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Introduction to Sleep Apnea

John Salak: Everyone seems to know someone who has sleep apnea, or at least thinks they have. [00:00:36] Sadly, they're probably right. Depending on who you ask, almost 40 million Americans, and roughly a billion people worldwide, suffer from the problem. What's even more frightening is that only 1 in 5 people who have sleep apnea have been officially diagnosed with a malady.

And this problem isn't going away. In fact, the overall number of people with this problem is only expected to grow in the coming years. All this means is that there are a lot of whys and whites surrounding sleep apnea. Not surprisingly, this fosters confusion about what the condition is, [00:01:12] its causes, potential harm, how to spot it, and how to treat it.

For the vast majority of people, sleep apnea refers to something that involves poor sleep and snoring, lots of loud snoring. The good news is that these reference points are correct. The bad news is, is that poor sleep and snoring fall far short of telling the whole story. Sleep apnea comes in a few different shades, but essentially it involves sleep related breathing disorders in which a person's airwaves are briefly blocked and they essentially stop breathing.

Obviously, [00:01:48] that's not a good thing, although usually people just wake up when this happens and they simply suffer from fitful sleep patterns. Yet, the consequences over time can be more serious, even deadly, if deep fatigue and other issues take hold, leading to cognitive problems, cardiovascular concerns, and an overall body breakdown.

Obviously, sleep apnea is nothing to discount or overlook, but since so many people don't realize they have it, it's easy to do, potentially turning a bad night's sleep into a major health risk. Thankfully, our [00:02:24] next guest is going to deliver a wake up call. On the problem's causes, high risk targets, symptoms, dangers, and treatments.

Listen up.

Understanding the Prevalence of Sleep Apnea

John Salak: Welcome to this portion of What the Health. And as we mentioned, we're going to tackle an issue that is everywhere right now. And that's sleep apnea. And we have the perfect person to speak about that. And that's Dr. Andrew Neyman, who is a member of the American Academy of Sleep Medicine, the public safety committee.

So Dr. Neyman. Welcome.

Exploring the Types and Causes of Sleep Apnea

John Salak: Sleep apnea is one of those phrases that's everywhere. Now you can't go into a doctor's office without somebody saying, have you been [00:03:00] checked for sleep apnea? But while we do a fair amount of work on it, or have done some coverage on it, I want you to explain so people have a working knowledge about of exactly what sleep apnea is. And is it one thing or many things? It is an umbrella phrase for many disorders or problems.

Andrew: Great question. There are a number of different sleep apnea syndromes out there for sure. Especially there are two major categories, obstructive and central. The most common that we see in our typical practice or in myself and during care of patients is the [00:03:36] obstructive apnea where patients are making effort to breathe.

But there's either reduced air flow or stop breathing altogether while they're sleeping. And when that happens, attributed to that and what we do in a sleep lab commonly, is we're looking at a drop in their oxygen level that occurs, and a reduction in flow for at least 10 seconds to qualify for that diagnosis.

Now, central sleep apnea is a little different, where you're not making any effort, no flow or reduced flow. And [00:04:12] again, 10 seconds with an appreciable drop in oxygen levels. Those two disease states differ based on the causality of those two diseases. Obstructive sleep apnea is what we commonly see among people who are, gaining weight or heavier or have craniofacial disease.

Central sleep apnea tends to be one related to other medical conditions, like strokes or folks with heart disease. And there are patients that are neither one or the other, but [00:04:48] both, and so some patients can have features of both. So, sleep apnea comes in a number of different flavors, too. So, we talked about central sleep apnea and obstructive.

But then there are folks that aren't quite completely obstructive, people that predominantly have low flows predominating, and that's called hypotenias. And then other people that have breathing related sleep different changes that can mimic sleep apnea and central sleep. [00:05:24] So it can, there's a large cadre of diseases associated with it.

And also conditions that can be a symptom of sleep apnea.

John Salak: Am I correct in assuming sleep apnea is always focused on the flow of oxygen or the ability to breathe or not to breathe or cutting off oxygen for some reason.

Andrew: That's correct.

