Transcription:
Sleep Apnea Treatment Options

Melanie Cole (Host): If you sleep poorly, you snore, you have morning headaches or are fatigued or excessively sleepy during the day; you might have a sleep disorder. My guest today Ruwanthi Campano. She’s an ENT doctor and a Head and Neck surgeon and a member of the medical staff at Palmdale Regional Medical Center. Dr. Campano who notices sleep disorders? Is it a loved one or are there symptoms that you would notice in yourself?

Ruwanthi Campano, MD (Guest): Good morning Melanie. Thank you. So, basically, sleep apnea is recognized by the bed partners most commonly. So, your wife, or whoever is sleeping in the room with you; they notice that you have pauses in your sleeping, usually it’s accompanied by loud snoring and it’s actually quite disconcerting when you see someone stop breathing while they are sleeping. And then it’s also you can notice yourself, because some people say I wake myself up from sleep, I snore very loudly, or some people are literally falling asleep at the wheel. So, they notice themselves that they are very fatigued during the course of the day.

Melanie: Who’s at risk for sleep apnea?

Dr. Campano: So, anyone potentially could have sleep apnea. However, it affects males about double women. If you are overweight, it can affect you more often. Patients who have body mass indexes of greater than 25 or 30 and higher. If you have a larger neck size, which basically means you have – like 17 inches or more for men, 16 for women. And you have more soft tissue, it can block your airways during sleep. When we are older, our metabolism tends to slow, so we tend to be a little bit heavier, sometimes. And then either patients who are basically sleep apnea can lead to hypertension. Sleep apnea can also run in the family so, if your parents have sleep apnea; you might have a higher chance of having sleep apnea as well.

Melanie: Thank you for clearing that up. I was going to ask you if there is a genetic component to it. So, then how it diagnosed? If somebody notices some of these symptoms, maybe they are at risk or their partner says you are stopping breathing in the night, like that, then what does diagnosis look like?

Dr. Campano: So, usually they come in. It’s usually a concerned loved one who say this is pretty scary, you stopped breathing. So, basically people have loud snoring or really frequently through the night snoring, the pauses; they actually choke or gasp for breath and then a lot of times they are just really tired during the day. Or they say heh, I was in bed for eight to ten hours and I just don’t feel rested or they are having insomnia, they are having headaches in the morning. They are waking up in the night to go to the bathroom; especially with children, sometimes they are wetting the bed. Difficulty concentrating, memory loss, they are irritable, just kind of grouchy because they are tired, decreased sexual desire can also be associated for adults.

And so, apnea is the cessation of breathing. So, you basically stop breathing because the brain recognizes it is actually carbon dioxide, but we usually just say your oxygen level drops, the brain recognizes that and says heh, I need to breath. Wakes you up from the deep stages of sleep when is REM sleep which is where we dream and it’s restful. You don’t have – sometimes people don’t even know that they wake up. They just get out of that deep stage of sleep. You wake up, you gasp for breath because your brain is saying heh, give me some oxygen. You gasp for breath and then you fall asleep again, but because you are not in that restful sleep; you feel tired. So you wake up just exhausted. People is they are sitting down, they are falling asleep. A lot of times, I will come into the office, into the exam room and the patient asleep and they have been in there for a minute or two. So, they are just kind of nodding off, they are just constantly fatigued because they are just not getting rest.

Now some things that can exacerbate that is if they drink alcohol. It loosens the muscle tone so the soft palate, all that tissue in the back can flop and obstruct the airway and so they notice that it’s kind of worse on those occasions than others. So, they come into the office and then I do an exam to see where the levels of obstruction are and then we go from there.

Melanie: So, then what? When you go from there, what does that mean? Is there medicational intervention, lifestyle changes or do you right away look to something like CPAP and if that’s the case; tell us what that even is.

Dr. Campano: So, the first thing we want to do is have them get a sleep study. So, the best sleep study is when you literally bring your teddy bear and you go spend the night at the sleep lab. However, that’s uncomfortable for most people and nowadays insurance companies actually don’t want to pay for it because it is about double what a home sleep study is. So, they send the materials home. It’s not as detailed, but they can check your oxygen level and the fact that you are having the apnea events. They can’t tell exactly what – they don’t have an EEG which is the encephalogram where they put the monitors on your head and then they can actually watch what stage you are in sleep, but they can basically tell are you stop – do you stop breathing or not. So, they calculate something called an apnea hypopnea index which is sort of the number of times you stop breathing over the number of times you sort of stop breathing and then they do a calculation. So, less than ten is normal. Ten to twenty is mild to moderate sleep apnea, twenty to thirty is moderate sleep apnea and greater than thirty is severe sleep apnea. So, depending on that level; would be how we treat patients.

