Transcription:
Sleep Apnea: Causes and Treatment Options

Melanie Cole (Host):  Welcome to BayCare HealthChat. I’m Melanie Cole and today, we’re discussing sleep apnea. Joining me, is Dr. Lisa Whims-Squires. She’s the Director of the Morton Plant Mease Sleep Disorders Center and a part of BayCare. Dr. Whims-Squires I’m so glad to have you here. Tell us what’s the health burden and impact of sleep apnea and really sleep disorders in general. How are they associated with poor overall health? What comorbidities might they contribute to or be a part of?

Lisa Whims-Squires, DO (Guest):  Sure. Sleep apnea – the way we approach it has changed over the years mostly because more information has come out about the links to other diseases, in particular cardiovascular disease, but we are also seeing the risks associated as well with diabetes and dementia. For instance, for people with high blood pressure, hypertension, about 50% of those people are found to have apnea, about a three times increased risk for developing high blood pressure and the people with high blood pressure who require three medications or more, about 90% of them have apnea. So, we see a high association with that as well as with treatment, it can impact the disease.

With heart disease, we see that about 65% of people with – we call it acute coronary syndrome so that seems like people with heart attacks and angina, about 65% of them have apnea. And if you don’t treat it, and you go ahead and do some kind of intervention whether it’s bypass or whether it is putting a stent; they have a higher failure rate after intervention if you don’t control the apnea. We see that it can lead to atrial fibrillation and treating that can actually decrease the risk of recurrence of atrial fibrillation. There’s an association with heart failure along with dementia especially you can see Alzheimer’s risk much more commonly in women associated with apnea. And just overall risk of early dementia in men, about a six-time increased risk and about three-time increased risk in women under the age of 70.

So, we see a lot of different risks. I didn’t mention that as well increased risk of diabetes as well, so it’s currently recommended to screen diabetics for apnea.

Host:  Well thank you for that. So, what is sleep apnea? Give us a little working definition for the listeners so they know what we’re talking about.

Dr. Whims-Squires:  Sleep apnea means that people quit breathing during the night. We can see sleep apnea all the way down into children through adulthood. So, it’s not something we just see in adults. But people associate it more commonly in adults. Basically, it occurs because of closure in the back of the throat and the throat itself. Back of the throat is just from extra tissue that’s there. Throat itself, is more because of obesity. Most of us have seen people who carry weight elsewhere they also carry it in their neck. And also once women go through menopause, or men hit middle age; we start seeing smooth muscle changes within the neck that causes some narrowing there as well.

Host:  So, let’s talk about who is most at risk. And if there’s a genetic component and also, people always seem to wonder if you snore, if you are a snorer, does that mean that you have apnea?

Dr. Whims-Squires:  Snoring is frequently associated with apnea but there are people that have just primary snoring, benign snoring. Sometimes it’s just snoring that wakes them up during the night. So, snoring doesn’t guarantee that they have apnea. It’s just one of the risks that we see associated with apnea. But if somebody is snoring and they have any other symptoms at all, then of course, you have to consider that it may be more than just something benign. Who is at risk, more commonly risk factor goes up dramatically; like I mentioned before, after women go through menopause, the incidence goes up significantly. Men after they hit middle age, it goes up. The incidence goes up. Overall, men are about two to three times more common – about two to three times more common than women; however, that becomes and equal playing field by the time of age 65 where it’s about 24% of women and about 26% of men.

Host:  What are the symptoms we would notice? Is it our partner that would notice that we’re doing this in the night? Would we notice something in ourselves, fatigue in the day? Tell us about symptoms and diagnosis so that we can get into some of the treatment options.

Dr. Whims-Squires:  Symptom-wise, there is quite a lot of different symptoms. Of course, most people think of the daytime sleepiness and that can be profound for some people or it could be just that they don’t feel as restored in the morning as they used to. Of course, you mentioned snoring. Sometimes it is a bed partner noticing that someone quits breathing. It can be things as simple as difficulty with short-term memory or concentration. It can mimic depression. So, you can see some of those mood changes as well. The other things that I kind of alluded to before, if somebody is having difficulty controlling their blood pressure, that’s someone that you may want to think of with apnea as well. So, sometimes, people are picked up because they are hard to control for their blood pressure or they are young, and they’ve developed atrial fibrillation. So, there’s quite a variety of reasons that people may get concerned that they may have apnea.

You did mention about treatment as well. Most commonly the treatment that we use is CPAP. It is basically a small compressor that applies a pressure to keep the throat open during the night. All it is doing is trying to open the airway because normally during the day, you’re fine. You can breathe. It’s just when the airway collapses during the night that it’s a problem. So, we just kind of splint it open during the night to make them breathe. But there are some other alternative treatments as well depending on the person’s individual situation. Sometimes we can use oral appliances or other modalities like ProVent which goes over the end of the nose to help give back resistance to keep the airway open.