John Salak: That's the central theme that goes through all of sleep apnea.

Andrew: Very essential.

The Impact of Sleep Apnea on Health

John Salak: How many people are affected by this?

Andrew: It has been estimated as many as a billion people worldwide. It's approximately 25 percent [00:06:00] of the population in the United States. And rates of this disorder are increasing for a couple reasons. One is The overall, body mass index has increased among patients across the United States, our obesity rates also people are living longer and when you have more conditions or medical problems, sleep apnea also tends to be more prevalent with more problems that you have.

So it's one of those things that happens because we're living longer with diseases [00:06:36] as well as patients. Our bodies are changing and we're getting heavier as a country and as a world.

John Salak: Does the environment play any factor in this? Just given the fact breathing this stuff in.

Andrew: In some instances, and not the most common our environment can, in fact, affect our breathing. And so when people with respiratory disorders that tend to be sensitive to their environment, they may actually demonstrate more what we call breathing related sleep disorders like sleep apnea, making it more challenging for those [00:07:12] folks.

For instance, a patient with asthma, that may be very sensitive to their environmental triggers. If they have sleep apnea as an underlying condition, they didn't know about it, and then they start having issues of asthma, They may notice more apnea like symptoms during their part of their acute illness.

So in ways that both conditions, can coincide with disease severity, a condition worse. It also can make the condition [00:07:48] more obvious. Maybe they didn't know they had it, and family members recognized it when they were sleeping with an acute asthma event, or what we call an exacerbation of their COPD.

John Salak: Okay. So we're having problems breathing at night. We're waking up, but I'm assuming there are other risks that either directly are caught from sleep apnea or perhaps sleep apnea is going to exacerbate or raise the risk level for. Other diseases, problems, some of which I assume could be pretty serious.

Andrew: There are a number of different risk factors with it, as you mentioned, [00:08:24] and we mentioned weight.

We mentioned for adults, mainly, folks that have what's called craniofacial changes. So, even though it's part of their normal anatomy, they were born with it, parents bequeathed it to them, people that may have a recessed jaw,

Tight nostrils, a narrow airway, all those things are looked at by physicians to say, you're a person that's at risk for breathing related sleep disorders or sleep disorder breathing. The other conditions that can make it worse, like I mentioned [00:09:00] to you, heart failure patients, can have more sleep apnea. So can patients that suffer strokes. Can have, if it affects their airway collapsibility, can affect sleep apnea.

People with neuromuscular disorders can have more apnea like episodes. And also folks that have other common breathing disorders like I mentioned already. So, these are very commonplace and as well as among patients who are diabetics. People that tend to be heavier, having issues sugar, [00:09:36] we've seen increased prevalence of sleep apnea, even in that.

John Salak: For someone who's diabetic, is it the diabetes that's raising the risk or the fact that they may tend to be heavier or overweight?

Andrew: More likely, they may tend to be heavier. And the sleep apnea actually can make their diabetes worse. So the stress of the apnea periods can heighten their nocturnal sugar levels.

John Salak: What risk does sleep apnea cause for people? Is it just you're going to have a lousy night's sleep or are there things that are, much more serious than that? Not that sleep isn't critical to your well being.

Andrew: No, [00:10:12] absolutely, and I appreciate you saying that. Because sleep apnea does cause a lot of insufficient sleep. where you have what's called micro arousals that lead to an unrefreshed night.

But sleep apnea alone has been attributed to high blood pressure, new onset rhythm disturbance, like atrial fib is one of those conditions, and also challenges with augmenting other conditions like I mentioned, even though it's more associated with heart failure, It can make heart failure worse.

John Salak: Interesting. Why do we [00:10:48] talk so much more about it today than it seemed like even three years ago, five years ago, certainly 10 years ago? I certainly don't go into the hospital a lot, but , I had an ankle replacement recently, and I was amazed they wanted to talk about because I was going to stay in overnight.

My sleep whether I had sleep apnea or not. I'd never been asked that question before. And again, not that I'm in the hospital overnight a lot, but a few times and I've never been asked that. So in general why do we talk about it so much now? Why is there so much greater awareness?

