Category Archives: Sleep Apnea

Could Your Child’s ADHD Be a Sleep Disorder?

Attention deficit hyperactivity disorder (ADHD) has again made top news in the past couple days.  The federal Centers for Disease Control and Prevention recently released data demonstrating that 11% of U.S. school-age children have received a diagnosis of ADHD, and that almost 1 out of 5 boys in the U.S. have been diagnosed with ADHD.  6.4 million children 4-17 years of age have been diagnosed in this country, making for a 53% increase over the past decade.  Millions of prescriptions have been written for these children, often, paradoxically, stimulants such as methylphenidate and amphetamine derivatives.

 

These are stunning figures, no doubt, sparking a renewal of debate regarding potential causes and solutions.  Fingers have been pointed at the pharmaceutical industry, doctors, parents, schools, and our burgeoning quick-fix technology, with iPhones and video games cluttering the landscape of our–and our children’s–lives.  However, there is a medical disorder–a sleep disorder–whose symptoms can be very similar to those of ADHD.  This sleep problem is very real, and one that is very often overlooked.

Obstructive sleep apnea (OSA) is much more common in children than many may realize.  The stereotypical sleep apnea patient is older, male, and overweight, and a misconception that may result from this stereotype is that young children, particularly skinny ones, are not prone to developing OSA.  Not only is OSA quite prevalent in children, it is also easy to miss, in part because the daytime symptoms from OSA can be different in children as compared to adults.

For adults, the most common daytime symptom is excessive daytime sleepiness:  drowsiness, a tendency to struggle to stay awake or to fall asleep at inopportune times, no matter how much sleep is obtained at night.  Children are different.  For many kids, the primary daytime manifestations of OSA are distractibility and irritability, potentially leading to poor school performance, problems concentrating, an inability to stay on task for long periods of time, and chronic conflicts at home or at school.  Sound familiar?  Patients diagnosed with ADHD also have such symptoms.  Additional symptoms attributable to pediatric sleep apnea would include bedwetting, sleep-talking, sleep-walking, frequent sleep disruption, headaches, profuse night sweats, learning problems, depression, and retarded growth.

A big clue to possible OSA is snoring.  The snoring of a young child, particularly 8 years of age and younger, really should be brought to the attention of the child’s pediatrician.  A child’s or teenager’s loud snoring should most definitely be discussed with the doctor.  And certainly if there are witnessed breathing pauses or gasping noises, the child’s doctor needs to be alerted as soon as possible.

Tonsillectomy and adenoidectomy represent the most common form of treatment for pediatric sleep apnea.  For many children, the removal of tonsils completely solves the problem, and it’s amazing how much the child’s (and family’s) life can change for the better as a result.

So today’s pearl, reflecting these recent news from the CDC:  sleep apnea is one of the most under-recognized and under-diagnosed medical disorders for children, and can present clinically in a way that is very similar to ADHD.  If your child is snoring at night and distractible or irritable during the day, I would recommend a sleep evaluation.

Have a great day, everyone!

 

Uncle Junior Had Sleep Apnea, and Wasn’t Even Overweight!

I love mob flicks. I always have. The Godfather films: love ’em all. Even the third one. I’ve read all the books (including the ones not written by Mario Puzo), memorized the movies. It’s become a tradition in my family to watch the first Godfather movie at least once per year.

Why? Because these “made” guys live lives that are so incredibly different and far-removed from my own. Because I empathize with them, these complex people that are so ruthless on one hand, but on the other protective and loyal to the death, doing the best they can for themselves and the ones they love. And, perhaps, there’s something seductive about the license they have to just simply . . . uh . . . do things–directly and definitively–about the people that wrong them. Whatever the reason, I find these films very cathartic. They never grow old; indeed, they get better with every viewing.

So imagine my happiness when The Sopranos debuted. Now I could follow the exploits of a New Jersey crime family every week! For years! (1999 to 2007, to be more exact.) I still miss it, now that its run is over.

