Cheryl Martin (Host): Sleep apnea is a potentially serious sleep disorder. It happens when your breathing repeatedly stops and starts, while you're asleep. Coming up, we learn more about sleep apnea and how you can overcome it to get the rest you deserve with Dr. Peyman Otmishi, Medical Director of the U. M. Shore Regional Health Sleep Laboratory.

Welcome to the Live Greater podcast series, Information for a Healthier You, from the University of Maryland Medical System. I'm Cheryl Martin. Dr. Otmishi, glad you're here.

Peyman Otmishi, MD, FCCP: Thank you. Thank you for having me.

Host: So let's dive into the world of sleep apnea. First, how common is it?

Peyman Otmishi, MD, FCCP: So, sleep apnea is a quite common disease. Based on the U. S. census in 2020, there's approximately 258 million adults and about 15 percent or 39 million U. S. adults have sleep apnea. But out of that 15% with the most recent research showed that about 12% of those patients have been diagnosed with sleep apnea and have sleep, ah CPAP machines.

So, overall is very common. So I would say somewhere around 15% of US adults, three, about 3% of which have sleep apnea have not been diagnosed yet.

Host: So, tell us what happens physiologically during sleep apnea.

Peyman Otmishi, MD, FCCP: So sleep apnea means, absence of breathing. So what happens when patients sleep, there are muscles that maintain the airway which is in the oropharynx or behind the tongue or behind the palate, nasal pharynx area. That airway is always open as we are awake. As you know, you don't snore when you're awake.

But as we fall asleep, the skeletal muscles lose their tone. And depending on anatomy and depending on how narrow the airway is and the orofacial anatomy, these muscles, especially the tongue or sublingual muscles or the palate that fall back towards the back of the airway and obstruct the airway.

So airway collapses on itself. When that happens, patient is trying to breathe that may get some air in the lung or may not get any air into the lung that causes a drop in the oxygen level in the blood. And the body senses the obstruction and the lack of breathing and sends signals to the brain and waking the patient up is called arousals.

Arousals are temporary. Most patients are not aware of these arousals, but it's enough time to wake the patient up to gain some muscle tone and get the tongue out of the way of the airway so patient can take a deep breath again. As the patient starts breathing, they fall back asleep and they go into deeper stages of sleep.

This could happen over and over and over again. Sometimes it can happen 50 times an hour, sometimes can happen 10 times an hour, just depends on how bad the sleep apnea is. So physiologically, essentially, is it the collapse of the airway or a lack of breathing, adequate breathing into the lung, leading to a drop in the oxygen saturation and arousals and non-restorative sleep.

Host: So, this of course, happens when a person is asleep. So, what would be the signs and symptoms that you may be affected by sleep apnea? How would that person know, I need to get this checked out?

Peyman Otmishi, MD, FCCP: Most of the time sleep apnea is triggered, I would say in my practice, about 50 percent of the time, the trigger for evaluation is the bed partner. Most of the time the bed partner tells the patient, you stop breathing, you're snoring loud, I have to keep poking you to turn on your side. And sometimes patients partners come in and they say, I'm afraid to leave the room even though that I can't sleep because of loud snoring.

Because I'm afraid the patient won't start breathing again. And these are the choking events we're talking about, these arousals that wake the patient up and all of a sudden there's a gasp of air and the patient wakes up and starts breathing again. So, some of the symptoms are, loud snoring. Patients can even wake themselves up. Choking, patients can wake up in a panic. When these events are happening, the body is under a lot of stress. Body cannot really recognize if you're sleeping and you're under stress or you're awake and being chased by a bear. So, the stress response occurs. A lot of these patients can wake up with a panic, palpitation, sweating, not knowing why they woke up.

They have a hard time falling asleep because of increase in glucocorticoids or adrenaline in the system. This quote unquote fight or flight system kicking in. So, patients wake up in the morning in what we call non-restorative sleep, wake up still tired, feel like they haven't slept much, even though they may have slept eight hours, they're still tired.

They feel foggy throughout the day. They have problems with concentration. They have anxiety issues. Sleep apnea has been linked to many different physiological effects, including insulin resistance, including depression, anxiety. So a lot of these patients have a lot of those conditions, but most of the time, patients are just tired.

