Maggie McKay (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Sleep is crucial to all of us, but what about when it's interrupted by obstructive sleep apnea? How do you deal with it so you can get some relief and much-needed sleep? Dr. Nikhil Samtani, Medical Director at the Skagit Valley Hospital Center for Sleep Disorders will tell us the latest options in treatment.

Welcome to Be Well with Skagit Regional Health presented by Skagit Regional Health. I'm Maggie McKay.

Thank you so much for being here today, Dr. Samtani. Would you introduce yourself?

Nikhil Samtani, MD: Oh, thank you for having me. I practice Sleep Medicine here at Skagit Valley Hospital. We have a full-fledged sleep lab. We have some adult patients with some pediatric patients, but I mainly see the adult side. I do have a Dual Board Certification in Internal Medicine and Sleep Medicine, but I generally practice 100 percent Sleep Medicine.

So, happy to be here, happy to help answer questions.

Maggie McKay (Host): Awesome. And I'm happy to hear more about this because my husband has sleep apnea and it's no fun for either of us.

Nikhil Samtani, MD: I look forward to hearing your side of it and happy to help.

Maggie McKay (Host): So to begin, what is obstructive sleep apnea or OSA?

Nikhil Samtani, MD: I personally think of this whole disorder like a spectrum of disorders, honestly. There can be this harmless, benign snoring component, where we sleep, and our muscles relax, which can cause some vibrations, resulting in the noise of snoring in some people. But as long as you're getting your air, as long as your oxygen is okay, generally, no problem.

You might be annoying people around you, but not necessarily harming yourself, you know, in any way.

Maggie McKay (Host): Exactly. What are the most common symptoms of OSA?

Nikhil Samtani, MD: If the snoring is having no downstream consequence, generally, that's not a problem though. But now if the snoring is causing, like, a collapse of your airway, or there's not enough air getting through that's causing dips in oxygen while you're sleeping, then of course, it's no longer benign and you fall under this whole sleep apnea side of the spectrum.

Because what's supposed to happen when you're sleeping is you have these beautiful sleep cycles that you go through, you know, non REM, REM sleep. And if you're having low oxygen, your body generally releases adrenaline to kind of wake you up or kick you into this lighter stage of sleep. So that prevents you from going into those sleep cycles that you need.

So generally, short term, that can cause just poor sleep quality, not waking up feeling rested, tiredness, fatigue during the day, but more importantly for me at least is the long term stuff, because your heart, your brain, all these organ systems like their oxygen when they're sleeping. You take that away, you're just at an increased risk for cardiovascular events, neurological events, strokes, heart attacks, all these things that we don't want. So it's not just the snoring thing, it kind of has this whole heart health component to it also.

Maggie McKay (Host): I did not even know that. So what causes OSA?

Nikhil Samtani, MD: Multiple different reasons, I should say. You know, there was a time many, many years ago when we thought that this was just a weight-related problem. The heavier we are, the larger the neck, and the more collapsible the airway can be. So of course that is a big variable still even today. But independent of weight, we're learning now that anatomy plays such a big role. Some people have this big open airway, and some of us just have a little less space. These things can increase your risk as well. If you look at Asia, Southeast Asia, the BMI or the weight is generally not too high, but the prevalence of sleep apnea is still about the same because anatomy plays a larger role in those populations.

And more recently, there's a lot more focus on muscle tone contributing to this as well. So when we're younger, we have a healthier muscle tone. As we age, muscle tone kind of gets a little floppy too. So more flax, the muscle tone, the more probability of sleep apnea can happen too. So it's kind of a combination of anatomy, muscle tone and weight. So different things can cause the problem to begin with.

Maggie McKay (Host): And how common is obstructive sleep apnea?

Nikhil Samtani, MD: It's fairly underdiagnosed in my opinion. There are different cohorts out there that estimate the prevalence of diseases and to the best of my knowledge, I think the last time this was done, it was about 15 to 30 percent of adult males and 10 to 15 percent of adult females that likely have obstructive sleep apnea in some capacity.

Maggie McKay (Host): Why would it be more male than female?

Nikhil Samtani, MD: Again, epidemiological studies that try to look at the prevalence is, they found some interesting stuff, I feel, like, when you look at pre-menopausal women, the incidence is a lot lower compared to men. But if you look at the around menopause or post-menopausal women, it kind of becomes exactly the same as men.