Remember Junior, Tony Soprano’s notorious uncle? Tony and Uncle Junior had, shall we say, a love/hate relationship, one full of turmoil and, at one point, near-murder. Well, here is a scene in which Tony and Uncle Jun are having a brisk discussion in a CPAP clinic. Junior had just been diagnosed with obstructive sleep apnea!

Warning: anybody who has watched an episode of The Sopranos knows about the harsh language. If you’re new to or unfamiliar with the series, consider yourself warned before you watch the clip above.

Anyway, I distinctly remember this scene when it first aired. It was so strange to watch this mob guy get fitted with a nasal CPAP mask. It made Uncle Junior much more human to me, a little vulnerable. Maybe that was the intent of the producer of the show. That passage has remained stuck in my mind since I first saw it. There are some important points to be made from this scene, however:

1. You do not need to be obese to have sleep apnea. There is this misconception that all sleep apnea sufferers are overweight. This is simply not true. I have an army of patients that are as skinny as can be, including 90-pound ladies that snore like freight trains and gasp and choke all night long without treatment. Your throat and mouth anatomy has much to do with this. There are numerous anatomic characteristics that you may simply be born with, and that can predispose to developing sleep apnea, independent of weight: a large or wide tongue; a high-riding tongue base; a low-hanging soft palate; a large uvula (the dangly thing that hangs down from the soft palate); a “highly arched” hard palate; large tonsils; and “retrognathia,” in which the mandible (lower jaw) is set behind the maxilla (upper jaw). So just because you’re skinny doesn’t mean your snoring and witnessed breathing pauses during sleep should be ignored.

2. The prevalence of sleep apnea increases as one ages, particularly in males. The statistics demonstrate that sleep apnea gradually becomes more common the older we get, even independent of weight.

3. There are many different types of CPAP masks available. The one shown in this clip is clunky and old-fashioned, frankly, though similar masks are still out there for potential use. Now there are numerous new masks that are smaller, less leaky, and more comfortable, and with smaller and better-fitting headgear. CPAP (continuous positive airway pressure) is a primary form of therapy for sleep apnea.

4. Sleep therapists are available to help you through the process of initiating CPAP use. If you undergo an in-lab sleep study to diagnose sleep apnea, you will work with a trained sleep technologist who will help you through the testing and answer questions you may have regarding the diagnosis and treatment of sleep apnea. It seems that Uncle Junior was a bit smitten with his. I don’t know if the man fitting his mask was a physician or a therapist. Usually sleep or respiratory therapists conduct the fitting process of masks following sleep study testing. The actual process of mask fitting is (or at least should be, if the CPAP provider service is worth its salt) substantially more detailed and lengthy than what is shown in this clip: the idea is to find a mask that is comfortable and leak-free, and that means trying on multiple masks, of different types, brands, and sizes, to find the right one. What you see in the clip is simplified for the sake of the show; I suspect the viewing public would become bored with a full-scale demonstration of different CPAP masks.

I love Tony’s sarcastic comment to Uncle Jun at the end of his mask fitting: “How many MIG’s did you shoot down last week?”

Think Sleep Apnea is Just Snoring and Sleepiness? Think Again

Obstructive sleep apnea is an important medical breathing disorder in which one’s upper airway collapses episodically during sleep.  The lack of oxygen and the buildup of carbon dioxide in the bloodstream resulting from airway closure then provoke frequent brief arousals from sleep throughout the night, causing substantial fatigue and sleepiness during the day.

The cardinal symptoms and signs of sleep apnea are well-known:  excessive daytime sleepiness, nocturnal sleep disruption, loud snoring, witnessed breathing pauses, gasping sensations out of sleep.  However, what is not well known to the public is that there are many additional symptoms–some subtle, some not so subtle–that can be caused by or attributable to untreated sleep apnea.  If you are experiencing one or more of the following in the setting of some of the above-mentioned sleep apnea symptoms, you may want to consider seeing a doc like me.

