Transcription:
Feeling Tired All the Time? It Might Be Sleep Apnea

Melanie Cole (Host): According to the Centers for Disease Control, nearly seventy million Americans experience occasional sleep problems, and about half have a chronic disorder that keeps them from getting the restorative sleep they need, and many are completely unaware that something's wrong. My guest today is Dr. Matthew Leach, he's an ENT and a member of the medical staff at Temecula Valley Hospital. So Dr. Leach, who notices sleep disorders? If somebody- maybe they're tired all the time, or those sorts of things, but if something is going on in the night, would they be the ones to know or would it be their partner?

Dr. Matthew Leach, MD (Guest): Yeah, it's often the sleeping partner who notices not only snoring but large pauses in breathing. So pauses up to ten, fifteen, twenty seconds, that at the end of that, the patient almost violently gasps or catches their breath. That can be very concerning to watch and observe by the patient's sleeping partner.

Melanie: What is sleep apnea? Will you just define it for us?

Dr. Leach: So it is a process by which the air flow that normally occurs during inspiration, during sleep gets obstructed, and it can occur really anywhere along the upper airways, so from the tip of the nose all the way down into the lower throat. And what happens, is as that air flow gets obstructed, the oxygen levels in the patient's bloodstream decrease and the brain senses that and brings the patient up to a higher level of consciousness, essentially waking the patient up from sleep so that the muscles of the throat and neck can tighten, and the patient can take a deep breath and have better air flow. And that process is going on hundreds of times a night, and so the brain is constantly having to work to do this, and so the brain is not allowed to get into its deeper phases of sleep, and get into its restorative cycle.

Melanie: So why would someone even come to see a doctor? I mean if their partner says, "Hey, you're making these breathing sounds in the night, or you're snoring uncontrollably," how would a person decide that okay, that's the time? Because a lot of people, doctor, think that this is just normal and that everybody snores, or everybody has gasps in their sleep.

Dr. Leach: Yeah, well it's becoming a growing health concern in that sleep apnea has been implicated in a number of other more common health processes like high blood pressure, heart disease, stroke, and so it's becoming more common for other healthcare providers to notice this, for instance a cardiologist, or a primary care physician to kind of inquire about a patient's sleep. But if it's symptomatic, if the patient knows this themselves, then they will often kind of put two and two together. "I'm tired, I'm not getting good sleep, I'm falling asleep at bad times during the day, and I snore," they kind of start to put two and two together and figure out that it actually is a problem with their sleep.

Melanie: Are certain people more at risk than others?

Dr. Leach: Typically men are more at risk, and patients who are overweight are more at risk, but that is not universal. There are plenty of young, otherwise healthy, relatively skinny patients who have this disease as well.

Melanie: So how do you diagnose it? People hear sleep studies and they say, "Oh there's no way I'd be able to get a good night's sleep in some office with somebody watching me." Tell us about sleep studies and the way that you can diagnose sleep apnea.

Dr. Leach: Yeah, well you absolutely need a sleep study to make a formal diagnosis because it looks at so many different parameters of a patient's body processes during sleep, that you can't just make the diagnosis by listening to a patient's story of snoring and being tired during the day. But you're right in that a traditional sleep study is performed in what's called a sleep lab, which is kind of like a motel room, and the patient is hooked up to a bunch of different monitors, so we're monitoring brain waves, we're monitoring heart rate, we're monitoring oxygen levels among many other things, and the patient is expected to fall asleep, and those parameters are all monitored by a sleep technician who is basically sitting in the next room. So it's a very artificial environment, and there can be an element of pressure in that you know you're there one night, you need to get the study done, you need to diagnose what's going on, and so I think that can put an element of pressure on the patient that it is artificially not mimicking the comfort of your own home. There's a growing trend to do what are called home sleep studies, which is where a patient takes home a kit, which has a number of the same types of monitors they would use in a lab sleep study, but the patient is given simple instructions and diagrams to show them how to place them on themselves, and then they fall asleep in the comfort of their own home. And so it takes a little bit of that artificial environment aspect out of it. And when I have a patient who comes in who's never had a sleep study, I almost always order a home sleep study first in the hopes that we can just avoid the trouble of going through a lab sleep study.

Melanie: So if you've determined that somebody does have sleep apnea, what are some of the treatments? When we hear the word CPAP, so what is that? How does it work? And do people really use them the way they're intended to be used?

Dr. Leach: So the gold standard and the kind of tried and true medical therapy for obstructed sleep apnea is CPAP, which stands for continuous positive airway pressure. There are variations on that. You may hear people talk about AutoPAP or BiPAP, it's essentially all the same thing. And what it is, is a machine that has either a face mask, or a nasal mask, or a mouth mask, and what it's doing is while you're asleep it's blowing a little bit of air into your mouth and throat with a little bit of pressure, and so it's not allowing the structures of the mouth and throat to collapse. It keeps it open so that there's continual air flow and the oxygen levels do not dip down and so the brain is able to get down into its desired level of sleep. They're very effective for patients who can tolerate them, meaning it is for many people a treatment- an effective treatment or a cure for their symptoms, but as you can imagine, that it can be hard to tolerate. You have this mask, which is kind of on- it can be very big and cumbersome, and it's strapped to your face, and so there are various ways that it can be uncomfortable, both just from the way the mask kind of sits on your face, but also from the fact that you're breathing against air flow, you know? Really as you breathe out, there's a positive pressure, so that can be kind of a suffocating sensation to a lot of patients. And even patients who use it, who force themselves to use it, many patients do not notice a benefit, they don't feel any better, so there's kind of a twofold issue with patients who don't like CPAP; it can be uncomfortable and it cannot- you don't necessarily feel any better.