They fall asleep quickly, they drowsy drive, they can't focus during their work. So some, those are the most common complaints that the patients have.

Host: You've already covered effects of sleep apnea, the depression, lack of concentration, being tired, feeling tired. Any other risk factors for sleep apnea?

Peyman Otmishi, MD, FCCP: Yes, there are physiological risk factors. Some of the most common risk factor is body mass index. Weight has been closely correlated. Increasing weight, increasing body mass index with likelihood of having obstructive sleep apnea. As we gain weight, we gain fat deposition in the neck area and subcutaneous tissues and tissues in the neck.

So that makes the airway even more narrow. So more collapsible during sleep. Other risk factors include age. Actually, the older we are, as we age, the more likelihood of having sleep apnea. Males in this country have more propensity to get sleep apnea than females, even though in recent years I've seen a lot more females coming in with sleep apnea complaints.

Also endocrine issues, people like hypothyroidism can increase the risk of sleep apnea, although not as common as age and weight. And also people with craniofacial abnormalities. So some people that have issues with retrognathia, what we call retrognathia is that lower jaw or the mandible is back. You have like an overbite that forces the tongue to obstruct the airway more readily in those people.

Uh, smaller airway, smaller mouths, larger tongue, as we would see in some patients with trisomy 21 or Down syndrome. A lot of those patients have enlarged tongue, which we call macroglossia. The larger the tongue, the smaller the mouth, the more likely that you would obstruct the airway. Also, there are behavioral factors. Alcohol consumption. A lot of times, you know, you hear that patients snores, but oh my God, when you add you know, you drank before we went to bed, you were snoring like crazy or stopped breathing. So, alcohol consumption and excessive alcohol consumption or consuming alcohol close to bedtime, sleep time, can cause sleep apnea or worsen the sleep apnea.

Alcohol is a sedative, so therefore sedatives themselves, people that take sedatives or hypnotics or sleep medications or sedatives because of anxiety, that can increase muscle relaxation and tend to cause sleep apnea. Patients that are on opioids, narcotic medication that can cause not only obstructive sleep apnea, but also central sleep apnea, which is the absence of breathing centrally in the brain.

Also cigarette smoking is one of the risk factors for sleep apnea. Cigarettes, you know, the patients that smoke cigarettes, they can have swelling of the airway that makes the airway narrow to begin with, and then they fall asleep and they can obstruct the airway.

Host: So Doctor, to what extent then can a person correct sleep apnea by reducing the risk factors you mentioned like obesity, alcohol consumption, and smoking?

Peyman Otmishi, MD, FCCP: Certainly uh, there are behavioral risk factors that can affect sleep apnea. I've had patients that have had seduced sleep apnea, and they go through weight loss programs or they lose significant amount of weight and we end up retesting them. I tell them a body mass index target.

I say, well, once your body mass index gets to this level, we can recheck a home sleep study and assess if you have sleep apnea and a lot of those times patients have much less amount of sleep apnea or have no sleep apnea at all. So that certainly, weight loss has been one of the major risk factor reductions of reducing the risk of sleep apnea or eliminating sleep apnea.

Again, like you said uh, alcohol consumption, drinking too much alcohol or changing the way you take your sedatives at night. Try not to take it before bedtime. That would be helpful. Certainly some people take sedatives to help them fall asleep because they have insomnia. One of the things that is not really understood by a lot of non sub specialty physicians is that some of these people that have insomnia and they get prescribed sedatives to help them sleep, they actually have underlying sleep apnea.

They don't sleep well at night. So when they get up, they have non-restorative sleep. During the day, they're tired. They come home from work, and they fall asleep, or they take a nap. When they take a nap, that reduces the homeostatic drive, or the drive to help you fall asleep at night. Therefore, those people can't fall asleep because they took a two hour nap earlier that day.

So what do they do? They take a hypnotic or sedative to help them fall asleep. But that sedatives makes this sleep apnea worse. So they'll be tired the next day and this cycle continues on.

Host: Wow. So, what are the treatment options, then, if sleep apnea cannot be corrected by reducing the physical risk factors?