 

1.  Headaches.  Many people with untreated sleep apnea have headaches, which are typically worse in the early morning or upon awakening as compared to later in the day.  Sometimes the headaches can actually cause awakenings in the middle of the night or in the morning.

2.  Nocturnal palpitations.  Because of sympathetic overactivity (hyperstimulation of the adrenalin system), untreated sleep apnea can cause people to awaken abruptly feeling like their hearts are “racing,” “pounding,” and/or beating irregularly.

3.  Night sweats.  Some people “run hot” while they’re sleeping, but sleep apnea can often cause people to sweat profusely and frequently in bed, sometimes to the point of being drenched, due to the effects of frequent brief arousals from sleep.

4.  Frequent urination at night.  This is a big one.  I can’t tell you how many patients of mine have previously undergone comprehensive urology evaluations because of multiple awakenings due to a full bladder.  This is a huge problem, one that men and woman alike often try to learn to live with for years before seeking medical attention.  Untreated sleep apnea tends to increase one’s urine production at night, and treating it often makes this problem improve or go away.

5.  Sexual dysfunction.  The association between untreated sleep apnea and erectile dysfunction and reduced libido is clearly documented in the medical literature, and sleep apnea treatment–such as with positive airway pressure (CPAP)–has been demonstrated to be helpful in improving or resolving these problems for many.

6.  Leg swelling.  Ever notice that sock line around your ankles when you take off your socks at the end of the day?  Sometimes this soft tissue swelling of the legs can be severe and painful.  Peripheral edema can be related to a number of different medical issues, sleep apnea being one.

7.  Memory problems and depression.  Think about it.  If you’re constantly awakening briefly from sleep all night every night for years, this problem can easily take a toll on your mood and your ability to concentrate and remember things.  On numerous occasions patients have visited me after having had extensive workups for dementia or depression, with treatment of their sleep apnea subsequently improving or even resolving their memory and mood problems.

8.  Difficulties losing weight.  If you’re tired and fatigued all day, you may not have the energy to exercise and burn off calories.  But in addition to this, untreated sleep apnea can impair your metabolism as well, affecting certain weight-mediating hormones such as growth hormone and leptin.  Treating the sleep apnea doesn’t necessarily make you lose weight automatically–you still have to work at it, with diet and exercise–but it may make it substantially easier to lose weight with a proper weight reduction program.

Bottom line:  sleep apnea can be associated with a surprising number of problems that initially may not appear to be related directly to your sleep.  Don’t ignore your symptoms.  The primary sleep apnea symptoms of daytime fatigue, loud snoring, and witnessed breathing pauses during sleep shouldn’t be ignored anyway, but additional problems like morning headaches or urinating a lot at night should increase your level of concern still further.

Have a great day, y’all!

 

May the PAP Be With You

Good evening!  My final act of the night before taking off for REM City:  to share a couple of great photos sent to me this afternoon by my good ol’ college friend and former bandmate, Ken, a Kansas Citian, bassist, fellow Jayhawk hoops fan, and Star Wars obsessive.

My last post featured photos of a bunch of bad guys in masks.  Here now are some good guys.

Where do you think all of Han Solo’s energy came from?

 

And why do you think the Force is so strong with Princess Leia?

 

Again, keep in mind, most people don’t need full face masks and can get away with small nasal masks or nasal pillow systems.  And you don’t need to use the CPAP device until you’re in bed and ready to sleep.

More serious posts will resume shortly.  Enjoy your dreams tonight, y’all!

Darth Vader: Really? Popular Misconceptions About CPAP

Obstructive sleep apnea is a common breathing disorder, in which the airway in the throat and neck collapses during sleep.  It’s very important to diagnose and treat this problem properly, not only because treating it can make you feel much more awake and alert during the day and stop your terrible snoring at night, but also because untreated sleep apnea increases the risk for substantial medical problems, including hypertension, heart failure, cardiac rhythm abnormalities, and early heart attack and stroke.

