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Prakash Chandran (Host): Do you snore at night? Loud, chronic snoring is one of the most frequently cited symptoms of sleep apnea and it’s one of the most common sleep disorders affecting approximately 20 million adults in the United States. But most people are actually unaware that their snoring problems might actually be an issue. I’m Prakash Chandran and in this episode of Northfield Hospital & Clinics podcast series, we’ll be talking about snoring and sleep apnea in adults. Here with us to discuss, is Dr. Gerard O’Halloran, an Ear, Nose and Throat doctor at Northfield Hospital and Board-Certified in sleep medicine. Dr. O’Halloran, thank you so much for educating us today.

Gerard O’Halloran, MD (Guest): Thank you so much for having me.

Host: It is a pleasure. I want to get started by understanding a little bit about what exactly sleep apnea is.

Dr. O’Halloran: So, sleep apnea is fairly easy to understand. When we normally are breathing through our nose and mouth, air goes down through our throat into our lungs; what changes when we fall asleep is the throat muscles relax and the tongue can fall back into the throat to make the throat narrower. If you don’t have sleep apnea, it means that that narrowing doesn’t cause any blockage, but if you have a narrower throat than anyone else; for example, big tonsils or upstream blockage of the nose or a very thick neck pushing in on the throat; the airway is narrower so that when it relaxes when you fall into deep sleep; it can shut all the way off. There’s really two main issues with sleep apnea. There’s the sort of general long-term risk of a higher chance of heart attack and stroke from not breathing well during sleep. And then every time your throat falls shut, and you quit breathing; to get enough muscle tone to breath again, you’ll move out of deep sleep into lighter sleep which interrupts your sleep. And so, some people, but not all, with sleep apnea feel pretty tired.

There’s a lot of bad things that are associated with sleep apnea in addition to heart attack and stroke. Those are the most well-established. We’ve known about that for 20-30 years. You can pretty much Google anything bad like depression, anxiety, fibromyalgia, probably decreased immunity; all have some correlation with sleep apnea. It’s very difficult always to prove cause and effect, though.

Host: Yeah, I had no idea that it led to all of those things and I think something that’s difficult is actually diagnosing when you have it because myself, I definitely snore when I sleep. My wife can attest to that. I know I get pretty loud sometimes and I’m wondering how do you separate people that just have a snoring problem from a sleep apnea problem?

Dr. O’Halloran: The way we do that is to do a sleep study. There are two types of sleep studies. Prior to just a few years ago, everyone would have to go to the hospital, get hooked up to a bunch of wires and be monitored overnight when they sleep. And we still do that for more complicated patients and some insurance companies for example, Medicare, Medicaid won’t pay for home studies. But the majority of the studies I order now in the Northfield Hospital & Clinic System are home studies, where the patient essentially picks up a device, a chest strap and a headband to wear overnight, where they have to pick it up because it is fit to them and then anyone can drop it off the next day and within a week or so, we would have a pretty good idea if they have obstructive sleep apnea or not.

Host: And when they give you the study, I guess over a period of a week; what are the things that you look for that tell you that they might have sleep apnea?

Dr. O’Halloran: Well, the things I look for when I’m deciding whether to order a test or not. The study by the way is just one night. It just takes a week to process. But the things I look for in the patient’s history would be are they tired during the day. Do they have sort of midafternoon lull where they could nap easily? Do they fall asleep very quickly at night? Are they loud snorers? Loud snorers have a very high chance of having apnea. Snoring is a narrowing or partial blockage of the throat so, it’s not big leap to think there might be some obstructions as well. High blood pressure is a sign.

Interestingly, anxiety and depression have a high correlation though. When I see patients in the office, I will ask about that because I’ve had several patients who had sleep apnea and they got treated for it and their anxiety diminished dramatically and one guy it went down from like if he had a dollar’s worth of anxiety at the beginning, he had about three cents worth after he was treated.

Neck size is also a big predictor. Patients with a 17-inch neck size for a dress shirt, for example, 80% will have sleep apnea. What’s the most difficult, is some people have sleep apnea and they really don’t have a lot of symptoms. They’re not tired at all and so that’s when we look at the physical things. Do they have a big neck? Is their throat crowded? When we examine them is the tongue farther back in the throat? Patients where their lower jaw is a little shorter have a very high risk of sleep apnea.

Host: I feel like all of the things that you just described as symptoms of a patient having sleep apnea; that’s all me. I feel sometimes tired. In the afternoon, I have that lull. I fall asleep very easily. So, it is something that I definitely need to get checked out and to do that test. So, my question is, once that’s done and let’s say you identify that I have sleep apnea, what are the next steps after that?

Dr. O’Halloran: So, typically, once a sleep study is ordered, the patient would follow up in the Northfield System, most of them end up following up with me. I believe I’m the only doctor in our system that’s boarded in sleep medicine. There’s another doctor at the other clinic in town that also is boarded who is very good. Dr. Bryan Hoff. But I typically see patients back one or two weeks after the study is done, review the study with them and if it’s positive for apnea; there are different levels of sleep apnea. I mean some people – to count as sleep apnea, you have to have five events an hour where your throat falls shut, quit breathing and move out of deep sleep.

So, five to 15 events per hour would be considered mild sleep apnea. Lower risk . Some people may be very tired from that, 15-30 events an hour would be moderate sleep apnea. And over 30 events an hour and I’ve seen patients up well over 100 events an hour; that’s severe sleep apnea.

