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Steven Y Park, MD  
Male, 52
New York, NY

Specialties: Sleep-breathing disorders

Interests: Running, Baking, origami
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212-315-9058
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Sleep Apnea - A Primer

Nov 18, 2008 - 15 comments
Tags:

Sleep Apnea

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obstructive sleep apnea

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CPAP

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dental devices

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surgery for sleep apnea

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UPPP



Note: This is an edited transcription of a podcast recording

So what is obstructive sleep apnea? Apnea means a total cessation of breathing and this happens only when one is sleeping.  So a person with sleep apnea can stop breathing from 10 to 50 to even over 100 times every hour with each episode lasting anywhere from 10 to 30 seconds.  Using strict criteria, it is estimated that about 4% of men and 2% of women have this condition, but using looser criteria, it can be up to 25% in men and up to 9% in women. The scary statistic is that this condition is not diagnosed in about 80-90% of people who have it, so instead, they are being treated for the end result which can be diabetes, depression, high blood pressure, etc. It is also known that significant sleep apnea happens in about 35% of chronic snorers. It’s also important to note that you don’t need to snore to have sleep apnea, as well.  

Some of the symptoms of sleep apnea include: snoring, depression or irritability, poor concentration, memory or focus problems, morning headaches, poor job performance, attention deficit disorder, and obesity.  A recent study came out describing the number of car accidents in one year. It’s estimated that about 800,000 car accidents occur every year due to sleep apnea and of these, there are about 1,400 fatalities. In addition, it’s estimated that of all the commercial truck drivers in America, about 28% of them had this condition, and of this group, about one third of them have moderate to severe sleep apnea.

There are a number of medical conditions associated with sleep apnea, as well. It’s found that people with sleep apnea have up to a 50% incidence of high blood pressure and people with high blood pressure have about a 50% incidence of sleep apnea.  Now the studies show that if you have had a heart attack, you are 23 times more likely to have sleep apnea and the reverse showed that if you have sleep apnea, you are about 1 ½ times as likely to have heart disease.  

Another study looked at 200,000 charts retrospectively and found that patients on medicines for depression or high blood pressure were 18 times more likely to be eventually diagnosed with sleep apnea. So what they concluded was that many patients are being treated for the symptoms or complications of sleep apnea rather than the underlying cause itself.  

I mentioned previously that attention deficit disorder was associated with sleep apnea. In an interesting study that came out in the Journal of Pediatrics, researchers recruited 78 children who were about to undergo a tonsillectomy for various reasons including recurrent infections or sleep apnea and compared them against 22 other children undergoing other types of surgical procedures. All these children underwent formal sleep studies and a battery of psychological tests including that for attention deficit disorder and found that 22 children, or 28% of the tonsillectomy group, were found to have ADHD by official psychiatric criteria.  The control group only had 7% that were found to have sleep apnea. After surgery, one year later, 11 children or 50% of the children who originally had ADHD, no longer had by official criteria.  Furthermore, after the surgery, the incidence of sleep apnea in the tonsillectomy group was equivalent to that in the control group.

I could go on and on about snoring and sleep apnea being associated with increased risk of children having memory, attention or cognitive skill problems, asthma, chronic cough, etc. but I’ll stop here. One more comment about adults and sleep apnea and ADHD:  there was one study that looked at three adult patients with attention deficit disorder and sleep apnea and all three of these patients were on Ritalin. Two of these patients, after treatment for sleep apnea, were weaned off the Ritalin and the third selected weight loss and conservative regimen. This goes to show that sleep apnea and ADHD can co-exist in adults, as well.

Other medical conditions include heart disease, stroke, diabetes, erectile dysfunction and obesity, seizures, migraines, and even preeclampsia, which is a condition where pregnant women get high blood pressure at dangerous levels.  All of these conditions have been associated with sleep apnea and to various degrees, respond to treatment.  

So how do you diagnose sleep apnea?  To diagnose sleep apnea, you have to undergo a formal sleep study, which is an overnight test where you go into a facility and they hook you up to all these monitors all over your body and they analyze all the different parameters like breathing, respirations, heart rate, brain waves, etc. while you sleep. This way they can calculate how many times you stop breathing every hour and how long for every episode. To officially get the diagnosis of obstructive sleep apnea, your apnea/hypopnea index, or the number of times you stop breathing totally or partially for greater than 10 seconds for each episode, has to be greater than 15 events every hour.  Now, if you’re symptomatic – if you’re very sleepy or if you have any of the medical complications of sleep apnea such as depression, diabetes, high blood pressure, etc.—then your number can be down to 5.  

One of the problems with these criteria for sleep apnea is that if you stop breathing for 9 seconds at a time and you stop breathing 50 times every hour, then officially you won’t have the diagnosis of sleep apnea and then you get into the realm of upper airway resistance syndrome, which I discussed in another article. If you snore only and don’t have any significant apnea or you’re otherwise asymptomatic, then you can elect to undergo snoring treatment, which I’ll talk about in a separate article. If you snore and have significant apneas, then treating the apneas will also treat the snoring, in general.  