Problem is, it’s estimated that out of the millions of people in the U.S. with sleep apnea, about 85% of them have not yet been diagnosed.  Why is that?  There are probably several reasons.  First, symptoms can be insidious.  You’re not awake to hear your own snoring or witness your own pauses in breathing; if you’ve felt tired for years, the fatigue can just feel “normal,” to the point in which falling asleep while driving or during conversations at parties becomes your “normal.”  Secondly, medical care in general is expensive, particularly with the increased deductibles many now have to pay, and in today’s economy some people elect to put off non-emergency medical care. Thirdly, and importantly, there are a lot of presumptions regarding testing for and treatment of sleep apnea which are inaccurate or simply untrue.

When I see someone in my clinic for the first time for possible sleep apnea, I make it a point to discuss thoroughly the nature of the disorder, the procedure of diagnostic testing, and all standard accepted treatment options.  A primary and common form of treatment for sleep apnea is continuous positive airway pressure (CPAP), a device that takes room air, pressurizes it at a pressure prescribed by the physician, and delivers it via a small mask into the nose and into the airway.  CPAP is not designed to push or force air into the lungs.  The air from the device acts as a splint for the upper airway, keeping it patent (open) all night and thus allowing air to travel into the lungs, where it’s supposed to go.  This then dramatically deepens sleep, because the brain no longer arouses constantly due to low oxygen levels, thereby making the patient much more awake and alert during the day.  The success rates in resolving the sleep apnea with CPAP are incredibly high, provided that 1) the device is utilized properly, and 2) the patient is willing to utilize the device.

Most of my patients come to me very open-minded regarding how to fix their breathing problems during sleep.  There are times, however, in which my first mentioning of CPAP in clinic is met with reluctance, or a flat-out refusal.  In some ways, it’s perfectly natural to have initial reservations.  We are designed biologically always to protect our airways, so it seems counterintuitive to cover your nose or nostrils with something that it meant to make you breathe better.  This can be a source of an initial sensation of claustrophobia for some.  In addition, there is not only a mask involved, which may seem daunting to the uninitiated, but also a change in night-time habits, and we, the humans that we are, are naturally inclined to hate lifestyle changes thrust upon us by someone else.  But I’m struck by the responses I get when I ask why there is such immediate pushback to the consideration for CPAP use, when the patient hasn’t even seen or touched the device.  Among the most common of these is, . . . “I don’t want to look like Darth Vader.”

Come on.  Really?  I’ve heard this, or the equivalent (“Oh yeah, that Darth Vader thing,” or “That’s the Darth Vader mask, isn’t it?,” or some other such statement), so many times, I wonder who are these people out there telling everybody they’ve become Sith lords after starting CPAP and inviting others to join the Dark Side by getting treated too.

Lookit.  I was a disciple of Star Wars growing up.  I was ten years old when the first Star Wars movie (now known as Episode IV:  A New Hope) was released in 1977.  In terms of pure love and sheer personal impact, I rank it right behind The Godfather on my list of all-time favorite films.  As a kid I studied it religiously, including its philosophies and characters.  I memorized the presentation, clothing, and mannerisms of all the characters through scrutiny of books, magazines, and my precious trading cards.  So trust me when I say, there are no CPAP masks that are remotely similar to Darth Vader’s mask.

Vader’s mask isn’t even really just a mask.  It’s a full-on helmet, covering the entirety of the head, designed and utilized not only for protection but also as a contained respiratory support system required due to massive injuries sustained following Anakin Skywalker’s unfortunate battle with Obi-Wan Kenobi on Mustafar.  Take a look:

 

Uh, the typical CPAP user is not using CPAP for these reasons.  All the CPAP device does is simply allow air to pass freely through the upper airway so oxygen can get to where it needs to go:  into the lungs and thus into the bloodstream so you can, you know, live.  In most cases all that’s needed is a small nasal mask that just covers the nose, with headgear to secure it in place:

 

Or small “nasal pillows,” soft prongs which are placed gently in the entrance of the nostrils:

 