And so there's this school of thought that estrogen has this muscle tone stabilizing sort of effect. As we age, we tend to lose that and that can independently increase the risk for sleep apnea-type disorders.

Maggie McKay (Host): You kind of touched on this already, but how does OSA impact sleep and a patient's overall health? You mentioned it could have consequences for your heart.

Nikhil Samtani, MD: My background is internal medicine, so I think of myself more as a generalist in sleep, so when you quit breathing, there are two downstream consequences that I'm concerned about, you know, you quit breathing, lack of air, number one, your oxygen goes low, number two, your body releases adrenaline to kind of wake you up or kick you into this lighter stage of sleep.

So all night long when you're supposed to be resting, you're having low oxygen, and spikes in adrenaline, which in the short term can cause short-term issues like poor sleep quality, fatigue, tiredness type problems, falling asleep in meetings, falling asleep behind the wheel of the car is the worst case scenario.

But more importantly, you know, like you were alluding to long term, your heart, your brain, these things need their oxygen when they're sleeping. So taking that away, you just are at an increased risk for having cardiovascular and neurological events, like strokes, heart attacks, all these things that we don't want.

And I always like to say that, you know, sleep is still a relatively new field compared to all our other sciences. So every year there's a new paper talking about how these consequences can impact other organ systems as well. So there's a lot of research on memory and dementia. There's a lot of research on our ability to generate an immune response.

At least the way I like to think of it is, when you're having low oxygen at night, it's not selectively going to impact one or two organ systems, right? It's going to impact your overall health. So, I think it's a really important variable to address.

Maggie McKay (Host): Absolutely. Is there a difference between sleep apnea and obstructive sleep apnea?

Nikhil Samtani, MD: Yeah, kind of. So I think sleep apnea basically just means you quit breathing while you're sleeping, right? So the traditional form of sleep apnea is something called obstructive sleep apnea or OSA. That basically means that there is a physical obstruction of your airway that's causing the collapse.

There is also a rare kind of sleep apnea referred to as central sleep apnea, which is, I think is very interesting. The end product is still the same where you have pauses in breathing. But it's not due to a physical obstruction of your airway. It's more due to a communication issue between your brain and your lungs.

For whatever reason, your brain is telling your lungs to quit breathing. So, yeah, we don't see that much. Yeah, I know, right? We don't see that very often, but sometimes there are medications that suppress the breathing center of the brain, which can cause these problems. Or if you have heart issues, then that can cause this delayed circulation time, which can cause these communication issues.

But, yeah, it's kind of like a spectrum of disorders, but obstructive sleep apnea is more like the bread and butter. Central sleep apnea can happen in certain patients.

Maggie McKay (Host): Dr. Samtani, what treatments are available for OSA?

Nikhil Samtani, MD: Quite a few now, actually. So, personally, I think of it more like a spectrum, right? So if you have sleep apnea, I should say the next question we ask is how bad is it? Is it mild? Is it moderate? Is it severe? And there are these validated metrics that we use to categorize sleep apnea.

In my practice, when someone has mild sleep apnea, I think of it more like a joint decision-making with the patient. It really depends on what your symptoms are and what we're trying to treat. So, I'm sure you've heard of something called a CPAP, which is the gold standard treatment, which is, breaking up the word is continuous positive airway pressure; basically, just a machine blowing air at you with the goal of keeping your airway open and preventing those collapses from happening.

That is considered the gold standard because it treats all the spectrum of sleep apnea, mild, moderate, or severe. But when it's mild and you're really symptomatic, then trying CPAP is not a bad idea. But if you're mild, not too symptomatic, there are a lot of other non-CPAP solutions as well out there.

They have these mouth guards that move your lower jaw forward, referred to as a mandibular advancement device. Those are well validated in the mild to moderate spectrum, by opening the space in the back of your throat sometimes can help with the disease severity. There are also positional interventions that you can try because we know that sleep apnea tends to get worse when you're flat and on your back.

So simply elevating the head of the bed can sometimes help, sleeping on your sides can sometimes help. These positional interventions are also great solutions for mild cases. Of course, there are a lot of other smaller options out there. We sometimes consult our surgical team as well, just to see if the right candidate might be an option. But different sets of spectrum different options, I should say, when you're in the mild spectrum of sleep apnea.

