack, coronary revascularization, angina, and ischemic cardiovascular disease death. 

This is not too surprising since most migraineurs have upper airway resistance syndrome or obstructive sleep apnea, and we know that obstructive sleep apnea can significantly increase your chances of suffering from heart disease, heart attack, or stroke.

If you have migraines, does your mother or father snore or have cardiovascular disease?

Ask Dr. Park: An Insider’s Guide To Sleep Apnea Surgery

Secrets To Sleep Apnea Surgery…

Are you confused by all the conflicting information about sleep apnea surgery? Does it work? Which procedure is right for you? Which surgeon do you choose? In this Ask Dr. Park Teleseminar Program you will learn about Sleep Apnea Surgery. Even if you’re not considering surgery the good think to learned what the other option are and the rational of offering a surgery.

Learn:

• Why consider Sleep Apnea Surgery?
  

• Are you a candidate Sleep Apnea Surgery?

• In-depth descriptions of different Sleep Apnea procedures.
  

• How to find the right Sleep Apnea surgeon.
  

Click here to purchase MP3 recording.

Is That Scratchy Throat Really A Cold? The Case Against Strep Throat (Part 1)

Here's a typical patient that I see 2-3 time every day in my practice: A young woman comes in complaining of waking up Sunday morning with a sore and scratchy throat. She thinks she may have caught her husband's cold, since she is also experiencing some sweats, low-grade fever and unrefreshing sleep. I ask repeatedly if she did something out of the ordinary a few days prior to the onset of her symptoms, and she says no. She denies any traveling, flying, eating or drinking late. She normally sleeps on her stomach, and her father snores like a train. She's worried that she has Strep throat. 

Her general exam, as expected, is normal. No throat inflammation, redness or swollen glands. Looking via a flexible endoscope, the back of her voice box is slightly inflamed and swollen, but there's absolutely no evidence of infection? What would you do?

Binge Drinking and Sleep Apnea: A Fatal Combination?

Former news anchor Ted Koppel's son, Andrew, was found dead after after a night of heavy drinking with friends. It's a sad occasion whenever anyone's son dies for any reason, but there were a few points in the Associated Press news article that's worth mentioning. After a night of heavy drinking, he ended up at a third friend's apartment, where they lay him down to sleep it off since he was clearly drunk. When they checked on him a few hours later, he was noted to be snoring, but had a pulse. A few hours later, he was found dead.

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