Tag Archives: Sleep apnea

Participate in Sleep Apnea Research!

I hope you are enjoying this hot and crazy summer!

As you know, we in clinical sleep medicine are here for you.  Without patients in need of help for their sleeping problems, there would be no physician sleep specialists, no sleep centers, no sleep medicine.

Sleep medicine is an independent medial subspecialty, just like cardiology, pulmonology, and neurology.  Though sleep medicine remains focused on the clinical evaluation and management of sleep disorders, it also must continue to move forward in innovation and search for answers to unknowns in our field.  These essential aspects of our work can only be accomplished through research.

An organization called SAPCON (Sleep Apnea Patient Centered Outcomes Network) is dedicated to promoting sleep apnea research around the country.  Organized in conjunction with the American Sleep Apnea Association, it is one of the largest networks to advance sleep apnea research.  My friend and mentor, Dr. Vishesh Kapur (Professor of Medicine, University of Washington; Steering Committee Member, SAPCON), asked me recently to spread the word about SAPCON, which has created a website designed to develop a sleep apnea patient community that will learn about and contribute to sleep apnea research.  Sleep apnea apnea patients may now easily connect with health care providers and researchers to share ideas and needs.  As Dr. Kapur puts it, through the website “patients will be able to learn what is new in sleep apnea research, suggest new areas of focus for sleep apnea research, and participate in research if they choose to.”  The website also contains valuable online tools to help you manage your sleep apnea.

The website:  www.myapnea.org

I encourage sleep apnea patients and their loved ones to visit the site and see all that it has to offer.

Stay cool and sleep well this summer, everyone!

 

Diabetes and Sleep Apnea–Increasing Evidence of a Link

Here’s hoping you’ve recovered from Thursdays’ turkey debauchery!

 

November is National Diabetes Month, and as we wrap up the month I want to bring to your attention an article recently published in the Huffington Post regarding diabetes and obstructive sleep apnea.  Recent published literature demonstrates that up to 7 out of 10 diabetic people have sleep apnea.  Those are astounding numbers considering how many people are diabetic in the United States.

Rather than repeat the contents of the article (written by my academy’s president, Tim Morgenthaler), I’m providing the link to it here:

http://www.huffingtonpost.com/timothy-morgenthaler-md/type-2-diabetics-get-eval_b_6214504.html?ncid=fcbklnkushpmg00000030

There are many reasons to be concerned about this connection.  First, obstructive sleep apnea is still a very under-recognized, under-diagnosed problem.  Epidemiologic studies show that out of the millions of Americans with sleep apnea, only about 15% have been diagnosed!  Second, there is increasing evidence that sleep apnea affects metabolism and weight more deeply and in more ways than originally thought.  Finally, both sleep apnea and diabetes are risk factors for the development of heart disease, such as heart failure, early heart attack, atherosclerotic disease, and rhythm abnormalities.

Diagnosing and treating sleep apnea early have the potential of making the sleep apnea patient feel MUCH BETTER and more awake and alert during the day, but among the fringe benefits are that the SNORING STOPS and hopefully there may be a REDUCTION IN RISK for cardiac disease.  I can’t underscore enough how important it is to seek medical help if you’re chronically sleepy during the day, snoring substantially at night, and having breathing pauses or choking or gasping events during your sleep.

Some of my readers may know that I’m back in school, which is why I’ve not been writing as much recently.  However, winter break will soon be here, and I will write more on the topic of sleep deprivation in the near future.  I wish you and yours’ a most peaceful (and snore-free) holiday season!

Former NFL Star Aaron Taylor Discusses the Importance of Sleep Apnea Diagnosis and Treatment

I must admit that, two months following Super Bowl XLVIII, I’m still flying high from our Seattle Seahawks’ resounding victory.  The win has also served to take some of the sting out of my Kansas Jayhawks’ second-round loss in the NCAA national basketball tournament several weeks ago.

Well, back to sleep problems.  If you’re reading this you probably have heard of a common but under-recognized, under-diagnosed sleep disorder called obstructive sleep apnea.  This is a breathing problem during sleep, in which one’s upper airway episodically collapses or closes down while asleep.  A study recently published in the Journal of Clinical Sleep Medicine has demonstrated that sleep apnea is independently associated with an increased risk of cancer, stroke and death, and that apnea sufferers are 4 times more likely to die if the sleep apnea is left untreated longterm as compared to people who do not have the problem. (1)

My wonderful and patient readers have had to put up with my many posts regarding the importance of diagnosing and treating sleep apnea.  Now it’s time to hear from another authority on the subject:  Aaron Taylor, former NFL offensive guard (Packers and Chargers) and now a sports analyst for CBS College Sports.  Recently Taylor was interviewed and featured on CNN’s The Human Factor.  Here he is, talking about his own journey through the discovery and management of his sleep apnea.

http://www.aasmnet.org/articles.aspx?id=4703&utm_source=WeeklyUpdate&utm_medium=email&utm_campaign=wu-4-18-14

All too frequently I hear from my patients about their longstanding symptoms of daytime fatigue and sleepiness, loud snoring, and gasping sensations out of sleep, and how something kept them from getting properly evaluated in a timely fashion:  lack of motivation or time, acclimatization to their symptoms, some misconception about the treatments.  However, for many sleep apnea sufferers, treatment can be a total life-changer, resulting in profound improvements in daytime energy levels and wakefulness, a resolution of snoring and breathing pauses during sleep, and, hopefully, reduced risks of developing medical problems in the future.  I appreciate Aaron Taylor’s advocacy in bringing sleep apnea awareness to the forefront.

