Deborah Howell (Host): We've all heard the term sleep apnea, but do we really know what it is and how it can affect the body and our long-term health? In this episode, Dr. Sarathi Bhattacharyya, a Pulmonologist and Medical Director of the Sleep Disorder Center at Memorial Care Long Beach Medical Center will shed some light on the often overlooked condition of sleep apnea, it's warning signs, health risks and the life-changing impact of early detection. Welcome, Dr. Bhattacharyya.

Sarathi Bhattacharyya, M.D.: Thank you for having me.

Host: Shall we dive right in?

Sarathi Bhattacharyya, M.D.: Let's go for it.

Host: Let's do it. What is sleep apnea and how does it affect the body?

Sarathi Bhattacharyya, M.D.: Sleep apnea is a pretty common condition, and it's something that affects the body specifically with regards to quality of sleep and then impairment in daytime functioning. So it's a condition that specifically affects airflow in the upper airway. I think there's a misconception that it might be a lung disease, specifically with the term apnea, which is in regards to breathing, but it's really a disease of the upper airway.

Host: Interesting. And what are some of the most common signs and symptoms people should look for, both in themselves and of course, their loved ones?

Sarathi Bhattacharyya, M.D.: Very commonly what I've experienced, and I know many others in their practice, or the patients themselves, what we hear often is snoring, loud snoring, frequent snoring, snoring that disrupts a bedtime or bedroom partner, and other symptoms such as nighttime gasping or choking episodes. These are pretty common during the night, and then the translation of that into the daytime is this feeling of tiredness, excessively sleepy, kind of difficulty getting going in the morning and the sensation that no matter how many hours of sleep someone gets, it's really not that refreshing.

Host: Right, right. And can you please explain the difference between obstructive sleep apnea, central sleep apnea, and complex sleep apnea?

Sarathi Bhattacharyya, M.D.: Of course. So obstructive sleep apnea is definitely the most common type, probably the most relevant for the vast majority of patients who have concerns for sleep apnea. I think, I like to explain it to patients that you are trying to breathe, but you can't. So your body is still going through all the natural processes of regulating breathing, but there is an obstruction in the upper airway that limits airflow and that relates to closure of the airway, causes low oxygen levels, and is basically the pathophysiology of obstructive sleep apnea.

On the other hand, central sleep apnea is not trying to breathe. Where there is some dysregulation in the brain's control of the breathing process, it's almost like you're holding your breath. There's no effort being made. There's not even any obstruction of the airway, and it's not as common as obstructive sleep apnea, but still something that's relevant in the sleep world.

And complex sleep apnea is kind of a general term that describes the combination of both obstructive and central sleep apnea, and it can be that they both coexist. It could be that central sleep apnea develops as a result of treating obstructive sleep apnea. So kind of a catchall term for a combination of the two conditions.

Host: Right. And is all snoring related to sleep apnea or not?

Sarathi Bhattacharyya, M.D.: Not truly, uh, there are people who can snore and not have sleep apnea. Snoring is really the acoustic manifestation of turbulent airflow in the airway. So it is possible to have snoring without sleep apnea. Not commonly, but it's still possible. And then it's actually possible to have sleep apnea without snoring.

Host: Oh, interesting. Okay, so what are the risks of untreated sleep apnea and how does it impact our long-term health?

Sarathi Bhattacharyya, M.D.: I think making it relevant for people explaining, you know, why it's important to address this condition that affects a good chunk of your life. If you spend at least six to eight hours sleeping, it's a good portion of your day. So the risks are mainly related to, I would say, in two categories.

One is kind of the quality of life impairment that people experience, and then two is the sort of long-term health consequences that arise from untreated sleep apnea. Quality of life could mean difficulty with daytime functioning, meeting obligations at work or school, or with family, feeling tired throughout the day, just kind of this unpleasant feeling of I'm not rested, I don't feel refreshed.

I am wanting to take a nap, or finding yourself dosing off during the day. On the other hand, the actual health consequences that we can track and measure are related primarily to cardiovascular risk. Things like untreated high blood pressure that maybe goes undiagnosed for a while or is very difficult to control.

Your risk of things like heart disease, coronary disease, arrhythmias that are either going to develop over time due to untreated sleep apnea, or if you have a preexisting cardiac condition, these can potentially get worse with untreated sleep apnea. There are risks related to the development of strokes, and there's been some research that correlates untreated sleep apnea with the potential earlier onset of cognitive impairment or dementia processes in older adults.

