Did Adam Yauch of the Beastie Boys Have UARS?

May 5, 2012

The hip-hop and pop music world was saddened to hear that Adam Yauch of the Beastie Boys died at at the age of 47. He had been battling parotid gland cancer. As you may know, one of my hobbies is to analyze facial features, particularly jaw configurations in relation to one’s ability to breathe and sleep properly at night. I came across this picture on MSNBC, showing Mr. Yauch’s narrow and recessed mandible, along with a very narrow and pinched in nose. Having small jaws leads to airway crowding, predisposing to breathing problems while in deep sleep during muscle relaxation.

There’s nothing more public about his health status besides his cancer, but one of his hallmark features was his raspy voice. If he had upper airway resistance syndrome, it’s likely he also had laryngopharyngeal reflux disease. Besides aggravating hoarseness, reflux can also cause chronic oral cavity, nasal and lung inflammation, potentially leading to a multitude of health problems. It’s also very likely that he didn’t like to sleep on his back, and had unrefreshing sleep. Studies are beginning to show that lack of good sleep may also be a risk factor for cancer.

All this is speculation, but celebrities are also modern humans, being susceptible to craniofacial features that can lead to sleep-related breathing disorders. Do you know of other celebrities that have small jaws or facial features?

Written by Steven Park · Filed Under Blog | 3 Comments

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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Early Puberty For Girls: A Sleep-Breathing Problem?

April 3, 2012

You may have seen reports about the epidemic of public hair and early breast development in 6 to 7 year old girls. A recent study published in Pediatrics revealed that by age 7, 10% of white girls, 23% of black girls, 15% of Hispanic girls, and 2% of Asian girls had started developing breasts. In this week’s New York Times Magazine, a writer profiles a young girl that developed pubic hair, tall stature, big feet, and a curvaceous body at age 6.

There’s a general consensus amongst pediatricians that early puberty is a growing problem and a number of factors are blamed. The obesity epidemic is thought to play a role, since excess fat is known to produce higher levels of endogenous estrogen. The most probable suspect is thought to be due to the presence of xenoestrogens, which are artificial chemicals in our food and water supply that has estrogen-like properties. The most well-known of these is bisphenol-A (BPA). Recently, the FDA rejected a motion by environmental groups to ban BPA, which is widely found in food containers. Most baby bottle manufacturers have voluntarily stopped using BPA in their products.

Xenoestrogens and other endocrine disruptors like PBA not only act to induce early puberty, but can also alter the optimal balance of reproductive hormones in a woman’s (and man’s) body. The idea have having too much estrogen (endogenous or exogenous) in your body has been coined estrogen dominance by Dr. John Lee. An important concept to emphasize is that too much estrogen (or estrogen-like molecules) can suppress progesterone, which can have significant detrimental effects on breathing, especially in post-pubertal women. Progesterone is an upper airway muscle stimulant, and increases tongue muscle tone. Post-menopausal women have lower levels of progesterone, and lower tongue muscle tone (genioglossus muscle), but when given progesterone, muscle tone increased significantly.

This is why many women sleep better when given hormone replacement therapy after menopause. In one study, the average apnea hypopnea index (AHI, or measure of obstructive sleep apnea severity) was over 50% lower in postmenopausal women taking hormones. I sometimes wonder if the incidence of sleep apnea in women shot up after women were advised to stop taking hormones many years ago due to increased cardiovascular risks. If more women have sleep apnea, then that in itself will significantly increase rates of cardiovascular disease, including heart attacks and strokes.

If these environmental effects are happening in adult women, think about what can occur in young children. There’s even suspicion that these chemicals can cause neuro-developmental delays in infants. If you already have a sleep-breathing problem, adding xenoestrogens can only make things worse. As far as I know, I’m not sure of any studies showing that xenoestrogens can cause sleep apnea, but it can be argued that anything that prevents proper facial growth and development can increase your risk for developing obstructive sleep apnea.

What do you think about this issue? Is it a real problem that’s not being addressed by the government, or is it an an overblown concern?

