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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Written by Steven Park · Filed Under Audio, Expert Interviews | 3 Comments

Chronic Pain & Sleep Apnea: Is There A Link?

July 18, 2011

Here’s a shocking statistic put out by the National Academy of Sciences—that 116 million Americans (37%) suffer from chronic pain. That’s more than diabetes, heart disease, and cancer combined. The article in the New York Times emphasizes the importance of more recognition of this condition by doctors. However, I doubt we’re ever going to make a significant dent in treating chronic pain unless we deal with their sleep issues.

It’s easy to argue that chronic pain can negatively affect your sleep quality. However, you can also argue that poor sleep can predispose you to chronic pain, once you experience a trigger (such as an accident, trauma, weight gain, or an operation). It’s been shown that poor sleep can lower your pain thresholds: Sleep deprived people were found to pull their fingers from a hot environment much quicker than people who had normal sleep. What this means is that the less quality or quantity of sleep you have, the more likely you’ll sense pain at very low levels.

If you think about the total number of people with obstructive sleep apnea (and even UARS), it’s probably about 1/4 to 1/3 of the population. Coincidence?

One general concept that Dr. Christian Guilleminault of Stanford describes is that sleep apnea patients have diminished nervous systems, whereas upper airway resistance syndrome (UARS) patients have intact nervous systems. In fact, I would argue that people with UARS have hypersensitive nervous systems. These are also the people who are overly sensitive to weather changes, chemicals, fumes, perfumes, odors and smoke. So perhaps people who are predisposed to chronic pain also have UARS.

Is it just coincidence that most of the patients that I see who have some sort of chronic pain also can’t sleep on their backs, have had excessive dental extractions, or have a parent that snores heavily? Most people with UARS can’t (or prefer not to) sleep on their backs, since that causes the tongue to fall back from gravity. Excessive dental extractions (usually from modern orthodontics) contracts the oral cavity space, leaving less room for the tongue, especially when in deep sleep, causing more frequent obstructions and arousals. As the person with UARS moves up the continuum, they’re more likely to progress into obstructive sleep apnea (like one or both parents).

If you’re truly committed to treating chronic pain patients, you have to simultaneously treat any underlying sleep-breathing problems. Giving sleeping pills just won’t cut it.

Written by Steven Park · Filed Under Blog | 3 Comments

Fatigue And Multiple Sclerosis, Along With UARS

July 2, 2011

There are probably a thousand different reasons for someone to be tired. Many people with neurologic conditions tend to report being overly tired. Not too surprisingly, fatigue was found to be reported as the first symptom with multiple sclerosis (MS), long before the first signs of MS show up. We know that MS is an autoimmune condition, where various parts of the brain are affected, leading to a number of different symptoms. But one thing I’ve noticed is that almost every person with MS also seems to have the upper airway anatomy of someone with upper airway resistance syndrome (UARS).

Women are more likely to suffer from both UARS and MS. They typically are thin, and won’t snore. Both groups in general tend to avoid back sleeping, and have narrow jaws with high arched hard palate. Women with (UARS) are more likely to have autoimmune conditions. Many will also have cold hands and feet, and have at least one parent that snores heavily. Whenever I look at their airways with an endoscope, the space just behind the tongue is usually only a few millimeters, especially when lying flat on their back.

My suspicions must be proven with prospective studies, but the similarities are pretty striking. Since we know that sleep-breathing problems can cause major structural and biochemical damage to the brain, I wouldn’t be surprised if someone proves that these two conditions are strongly connected. Just to be clear, I’m not talking about obstructive sleep apnea. Rather, people with UARS are unable to attain deep quality sleep due to frequent microobstructions and arousals, without frank apneas or hypopneas.

If anyone reading this has MS, do you have cold hands or feet? Can you sleep on your back at all? Do your parents snore heavily?

Written by Steven Park · Filed Under Blog | 2 Comments

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….

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Written by Steven Park · Filed Under Expert Interviews | 2 Comments

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?

Written by Steven Park · Filed Under Blog | 1 Comment

Is Insomnia Caused By Obstructive Sleep Apnea?

April 27, 2011

Common sleep medicine dogma states that chronic insomnia is a completely separate disorder from obstructive sleep apnea (OSA). But just like other seemingly disparate medical conditions, there’s increasing evidence that there may be a certain degree of overlap between these two conditions. It’s been shown that anywhere from 39 to 58% of patients with OSA also have insomnia. Conversely, up to 43% of older people with chronic insomnia were found to have undiagnosed sleep apnea.

It’s been stated that chronic insomnia and sleep apnea can co-exist together, but very few studies are saying the one could cause the other. To challenge this assumption, Dr. Barry Krakow and the Sleep and Human Health Institute is looking at the provocative theory that a large percentage of people with chronic insomnia have undiagnosed breathing problems during sleep.

I wrote in my book, Sleep, Interrupted, that almost every patient that I see with chronic insomnia has significantly narrow upper airways, and one or both parents snore heavily. Most chronic insomniacs prefer not to or absolutely can’t sleep on their backs, due to the tongue taking up relatively too much space within the confines of smaller jaws. When in deep sleep, especially when on their backs, the tongue can fall back due to gravity, and because of additional muscle relaxation, causes breathing pauses and an inability to stay asleep.

It’s also not surprising that most people with sleep maintenance insomnia keep waking up at various 90-120 minute intervals, usually around the same times. This makes sense since at the end of one sleep cycle, your muscles will be most relaxed. Not sleeping deeply can lead to chronic sleep deprivation, which causes adrenaline overload and a hyperactive nervous system, which you can’t shut down when you’re ready to go to sleep. This process can explain sleep onset insomnia. One recent study showed that sleep deprivation can even cause a kind of euphoria, which can lead to poor judgement and even addictive behaviors.

Maybe this is why cognitive behavioral therapy (CBT) for insomnia works very well, but not for everyone. There are numerous studies and personal experiences that confirm that treating the underlying sleep-breathing problem can fix the insomnia issues.

Granted, even if only 50% of people with chronic insomnia have obstructive sleep apnea, it’s likely that another 30 to 40% will have upper airway resistance syndrome (or UARS), which is a huge topic that has been discussed elsewhere.

What do you think about my suspicion?

Written by Steven Park · Filed Under Blog | 5 Comments

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?

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

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

Expert Interview: Dr. Avram Gold on UARS, Chronic Fatigue & Functional Somatic Syndromes

March 16, 2011

In this month’s Expert Interview, I interview Dr. Avram Gold, a pioneer in researching the link between upper airway resistance syndrome, chronic fatigue, and the functional somatic syndromes. Some of the topics will include:

- What are the functional somatic syndromes and how are they related to sleep-breathing disorders?

- What’s the relationship between central sensitivity syndrome and stress?

- How is sleep-disordered breathing related to stress?

- How is anxiety or depression related to functional somatic syndromes?

- How is chronic fatigue syndrome connected to the this condition?

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Written by Steven Park · Filed Under Expert Interviews | 14 Comments

Viagra, Raynaud’s & Sleep Apnea

March 16, 2011

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?

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Brain Damage in Chronic Fatigue Syndrome and Sleep Apnea

March 5, 2011

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?

Written by Steven Park · Filed Under Blog | 6 Comments

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