Host: Oh, I'd never heard that element. Wow. So it's very serious and needs to be addressed.

Sarathi Bhattacharyya, M.D.: I think so. It's definitely a condition worth addressing and I think the challenge with convincing patients of that, but also recognizing it yourself as a provider is that these are long-term risks. They don't develop after one or two nights of sleep apnea. They may not even develop after one or two years of having untreated sleep apnea.

They really come on after decades of untreated sleep apnea. So earlier diagnosis, detection, and treatment is really the goal.

Host: Got it. Now, who is most at risk for developing sleep apnea? We don't see it in children, for example.

Sarathi Bhattacharyya, M.D.: You actually do see it in children. It's not a very common condition in children. Pediatric sleep apnea is, very specialized field, very often related to anatomical issues, developmental conditions. We see it very often in the population of children with Down's syndrome, for example.

And there's a kind of a whole pathway of treatment that does differ from adults, but focusing on adults, it's very common in men, more so than women. I would say that that's pretty true across all countries. Ethnicities, age groups in adults, I would say about 10 to 15% of women, which is increasing in our identification because we are appreciating it more in women and how they present maybe a little differently than men.

And about 15 to up to 30% of men would probably be at risk of sleep apnea. Things like age over 50 is a risk factor, gender, as I mentioned, male versus female, neck circumference. So we've kind of identified through screening tools a neck circumference cutoff of 16 centimeters as a sign of more risk of sleep apnea.

Host: So the larger neck circumference shows a larger percentage of sleep apnea?

Sarathi Bhattacharyya, M.D.: It correlates more highly with an increased risk of developing sleep apnea, the larger your neck circumference is.

Deborah Howell (Host): Okay. Interesting. Alright. I have a friend who tapes her mouth shut when she goes to sleep so that she will not snore. What's your response to that?

Sarathi Bhattacharyya, M.D.: It is actually a pretty effective treatment for snoring. There are commercially available mouth tapes that are designed for this purpose. There are patients who I've seen that have kind of done it on their own before seeing me, and it can be effective for snoring. It essentially creates a positive pressure system when you're exhaling to help stent open the airways in a kind of a way that's similar to one of the treatments for sleep apnea, a CPAP machine, probably not as effective as a CPAP machine on its own, but definitely a reasonable therapy if snoring alone is the issue.

Or if you haven't yet seen a sleep provider and you're trying something, mouth taping is a pretty common home solution that a lot of people try.

Host: Okay, interesting. Now who is most at risk for developing sleep apnea?

Sarathi Bhattacharyya, M.D.: So we have a screening tool called the Stop Bang Tool, and it's essentially an acronym that, has eight different categories. We screen our patients by asking them do they snore, do they feel tired? Do they have observed periods of breathing cessation? Do they have high blood pressure? Do they have a BMI above 35? Are they above 50? What is their neck circumference and what is their gender? And depending on how many points you score on this scale, ranging from zero to eight, your risk increases. So zero to two is considered low risk. In the three to four range is considered intermediate, and five and above is considered high.

So you can imagine if say a man over 50 with a neck circumference of 17 comes to you, that's already three points in the intermediate risk range.

Host: Interesting. Okay. Let's try to solve this problem. Are there any lifestyle changes that can help manage or reduce symptoms of sleep apnea?

Sarathi Bhattacharyya, M.D.: There are definitely some lifestyle changes that I think are good adjunctive therapies to some of the more traditional treatments. Weight loss is a very common one that I recommend and that I think patients themselves are already asking about or aware of. It probably by itself is not going to be effective in most patients, but there's a lot of research being done into weight loss, specifically with new weight loss medications that specifically applies to treatment of sleep apnea in addition to managing weight. So I think that's going to be a very interesting area for future development. There's already a lot of interest in this area just due to the other health consequences of obesity and weight in the United States. So I think that's probably one that we'll see a lot more information on in the coming years.

Other lifestyle changes, these are maybe, again, not as effective as main treatments, but worth considering things like side sleeping. So sleeping on your left or right side rather than sleeping on your back, which, can be hard to know what you're doing when you're asleep. But there are people who, for various reasons may preferentially sleep on one side or the other, or even incline sleeping, sleeping, propped up on a few pillows or on an adjustable bed at an incline.

Host: And what about stomach sleepers?

Sarathi Bhattacharyya, M.D.: Stomach sleepers perhaps have a lower risk of as many symptoms of sleep apnea. Mostly because that airway closure that's happening in obstructive sleep apnea is due to gravity pulling your tongue back. There's natural kind of relaxation of the muscles that occurs and airway closure that occurs as a result of going into deeper and deeper stages of sleep.

