Governor Chris Christie Undergoes Weight Loss Surgery

 

Today it was announced that New Jersey Governor Chris Christie underwent lap band surgery for weight reduction in February.  Governor Christie’s longstanding struggle with his weight has been the subject of intense media scrutiny–perhaps in some cases unfairly–in recent years, but at least the publicity has brought some high-profile attention to a problem that many find difficult to discuss openly:  what to do about the American epidemic of obesity.

Bariatric surgery for weight loss has been around for a long time, but public awareness of the availability and benefits of bariatric programs has increased substantially in the past decade or so.  There are now numerous surgical techniques to modify the anatomic volume and functional volume of the stomach and surrounding gastrointestinal structures to reduce hunger, food intake volume, and therefore weight.  Historically bariatric procedures centered around the physical reduction of stomach size.  More recently, however, technological advances have allowed for many to undergo less invasive procedures, such as gastric banding (commonly known as lap banding).

 

Aggressive measures to lose weight are not just for cosmetic reasons.  Many people undergo bariatric surgery due to medical problems associated with obesity–such as diabetes and hypertension–or to reduce the likelihood of later developing obesity-associated chronic illnesses, including cardiovascular disease.  Though it is a misconception that you have to be overweight to have obstructive sleep apnea, it is true that your chances of having sleep apnea increases substantially if you’re overweight or obese.  Over the years a great many of my sleep apnea patients have undergone such gastric procedures, usually with great–and even dramatic–success.  Usually these folks experience a gradual improvement in their baseline sleep apnea as the weight loss progresses, and in some cases the sleep apnea may go away completely with sufficient loss in weight.

It’s important to know that a sleep evaluation is usually a standard, integral component in the overall assessment for one’s fitness for bariatric surgery, not only because sleep apnea is a common medical problem for overweight people, but also because sleep apnea represents a peri-operative risk, particularly following extubation while recovering from anesthesia.  Often I am called upon to evaluate a bariatric candidate’s sleep well prior to surgery.  If sleep apnea is diagnosed, treatment is initiated and continued.  In addition, the patient and the physician sleep specialist should interact regularly in the months following surgery.  If CPAP (continuous positive airway pressure) is utilized for the patient’s sleep apnea, for example, the CPAP air pressures likely will start to feel uncomfortably strong as the weight goes down, and adjustments will need to be made accordingly.  Mask and headgear fit often also require adjustments and re-adjustments.  Finally, once the weight has “plateaued” (such that no further substantial weight loss is anticipated), it’s standard to reassess the patient formally to determine the extent to which the pre-existing sleep apnea has improved or, hopefully, resolved completely.

There are many great bariatric programs around the country.  They offer hope to many people that have utilized more conservative measures to lose weight with limited success.  I wish the very best for Governor Christie.

Have a great evening, everyone!

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Happy National Sleep Apnea Awareness Day!

I’m sure this is common knowledge to most all of you, but today, the 18th of April, is National Sleep Apnea Awareness Day.  All RIGHT!  In a week full of terrible, tragic national events, we need something to celebrate!

Increasing awareness of sleep apnea is part of my job.  However, there is a selection bias of sorts at work:  by the time patients with probable sleep apnea come to my clinic for a visit, they usually come with some at least rudimentary awareness of the disorder, or else they may well not have come in the first place.  So it’s nice to use this written forum for the purpose of raising public awareness as well.

Obstructive sleep apnea is a medical disorder in which one’s upper airway collapses down during sleep.

The closure of the upper airway in and around the throat causes your blood oxygen levels to become low and your carbon dioxide levels to become high, because air doesn’t flow into the lungs properly.  These chemical changes in your blood are toxic to your brain (among other organs), which responds by forcing you awake frequently throughout the night to relieve the obstruction.  These awakenings are often so brief you don’t recall them (though occasional brief gasping sensations or snorting sounds may be perceived suddenly out of sleep by those suffering from sleep apnea), but if this occurs all night long your sleep becomes so disrupted and of such poor quality that you end up feeling tired, fatigued, and sleepy during the day.  Sleep apnea is often associated with substantial snoring, and bed partners may also witness stoppages in your breathing while you are sleeping, followed by a choking or gasping noise when you arouse briefly because of the low oxygen levels.

