Are You Ready For Some Football?

Indulge me for a moment.  Walk outside, stand quietly, and take in a deep breath.  What do you smell?  What is that that you sense?  You know what it is.  It’s the coming fall.

I love autumn.  Always have.  Even though I’ve been (thankfully) out of school for many moons now, the fall season to me is still all about the start of the new school year (now for my kids), intellectual beginnings and renewals, new activities, a prelude to colder weather and the holiday season, and, of course, that great American institution, football.

 

 

Truth be told, I’ve always been more of a basketball fan than a football fan, but I thoroughly enjoy a good gridiron game now and then.  Our Seattle Seahawks are lookin’ great this year, but I have mixed feelings and loyalties regarding the upcoming preseason rematch with the Green Pay Packers, my first NFL love (having spent 5 years of my childhood in south central Wisconsin).  Admittedly, what I love more than the game itself is the feeling of football season:  those bright crisp autumn days, the stadiums, the pulse of the marching band (in which I participated all through high school), tailgating parties, communion with close friends while rooting for our team.  That nondescript but powerful feeling remains part of why autumn has always been my favorite season.

Why is football pertinent to a discussion regarding sleep, other than sleepless nights from all the excitement?  Football players–particularly defensive and offensive linemen–have a particularly high risk of having obstructive sleep apnea, a breathing disorder in which prolonged pauses in breathing–due to closure of the upper airway–are followed by brief arousals from sleep, thus leading to symptoms such as nocturnal sleep disruption and substantial daytime sleepiness and fatigue.  Unfortunately, untreated sleep apnea increases the risk for developing heart disease, high blood pressure, and sudden cardiac death during sleep.  Reggie White, for example, was a Green Bay Packer whose tragic, unexpected death at 43 years of age has been attributed to sleep apnea.

 

People often–and mistakenly–presume that you need to be obese to have sleep apnea.  Though certainly it is true that being overweight increases your risk of developing sleep apnea because of increased soft tissues surrounding your airway, you don’t need to be obese to have the problem.

Many or most college and professional football players are not necessarily obese, per se, but they tend to be big people, obviously, often with large necks due to hypertrophied neck strap muscles.  In general, having a big neck does increase your statistical risk of developing or having sleep apnea.  In a clinical setting, the magic number is 17:  adults with shirt collar sizes of 17 or higher are at increased risk.

 

Earlier this month, the American Academy of Sleep Medicine announced its campaign to raise awareness of sleep apnea in football players.  CBS Sports college football analyst Aaron Taylor (also formerly a Packers player) is helping the AASM get the word out regarding the importance of diagnosing and treating sleep apnea:  he himself has been diagnosed with this disorder, and he has enjoyed substantial clinical benefit from being treated.  I appreciate the fact that Mr. Taylor is encouraging athletes to consider sleep apnea diagnosis and management.

 

To read more of Taylor’s story, click here:

http://www.sleepeducation.com/news/2013/08/08/aaron-taylor-warns-young-football-players-to-be-aware-of-sleep-apnea-risk

The take-home point here tonight is that certain athletes are at risk of having sleep apnea–such as football players and wrestlers–in part related to increased neck size, even if not due to fat.  If you know someone who is a football player, and if that person is a loud snorer who tends to feel tired and sleepy during the day, it may well be beneficial for that person to seek medical attention.  Treating sleep apnea can result in dramatic improvements in levels of energy and wakefulness during the day, and may even improve muscular strength and athletic endurance.  Then, hopefully, everybody wins:  players, families, teams, and fans!

It should be a great football season, y’all, and not a bad prelude to Jayhawk basketball!  Cheers, everyone!

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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!

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!