Andrew: Well, I think that's number one. Our science has gotten better. We have actually learned more and more about sleep apnea and its potential [00:11:24] impact. Sleep apnea has been one of those conditions that have been difficult to recognize, even for medical scientists. Understanding its impact is more long term.

So, somewhat It's more difficult to understand its impact to a person's health condition except with the, with very well designed long term studies that kind of say, Oh, we see that signal creating that problem. And so those have made it challenging for us to understand the impact of sleep apnea.

The second thing [00:12:00] of the additional, like we talked about, We're just getting heavier as a country and as a world, and as a result of increasing weights, we've seen a higher increase in sleep apnea rates, as well as like I mentioned to be before is that we are also living longer with comorbid conditions that are affected by sleep apnea.

So what we also recognize is that sleep apnea has been associated with folks coming to the hospital. And in some cases, like you said, you're maybe going to go through a, an [00:12:36] elective procedure and your doctor and the anesthesiologist ask you, Hey do you have these problems that we attribute to sleep apnea?

And so trying to minimize or mitigate those events in the hospital, whether you're oxygen drops, getting more pneumonias, or in fact, having a respiratory event may be avoided if identified and detected.

John Salak: Most people are going to think off the top of your head.

Identifying Sleep Apnea Symptoms

John Salak: Well, if you're snoring, You've got sleep apnea. There's probably some association, but is it an absolute [00:13:12] link?

Andrew: No, not at all. There's a lot of people that have just simple snoring disorders without any associated gasping. And I would say a lot of folks are like,

John Salak: What are some of the other symptoms? Before we get into testing and what are the potential treatments? Would we even know we had sleep apnea or would our partner know we had sleep apnea other than the fact you may be getting a lousy night's sleep.

Andrew: I will say, patients sometimes have a hard time identifying their symptoms when they sleep at night, because we're in that deep phase. Oftentimes, we recognize the problems of sleep [00:13:48] apnea from the bed partners raising the concern. He stopped breathing. One major symptom.

John Salak: Okay. Yeah.

Andrew: Choking at night. Another major symptom. You're waking up all the time and very restless and it appears to be related to your breathing and your snoring, symptom. And also, too, having issues where you just stop breathing.

So, those symptoms are seen in sleep apnea, not the only is seen.

And sometimes snoring is the only symptom a patient may have at night [00:14:24] and could be related to sleep apnea. But some of the other symptoms we see during the day. Feeling tired all the despite a good night's rest. Having difficulty with focus and memory. So having some snoring with some focus issues or memory loss that you can't attribute to anything else, or feeling unrefreshed after a night's sleep, and feeling sleepy during the day, where you want to take naps.

When everybody else doesn't want to and you're not accustomed to doing it. Or [00:15:00] falling asleep during passive activities like, sitting in a car for an hour, as the passenger. Or, talking to someone during conversation. Or, just relaxing in a park, feeling the pressure of sleep or dozing during that time.

John Salak: Yeah. And imagine and things like not breathing at night, it's really hard for the person I would assume, to recognize whether they do that. I swear I don't snore. But if my wife came on to this podcast yeah, he snores incredibly loudly. But, so it must be very difficult for the individual [00:15:36] to judge.

I mean, you can judge whether you're having lousy night's sleep, but it must be difficult to judge whether you have these other symptoms.

Andrew: Yes, it is difficult for them to judge and I often have patients that, don't quite believe their bit partner when they hear the story. So one of the things is I think our bodies have learned to accommodate challenges to our respiratory system and to our sleep. And as a result of that, the person with the sleep apnea oftentimes cannot believe what their bit partner is witnessing because they've lived with it for so long.

And those are some of the other [00:16:12] challenges. I mean, if you think, a stop breathing episode lasting 10 seconds with a drop in your oxygen level and you're not waking up fully to it, you're having what we call these micro arousals. Well, when we look at it, what we used to do is measure patients blood pressure during these episodes and very simply, the more severe the apnea, the higher the blood pressure in some cases.

