Transcription:
Advances in Sleep Apnea Care

Melanie Cole (Host): Welcome to Back To Health, your source for the latest in heath, wellness and medical care;
Keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics, and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I am Melanie Cole and our topic today is advances in sleep apnea care and my guest is Dr. Maria Suurna. She’s an assistant professor with Weill Cornell Medicine. She’s an ear, nose, and throat head and neck surgeon and board certified in sleep medicine. Dr. Suurna what is the health burden and economic impact of sleep apnea and sleep disorders in general?

Dr. Maria Suurna (Guest): Well sleep apnea has been getting much more attention because we’re now much more aware that untreated sleep apnea has sequelae of at least health problems especially cardiac disorders, depression, hypertension, diabetes; it’s also associated with a lot of motor vehicle accidents. People are three times more likely to get in a car accident if they have untreated sleep apnea. It also has very significant economic impacts as well, and not just from the healthcare standpoint but also absentees from work, poor attention span, patients – people actually getting into industrial or car accidents and so it’s actually been estimated that the economic burden could be somewhere around 150 billion dollars a year in the United States. So unfortunately the majority of patients with sleep apnea actually go undiagnosed and so if we could diagnose more patients with sleep apnea then those costs could be potentially cut down and then also people could have their health issues prevented that could be easily prevented by just diagnosing and treating sleep apnea.

Melanie: Who notices sleep disorders? Is it a loved one, your partner or are there symptoms that you would notice in yourself?

Dr. Suurna: Well patients are not really – they’re not usually aware of their problems with sleep. A lot of times their family member or a bed partner would complain of them snoring or having disruptive sleep, pausing during sleep, having very restless sleep, so they would be the first ones to complain about sleeping issues because their quality of sleep is also disturbed just because their bed partners are sleeping very loud or has a lot of movement during sleep or wakes up throughout the night, but as far as patients themselves, they usually might – they might complain of fatigue or waking up with headaches or not feeling rested despite of sleeping for seven to nine hours and sometimes they fall asleep during the day, they might be falling asleep driving, so sleepiness is probably one of the most common complaints from the people with sleep apnea, but again a lot of times they might blame it on some other factors and not necessarily be aware of ongoing problems during sleep. So a lot of times, actually yes you’re right, the loved ones and the family members are the first ones to point out that there is some sleep disturbances in the individuals.

Melanie: Who is most at risk for sleep apnea? Is there a genetic component and what are some medical disorders that may induce sleep disturbance or sleep apnea?

Dr. Suurna: So people – there’s definitely some genetic component to sleep apnea because people who have their parents or grandparents or siblings who have sleep apnea, they also seem to be more likely to have sleep apnea. In general, older people, men more than women, and certain ethnic populations they actually have more predisposition to sleep apnea. There is a genetic component but we haven’t really fully discovered the underlying genetic gene or genetic group specifically that we can actually test for but definitely there is a presence of positive family history of sleep apnea. Most of the people tend to have a bigger or larger neck size or crowded airway and sleep apnea is more prevalent in people who are significantly overweight and obesity has been a kind of slowly progressing problem in this country and there’s very, very high association with sleep apnea when people get over a certain weight.

Melanie: So I think a very important question are some of the complications of untreated sleep apnea. Some people don’t even know that they have it, and so what else can it cause if it is not diagnosed and treated.

Dr. Suurna: Yeah a lot of people who have sleep apnea some of them might not even be aware of it because they might be living alone, their bed partners might be sleeping in a separate room, or their bed partners are so used to it or just may be sound sleepers and they’re not really paying attention to what’s happening to their loved one, but a lot of times actually people don’t really experience any health issues. Some people actually don’t even feel tired despite having sleep disturbances during the night, but some of the things that are commonly associated with untreated sleep apnea is actually persistent high blood pressure. People have high risk of developing heart disease and irregular heart rhythm. They’re more likely also to die from untreated sleep apnea and also getting into car accidents. So I think car accidents, they’re not just putting that individual at risk but they’re also putting other people at risk. So I think those are some of the main issues with untreated sleep apnea and as society it’s kind of hard to ignore it just because of the – not just individual but also the effect on the society as a whole, especially when we’re talking about pubic transportation especially we talk about derailing of the trains or incidents that are caused by when it’s actually more of a public transport and the person who’s operating the vehicle has actually untreated sleep apnea. So from that perspective, it’s not just individual but also a social concern.

Melanie: That’s an important point Dr. Suurna. So tell us a little bit about diagnosis. How is the assessment and evaluation done to find out that someone has sleep apnea?