OK.  So you don’t look glamorous with these things on, and it can take a little while to get used to; that’s the reality of it.  However, your bed partner or spouse isn’t going to care much how you look while asleep; he or she presumably will care more about your health and longevity than how you appear while you’re sleeping, and will appreciate that your heroic snoring is now completely gone.  My patients generally become accustomed to CPAP use quickly, and these mask interfaces are more comfortable and tolerable than one may think.  With proper support from the sleep physician, the sleep center, the durable medical equipment service providing you with the materials, and your family, nightly use of this device can be a complete game-changer, dramatically improving the way you feel (and thus, the quality of life) and the way you sleep.

Another reason why people may relate CPAP use to Darth Vader is the presumption that the device is noisy, with some loud, pervasive inhale/exhale sound that keeps everybody awake all night.  Since the CPAP machine is at its core essentially a blower, there is some noise, but the devices now are incredibly quiet, in many cases virtually imperceptible, and the tonal differences between inhalation and exhalation can be adjusted with the new technologies built in to modern devices.

Ultimately, my sense is that some people have heard from someone–Uncle Frank, or Bill down the street–in the distant past about some negative experience with CPAP, and the resulting conjured images just get stuck.  As we all know, once an image is lodged in your brain it’s hard to unstick it.  And it’s true that ten years ago CPAP machines were loud and bulky, with limited choices of available masks.  But think of how technology in general has changed and improved over the past decade.  Look at our cell phones now, our desktop and laptop computers, our TVs.  Of course everything is better and smaller (well, the TVs are bigger, but thinner and lighter).  Same goes for CPAP use.  The devices are now very small and whisper quiet, with lots of built-in bells and whistles to make them more comfortable and easier to use.  There are dozens and dozens of different masks available now, all in different sizes, so it’s very rare now for my patients to have difficulties finding a mask that fits well.  I’d also ask that you look at this from a different perspective:  the companies that produce these machines and accessories are all competing in a race to make the best, most comfortable, most popular products.  As such, new products come out all the time.  You, the consumer, therefore have an advantage, with an ever-expanding circle of choices for products to use to optimize your treatment experience.  Ahh, capitalism at its finest!

Having said all of this, there are plenty ways for CPAP use to go sideways (literally and figuratively), limiting one’s abilities to tolerate and use the device.  Virtually all of these potential problems are fixable, however, and I will discuss these issues in future posts.

Some think that full face masks must be used when using CPAP (these masks cover both the nose and the mouth).  Though these masks are available and may be necessary or desired in some very specific circumstances (a topic for another blog entry), the substantial majority of CPAP users just need a simple small nasal mask or nasal pillows.  Full face mask or not, you will not end up looking like Bane from the Batman series:

 

. . . or another of my favorite bad guys, Hannibal Lector:

 

I also sometimes hear, “Won’t I suffocate with the mask on?”  My reply to that is, “No, quite the opposite.  You’re suffocating every night without the mask on.”

You know what would be cool?  Since George Lucas recently sold the Star Wars franchise to Disney, maybe I should approach someone at Disney about creating and marketing an actual Darth Vader CPAP full face mask.  You know, paint it black, have it play John Williams’ ominous Darth Vader theme music when you put it on.  Then all of these references to Darth Vader could actually become true!  I’ll look into it.  Wish me luck on that one.

So here’s my take-home point for today:  don’t deny yourself the diagnosis and treatment of an important medical problem because of what you think the treatment might be like.  Explore, speak with your doctor, keep your mind open to trying something that can actually change your life.  Insurance companies rent the CPAP device on your behalf for the first several months of use, because they don’t want to pay for a CPAP machine you don’t end up using.  If you really hate the machine no matter what is done to try to make things better, you can return it.  In other words, you have very little to lose and a lot to gain by at least trying it, if it’s recommended by your sleep doctor.  You’ll never know how much it can help you unless you try.

“You’re disoriented.  You just woke up.  You’re in the future.  You’ve been asleep for eight hours.” — Jarod Kintz