Maggie McKay (Host): So that's good to know that there are so many options for patients who can't tolerate CPAP because they are a little claustrophobic, to some people.

Nikhil Samtani, MD: That's true. I mean, I always tell my patients that the CPAP machines of the past were these loud, clunky machines with these big fighter pilot full face masks. These things have improved a lot over time. The machines are smaller, they're quieter, and they have these nasal-only or nose-only interfaces.

Even the way we give pressure has changed a lot. Back in the day, it was all constant, fixed pressures. Now we have these auto-adjusting algorithms. So yes, it is stuff on your face, it is sometimes inconvenient, but it has come a long way from what it used to be.

Maggie McKay (Host): Mm-hmm. What's Inspire® therapy and who is a candidate for such an option?

Nikhil Samtani, MD: Inspire® therapy is a great option. You know, part of the surgical solutions for sleep apnea is where I would classify Inspire® therapy. We discussed the spectrum of sleep apnea. So Inspire® is not really an option if you have mild sleep apnea. But if you're more in the moderate to severe range of sleep apnea, then Inspire® does become something that's an option for you.

The way I discuss Inspire®, or I like to explain it is We've all heard of pacemakers for the heart, right? This is similar, you know, it's a surgically implanted pacemaker. It has a little sensing lead that tells this device when you're breathing. And then it has a little stimulation lead that stimulates your airway muscles when you're sleeping.

So the science behind that is if your muscle tone is floppy at night, let's stimulate those airway muscles, keep it open, and prevent those collapses from happening. So it is an FDA approved way to treat sleep apnea, but it's not approved for everyone. They have this little ABCD criteria, which I'll share with you if you'd like.

But you know, the A is like the apnea-hypopnea severity, which is basically how we grade sleep apnea. So it's not for the mild cases. It's mainly for moderate to severe cases. The B is like the BMI, which is a measure of your height and weight. So whenever things are new, they're always tested on the healthiest people first.

So there's like a weight cutoff for these set of procedures. This is an ever-changing threshold, I should say, because when they first released, it was a BMI of 32, but now slowly we're increasing that as much as 40. So it's really insurance-specific and payer-specific, but you know, under 40 is kind of where you should start thinking of Inspire® being an option for you.

And the big one, I think, is CPAP failure. So it is an FDA approved device, but it's not approved as a first-line treatment, which means you have to try and fail the gold standard that is CPAP before things like this become an option. And then D is something called DICE, or it's breaking up the word is a drug-induced sleep endoscopy.

A lot of fancy words, but basically, we put you to sleep, stick a camera down your throat, and see how your airway is collapsing. If it's like a side-to-side collapse, these devices do fairly well. If it's those complete collapses, this device doesn't do a whole lot. So if you kind of go through the screening tool with your provider and you meet those A, B, C and D criteria, that's when Inspire® becomes a realistic option for you.

Maggie McKay (Host): I mean, sleeping with a CPAP on your face is one thing, but sleeping with a camera down your throat, I don't know how you'd ever get to sleep. But I think the takeaway is, if I'm understanding correctly, don't ignore symptoms because, as you said, it can have consequences for your overall health.

Nikhil Samtani, MD: No, I agree. And, the camera was just a test to screen if you're eligible for Inspire®, but once, once you get the device implanted, it's basically a very straightforward outpatient procedure. You're kind of home the same evening barring any complications. You get this little activation device that you activate that device when you're sleeping and it's keeping your airway open. So it's less.

Maggie McKay (Host): Well that's good.

Nikhil Samtani, MD: There's no camera down your throat. That would be interesting.

Maggie McKay (Host): Okay. Yeah. I was like, wait, well, thank you so much for being here and sharing your expertise, and making the time, this information has been very helpful and hopeful.

Nikhil Samtani, MD: Thank you for having me. I'm obviously biased with the sleep and if you're sleeping eight hours, you're spending a third of your life sleeping. So addressing variables in that third becomes really important. So thanks for having me.

Maggie McKay (Host): Absolutely. Absolutely. Oh, thank you for being here. Again, that's Dr. Nikhil Samtani. Visit SkagitRegionalHealth.org to learn more. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. This is Be Well with Skagit Regional Health from Skagit Regional Health. Thanks for listening.