Peyman Otmishi, MD, FCCP: So there are many different treatment options depending on the age of the patient. As you know, the children can also have sleep apnea and one of the primary approaches in children other than weight reduction, is also at ENT evaluation for possibility of removing tonsils because tonsils, again, those are structures in the back of the throat that can contribute to narrowing of the airway so they can have tonsillectomy and repeat the sleep study to see if they have significant sleep apnea.

The major way to treat the sleep apnea is the use of continuous positive airway pressure or CPAP. Basically, to simply put, a CPAP is a pneumatic stent. If I may explain what that means, it's basically air pressure delivered by a device basically like an air compressor that pushes air into the upper airway, and that air pressure helps to maintain the airway open once the patient falls asleep. So, it stents the airway open with air pressure, so the airway doesn't collapse on itself. Most of the new devices, new CPAPs have sensors, they're very advanced technologically. They sense as the airway is closing up, they increase the pressure or decrease the pressure.

So one of the mainstays of therapy is essentially CPAP. However, we have different degrees of sleep apnea. We have anywhere from mild snoring to obesity hypoventilation syndrome. Those are the two ends of the spectrum of sleep apnea. So depending on how bad the sleep apnea is, the treatment is also different.

So there are people that have only positional sleep apnea. So if they're laying on their side, they don't have much sleep apnea. As you can imagine, if you lay on your side, your tongue falls to one side of the mouth or the other side of the mouth. But if you lay on your back, your tongue falls back and obstructs the airway.

So sometimes when patients only have mild positional sleep apnea, we recommend positional therapy and weight loss and that usually takes care of the problem. So it all depends on severity. There are some new studies and new devices that have been approved by the FDA. Some implantable devices, they're called hypoglossal nerve stimulators, like Inspire device that basically is an implantable electrical, electricity generating device with the wires going to one side of the tongue underneath the skin and they stimulate the tongue. The device can sense when the patient's breathing, increase electrical stimulation of the hypoglossal nerve that tenses up the tongue and gets the tongue out of the way.

Those are more complicated devices. The mainstay of therapy and my recommendation would be to first be evaluated by a sleep physician to see if you're a candidate. A lot of patients come in and they want no mask on their face. Well, these devices carry their own risk. You know, patients have to go under anesthesia.

They would have to have an implanted device. They're certainly approved for moderate to severe sleep apnea. But most of the times the ENT surgeon or the sleep specialist that does Inspire therapy, recommend patients to try, at least try CPAP therapy before they go under any anesthesia or surgery for placement of those devices.

So those are the mainstays of therapy for obstructive sleep apnea.

There was one more device that I would like to talk about something called the Mandibular Advancement Devices or Oral Appliance Therapy. These are devices that actually are placed in the mouth after a well trained dentist, a dental sleep specialist, forms a mold of your teeth and sends it to a company in which they make a device in that you put in your mouth at night. This device as the name would suggest, advances the mandible, the lower jaw. Remember I said that some people have an overbite? This device causes an underbite. So it pulls the lower jaw forward. Therefore, bringing the tongue out, protruding the tongue out more out of the airway. And those devices are recommended for snoring and mild sleep apnea, and they also do work and approved by American Academy of Sleep Medicine.

Host: So if I'm coming in for a visit, what is that experience like?

Peyman Otmishi, MD, FCCP: A typical visit, the patient is recommended to me or patients have been evaluated by the primary care physician and their spouse or bed partner says, is snoring, stopping breathing, can you send them for evaluation for sleep apnea? As the patient shows up, we do a typical history and physical focusing more on their sleep habits, their symptoms, snoring, choking. It's encouraged to bring the bed partner in. So, there are a multitude of different sleep disorders that we evaluate for. Daytime sleepiness. So history and then physical exam evaluating the patient's airway is very important. Also, what is important is looking at underlying comorbidities.

Certainly, sleep apnea treatment is very important, especially with people with significant cardiovascular comorbidities. Sleep apnea is known to to affect cardiovascular system, increase the heart attacks, heart failure, increased risk of stroke. So these patients need to be assessed historically what the other comorbidities are because ultimately we have to decide depending on degree of sleep apnea and their sleepiness and their wakefulness during the day, what mode of therapy we're going to use to treat these patients. So history, physical exam, thorough review of their history and family history. Sleep apnea does run in families as well. There is a genetic component of that.