Even reaching very high pressures and that's why it has been attributed to like high blood pressure control, strokes, heart attacks.

John Salak: What would [00:16:48] be the relationship to memory in sleep apnea?

Andrew: There's been actually quite a bit of studies looking at cognition and sleep apnea and I would say the impact is two fold. One, the number of sleep apnea events in unrefreshed sleep. And this is only a part of the equation, but the second is drops in oxygen levels. So if you're having drops in your oxygen level and arousals and stop breathing episodes and other, what we say, inflammatory mechanisms that start occurring as a result of [00:17:24] these events, it can affect.

Neurotransmission, affect some of the, what we call white matter changes in the brain. Some of these things have been well described in the literature, but still we're trying to understand it and try to identify mechanisms to mitigate those effects.

Right.

John Salak: So it's not simply a matter of not getting enough rest, which, again, has all sorts of horrible consequences over time, but there's an actual neurological impact that sleep apnea

That can be seen. Yes, sir. Not in everybody, but in [00:18:00] some.

Okay.

Testing and Diagnosis of Sleep Apnea

John Salak: So we kind of know what it is now, and I know we're taking, if not a 40, 000 foot view, probably a 5, 000 foot view.

We know what it is. We know it comes in different forms. Is there a simple test? How do we identify it once we go to a professional?

Andrew: Once your professional has identified that you have symptoms that are consistent with the possibility of sleep apnea, those are the folks that should be tested. And, there are a number of great new devices making it very easy for a patient to be tested.

Especially patients that are [00:18:36] relatively healthy and don't have a lot of medical conditions. And that is something called a home sleep test. And they come in a lot of different versions. But are very, have improved in their accuracy in identifying patients with sleep apnea. As well as help access for patients.

to getting a sleep study. Whereas before it was always inside a lab that comes through the second one where people are most familiar with. So now we can do studies at home called home sleep testing.

John Salak: Do they have to be [00:19:12] prescribed by a doctor or medical professional? They do. Okay.

Andrew: Yes, they do. Now, you have consumer technology that's out there that helps you try to understand if a person's at risk. Now, not all of those are well controlled or FDA approved for this stated indication. So, we always ask folks, go to the AASM website, take a look at consumer technology. We provide some great insight into that arena.

That being stated,

John Salak: And just, I just want to point out here, ASM is a medical, Academy of Sleep Medicine,

Andrew: American

John Salak: [00:19:48] American Sleep Medicine. Okay. I just want, okay. All right. Go ahead.

Andrew: Then at the same time a home sleep test that is approved, FDA and cleared by the a SM has been helpful, like I said, in accurately identifying patients with sleep apnea. Now, if you're a person that has a significant medical condition, I'll say it in those terms, like severe COPD or heart failure.

History of stroke or rhythm disturbance and your doctor feels like you're more appropriate for an in lab [00:20:24] test because it is our gold standard. It is our best test for identifying sleep apnea. It is a series of 12 procedures, leads placed on your scalp, above and below your eye. tubing across your nose and mouth, leads placed on your chin a strap across your chest and belly, EKG leads, oxygen detector on your finger, and leads on your legs.

And I tell you that as well as your, those folks that are listening, is to be prepared. Because it is the gold standard, it should be done [00:21:00] in the right patient. And you should do the right test when you're the right patient for that test. And avoid the simple test just because you're a little overwhelmed by the NLAB test.

Because we want to identify the patient that really needs to be identified.

John Salak: How long does that test take? Is that something you might see in a movie, you're in a sleep lab overnight and people are staring at you or something, how do I say less?

Andrew: It's a complete overnight study. So we want a representative sample of your sleep.

We want you to be under ideal [00:21:36] conditions. We would also want to be able to identify what a typical night is it for John. to sleep with a home study or an in lab study.

John Salak: How do people sleep in sleep labs? I don't know that I would ever be able to fall asleep in a sleep lab. And maybe people do. I mean, you're the expert, but it just seems like it would be so far and it would take me a while to get acclimated to that.