Dr. Suurna: So a lot of times as I said a lot of people come in because they’re mostly either referred by their primary care physicians who are suspecting that patients might have sleep apnea just based on their history and their exam or even past medical history or if their spouses actually encourage the patients to get evaluated. So obviously this diagnosis starts with thorough history and physical exam. Most standard diagnosis for sleep apnea is actually performing a sleep study and the sleep study nowadays can be performed either in a lab where patients go in and spend the night in a kind of outpatient healthcare facility or they can actually take equipment home and do the sleep study in their home environment using portable equipment.

Melanie: So you said that they can bring equipment home because people hear about sleep studies, Dr. Suurna and they’re anxious and they wonder how they can even get to sleep with somebody watching them or if they’re all hooked up. How can you get a good result at the actual clinic for a sleep study and what’s the difference between what they have to do at home?

Dr. Suurna: So yeah that’s a very, very good point. Patients do get a little concerned about sleeping in the unfamiliar environment. So in the lab sleep studies, yes you do have to spend the night somewhere outside of your bedroom, outside the comfort of your home. It is in a facility that sometimes could be not exactly the right temperature. Sometimes it could be – might be a little bit noisy, and again being in an unfamiliar environment, some people feel very uncomfortable. So that’s one of the downsides of doing the study in the lab facility. Still some of the things you can do. It’s kind of hard to say what you can do. Sometimes you get into the lab at the time where you are about to go to sleep, so you are trying to schedule the sleep study during the time when you normally would go to sleep. We usually suggest to patients not to drink too much caffeine, avoid alcohol, and try to avoid naps before going for a sleep study and trying not to do any activities that are more stimulating and trying to stay more relaxed and avoid any kind of anxiety or any kind of stressful situation. So by the time they get to the sleep lab they can be relaxed and ready to sleep, and so yes unfortunately the most uncomfortable part I think is mostly the wires that get attached to the head and chest and little sensors that are being placed on the body. Nowadays they are trying to make them more comfortable, minimize them, and make them smaller but that is still some people find very uncomfortable. So that is why the home sleep studies actually have gained more popularity because this is something that you can bring home with you and you can use that in the comfort of your home. They’re much easier to setup because a lot of the home studies just really have a finger sensor and a sensor that you put on your chest and some of them have a little bit more sensors that are going to go around your face and not just your fingers and the chest but something that also comes onto your face as well, but depending on the equipment type. But a lot of the take home studies are much more comfortable and easier to use and then also patients are not – their sleep is not disrupted by being in an unfamiliar environment. There is a little bit of a difference when you talk about doing in the lab versus home sleep study because in the lab you can get – it’s a monitored sleep study. Somebody’s always watching you sleep. If there’s something that goes wrong, there’s a sensor that’s off you can actually have the technician help you replace it and they also are able to get more information. Not just about sleep apnea or obstruction but also about sleep stages, about breathing patterns, about your heart rate, about movement and etc. Some of that information is not really available when you perform a home sleep study. So home sleep studies are good for patients in whom you suspect sleep apnea, obstructive sleep apnea, but when it comes to diagnosing some other sleep disorders, we’re still relying mostly on using a sleep lab facility.

Melanie: If someone is diagnosed with sleep apnea, tell us about the first line treatment and explain what CPAP is; they’ve heard about it in the media and tell us what it is, how it works, and if there’s an issue with adherence to CPAP and compliance and are people not wanting to use this device to help them?

Dr. Suurna: So CPAP has been available to people since about 1980s, early 1980s, and I believe at that time it was a revolutionary treatment because it allowed people to be treated without actually undergoing any kind of invasive procedures. So what CPAP is, it’s equipment that gets placed over the patient’s face through the nose and mouth and it provides positive pressure that allows the airway to stay open because if you think about what sleep apnea is, is the airway obstruction during sleep. What happens is the muscles relax and once the muscles relax, the airway starts to collapse and if the airway collapses it reduces the airflow and occasionally people can actually stop breathing for a period of time during sleep. So what CPAP does is it provides positive pressure that keeps the airway open and prevents it from collapsing and it’s an effective treatment. You have to wear it on your face every single night and the entire night in order for it to actually prevent sleep apnea and provide people with treatment benefits. So a lot of times people find – well I guess some people find it amazing. Some people actually put the mask on and they sleep so much better with the CPAP that they cannot imagine sleeping without CPAP ever. Some people find that the mask is uncomfortable, they don’t like having anything on their face. They try – over time they can get desensitized from it and they can get used to it and in some cases it’s more of a matter of finding the right mask, the right fit. The mask is actually comfortable. That it doesn’t restrict their mobility and it doesn’t restrict their movement and doesn’t disrupt their sleep. Some people find it’s being very claustrophobic so no matter what type of mask they put on their face they just feel that it’s suffocating and they just can’t use it. So it’s very individual, so you kind of have to approach each patient with a little bit more individual needs depending on 1) The severity of sleep apnea. 2) Their anatomy, can they use a nasal mask versus a full face mask because if some people, if they’re for example mouth breathers or they have blocked nose, those are some of – in those cases the nasal mask might not be the right fit. So doing more of an individualized approach and actually looking at patient’s anatomy, their needs, their severity of sleep apnea might be the key of trying to get them fitted with the right mask and then also patients can try different masks, different sizes of masks, different material – like masks can be made of different materials and et cetera. So compliance is an issue and the CPAP is only as effective as compliance with the treatment. In order to benefit from CPAP you unfortunately have to wear it all the time, the entire night, and pretty much for the rest of your life. Currently the compliance rate, like long term compliance rates are about 30% or so in the general population. With more of a therapy like CPAP desensitization and trial of difference masks, compliance could be improved. There are also machines that have gotten quieter and then also there is auto adjustable pressure on some of the machines that kind of again adjust he strength of the air pressure depending on the people’s needs. So some of these things have evolved, like technology has evolved so that has improved patient compliance, but again it’s still not – it still has been the major issue when it comes to treatment is the compliance with the treatment.