Melanie: Well if people aren't adhering to the use of these, how can you determine that they're being helped?

Dr. Leach: It can be difficult. So there are ways to determine if there is adherence. If you wear your CPAP, the CPAP measures how much you're wearing it. And then once you've been wearing it for a while, you can repeat the sleep study with the CPAP on, and you can see actually is it fixing your sleep apnea? So there are different ways to kind of measure whether it's working or not. But even patients where it looks like it's working from a data standpoint, they don't necessarily always feel better. So I've had many patients like that where they use it, they force themselves to use it, they wear it every night, they've done their follow-up sleep studies, they're doing everything they can, and they don't necessarily feel better. And it can be somewhat cumbersome for patients. You know, if you have to take your CPAP on an airplane it's a whole other suitcase, and there's lots of- you have to clean the tubing, you have to change the water filter, it can be a process and so there's many reasons why patients may or may not like it.

Melanie: Are there other forms of treatment besides CPAP? I've heard of dental devices, is there any medication? What other treatments are available.

Dr. Leach: In general, there are not really medications. There are medications which kind of treat the symptoms, so there are medications you can take during the day that kind of help you stay awake, but they're not actually treating the reason why you're sleepy. A dental appliance can be a very effective option for patients, especially with mild sleep apnea, and that works by pulling your jaw a little bit forward so your jaw kind of juts forward and that allows the muscles of the back of the mouth and tongue to pull up off the back of the throat, and it creates a little more room in the back of the throat, and they can be effective, and they can sometimes be effective when combined with CPAP. They can make your CPAP a little easier to use, or make it slightly more effective. So it can definitely- you can definitely have combinations in your therapy. And I'd like to add that there are some- well many, actually, surgical options for sleep apnea. In general, surgery for sleep apnea has been fraught with issues of it not working well, and being relatively painful for the patient. And so the biggest thing with deciding on whether a patient is a candidate for sleep surgery is figuring out exactly the type of surgery that may benefit the patient, and this can often take the form of nasal surgery, surgery in the mouth, or surgery in the throat, or as we're finding, some combination of the three. Generally these are for- these options are for patients that are well-motivated, because for many they improve the sleep apnea but not cure it, and for many of those types of surgeries, there can be significant pain and long-term healing before they see a result. There's a new type of surgery that shows a lot of promise for sleep apnea, and this is known as a hypoglossal nerve stimulator, or Inspire, which is you can think of it like a pacemaker which stimulates the tongue during a patient's sleep. So every time the patient takes a breath during sleep, it gives a small stimulus to the tongue muscles, and it brings the tongue a little bit forward and out of the back of the patient's throat, and so it opens up the airways. It's a fairly novel approach in that almost every other type of sleep surgery involves removing tissue from either the nose, the mouth, or the throat, and as you can imagine that's associated with most of the morbidity and pain with those surgeries. This type of surgery is different in that it does not remove any tissue. It's what we call a more physiologic type of surgery in that it's using the body's own nerves, and muscles, and sleep processes, but hopefully to better affect and to better sleep parameters.

Melanie: Dr. Leach, give us some of your best advice about sleep hygiene and good sleep habits, because with this age of electronics, and white light, and everyone's on their phones and busy at bedtime, it's hard to fall asleep and get that restorative sleep that we need, so sometimes it's just a little common sense and good advice.

Dr. Leach: Yeah, so with sleep hygiene, I think it can nicely be summed up as you want your bedroom to be used primarily for sleep and nothing else. So you don't want to be doing TV watching, even reading is considered not necessarily a great thing from a sleep hygiene perspective. But you don't necessarily want to be paying your bills in bed, or eating, so that can be one way that you can improve your sleep hygiene, by really keeping your bed and your bedroom for sleep only. Other things are decreasing your screen time right before bed, decreasing meals right before bed, really anything which is kind of a stimulatory behavior for either your mind or your eyes we think of as detrimental for getting good sleep.

Melanie: What about things we've seen on the market over the counter like melatonin? Do those hold any merit?

Dr. Leach: I mean, I think they can be helpful for some patients, although there is evidence that a lot of the sleep aids, things like Ambien or over-the-counter sleep medications, while being helpful for falling asleep do change what's called your sleep architecture. So they may not necessarily be the best thing to get good restorative sleep, although they may help you fall asleep.

Melanie: So then give us your best advice, wrap it up about sleep apnea, what you want the listeners to know about recognizing the signs and symptoms of it, and getting into a sleep study to get diagnosed so that they can get treated for it.

Dr. Leach: Yeah, I think the biggest thing is recognition that it can affect your long-term health in major ways, you know? Patients get very scared when we think of things like stroke, and heart attack, and things like that. Your sleep is something that you may not necessarily ascribe the same level of importance to, even though years of untreated sleep apnea may absolutely increase your risk of heart attack, or stroke, or early death. So I just want patients to know that it's important, and that there are treatment options available.

Melanie: Thank you so much, Dr. Leach, for being on with us again. You're such a great guest, thanks for being with us. You're listening to TVH Health Chat with Temecula Valley Hospital. For more information please visit www.TemeculaValleyHospital.com. That's www.TemeculaValleyHospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.