About 42 million Americans have obstructive sleep apnea.  Please think about this for a moment:  that’s huge numbers of people.  It’s estimated that about 25% of adult patients seen in primary care clinics have sleep apnea.  And out of these millions of people with sleep apnea, the substantial majority of them have not yet been diagnosed.  Why?  Sleep apnea symptoms are easy to blow off because 1) they’re usually not physically painful (unless you wreck your car due to falling asleep behind the wheel, of course), 2) you’re not awake to experience the breathing pauses first-hand, 3) you’re not awake to hear your own snoring, 4) people tend to get used to the feeling of chronic drowsiness, such that daytime fatigue eventually just feels normal, 5) many people don’t feel that suffocating in their sleep is an emergency (!), and 6) some think it would be a pain or an inconvenience to get evaluated.  Add in our country’s financial problems and increased insurance deductibles, and you have lots of incentives not to make that clinic visit.

I encourage you to consider a few points, however.  These days, treatments for sleep apnea are excellent and usually very successful with proper ongoing support from the physician sleep specialist and the sleep center.  It’s very gratifying to hear my patients tell me about the dramatic, life-changing “night and day difference” they often feel as a result of treatment.  People feel much more awake and alert during the day, there is much less sleep disruption at night, and, as an added bonus, the obnoxious snoring GOES AWAY, making spouses and bed partners very happy.  I’ve had patients’ spouses hug and kiss me out of happiness!  Finally, it’s important to know that untreated sleep apnea is clearly associated with an increased risk of developing medical problems, including early heart failure, early heart attack and stroke, high blood pressure, and sudden death during sleep.

There are excellent ways to diagnose and manage this huge problem, but such things do not come to pass unless the sleep apnea sufferer recognizes and acknowledges that there is a problem and seeks an evaluation.  My recommendation would be to seek the services of a well-trained physician sleep specialist in a sleep center accredited by the American Academy of Sleep Medicine (AASM).  To find an accredited sleep center in your area, try this weblink:  www.sleepcenters.org

Happy National Sleep Apnea Awareness Day, everyone!

To Dream of Drowning

 

It’s a sleep experience shared by many:  awakening abruptly from a dream, wet with sweat, grateful that you’re not actually drowning.

Our recalled dreams often consist of imagery that is unpleasant.  Visual images can range from monsters to some amorphous figure coming after you.  Just as frightening, however, are the formless, soundless sensations you may feel given the place and circumstance you’re in during the dream.

One dream element that I often hear about in clinic is the feeling of drowning or suffocating.  This sensation is described by my patients in many various ways:  the imagery can be very specific, such as swimming in the middle of the ocean, sharks and fish surrounding the dreamer as he or she is slowly but surely pulled under the surface, or vague and nonspecific, such as the general feeling of air escaping the lungs and throat.  The feeling of asphyxiation may be associated with imagery of water submersion, a premature burial, perhaps, or hands or rope constricting one’s throat.  Common to these different scenarios, however, are the terror felt upon abruptly arousing from the dream and substantial relief upon realization that it was a dream.  Sometimes patients suddenly sit bolt upright out of breath, or even jump out of bed and run to an open window to get some air, because the sensation of breathlessness is so intense and uncomfortable.

Such dreams may occur out of nowhere and for no discernible reason.  However, there is a sleep disorder that can often cause people to awaken abruptly from a dream with the sensation of air hunger.  Obstructive sleep apnea is a breathing disorder in which one’s upper airway collapses or closes down episodically during sleep.  One thing that is important to know is that sleep apnea is often made worse in the setting of rapid eye movement (REM, or dream) sleep.

There are a couple reasons why this is the case.  We humans naturally breathe more erratically during REM sleep.  In addition, during REM sleep most of your body muscles are temporarily paralyzed (otherwise we’d all be in bed physically enacting our dreams); under normal circumstances, there is minimal sustained muscular tone while you’re dreaming.  Your airway therefore may be more prone to collapse, and for longer periods of time.  As such, people with untreated sleep apnea often demonstrate a substantially worsening of the sleep apnea during dream sleep:  in analysis of overnight sleep studies, for example, it’s common to see longer pauses in breathing and dramatically more severe blood oxygen abnormalities during REM sleep as compared to during other sleep stages.

So here is my suggestion.  If you awaken abruptly from dream imagery of drowning or suffocating, such that you feel like you had not been breathing or like you were not getting in enough air, ask your bed partner if you’re snoring loudly, gasping, or sounding like you’re stopping your breathing during sleep.  If there are no bed partners or roommates, ask yourself if you’ve awakened hearing a brief snort or with a brief gasping sensation out of sleep, including without preceding recollection of dream imagery.  Also determine in your mind if you have daytime sleepiness:  a tendency to fall asleep by accident while sedentary during the day or to become drowsy when you shouldn’t, such as while driving.  If you’re experiencing such things, you probably would benefit from seeing a doc like me.  Sleep apnea is an imminently treatable problem, and this frightening sensation of dreaming of being underwater usually evaporates with treatment.

Have a good day and stay dry, everyone!

 

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!