Host:  Well then let’s talk about CPAP for a minute. People are a little bit wary of using this. Maybe adherence is not what it should be. They have mask issues. And pressure issues. Tell us a little bit about what you’ve seen as far as adherence to CPAP and if you can offer some tips and advice for people that do use CPAP in making it just a little bit more comfortable and a little bit more efficient.

Dr. Whims-Squires:  When you look at the overall success rate with CPAP, for across the United States, is very poor. But of course those different hands managing it which sometimes impacts that as well. Our machines have gotten a lot better which has made it more tolerable to people by adding things like heated tubing that helps with better humidification. In the past, that was a lot of people’s complaints that they would get stuffy or have trouble with dry mouth. So, our humidification systems have improved.

At times, you mentioned people have difficulty with pressure intolerance. In those cases, we can go to a specialty machine called a BIPAP. And it basically gives one pressure when the person breathes in and a lower one when they exhale. Because it’s usually that pressure we have to breathe out against that makes people have difficulty with tolerating the pressure. So, sometimes we can change over to a different modality. The other benefit is our masks have gotten much better. When I started doing sleep back in the mid to later 90s, we only had a few masks to choose from. Now we have ones that just sit under the nose. They don’t even have to cover their nose. We have ones that are just nasal pillows that just go in the nostrils. Ones that now connect over the head, so you don’t have to even fight with a tube in front.

So, there’s so many different options to help that person become more tolerant of using the machine at night. Other things that help too is utilizing a ramp during the night, so a ramp basically gives them time to fall asleep before the pressure increases. So, that as well helps with being able to adhere to treatment.

Host:  So, before we wrap up, Dr. Whims-Squires, tell us a little bit about some other types of treatments, some alternative to CPAP that you might recommend for someone and how do they go about choosing which treatment option and how do you discuss that with them?

Dr. Whims-Squires:  Well, people with severe apnea, it’s a little more challenging to do alternative treatments. Although there is a stimulator that can be used. It’s not something that people go into lightly because it’s a surgical alternative. They need to look at the airway with – they usually use propofol and look at the airway to see if it’s an appropriate airway before stimulator is ever placed. And then it actually is implanted. It looks almost like a pacemaker when it’s put in, although it’s on the right side. And what it does is it sends a message up to the nerve that goes to the tongue and makes the tongue go forward. So, that can be used in moderate to severe patients. It’s not something that people go into lightly because obviously it is something that’s implanted and that carries with it risks of its own.

For people that are more mild to moderate, then sometimes, oral appliances can be used. And they basically are made custom to their mouth and they are adjustable to bring the jaw forward at night. And they do work well. Generally the biggest drawback to those is coverage from the insurance standpoint. Because they are quite costly. And then another option is ProVent. ProVent goes over each nostril and it has a one-way valve so when the person exhales, it gives back resistance to keep the airway open. It’s kind of a hit or miss and it’s an out of pocket expense. So, usually what we’ll do is let somebody try it and then do at least a home sleep study to see if they are being adequately managed with that.

No matter what we do, if somebody is obese, we try to work on getting their weight down. Because that will also help to minimize the apnea. And also once people are treated, sometimes they get the benefit of improving the ratio of their leptin and ghrelin which are hormones that regulate our metabolism so sometimes it does get a little easier to lose weight once people are adequately treated.

Host:  This is really a great topic and it’s so prevalent. So, as we wrap up, Doctor, give your best advice. You’ve just given us some things that we can try to help but give us your best advice about sleep hygiene in general and possibly reducing our risk for sleep apnea.

Dr. Whims-Squires:  For sleep in general, probably the biggest problem that we have as Americans is our constant crazy lifestyle. So, people tend to put sleep on the back burner. People in the sleep community, we look at sleep just as important as somebody’s exercise, their nutrition. It’s up there are far as eating during the day. You should be prioritizing it. So, people should be trying to achieve at least seven hours of sleep at night. There’s actually cardiovascular risk for having people sleep under five hours at night. So, trying to keep a consistent sleep schedule also helps to ensure that you’re getting proper hours and also it sets you up to feeling more restored during the day.

As far as trying to avoid caffeine close to bedtime, usually a lot of times cut it out after noon. And trying to avoid using things with blue light at night if you can. A lot of times people are using computers or phones or laptops that also will impact them being able to go to sleep at night. There are blue light filters that can help that. As far as the apnea in general, trying to keep your weight down. Not everybody who has apnea is heavy. A lot of postmenopausal women I see are thin so that doesn’t always correlate. But obviously, looking for the symptoms and treating it so that you can modify the diseases that it can cause is beneficial.

Host:  Thank you, Doctor, for joining us today. It’s really great information and so important for us to hear about sleep apnea and the treatment options that are available. To learn more about BayCare’s Sleep Medicine Services please visit www.baycaresleep.org for more information. That concludes this episode of BayCare HealthChat. Please remember to subscribe, rate and review this podcast and all the other BayCare podcasts. I’m Melanie Cole. Thanks so much for listening.