Sleep Soundly Every Night, Feel Fantastic Every Day (23 page)

    
  
CSA caused by the use of pain medications of the opioid family
like morphine, methadone, oxycodone, and hydrocodone. In some studies, as much as 40% of the patients on methadone programs to stay off heroin, are experiencing this type of CSA. The accompanying
sedatives and sleeping pills frequently given to these patients can exacerbate it.

    
  
Complex sleep apnea
is a form of sleep apnea in which central apneas persist or emerge during attempts to treat OSA with a CPAP or bi-level BiPAP device. I is more common at higher altitudes of mountainous regions.

The good news for persons diagnosed with CSA is that once diagnosed, all of these forms of CSA can be treated. In some patients, it may be as simple as supplemental oxygen at night. In other patients, improving cardiac function or getting off opioids when possible may eliminate the problem.

However, in cases where this is not possible, sleep medicine has some sophisticated machines to deal with the problem. Recently, an adaptive servo ventilation device was approved by most insurers and Medicare for this condition. The unit is not much larger than a CPAP machine and takes care of both the OSA and central apneas. Unlike CPAP machines, if it senses an absence of an effort to breathe (a central apnea), it can generate timed back-up breaths until the person begins to initiate a breath on his or her own.

Q.
 
For several years I have been having trouble staying awake. My doctor sent me for a sleep study and told me I had CSA. How is that different from the more common OSA?

A.
 
In CSA, the person makes no effort to breathe during the event. The brain's respiratory center does not
send any signals to the respiratory system to breathe. This results in arousals from sleep and poor sleep due to low oxygen levels. There are many causes for CSA. Sleep experts see it in patients on large doses of narcotics, in patients with weak hearts, and in those who have suffered from strokes in the past. In addition, a significant number of people have no underlying cause whatsoever.

Q.
 
My 17-year-old son appears to sleep soundly. However, I have noticed that he usually takes three deep breaths at a fast rate, followed by no breathing for 7 to 10 seconds. Then the pattern repeats. He does not snore or gasp for air. He is overweight and I worry that he has sleep apnea.

A.
 
From what you are describing, this could be a form of sleep apnea called CSA, which is caused by an intermittent failure of the ventilatory control center in the brain to signal the respiratory system to breathe. There are two important issues about your son. Does he have any symptoms during the day such as sleepiness, irritability, or trouble concentrating? In addition, does this go on throughout the night or just as he is falling asleep? If the latter, it may be normal, as central apneas are normal during our transition from wake to sleep.

Q.
 
Is it true that if untreated in children, sleep apnea can lead to problems? My grandson is nine years old and when he sleeps over he snores like a freight train and I think he stops breathing. My daughter thinks I'm being an alarmist and there is no need to be concerned. What do you think?

A.
 
I cannot tell you if your grandson has sleep apnea, but I can tell you that the American Academy of Pediatrics recommends a thorough evaluation for sleep apnea in children who snore chronically. I can also tell you that a recent study published in the journal
Sleep,
showed that children with moderate sleep apnea had significant elevations of blood pressure during apneic events while sleeping. This was especially noted during REM (dream) sleep. The authors feel that since elevated blood pressure in childhood predicts adult hypertension, this should be addressed as early as possible. Another recent study showed a high incidence of depression in children with OSA.

Q.
 
My eight-year-old daughter snores loudly. I took her to see an ENT (ear, nose, and throat) specialist who advised we have her tonsils and adenoids removed. My pediatrician said we should first get a sleep study performed. What do you think?

A.
 
I agree with your pediatrician for several reasons. First, before performing any surgery, you want to know if it is necessary. In the absence of sleep apnea, it might not be indicated. Second, if your child has severe sleep apnea, postoperative respiratory complications are more common, and precautions such as overnight monitoring after the surgery are indicated. Finally, if the sleep apnea is severe, a repeat test after surgery is necessary in most cases to confirm it has been cured.

Q.
 
My 74-year-old mom was diagnosed with early dementia. She has been having problems with her memory and can never remember where she puts things. She snores and her new neurologist wants to do a sleep study on her.
He says that sleep apnea can be the cause of some of her issues. Is this true?

A.
 
Yes it is. It is not uncommon for sleep apnea, especially in the elderly, to present with problems using memory and focusing. In fact, a particular area of the brain involved in memory called the hippocampus is very likely to be damaged by low oxygen levels associated with sleep apnea. I would advise you to urge your mom to be tested. If positive, there could be a significant improvement in her mental status.

Q.
 
My doctor recently ran some blood tests on me and found that I am prediabetes. I snore loudly and she told me that if I have sleep apnea, treating it might improve my blood sugar. Is this true?

A.
 