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Ask Dr. Park: Women’s Sleep Issues

February 29, 2012

In this Ask Dr. Park teleseminar, I talk about common sleep problems that occur in women: insomnia, prementrual issues, pregnancy, and menopause.

Some of the questions I answer include:

- Why are women light sleepers?

- How is sleep different in women compared to men?

- How can I go back to sleep if I wake up in the middle of the night?

- Will estrogen supplements help with sleep?

- What’s the difference between bio-identical and synthetic hormones and how do they affect sleep?

- How does estrogen dominance cause sleep problems?

- What causes throat pain just before your periods?

- How can hypertension and diabetes be prevented during pregnancy?

- Which hormone is responsible for sleep problems during menopause?

- And much more….

Purchase MP3 recording ($17)

PDF of slides (free)

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Why Do Some Insomniacs Keep Waking Up At the Same Time?

December 7, 2011

One of the most common complaints that I get from patients is that they keep waking up at the same time in the middle of the night and are unable to get back to sleep, or they keep waking up every 90 to 120 minutes. This phenomenon is called sleep maintenance insomnia, when you are unable to stay asleep during the night. In contrast, sleep onset insomnia is when you’re unable to fall asleep in the beginning of the night.

A low-dose version of zolpidem (Ambien) was recently FDA approved as Intermezzo to treat these middle of the night awakenings. It’s purpose is similar to zaleplon (Sonata), which is a very short-acting sleep aid, so it can be used in the middle of the night to get back to sleep, without the “hangover” effects that people feel with typical sleep aids.

There are a number of different explanations for why some people keep waking up in the middle of the night. One theory is that people with insomnia are hyperarousable, with higher levels of brain activity and stress hormones. If it’s due to these factors, why is it that insomniacs keep waking up at the same time? One possible explanation is that it has to do with sleep stages. Humans go through 4-5 cycles of sleep, where deep sleep (slow wave) predominates in the first half of the night and REM sleep is more common in the second half. As the night progresses, the periods of REM sleep become longer and longer. Since we know that throat muscles are most relaxed during REM sleep, you’re more likely to have breathing pauses during REM, especially if you’re anatomically predisposed (narrowed upper airway anatomy).

This can explain why many people say that they keep waking up at 3AM, like clockwork. Some people wake up when REM length reaches a critical period, whereas other keep waking up with each successive REM period. Transitions into and out of REM can also predispose one to upper airway instability.

One thing I’ve noticed is that in almost all cases, severe insomniacs have very narrowed upper air passageways. On endoscopy, the space behind the tongue is very narrow, and most people can’t (or prefer not to) sleep on their backs, since the tongue is more likely to fall back then supine. Dr. Barry Krakow did a study a while back showing that the vast majority of insomniacs who were resistant to sleeping pills had sleep-breathing problems.

What I’m describing is not necessarily obstructive sleep apnea. Once you obstruct or have partial obstruction, you can either continue the breathing pause for 10 to 40 seconds (this is called an apnea or hypopnea). But if you wake up quickly within a few seconds, then it’s called an arousal. Insomniacs typically have lots of arousals.

This is why even if you have classic insomnia, you need to look for and treat any underlying sleep-breathing problems, regardless of whether or not you have apneas.

If you are an insomniac, what time do you wake up in the middle of the night?

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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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Expert Interview: Eric Cohen on How to Achieve 89% CPAP Aderence Rates

August 9, 2011

In this Expert Interview, I talk with Mr. Eric Cohen and Mr. Jake McCabe of National Sleep Therapy on how their company achieves an 89% CPAP adherence rate.

Besides revealing their secret to getting very high adherence rates, here are some other questions we covered:

- Define compliance or adherence, and medicare criteria
- What’s the national CPAP adherence rate average?
- Being compliant or adherent doesn’t necessarily mean that you’re sleeping better, right?
- How does the patient, doctor, and DME work together to raise adherence rates?
- How long do you stay with the patient?
- Do you have any special tools to help the patient?
- What would you say are some of the top things patients can do?

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UARS Article In Forbes.com

August 6, 2011

Here’s a good summary of upper airway resistance syndrome (UARS) in the Forbes.com health blog, where I get interviewed about this all-too-common condition.

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