 

Have a great weekend, everyone!

(1) http://www.aasmnet.org/jcsm/ViewAbstract.aspx?pid=29425&utm_source=WeeklyUpdate&utm_medium=email&utm_campaign=wu-4-18-14

“Why is My Mouth So Dry With CPAP Use?”

I must have struck a chord with yesterday’s post on dry mouth, given the responses I’ve received.  Dry mouth is a very common symptom associated with sleep.  So let’s continue this topic, but with a little twist.  Do you awaken with your mouth feeling dry during a night of CPAP use?

As mentioned briefly yesterday, obstructive sleep apnea (OSA) is a sleep disorder of breathing associated with episodic collapse of your upper airway while you are sleeping; sleep disruption, gasping sensations at night, witnessed breathing pauses during sleep, substantial snoring, and daytime sleepiness are common clinical features of this very prevalent but under-recognized medical illness.  CPAP (continuous positive airway pressure) is a primary form of treatment for OSA.  CPAP is an electronic device which pressurizes room air and gently sends it down the throat via a mask to keep the airway open all night.  If properly used, CPAP stops the snoring and breathing pauses, deepens your sleep dramatically, and therefore makes you feel much better and more awake and alert during the day.

 

Some still think of CPAP use as a primitive, invasive, or unavoidably uncomfortable medical therapy based on what they’ve seen or heard a decade or more ago; this is unfortunate, in part because many people end up foregoing medical evaluation and treatment for their sleep apnea for many years based on an erroneous perception of what their treatment may be like.  There are now dozens of mask interfaces available, each with different sizes; the CPAP devices themselves are much smaller and quieter than they used to be, with lots of bells and whistles to make them more comfortable and easier to use.  If used properly and if you are willing to use it, CPAP can be an absolute game-changer; untreated sleep apnea can wreck your life, and proper treatment can dramatically turn things around.

Having said that, though, there are lots of potential ways for CPAP use to go wrong, causing people to have difficulties using it or to stop using it altogether.  I will write about these problems more in later posts, but one problem some CPAP users may have is dry mouth.  The majority of CPAP users don’t have substantial problems with this, but if this is relevant to you or someone you know, read on.

Presuming that your dry mouth isn’t caused by one of the problems I wrote about in yesterday’s post, and if the dry mouth started or became much worse after having started CPAP, most likely this symptom is caused by oral leak or oral breathing.  Your jaw muscles naturally tend to relax when you fall asleep.  In some cases, the lower jaw (mandible) may then drop slightly due to gravitational forces.  If you are using a nasal mask (i.e., a mask that covers your nose but NOT your mouth) or nasal pillows (i.e., soft prongs which are placed gently at the entrance of your nostrils), and if the mouth opens a little, then air from the CPAP device may then divert and escape out of your mouth.  This is obviously a problem.  The air dries your saliva, first of all, causing you to awaken more from sleep with that uncomfortable, parched, “Sahara desert” feeling in your mouth.  Just as importantly, though, if air is leaking out of your mouth and escaping into the open space instead of going down your throat the way it should be, then you aren’t being adequately treated because your airway may again be predisposed to collapse due to insufficient air pressure.  So due to sleep disruption and inadequate treatment, oral leak can lead to a perception that CPAP doesn’t work because you may still feel sleepy during the day despite CPAP use.

Oral leak is a very fixable problem.  Don’t turn your CPAP device into a very expensive doorstop because of it.  Before reading how to repair oral leak below, though, make sure you’ve determined where the dryness is; this is particularly important because people often don’t actually feel the air coming out of their mouths, because the leak happens while they’re asleep (when you awaken your muscles abruptly regain their tone and the mouth usually closes).  If the sensation of uncomfortable dryness is in the nasal passages and/or the back of the throat, but NOT in the mouth, oral leak is probably NOT the problem; I would suggest increasing the heated humidity in your CPAP device if this is the case.  However, if the dryness is clearly localized to the mouth chamber–with a pasty sensation in the mouth, for example, a feeling of having to “peel” your tongue from the roof of your mouth, dryness of the lips and teeth–oral leak is then likely the cause.