Host: So if someone comes in, how long should it take the process for them to actually get fitted? Especially if that's the decision made for a CPAP machine, if that's the case.

Peyman Otmishi, MD, FCCP: So generally when the patients come in, we evaluate the patient, see what mode of diagnosis is appropriate for the patient. We have two different ways we can assess for sleep apnea. One is called the polysomnography. That is an in lab sleep study.

Patient goes into the lab one night and sleeps and they're monitored. When they're sleeping, the physiology is monitored. That includes the oxygenation, how they're breathing, how the air flows into the lung, their EEG to see what stage of sleep they're on, how many arousals they have, their limb movements.

So those are monitored in the sleep lab. If it's a straightforward case and it's somebody who is younger and more technologically now astute, we do a home sleep study, the comfort of their home. They set up an appointment with a technician who will set up the device in which they would wear three bands on your chest and abdomen and the device that attaches to the middle one and then nasal cannula that monitors airflow to the device and a pulse oximeter that is attached to the nasal cannula. And if we're trying to just answer, is this patient having obstructive sleep apnea or disordered breathing, a home sleep study would suffice.

So once the patient has, let's say we have either a polysomnography or home sleep study resulted, it's been analyzed and scored, patient comes back. At that time we discuss the findings, discuss the severity and the treatment options with the patient. And at that point in my practice, during that appointment, I will order the appropriate device, CPAP for example, or AutoPAP.

And uh, send the prescription to a durable medical equipment company that manages these devices. And from then on, it just depends on insurance approval and timing of setting up the device. Because the patient doesn't come here and get set up, they get set up by the durable medical equipment company.

So, they go there, they get fitted for the mask. Sometimes they send all three sizes, four sizes of the mask to the patient and the patient they virtually can set them up on the computer, on the internet or physically in person and patient starts using the CPAP at that point.

Host: Now do you need a referral for an office visit to discuss a sleep condition?

Peyman Otmishi, MD, FCCP: Referral is important. Certainly patients do self refer, so the patients that are in the system. It is important to me, in my opinion, that patients sometimes be referred at least by the primary care doctor either to the sleep lab or to a sleep specialist. Because we really need to dig deep into the history, into the sleep habits, into the medications they're taking that could be contributing to sleep apnea or daytime sleepiness.

So that takes a little bit of work. and it's also important to get a history from the primary care doctor that usually sees and treats the underlying conditions of the patient.

Host: Thank you. And I'd like to close just on this question. What do you want to be the key takeaways from our time together?

Peyman Otmishi, MD, FCCP: Most importantly is patients realizing it's a very common disorder. Okay. And as we age, we have a higher likelihood of having sleep apnea. And a lot of times patients don't realize they have it. And most of the time their bed partner realizes that the patient is not breathing. So listen to your bed partner.

If they keep poking you at night, telling you to turn to your side, or they have to move out of the bedroom to sleep in another room, which we call a sleep divorce; that's what happens when patients bed partner can't sleep with them anymore because of loud snoring and fear of them not breathing.

So that's important and it's very common. Like I said, 33 million U. S. adults use CPAP machines. And that's just adults. That's out of 258 million adults by the National Council of Aging. So, it's common. So listen to your bed partner. And the most important thing is that severe sleep apnea, moderate to severe sleep apnea, needs to be treated, especially severe sleep apnea because of the down the line consequences, the sequelae, which are some of the most common causes of hospital admissions.

Some of the most common causes of death in the United States, cardiovascular disease, stroke. Those are, this is one risk factor that can contribute to stroke, that can contribute to heart failure, to heart rhythm problems, insulin resistance, and even worsening of obesity. So, those are important things that patient needs to realize.

If you're tired, If you're exhausted, if you feel like you get up and you didn't, you feel like you didn't sleep, feel like you get up and like you were wrestling all night long, there might be something wrong and you may need to be evaluated by a sleep specialist.

Host: Dr. Otmishi, thank you so much for educating us on sleep apnea. Great information. Thanks so much.

Peyman Otmishi, MD, FCCP: You're welcome. Anytime.

Host: You can find more shows just like this one at umms.org/podcast and on YouTube. Thanks for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again and please share this episode on your social media.