Sleep Soundly Every Night, Feel Fantastic Every Day (22 page)

So what are the implications? First, weight loss is extremely important and can improve both diabetes and sleep apnea. However, if you have been diagnosed with early diabetes and snore loudly or are constantly sleepy or fatigued, you may have sleep apnea. In this case, bringing it to the attention of your health care provider could result not only in an improvement in how you feel but also in your blood sugar control.

We often think of OSA as an ailment of the middle-aged and elderly. Yet it can affect anyone, even children. The causes of OSA are different for kids, as compared to adults, such as enlarged tonsils or adenoids. The symptoms, however, are often the same in children and adults: snoring, sleepiness during the day, trouble paying attention, and even behavioral issues. However, unlike adults, many children
exhibit hyperactivity. In fact, many children with OSA are mistakenly diagnosed with attention deficit hyperactivity disorder (ADHD).

The most common treatment is surgery—either a tonsillectomy or adenoidectomy. Some children are prescribed a CPAP machine, or in the case of childhood obesity, placed on a weight loss regimen.

Do you experience these symptoms during the day?

1.
 
Sleepy

2.
 
Foggy

3.
 
Forgetful

4.
 
Depressed

5.
 
Anxious

6.
 
Mood disorder

During the day, those with sleep apnea may feel sleepy, foggy, or forgetful. They may also experience depression and anxiety that rise to the level of a mood disorder. Women with OSA typically have more daytime sleepiness, anxiety, depression, and reduced quality of sleep. Researchers attribute this to structural changes in the brain, specifically the white matter, caused by sleep apnea.

Do you experience any of the following at night?

1.
 
You experience a higher than normal incidence of pauses in breathing while you sleep, whether four or five times an hour or as frequently as once or twice a minute.

2.
 
When you start breathing again, it's with a loud snort or choking sound.

3.
 
You urinate several times during the night.

4.
 
You experience sexual difficulties.

You would recognize these symptoms if you suspect that you or another has OSA:

Sleep apnea is commonly associated with frequent nighttime urination. How this happens has only recently been understood. When someone has an episode of apnea, an effort to breathe against a closed airway occurs. This results in the development of profound negative pressure in the chest cavity. Consequently, the heart, especially the small chambers called atria that sit atop the muscular chambers called ventricles, are stretched. When these chambers are stretched, they respond by putting out a hormone called atrial natriuretic peptide. This hormone is a diuretic. That means it induces an increase of urine. You see, the heart is not that smart. When stretched, it interprets the stretching as too much fluid in the body. This is an appropriate response when dealing with heart failure, but is a nuisance when the cause is OSA. The good news is that when the obstruction to breathing is reversed, the nighttime urination comes to an abrupt end.

The connection between sleep apnea and sexual dysfunction is well–documented, and all the studies have historically focused on men. Definitely, sleep apnea relates to erectile dysfunction (ED) and also to sexual dysfunction. The prevalence of men with sleep apnea who also have ED is as high as 40%. The reasons for this problem appear to be twofold. In some men, sleep apnea can cause low testosterone levels. In others, repetitive drops in oxygen cause a problem with the ability of small blood vessels to supply adequate blood flow to the penis. This is called endothelial dysfunction and is very common in sleep apnea. The
good news is that the majority of men afflicted with sleep apnea will show significant improvement in sexual function when their sleep apnea is treated.

More recently, however, doctors have found that women suffering from OSA also experience sexual difficulties, including problems involving desire, arousal, orgasm, pain, vaginal lubrication, and sexual satisfaction. In fact, studies have shown that between 34% and 54% of women with sleep apnea also experience female sexual dysfunction (FSD). Like men, the severity of the sexual symptoms are in direct correlation with the apnea itself, specifically, the drops in oxygen that occur during the “pauses” in breathing. When the oxygen gets low enough, the person takes a breath, thus bringing up the oxygen level again. This yo-yoing cause is known as oxidative stress; it introduces free oxygen radicals, which can damage nerve tissues, as well as the lining of our blood vessels. That puts women with sleep apnea at a much higher risk of stroke and heart attack. For women, the destruction of these nerve endings also affects sexuality, hence the FSD.

Men with OSA often have low testosterone. This does not seem to factor into sexual dysfunction in women. Studies show that levels of estrogen, progesterone, and testosterone are the same in women with sleep apnea, whether they have FSD or not.

Women experiencing sexual dysfunction should definitely tell their health care providers that they would like to be tested for sleep apnea. The good news is that once the sleep apnea is treated, the FSD usually disappears.

The best way to diagnose sleep apnea is by visiting a special sleep clinic. The patient spends the night at the clinic, while
trained sleep specialists monitor his or her breathing, heart rate and other vitals. (There are home monitors that gauge these things, but they are not as effective.)

Once it is determined that you do have sleep apnea, your doctor will characterize its severity based on several factors, including how often these breathing pauses occur, how low your oxygen drops during these pauses, and how sleepy you feel during waking hours.