Yes, several studies have shown that treatment of sleep apnea improves blood sugar control in diabetes and prediabetes. Sleep apnea causes insulin resistance and in most studies insulin resistance improved within two weeks of treatment.

Q.
 
I have severe sleep apnea and have been on CPAP for three months. I don't feel any better now than I did before. What do you think?

A.
 
First, you need to be sure that your machine is working effectively. Most machines come with a downloadable smart card. Your physician should be able to review it and tell if your sleep apnea is being successfully treated. Second, not all people placed on CPAP will “feel better.” Up to 10% of those treated may continue to feel sleepy
and fatigued. However, they are still getting the same benefit in terms of stroke and heart attack reduction that the other 90% get. So make sure it is working effectively and stick with it.

Q.
 
I was recently diagnosed with sleep apnea and I use a CPAP machine every night. I am very obese and have read that if I lose a lot of weight I will no longer need to use the CPAP. Is that true?

A.
 
It is possible that you will not need the CPAP. It depends on how severe, how many times you stop breathing per hour, and how much weight you lose. I can tell you that after bariatric surgery, approximately 60% of patients with sleep apnea no longer require CPAP. The good news is that weight loss is much easier after the treatment of sleep apnea. If you do lose a lot of weight you probably should be retested to see if you still have the sleep disorder. Don't make the mistake of just stopping treatment because you think it is no longer necessary. Unfortunately, I am frequently referred patients who mistakenly made this assumption.

Q.
 
My 52-year-old brother has epilepsy. He is on three medications but still has frequent seizures. According to his wife he was diagnosed with sleep apnea but rarely wears his CPAP mask. Could the sleep apnea have anything to do with his seizures?

A.
 
Yes, the incidence of sleep apnea in refractory epilepsy is 30% to 40%, shown in several studies. Treating the sleep apnea results in a 50% decrease in seizures in most and a reduction in the number of anti-epileptic drugs required.

Q.
 
I had a sleep study done last month, and I have a form of sleep apnea referred to as CSA. The report that my doctor received said that I should return to the lab for treatment of this condition. They recommended a machine called an ASV. My doctor explained the difference between a CPAP and an ASV, but I didn't understand. Could you please explain?

A.
 
In CSA, you periodically make no attempt to breathe during the night. CPAP machines are designed to work on the obstructive form of the disease. They splint the airway open with pressure to prevent it from collapsing. However, the CPAP machine cannot respond to a failure to make any effort to breathe. The ASV machines will sense this absence of effort and cycle in and breathe for you when this happens. They are specifically designed for CSA.

Q.
 
I had a sleep study performed and was diagnosed with sleep apnea. I was then asked to return to the sleep lab for a second study to determine the level of CPAP required in order to treat this condition. I was surprised when a third study was requested. Apparently, I have what they call complex sleep apnea, which requires a different type of machine other than a CPAP. What is this condition and why couldn't they get it right in the first place?

A.
 
Complex sleep apnea is a newly described form of sleep apnea. About 10% to 15% of patients, when placed on CPAP, have episodes in which they stop breathing and make no effort to breathe for 10 seconds or more. It is as if they forget to take a breath. These events are called CSAs, as opposed to the more common OSAs. Central apneas turn out to be just as disruptive to sleep as obstructive apneas and cannot be treated with CPAP alone.

There is a new form of treatment for complex sleep apnea called adaptive servo ventilation. Returning to the sleep lab is normal for a third study with this new device, which is a small unit that delivers pressure just as CPAP does. However, it eliminates both types of breathing-related sleep abnormalities—central and obstructive apneas. Most of the research on this new machine is from the Mayo Clinic. This is probably what you will be treated with when you return for your third study.

Q.
 
I have been on methadone for pain for several years. Recently I underwent a sleep study and was told I have CSA, probably due to the methadone. I don't understand why it has no effect on my breathing during the day. Can you explain?

A.
 
Most patients' respiratory systems adapt to narcotics within four weeks. However, that is not the case concerning their breathing while asleep. Unfortunately, up to 40% of patients on methadone develop CSA. This may also be an undetected cause of persistent fatigue in these folks.

Q.
 
I was recently diagnosed and treated for obstructive sleep apnea. They put me on a CPAP machine. However, I then developed central apnea. I was told that a failure to make any effort to breathe characterizes central apnea and that the treatment with CPAP caused this. I changed to a machine that can treat my central apneas as well. Why would a CPAP machine cause this to happen?”

A.
 
This is a great question. What you are referring to is called complex sleep apnea. We believe there may be two mechanisms that cause this in some patients. One is a stretching of the lung by the positive pressure. This can
elicit a reflex that depresses respiration. The other is a drop in carbon dioxide brought about by the CPAP machine. The brain does not like low carbon dioxide levels and will stop sending signals to the lungs to breathe until the carbon dioxide builds up again.