So it's possible that front sleeping may be perhaps more effective than back sleeping, but typically we recommend lateral sleeping as we even see correlations on sleep studies where changing position from sleeping on your back to sleeping laterally on your sides does reduce the number of sleep apnea events someone has.

Host: So basic question, how is sleep apnea diagnosed?

Sarathi Bhattacharyya, M.D.: I like to joke that sometimes it's diagnosed by the spouse. That the spouse comes to the appointment with the patient and they provide the whole story that they're awake all night listening to the snoring and counting how many times their husband or wife stops breathing. That's a pretty good marker. But officially, you know, for medical purposes, we diagnose it with a sleep study; either one done at home or one done in the sleep lab.

Host: Interesting. And what type of treatment options are available for sleep apnea, if not for the spouse?

Sarathi Bhattacharyya, M.D.: For the spouse kind of gets the secondary benefit. But the main treatment, kind of the gold standard I mentioned earlier is CPAP, which is an acronym that stands for continuous positive airway pressure. It's delivery of pressurized air, gentle pressurized air into the nose and or the mouth, depending on the type of mask the person uses, and it helps keep the airway from collapsing or closing during sleep.

There are a few other treatments for sleep apnea that are considered either second line or kind of supportive or alternative therapy. So I mentioned CPAP as the gold standard. Earlier I mentioned sleeping laterally or on an incline. It's a kind of supportive therapy. Weight loss, of course, as an adjunctive therapy.

And then there's devices that are surgically implanted; the hypoglossal nerve stimulator. This is become, I think, a lot more common recently, but it's actually been around for almost a decade, probably longer, where you go visit an otolaryngologist or an ENT surgeon and they evaluate you for this nerve stimulator and a small device is surgically placed under your skin and a lead from that device is passed up from the device, and coats the nerve that controls your tongue. And essentially what happens at night is you turn on the device and with each breath, you take, this generator, senses the breath, and then sends a signal to your tongue and moves your tongue forward, essentially opening the airway and alleviating the obstruction.

This is a non CPAP therapy, no masks or tubes, and you know, a little bit more invasive, but for the right person could be a very effective treatment.

Host: Fascinating. Just moving the tongue forward. Wow. Is that called the Inspire device or is that something separate.

Sarathi Bhattacharyya, M.D.: That's the same as the Inspire device, right.

Deborah Howell (Host): Okay. What about sleep lab testing?

Sarathi Bhattacharyya, M.D.: So sleep lab testing is useful for treating sleep apnea if you have a patient who perhaps needs to start on CPAP, but you are not sure of the settings that they need to use. There are various other modes of pressure delivery such as BiPAP or ASV. These are more advanced modes that some patients might need, so you can perform as a provider, a sleep lab test to determine what settings of pressure to give the patient. For the Inspire device or for the hypoglossal nerve stimulator, there is part of the treatment plan where once a patient has had the surgery and you've seen them in follow up a few times, and you've determined essentially what settings to put on that device, you can then send them to the sleep lab where they get tested with the Inspire device running so that you can demonstrate that their sleep apnea is treated.

Host: Got it. And what advice would you give to someone who suspects they may have sleep apnea, but hasn't sought help yet?

Sarathi Bhattacharyya, M.D.: I would think a good resource to start with is your primary care provider. It's a pretty common condition that they're all very familiar with. Whether they're able to order the studies or refer you to someone who can, I think it's a good place to start and the advocation that I would give for getting checked out for this is that quality of life improvement can be significant.

You can experience more energy, better quality, more restful sleep, and then of course, all these long-term health consequences that we discussed could potentially get addressed.

Host: So much great information. I know people are listening and have learned a lot, but where can people learn more about the Sleep Disorder Center?

Sarathi Bhattacharyya, M.D.: You can visit our website, memorialcare.org/sleepdisorders. There's a lot of great information there about our center, about sleep apnea, about the different types of testing that is offered and can give us a call if you're interested, talk to your doctor as well and hopefully get on the path to better sleep.

Host: Once again, that's memorialcare.org/sleepdisorders. Thank you so much, Dr. Bhattacharyya for your time and your expertise today. We really, really enjoyed having you on the podcast.

Sarathi Bhattacharyya, M.D.: Of course. Thank you so much for having me.

Host: That's all for this time. I'm Deborah Howell. Have yourself a terrific day.