So, if they have the sleep study and it says that they have severe sleep apnea; the gold standard of treatment is a CPAP machine. So, people are kind of in fear of this machine. It’s called CPAP, it’s continuous positive airway pressure and it basically steps with a column of air, a channel of air all the floppy tissue that’s in your throat that can obstruct. So, when patients come in, though, that’s not my first for sure treatment. But that is the gold standard because it for sure – we do a second sleep study which we can titrate exactly the level of the pressure of the machine that would be required to eliminate that apnea. So, 100% we know we can eliminate apnea if we use a CPAP machine. There is an alternative called a BiPAP machine which is bilevel, so, basically when you are breathing in, it’s a high channel of air and then when you are exhaling because you don’t want to exhale against this wind tunnel; then it’s more physiologic, it’s more comfortable for patients. Also, if they have other forms of apnea like a central apnea; that can also help.

But they come in basically to the office. I examine them so, I look at sites of obstruction. So, we had previously talked in the last podcast about snoring. Basically, snoring is air is coming in and hitting tissue and it’s vibrating. But this is far worse than snoring. And so, basically, I examine their nasal airways. If you can’t breathe through your nose, however, you automatically start breathing through your mouth. So, eliminating the nasal obstruction with surgery or medications could be a benefit, but it’s not going to eliminate the apnea. So, then we look at the throat. So, you look at the uvula. That’s the punching bag, the thing in the back of the throat that dangles. You look at the tonsils if you still have them. You look at the back palate, the floppy portion of the soft palate and then you look at the tongue. I think the tongue is a very large component for patients. So, that goes and obstructs the airway. I look at where their chin is in relation. It’s called retrognathia if their jaw is a little bit recessed, the tongue is attached to the jaw and so if their jaw is recessed; their tongue is automatically going to obstruct the airway. Then I do an endoscopic exam. I go through the nose and analyze the nasopharynx which is the area behind the nose and I go down to the throat and examine. I also have them do certain manipulations to see what collapses. So, sometimes the lateral pharyngeal walls, which is the back part of the soft palate in the throat collapses down or even lower.

So, there are certain surgeries that actually could be done that can treat sleep apnea. So, for instance if the tonsils are very large or the adenoids which are sort of like tonsils but straight in the back of the nose; if they are obstructing, then we take those out. In children, for example, that’s basically our treatment for sleep apnea, is we take out the tonsils and the adenoids and then usually after any surgical intervention; I wait about four months for swelling to go down and we order another sleep study to see if the apnea is eliminated. And then in adults; you can take out the uvula, a portion of the uvula or the entire thing and a portion of the soft palate that’s floppy and then I kind of sew everything open so it’s like a large arch and then you can do very complicated surgeries. Which basically, breaks the jaw, brings it forward, the tongue is tethered to that. There are other things we used to do for sleep apnea such as taking radiofrequency and reducing the size of the tongue. Other things like that, that tends not to be what we do now because the tissue kind of regrows and obstructs again. So, there are complicated surgeries, there’s not so complicated surgeries and then there’s the CPAP machine.

Melanie: Dr. Campano what if people don’t want to use the CPAP machine? What do you tell them about adherence and compliance because that would seem to be one of the limiting factors in sleep apnea?

Dr. Campano: Absolutely. Absolutely, so patients will come in and say I just don’t want – well a lot of times it’s also fear and fear of the unknown. So, they’ll come and say I just don’t want to use that machine. They have never tried it. They said they had the sleep study and they put it on them and a lot of times during it, they don’t put the optimum mask on them. So, it’s not the most comfortable experience. So, I usually just look at their anatomy and see why are they not able to tolerate the machine. A lot of times, it’s nasal obstruction. So, if we can eliminate that, then they can breathe better.

