Dr. Barry Krakow’s Review of Totally CPAP – Part 8

Non-surgical Options

Read what Dr. Barry Krakow, author of Sound Sleep, Sound Mind: 7 Keys to Sleeping through the Night, has to say about my new book, Totally CPAP. This is Part 5 of a multi-part in-depth, critical review. This is taken from his blog. Read Part 1Part 2 Part 3Part 4Part 5, and Part 6, and Part 7.

In Chapter 8, Section 1, Dr. Park offers great tips on the critical issue of nasal patency. First, he reviews the medical or non-surgical approaches to the problem and then wades deeply into his bailiwick, the surgical interventions. And, we’ll discuss the whole chapter using the same format of highlighting some of his key pearls and occasionally providing our commentary.

Dr Park unequivocally stresses the value of “keeping your nose clean.” He points out one of the most obvious factors, surprisingly overlooked by many sleep physicians; namely, when your nose is closed, your mouth is open. And, he incisively explains that even the use of a full face mask is no fail-safe method when nasal congestion issues are not adequately addressed. As much as his background began as an ENT surgeon, he clearly wants his patients to begin with medical or non-surgical interventions, because they often bring a high rate of success at a cheaper and less invasive cost to the patient.

He describes 7 key factors in evaluating nasal blockage issues, many of which overlap in terms of how they affect nasal breathing and how they are treated. We’ll go through most of these items with brief summaries:

1. Flimsy Nostrils

The thrust of this problem is that your nasal anatomy is just too small to begin with or the walls of your nostrils may not been sufficiently strong enough to let a normal volume of air flow into the nasal cavity. As you can imagine, many possible solutions include external nasal dilator strips and internal nasal dilators. Some of the products he has recommended to his patients include Breathe Right nasal strips, Nozovent, and Sinus Cones. I want to mention here that we have had some recent experiences with the ASO nasal strip brand, a product you can find for example in Wal-Mart sold under the Equate brand name. We have been very pleased with this product because it is so much easier to apply and remove without seeming to cause any skin irritation. We featured these strips in my recent TEDx talk, where we showed some graphics on this brand.

2. Nasal Sprays or Irrigation

The usual approaches with nasal saline and netipot washes including sinus rinse products are described, including a do-it-yourself version of the solution. Dr. Park and I are on the same page here in noting that you can never underestimate the potency of simply cleaning out your nose every day with one of these approaches. I am certain he has seen the same experiences we have observed at our sleep center where individuals literally start sleeping better just by “keeping their noses clean.” The only caveat I would mention is that using irrigations or sprays too close to bedtime may lead to annoying drainage in the back of your throat, which may be a bit vexing if you’re using a PAP device at the time.

3. Avoiding Late Meals

He recommends no further eating about 3 to 4 hours before bedtime, and I believe he is spot on for those patients with tendencies toward reflux (whether they know it or not). However, many people snack at night for many different reasons, some healthy (e.g. diabetics to prevent hypoglycemia during the night) and some unhealthy (e.g. emotional eating to relieve anxiety). Regardless, we both agree that large meals in particular are not a good idea the closer you get to bedtime.

4. Avoid Alcohol Near Bedtime

On this one, we’re in 100% agreement, primarily because scientific evidence clearly notes alcohol worsens your snoring and sleep apnea. Therefore consuming beverages around dinner time is more optimal. Moreover, this timing often produces a relaxation effect that carries over into the evening hours after the alcohol has been metabolized by your body. Drinking a glass of wine at dinner is described by many people as their ritual that helps turn off the mind and getting them into that feeling they can leave daytime worries behind. We call this experience, “finding emotional closure” on the day, which is a potent therapy for insomniacs. The irony that most drinkers know intuitively is that when you drink a lot near bedtime, it will sedate you and put you into deeper sleep, but halfway through the night you go into a mini-withdrawal state from the absence of alcohol, which then leads to constant sleep fragmentation the remainder of the sleep period.

5. Control Your Allergies

The discussion here is extensive and for a PAP user who has never broached this area of treatment, the content provides clear insight into nearly all facets of care needed to aggressively “keep your nose clean.” Two items I would add refer to some research building on the use of nasal allergy drops to supplant traditional immunotherapy (weekly or greater injections for months or years). I know of several patients who are using this newer approach and reporting good results, but my sense is that the technique is not widely accepted or available.

I was somewhat surprised there was no mention of nonallergic rhinitis, but then we have a keen interest in the topic as we researched the condition and published on it as well. You may recall we first wrote about NAR as a major contributing factor in PAP-induced aerophagia. Then, we revisited the issue in a subsequent post on our research publication. 

We continue to be impressed with the vast number of OSA/UARS patients suffering from the combination of allergic and nonallergic rhinitis, and the single most common presenting complaint is typically, “I’ve tried nasal steroids and the response was so-so.” We have been using azelastine (Astelin, Astepro) nasal sprays for several years and seen great results. In the past year, we’ve learned from local ENT docs who have also seen great results with ipratropium sprays, the older version being Atrovent, but newer variations of this type of drug may be forthcoming for NAR treatment

NAR is a very big deal in some proportion of PAP users, because PAP itself involves “wind blowing the face,” a relatively common trigger for NAR. Thus, in the worst case scenario if the NAR diagnosis is not established early on, the susceptible PAP user could develop worse congestion and even sinus inflammation just by initiating treatment with a pressurized air device. In such cases, we react quickly to halt the patient’s use of PAP and initiate either Astelin or Atrovent for a week or two and then retry PAP therapy.

6. Exercise Your Nose

I like this instruction because of the general health benefits, but Dr. Park astutely points out that vigorous physical exercise can lead to increase sympathetic nervous system effects on the nasal blood supply. This effect leads to vasoconstriction, which means the clamping down of blood flow, and in so doing, decreases congestion. On the other hand, among patients who report difficulty with exercising, conceivably there are nasal anatomy issues preventing a fuller volume of breathing in which case surgical interventions may be relevant.

7. Lower Stress

While this section is relatively brief, two very important points are brought forward. First, stress or what I prefer to call “emotional tension” or “unprocessed emotional residue” physically causes sufficient tension in your chest cavity to constrict your natural breathing tendencies and produce shallower breathing. Dr. Park points out these changes are not natural and may have their own adverse influences on nasal breathing as well as on the development of nasal congestion. Although not directly stated, this point correlates with second issue related to stress, which is that anxiety itself causes nasal congestion in some people. According to a paper published in the research literature a few years back by Dr. Christian Guilleminault—who discovered UARS—at least as far back as the 19th century doctors were aware of emotional distress interfering with nasal breathing.

This information is very important to so many more sleep apnea patients than most sleep physicians realize. The importance relates to how anxiety and nasal congestion interfere with someone’s efforts to use PAP therapy, which brings us back to the discussion in point #5 above on non-allergic rhinitis. NAR in fact seems to be the culprit in patients having a congestion response to PAP therapy. As PAP therapy is wind blowing in your face, most sleep doctors should know that “wind-triggering congestion,” especially in seasons other than spring or fall, is a fairly reliable marker of NAR.

Thus, lowering stress levels (especially anxiety levels) is valuable for many health reasons, but in particular if you suffer this type of distress-related congestion in which your anxiety triggers a NAR response, you will either need to find relief through the nasal sprays described above or in the some case, you may discover a certain type of emotion-focused psychotherapy will be of value in your ultimate quest to regularly use PAP therapy without congestion.

Next up, surgical interventions to improve nasal airflow.


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