The most commonly prescribed, and most thoroughly researched treatment for OSA is a CPAP machine. The machine pushes a constant stream of air through a mask that keeps the throat and airway open. There are different kinds of masks; some fit over the nose, while others fit over both the nose and mouth. For effective treatment, the patient must use the machine every night, and most likely for the rest of his or her life. A patient can choose to cure their sleep apnea through some other means (surgery or weight loss). However, researchers noticed marked improvement after three months of using CPAP, with restoration of gray matter lost as a result of the sleep apnea.

CPAP treatment can also help with OSA's assault on the limbic system; however, it may take some time, especially if the coexisting disorder has taken on a life of its own. This often leads to a vicious cycle. After beginning treatment, patients may still experience light sleeping, claustrophobia, and shortness of breath, which only makes the CPAP machine—with its mask that covers the nose and/or mouth—even less appealing. This is especially true for returning veterans with PTSD, who are statistically the less likely to adhere to treatment. Still, I have found that with continued treatment, patients will experience a very noticeable improvement over time. Often a willingness on the part
of the physician to explain both the long-term benefits and the expected initial problems is extremely helpful in getting the patient to comply.

This is a mouthpiece—usually made of hard plastic—that covers the upper and lower teeth. Like the CPAP, there are several different kinds of MADs. Some hold the tongue in place, keep the jaw forward, and the airway open.

Dr. Barry Krakow of New Mexico pioneered PAP-NAP, a daytime approach to help patients who are anxious or claustrophobic or have difficulty using the CPAP approach. The patient works personally with a sleep technologist through coaching, relaxation, use of imagery, desensitization, and deeper breathing while being exposed to various masks and forms of pressure delivery for achieving CPAP compliance. Patients can nap during therapy. This is a novel approach to acclimating people to the usage of positive airway devices for sleep apnea. In my sleep centers we have found it to be an invaluable tool in achieving compliance.

A hypoglossal nerve stimulator (HGNS) is an implantable electronic device that acts like a pacemaker. It stimulates the hypoglossal nerve during inhalation. This in turn stimulates the muscles of the tongue resulting in protrusion and opening of the airway during sleep. It is very close to being released as a treatment for OSA.

Since obesity is often a factor in OSA, it stands to reason that with substantial weight loss, one can often lessen the severity of the OSA or, in some cases, cure it altogether. The measures one takes to lose the excess weight depends on several factors, including lifestyle and how much weight
they need to lose. Some combine diet and exercise, while others undergo bariatric surgery.

Uvulopalatopharyngoplasty (UPPP or UP3) is a surgical procedure to make the airway wider. The doctor removes excess tissue, whether it is the uvula (the soft tissue that hangs down from the back of the throat), part of the soft palate (at the roof of the mouth), or the tonsils and/or adenoids; the doctor may even remove part of the tongue if he/she determines it is contributing to the apnea. This surgery has received mixed reactions from the medical community. In addition to the usual risks that accompany surgery, UPPP does not always work. Worse yet, it sometimes appears to have been successful when in fact it wasn't. In other words, the patient may stop snoring, but is still experiencing those dangerous pauses in breathing. This means he or she still has sleep apnea that requires treatment. In fact, many patients still need to use CPAP after undergoing UPPP.

Central Sleep Apnea occurs when your breathing repeatedly stops for 10 seconds or longer because the brain's respiratory control center fails to send a signal to the respiratory system to breathe.

Why does this happen? Think in terms of what would cause a break in communication between the brain stem and the body. Possibilities include tumors, strokes, opioid medications, or influences such as neurological disorders.

Breathing stops numerous times throughout the night with no visible effort to breathe followed by:

1.
 
A drop in oxygen

2.
 
A rise in carbon dioxide

3.
 
A brief arousal from sleep in order to take a breath

Normally, when you go to sleep, carbon dioxide levels increase because your breathing is shallow and your respiratory rate drops. While asleep, the respiratory center shuts down if carbon dioxide levels drop to slightly lower than normal wakefulness levels. This level, called the apneic threshold, lasts until the carbon dioxide amount rises to normal sleep levels. People with CSA tend to have an unstable respiratory center that responds excessively to the return of elevated carbon dioxide. They then hyperventilate and again drop carbon dioxide levels below the apneic threshold, resulting in another central apnea.

There are two major forms of CSA:

  
Primary CSA
is a form of sleep apnea that has no underlying medical condition or medication causing it. It is rare, occurring in about 5% of all cases of sleep apnea.

  
Secondary CSA
is more common with several types.

    
  
Cheyne-Stokes breathing
refers to a cyclic pattern of breathing and is most common in people who have experienced a stroke or have weak hearts. As an observer, you would see a person demonstrate periods of increasingly deeper breathing that would reach a peak in 30 to 60 seconds, followed by a decline in the depth of respirations. After 30 to 60 seconds of this decline comes a complete absence of breathing for at least 10 seconds. This is the apnea, after which the whole pattern tends to occur repeatedly during the night.