The most common mask is called a nasal pillow mask which if you have ever been to the hospital and had surgery, there’s the little cannulas of oxygen that we put in the nose. So, we can put – it’s something like that. So, it’s not as claustrophobic as some of the other masks. But if you have a lot of nasal obstruction, then you do need – the nasal mask won’t work so sometimes people need a full-face mask. If people have facial hair, sometimes you can’t get a good seal with some of the other masks if they do use a full-face mask. Now if they absolutely can’t tolerate anything, there’s actually a dental device that the dentist – I highly recommend – only thin the dentist that specializes in sleep medicine because a lot of dentists can make these night guards, but if you have one who actually specializes in sleep medicine, it is basically a contraption that they put in the mouth and then you kind of crank it forward. It brings your jaw forward. Now you have to make sure you do some exercises in the morning to try to get that jaw to go back; otherwise you could start developing some TMJ, the temporomandibular joint dysfunction if you are doing that. But, that’s another possibility for patients who don’t tolerate the CPAP machine. But a lot of these aren’t covered by insurance because the insurance company knows for sure CPAP gets rid of the apnea, the dental devices may or may not. Surgeries honestly, may or may not depending on your anatomy. So, if people have huge tonsils, then I know they might have a good chance. But when you look at the statistics, about 50% of those patients, the tissues will become floppy again and they can have sleep apnea again. I also tell people to lose weight. So, if you are overweight, there’s more floppy tissue back there. So, you want to try to lose weight. A lot of times, unfortunately though, patients are so tired, that they don’t have the ability to – they don’t have the energy to lose weight or exercise. So, if a lot of times, they will use the CPAP machine and then they say oh great, doc I have energy, they come bouncing in. It’s just – it’s very – but you’re right, it’s compliance. If they are not tolerating their CPAP machine; that’s a difficult thing. So, then we have to look at other options for them to try to get them to be compliant.

Melanie: Wrap it up for us then Dr. Campano with your best advice about if you recognize in yourself or a partner has recognized in you that you have a sleep disorder, that something’s not right or you are really, really tired in the day; what you want them to know about sleep apnea and getting the help that they need so they can get that quality night’s sleep that everybody requires.

Dr. Campano: So, I try to tell patients because it’s not just snoring. I tell patients snoring just bothers your spouse or the people on the plane, but it doesn’t – it won’t kill you. Sleep apnea will prematurely kill you. If you look at those big huge football players back in the day, sudden cardiac death, untreated sleep apnea. So, basically if you think about it; your heart is a muscle, it’s pumping the oxygen that it has to the rest of the body. It’s physically a muscle so, it’s getting bigger. The little tiny blood vessels supplying it, don’t work so well. And so, then you can get a heart attack, things can back up; you can get lung problems and things like that. So, sleep apnea is a very dangerous thing that can lead to high blood pressure, other issues and including heart attacks and sudden cardiac death.

So, it’s not snoring. Snoring just bothers people. Sleep apnea will prematurely kill you. So, when patients say I don’t tolerate that CPAP machine, sometimes they’ll come in with their kids and say do you want to see your daughter walk down the aisle one day? You may not because you might not be around. All you have to do is do certain things and we really can help you. It’s very difficult to lose weight after some time, but some people can do it. It’s very difficult to tolerate this machine sometimes, but some people can do it. Worse case scenario, if people really don’t tolerate anything because the oxygen level is so important, sometimes I will prescribe oxygen for the patient to use at night and simply that could be a treatment and then we do what we call a pulse oximetry test. We put something on their finger to check their oxygen level. So, it’s really important. It’s not snoring. Snoring pretty much everyone who has sleep apnea has snoring, but everyone who snores, doesn’t have sleep apnea. If there’s a question, you have daytime fatigue; I would highly urge patients go to your doctor, go to your ear, nose and throat specialist, get that sleep study. Your cardiologist a lot of times, because it affects them directly with what they do; will order that for you and then see an ENT, see what your anatomy is like, see if you are a surgical candidate if you have sleep apnea, see if you need to use the CPAP machine and treat yourself for your loved ones, for yourself, everybody.

Melanie: Thank you so much Dr. Campano. What great information. Thank you sharing your expertise and explaining this so well and explaining the true health implications of untreated sleep apnea. It’s so important for people to hear so that they comply and adhere to their prescribed regimen. Thank you again for joining us. You’re listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information please visit www.palmdaleregional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.