1.  If you’re using a nasal mask or nasal pillows and you like your current setup, a chinstrap is usually effective.  When wrapped gently around the head, it mechanically keeps your mouth gently closed.  It does not need to placed tightly; it should be just secure enough to be effective, but not so tight it’s uncomfortable.  People usually become accustomed to chinstrap use pretty quickly.  Many straps are made of thin neoprene.  However, particularly for my patients who are more heavyset or who have larger neck circumferences, I prefer a “deluxe” or “heavy-duty” chinstrap, which is wider and made of less stretchy material and therefore more likely to be effective.  An added bonus:  in some cases chinstrap use can be temporary; over time you may find that tendency toward oral leak has stopped after having discontinued the use of the strap.

2.  Another way of addressing oral leak is with the use of a full face mask, which covers both the nose and the mouth.  There are now many different full face masks available on the market.  Potential issues with full face masks, however:  since they’re larger masks, they may be more prone to leak than smaller masks; also, they don’t keep the mouth from opening, so you can still have some dry mouth if air continues to go in and out of your mouth (though usually substantially better).  Try increasing the heated humidity (which usually comes standard) in your CPAP device should this be the case.  But if you’re already using a nasal mask or nasal pillows and you’re comfortable with your current setup, a chinstrap usually does the trick with relative ease.

3.  Finally, as mentioned in yesterday’s post, addressing problems causing decreased airflow through the nose (such as seasonal allergies, hay fever, sinusitis, or anatomic nasal disorders) may well reduce the tendency to open the mouth during sleep.  Consider a visit to your primary care physician or an ear, nose, and throat doctor should you have symptoms that suggest such problems.

Sleep well tonight, everyone, and stay warm!

“Why is My Mouth So Dry at Night?”

Many of us have experienced this problem at one point or another during our lives:  awakening with that nasty sensation of uncomfortable dryness in the morning.  Your saliva–or what’s left of it–feels like paste; there’s that funky, faintly cheesy taste in your mouth that you’re sure doesn’t smell good either.

 

Dry mouth, or xerostomia, can be a particular problem at night.  Saliva is necessary to protect and lubricate the structures of the mouth and throat, as well as their fragile mucosal linings, from friction, foreign particles (food), and virulent organisms (viruses and bateria).  While sleeping, your salivary glands naturally and normally slow down production of this saliva, and so in some respects it may be natural to awaken feeling like your mouth is a little dry.  In some, however, dry mouth at night or in the early morning can be a substantial problem and a source of genuine discomfort; the words “Sahara desert” and “bone dry” are often used by my patients, for example, to describe this unpleasant sensation.

There are a number of potential causes for substantial dry mouth.  Aging into your 70’s and 80’s, for example, often further slows down saliva production.  Dehydration and metabolic imbalances may cause dry mouth as well.  Certain medical disorders, such as Sjögren’s Syndrome and lupus, often are associated with dry mouth, as are a variety of different medications, such as antihistamines, certain blood pressure lowering drugs, diuretics (“water pills”), and anti-depressants.

Another important thing to think about is whether your mouth is open while you are sleeping.  For many open-mouth breathers, the lower jaw (mandible) may naturally fall a little due to a combination of gravitational effects and jaw muscle slackening while asleep; some may be predisposed to this tendency more than others, and other factors–like body weight, neck circumference, and body position(s) of sleep–may influence mouth opening during sleep as well.  However, it’s important to know if there are other problems that may cause chronic mouth opening during sleep as well, in particular things that can cause nasal congestion or other decreases in airflow through the nasal passages–such as chronic allergies, a substantially deviated nasal septum, and sinus infections.  It stands to reason that if you can’t breathe properly through your nose, your mouth may be more likely to open during sleep to maintain proper airflow.

Another problem is that obstructive sleep apnea (a breathing disorder in which the airway collapses during sleep) is commonly associated with open-mouth breathing and, hence, mouth dryness and throat and oral irritation at night or in the morning.  People with sleep apnea often snore loudly.  Now keep in mind that you can snore with your mouth or closed (try simulating snoring with your mouth open and then with your mouth closed; you’ll see what I mean), but the snoring is generally louder with your mouth open.  As a result, sleep apnea can be more noticeable to a bed partner, because the snoring is more bothersome and the loudness of the snoring provides a greater sound contrast when you sound like you stop your breathing during sleep (which is what the sleep apnea does, due to blockage of the upper airway).  So as a clinician, I actually look at the open-mouth breathing as, in a paradoxical way, a good thing:  it makes the sleep apnea more bothersome to both the patient and the bed partner, thus making it more likely to be brought to the attention of a physician (studies demonstrate that in the United States, about 85% of sleep apnea cases are still not yet diagnosed!).

So here are my first take-home points of 2014!  I recommend that you consider these possibilities if you frequently awaken with xerostomia.  Bring symptoms consistent with reduced airflow through your nose to the attention of your doctor when you speak with him/her about the dry mouth.  If your oral symptoms are accompanied by a history of substantial snoring, and certainly is someone is telling you that you sound like you’re also stopping your breathing during your sleep, I strongly urge you to discuss these important issues with your doctor and consider an evaluation by a person like me, a physician who specializes in sleep medicine.

Have a great week, everyone!

 

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!

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?”