The treatment sometimes varies, but the common treatments are positive airway pressure. So, CPAP machines. Most people have heard of those. A CPAP is really an air compressor then you attach it to either little tubes that go in the nose or a mask over the nose or a full mask over the nose and mouth, if the nose is blocked. CPAP is probably the most reliable treatment for sleep apnea. But there’s a fairly high hassle factor, not always tolerated. But about three fourths tolerated.

My brother has sleep apnea, one of my brothers has sleep apnea and he wouldn’t try the CPAP for two years, but the first night he tried it, he had a great night’s sleep and wondered why he hadn’t done it sooner. The other treatment options for either those who don’t tolerate CPAP or for certain patients which we are kind of clued into the study. If some is much worse on their back than they are on their side, that implies that their tongue falling back is a big part of the issue. So, some dentists can make a custom oral appliance, similar to a sports mouth guard that will fit on the upper and lower teeth and ratchet the lower jaw forward to pull the tongue forward with it. Those are a little more expensive to get but typically covered if you have a positive sleep study by your insurance. Much easier to use because it’s just like putting a mouth guard in at night.

Other treatments are - surgery is a potential treatment. I’m an Ear, Nose and Throat surgeon. I do the surgery for sleep apnea. It’s not typically the first thing I recommend because the reliability of it fixing the apnea is fairly low unless it’s someone who has very specific things like if someone is very young and thin and their tongue is in good position and has huge tonsils; taking the tonsils out might help – has a pretty good chance of helping them. But for someone who has a thick neck, a large tongue; we can do – we can take out tonsils. It’s a big operation to go through. It’s very expensive. And the reliability of curing the apnea is fairly low. So, surgery as a general rule is sort of the last choice for sleep apnea.

The one exception to that would be if someone has a deviated septum, where the middle wall of their nose is crooked and is blocking their nasal passages. Some people will need to have that fixed to tolerate any other treatments for apnea. For example CPAP blows – it’s most comfortable if you use those that blow through your nose, but if your nose is blocked and you have to use a full face mask; that’s much less pleasant. Some people become claustrophobic and it tends to leak more. So, I have several patients a year, not a ton, but five or six that will have to fix their nose so they can tolerate a CPAP.

The dental appliances work much better if you have a good nasal airway. Now would we do the nose surgery first? Not necessarily. We’d usually try the dental appliance because if it works, you are kind of done, don’t need to have surgery. But if it doesn’t work perfectly then we do think of fixing the nose.

There are other treatments for apnea. There’s one that’s commonly seen that I’ve seen at least a lot on Facebook which is really just a little thing that goes in the nose that holds the nasal airway open. I’m not aware of any studies that show that that’s very effective. There is for people who sort of fail all other treatments, there is the Inspire which is advertised frequently on PB Radio I believe which is a pacemaker that’s attached to a nerve to your tongue so when you take a breath, it pushes you tongue forward to try to relieve obstruction. Those are fairly new, and I tend not be an early adapter of the really new technologies until they’ve been around a while to make sure that they don’t hurt anybody and that they actually work well. And currently, that I believe is still mostly reserved for people who have failed other treatments.

Host: Yeah, that is a very comprehensive answer to all of the different ways that you can treat sleep apnea. So, if I’m hearing you right kind of the three most common things are the CPAP machine like you were saying and either through the nose or kind of that full face mask, the mouth guard option and then finally but less often recommended is the surgical option and then there are the other kind of unproven methods as well. I think something that came up while you were talking about this is once I am let’s say I use the CPAP machine; how long do I need to do that for, for me to kind of be fixed or is it kind of like a rest of my life?

Dr. O’Halloran: CPAP is more of a rest of your life kind of thing unless something changes. One treatment I didn’t talk about is weightloss. Some people if they are very overweight and loss a lot of weight; will be cured. They can cure themselves. That does happen. It’s not as reliable as you might think. I mean people who have gastric bypass and drop 100 pounds, some of them will cure their sleep apnea. But the – oftentimes it’s more the – it’s a combination of weight plus the anatomy of their head and neck and where the tongue is positioned in the throat.

So, weightloss isn’t a guaranteed cure. It tends to be more of a guaranteed cure in people who remember when they were thinner that they didn’t snore and weren’t tired where if they get back to that weight, they may be okay again. But CPAP and the dental appliances are really a – what we call palliative treatment which means it’s something that treats it, but it doesn’t cure it. So, it’s a long-term thing and requires long-term monitoring as well.

Host: Okay. That makes sense. And one of the last things that I wanted to ask you that you kind of addressed is are there any preventative measures that you can take to prevent sleep apnea? I know you said weightloss sometimes works. But is there anything else?

Dr. O’Halloran: Probably not. Most of this is somewhat genetic. Sleep apnea runs in families. If everyone in the family has a big neck, you likely may have that as well and so you’re going to be more prone to sleep apnea. Avoiding sedatives. If you are going to have a glass of wine before – have it earlier rather than right before bed because alcohol would make sleep apnea worse. Antihistamines may make it worse to some degree but not as much. And any kind of sedative would make sleep apnea worse. But otherwise other than exercise and staying relatively thin, most of the time; sleep apnea isn’t anyone’s fault.

Host: Yeah, that’s really good to know and Dr. O’Halloran, I really appreciate you educating on this topic today. For more information please visit www.northfieldhospital.org. My guest today has been Dr. Gerard O’Halloran. I’m Prakash Chandran. Thank you so much for listening.