There are a number of conservative measures that are recommended to treat snoring and sleep apnea including weight loss, positional therapy, sleeping with the mouth closed as well as a number of different snoring treatments but there’s only so much one can do with this. First of all, it’s hard to lose weight because you’re so tired and it’s hard to exercise. In terms of trying to sleep on your side or on your back, you only have so much control over that when you’re sleeping. One note about snoring treatments: over-the-counter snoring treatments have been found to work sometimes but a recent controlled study which looked at three popular snore aids, including a nasodilator strip, an oral lubricant and a pillow. All were found objectively not to have any significant benefit. However, I have many patients who swear by these over-the-counter snore aids, but in my experience, it only works sometimes for some people but in general it doesn’t work most of the time.  

If you’re found to have obstructive sleep apnea, the best way to treat this condition is via what’s called a Continuous Positive Airway Pressure machine, or CPAP. This is a small device that acts as an air pump which blows some positive gentle air pressure through your nose and it stents your airway open so you don’t stop breathing at night. When used effectively, it works. You wake up feeling much more refreshed, have much more energy and all the medical problems start to get better. One of the problems with CPAP, however, is that people just don’t like to use it, but with good counseling and proper follow-up from clinic staff and the equipment people that administer the device, many people can do well with this device.

However, there are certain people who just can’t use CPAP for other reasons despite trying different kinds of masks, headgear and devices. These people end up going to different devices, one of which is a mandibular advancement device, which are oral appliances that dentists make. They make an impression of your teeth and the bottom part, the mandible, the jaw bone slowly is pushed forward.  The way this works is that it pulls the tongue forward, which is one of the reasons for sleep apnea, amongst many other reasons. Again, when applied properly and when patients use it, this device does work especially for snoring and for mild to moderate sleep apnea.  But compliance is also a problem due to jaw pain, dry mouth, ear pain, headaches, and bite problems.

The last major option is surgery and this is a huge topic in itself and I will discuss this in detail in another article, but just to summarize, when considering doing surgery, people have to have failed trying CPAP, or at least consider the mandibular advancement device and reject it. One has to be really motivated. Secondly, there has to be some type of anatomic reason for the collapse so when I do the examination and do the endoscopy to look inside the airway passages, I have to see is some sort of obvious collapse to address it via surgical measures.  

The first and most obvious area of obstruction is actually the nose. If your nose is stuffy for whatever reason—allergies, polyps, deviated septum, or anything else—that’s the first thing that I address, whether medically or surgically. This is because if you don’t breathe well through your nose, then everything else downstream is more prone to collapse. So once the nose is taken care of and if you still have sleep apnea, then you can try going back to the CPAP. Many people with stuffy noses can’t tolerate CPAP that well, but once that problem is corrected, a certain number of people can start using the CPAP more effectively. If you go further downstream, the other two major areas are at the palatal level and the tongue level. In our field (ear, nose, throat, head & neck surgery) we’ve been focusing too much on the palate because that’s typically where the snoring sounds are coming from, but that’s not the only area. If you don’t address the tongue, as well as the palate, then your success rates aren’t going to be that great.

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Steven Y. Park, M.D., author of Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. Endorsed by New York Times best-selling authors Dr. Christiane Northrup, Dr. Dean Ornish, Dr. Mark Liponis, and Mary Shomon.

www.doctorstevenpark.com


Comments
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Avatar universal
by jan401, Nov 19, 2008
I enjoyed your article, and have been diagnosed for about 15 years with OSApnea, and believe I have had it for many years prior to that time.  I am considering UPPP surgery fore OSA, and Xolair treatment fro severe asthma.  I am unsure if either of these will help, but hope for a 'night of restful sleep', which I have not probably had in the last 30 years!  I am 56, female and looking for more information regarding the above conditions and possible side effects.     Thank you so much!

Avatar universal
by Steven Y Park, MDBlank, Nov 19, 2008
Thanks for the feedback. I'm working on two more articles, one on surgery for OSA and another one on upper airway resistance syndrome. They should be up soon.

Have you tried CPAP or dental devices yet?

The topic of UPPP for sleep apnea is very controversial. You'll find people at extreme ends volleying back and forth with their pro and con arguments. Overall, it's accepted that a UPPP operation alone has a 40% chance of "success." If you address the tongue simultaneously, success rates will be much higher in the 60-80% range.

Stay tuned for more information on these topics.

http://www.doctorstevenpark.com

Avatar universal
by jan401, Nov 19, 2008
Hi there- thanks for the reply.  I was unsuccessful with CPAP as I develop hundreds of nasal and tonsil polyps.  I use a n orthodontic device that pulls the lower jaw forward, but I am still snoring terribly and not getting restful sleep.  I have had multiple sleep studies, and with a CPAP and my ortho device, I am still having about 47 awakenings per minute. Any advice??

Avatar universal
by Steven Y Park, MDBlank, Nov 19, 2008
I wonder if your CPAP pressure is accurate. When was the last time you underwent a titration study? If you're still snoring with CPAP, then the pressure may be too high or too low. The dental device will help in certain people with mild to moderate sleep apnea where there's mostly tongue collapse. If you have severe palatal narrowing, then the dental device may not work as well (or it may need to be re-adjusted). Are  you overweight at all?