Melanie: So tell us about a new alternative to CPAP. Speak a little bit about hypoglossal upper airway nerve stimulation and what that is as compared to CPAP and how it can help patients.

Dr. Suurna: So CPAP is still as I mentioned is considered to be the gold standard treatment, the first treatment and a noninvasive treatment for people with sleep apnea. If people are not able to tolerate CPAP then we start looking at alternative treatment options. Some of the alternative treatment options include oral appliances, mouth guards that could be made by the dentist and what they do they pull the jaw slightly forward and that opens up the airway and prevents the airway from collapsing and prevents the tongue from collapsing during sleep and so that can be very effective for some patients. If this is not a treatment option for whatever reason and people cannot even tolerate the oral appliance or they are not candidates for oral appliance, then we start looking at the surgical treatments, and in the past the only surgical treatments that we could offer were the treatments that were geared toward opening up the airway either by removing some of the palate and tonsillar tissues or reducing the size of the tongue or changing craniofacial structures by moving the jaw forward. Nowadays we have an alternative therapy available, which is an implantable device. This device is implanted; it’s similar to a pacemaker type of device and it’s implanted under the skin and the device is connected to the nerve, the hypoglossal nerve. This nerve innervates the tongue and moves the tongue forward and also is responsible for opening up the airway by protruding the tongue forward and stiffening the muscles, the airway. So during sleep this device – so before you go to sleep, you turn the device on and then once you’re asleep the device provides mild neurostimulation to the nerve and that in turn opens up the airway with each breath. There’s also a breathing sensor that sits between the ribs and monitors the airway, the pattern of breathing in each individual and the device tries to deliver neurostimulation before each individual breath so that it keeps the airway open and prevents it from collapsing. It is a surgical procedure. It’s an outpatient procedure that requires an implantation of the device. People usually go home the same day and it’s a couple days of recovery from just incisional discomfort but that does not result in any long term sequelae in terms of swallowing issues or changes in anatomy of the airway or changes in – structural changes of the face or in the throat.

Melanie: Wow, what a fascinating discussion about sleep apnea that so many people suffer from and some don’t even really realize that they do have sleep apnea. It’s so important that they get it diagnosed and get it treated. Wrap it up for us, Dr. Suurna with your best advice regarding sleep apnea and getting diagnosed if you think that you might have some of the symptoms or risk factors that you’ve mentioned here today.

Dr. Suurna: I think it’s very important to get diagnosed and to know whether you have sleep apnea. If you feel that you don’t get quality of sleep, quality sleep despite many hours of sleeping and staying in bed. If you feel like you’re waking up tired, during the day you feel fatigued, fall asleep while in the meetings or during the day, during lunch meetings or even watching TV or easily fall asleep behind the wheel, then those could be signs and symptoms of potential sleep apnea. Also pay attention to your bed partners and family members because sometimes they could be the first to notice breathing issues during sleep especially when it comes to airway obstruction and snoring. If that’s the case then I would suggest to start at least with your primary care physician so they can direct you towards the right treatment, recommend either sleep specialist who can further evaluate you or diagnose you with sleep apnea.

Melanie: Thank you so much Dr. Suurna for coming on with us today and sharing all this great information about sleep apnea and the importance of getting diagnosed. Thank you again. Thank you for joining us today. This concludes today’s episode of Back To Heath. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, and Google Play Music. For more health tips go to weillcornell.org and search podcasts. Parents – don’t forget to check out Kids Health Cast!