If it's been a while since undergoing a titration study, I would address this issue first.

Avatar universal
by jan401, Nov 19, 2008
Hi- What is a 'titration' study?  I do not know if I have had one or not.  I am probably 15-20 lbs overweight, but not 'fat'. my last sleep study was about 8 months ago, and that's when my pulmonary dr and ENT dr agreed on UPPP.  I am just concerned, as once all that tissue is cut out, there is no going back.  Should this be a concern?

Avatar universal
by Steven Y Park, MDBlank, Nov 19, 2008
Sorry.....A titration study is a sleep study where they place a mask on your face and calibrate the best pressure for your degree of apneas. Has your weight changed significantly since your last study 8 months ago? If so, then the pressure may be wrong. Just be aware that a UPPP alone has about a 40% or less chance of success. Depending on your anatomy, studies have shown up to 70-80% success rates with multilevel surgery, which includes the tongue.

For now, I would try to optimize your CPAP usage. Do your research about surgery, and take it slowly.

Avatar universal
by jan401, Nov 20, 2008
Hello-  I am not able to use the CPAP due to the hundreds of nasal polyps and tonsil stones that I developed while using it.  Since then, I am just using the ortho device, but it is not at a savior, either.  i do still have my tonsils, which are large, and have had surgery twice for deviated septum.  I just would love to enjoy a full night of sleep!! Thanks!


Avatar universal
by Steven Y Park, MDBlank, Nov 20, 2008
jan401,

I just posted an article on surgery for obstructive sleep apnea. Hopefully, you'll find it helpful

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by sharonanne, Feb 16, 2009
hello Dr. park my boyfriend has sleep apnea and for the last few months is snoring is so loud that i have moved to the couch,why is this happening?? and the funny thing is that its not every night... and the 2 question i have is being is partner is their any thing i should watch for,i am concerned that he might stop breathing one time and i wouldn't know what to do thank-you i really learned a lot on you article

Avatar universal
by TreatmentforSleepApnea, Nov 25, 2009
Snoring, Sleep Apnea, or CPAP intolerance is a big issue in 90%'s life.Treatment for Sleep Apnea is required for them.It is needed to escape their life from worries and troubles.Treatment for Sleep Apnea, exists to deliver the very best in personalized treatment.Treatment for Sleep Apnea, works with you to discover exactly what is required to deliver the maximum results possible and offers customized treatment programs

Avatar universal
by TreatmentforSleepApnea, Nov 25, 2009
Your imformation is really very helpful. Snoring, Sleep Apnea, or CPAP intolerance can ruin your life.Treatment for Sleep Apnea can escape you from the worries and troubles that come from Sleep Apnea, Snoring, or being CPAP intolerant.Treatment for Sleep Apnea will wok with you for your required approch.


Avatar universal
by findik, May 02, 2010
Thanks for the info. I am 36, male, 173cm, 172lb. I have at least 15 years septum deviation problem, and one nose is almost completely closed so most of the time I breath while mouth open. So I thought the surgery would be the solution and wanted to have a surgery but I find here ENT doctors are a bit conservative about surgery. I got a sleep test 10 years ago when I was doing my PhD study and they found a mild sleep apnea.I have been in a busy research schedule and find myself not energetic, unfocused, depressed. So I saw another ENT recently, he was not sure to go for surgery or not. He suggested a sleep study and again mild apnea. I will try CPAP but with breathing problem from my nose, I am not sure CPAP is a good choice and I think main problem (septum deviation) should be solved before CPAP. He said even septum deviation issue resolved, I may have still sleep apnea, they may not be too much related. I understand in medicine there is no 100% for sure and "may" is used very strategically compared to science. I am a pure scientist, if there is a problem in the nose, it should be solved in my opinion. Your opinions highly appreciated.

Avatar universal
by Steven Y Park, MDBlank, May 03, 2010
findik,

Breathing well through your nose is important to help you with your treatment options for obstructive sleep apnea, whether it's CPAP, oral appliances, or even surgery. While nasal surgery won't cure your sleep apnea (it only happens in about 10% of patients), breathing well through your nose is a worthwhile goal, as well as optimizing other sleep apnea treatment options. I'm about to release a free ebook called Your Nasal Survival Manual, which answers many of your questions. Please check my site at http://www.doctorstevenpark.com for updates and availability

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by irishliz1962, Dec 31, 2012
I had a sleep study done about a week and half ago and i remember not being asleep very long and they put a cpap on me for the rest of the study does this mean i have probably sleep apnea???

Avatar universal
by Skyedancer, Nov 07, 2014
Hi I have sleep apnea and now i have a bi pap machine which is better than the regular one, but I am still leaking air and getting very tired. I was given a very low dose of ritalin because I get so tired when I drive its not good. I have had some side effects that most people have and its ok , I dont take it all the time. This is really really weird but I wonder if anyone has heard of this - after I take it , the next day or so I keep seeing things our of the corner of my eye and get kind of startled sometimes by it. I think something is there or something that is there is a person or something and its not. I didnt really want to tell the dr because it sounds nuts! Thank you

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