Andrew: It's a different environment. It takes a little bit more to settle down. But in sleep labs, we try to help people avoid their phones. So some people actually fall asleep a lot quicker. And then [00:22:12] the overall efficiency of patients sleep in the majority of time may be not as good As at home some cases better, but a majority take a little bit longer, but overall, give us a good

John Salak: So we've identified if somebody has sleep apnea whether it's a home test And maybe assuming some home tests maybe then are elevated to a full test But regardless we've identified somebody has sleep apnea. .

Treatment Options for Sleep Apnea

John Salak: What do we do now?

Andrew: Very good point. And it depends upon the sleep apnea, the severity of the sleep apnea, and that conversation with your provider. So, [00:22:48] for the patients with medical conditions that are symptomatic, a trial, a positive airway pressure, what is commonly referred to as CPAP. where you get a constant flow of air.

And if you think of the airway being like a donut and collapsing during sleep apnea, obstructive events, that, see, positive airway pressure keeps that airway open and in a better size, as well as maintaining that airway. Then, apneas don't occur. And so [00:23:24] it takes pressure to kind of inch that airway open.

That being stated, there are a number of different positive airway devices out there. There is something, and different ways we deliver that positive airway pressure, all in an effort to optimize that, the patient's interface with something that is foreign to them. And, but all for the benefit of reducing those events.

We talked about earlier, the snoring, the choking, the gasping, hopefully [00:24:00] relating to reprovement in their blood pressure or blood sugars and other clinical conditions.

John Salak: Can sleep apnea be cured or reversed? Again, it probably depends on the type. So is someone always going to have to use one of these devices?

Andrew: I've done this for Couple of decades and I've had patients who have been on it before they met me and are still on it today So that being stated Yes, in some cases people do live Their entire life with CPAP and are very happy that they do. I [00:24:36] also have patients that have been Challenged by CPAP and have sought alternative therapies of, which can also include, especially in those folks that have mild to moderate disease, something called an oral appliance, which is something a sleep dentist or a dentist that practices and sleep can provide to help keep the air, the jaw from collapsing and air advanced.

And then there are other therapeutics that are out there. that are intended to keep the tongue out of the way of obstruction and the back of the airway open, [00:25:12] something now called a hypoglossal nerve stimulator.

John Salak: Okay.

Andrew: been demonstrated to reduce the number of apnea events, as well as improve, hopefully, the long term outcomes of these patients.

John Salak: For those people who are suffering from sleep apnea or who have exacerbated their sleep apnea because they've gained weight, obviously losing weight is always a good thing. But would that relieve or possibly totally mitigate sleep apnea? Or once it sort of started, yes, it's good to lose weight, but you still may have an issue.

Andrew: I'm so glad you mentioned that point, because [00:25:48] there are a lot of folks that, position themselves to the side and their sleep apnea is much improved.

John Salak: Ah.

Andrew: Some people see a surgeon for their sleep apnea, which in some smaller cases improved. But like you said, we like to help our patients A, have a great or improve sleep hygiene.

Make sure their sleep environment is nice and cool. No distractors, no bright lights, no telephone close to the bedside. And we also like them to have a better sleep apnea life, meaning early [00:26:24] morning exercise routines, and trying to lose that weight that kinda may have actually been the cause of pushing them there.

But although we attribute it to weight alone is not the only cause for sleep apnea. And I don't want it to be the Assume that it only occurs in heavier patients. It does not.

20 percent of patients have a normal BMI. So, that being stated, in the heavy patient, optimize your weight.

Lose weight. That has been associated with reduction in at least the severity of [00:27:00] sleep apnea. And in some cases, it's been reported, resolution of their sleep.

John Salak: What are the percentage of people who actually cure or eliminate their sleep apnea? is it a matter of reducing it to a level or, and I don't mean it in a bad way, because we've identified a problem and you're working to help people address it.

Andrew: Yeah, some estimates with adequate weight loss, up to 10 percent of patients may have improvement or near complete resolution

John Salak: Interesting. All right. What we want to do is give people enough information so they feel confident to go to other sources for more. That's the goal of what we [00:27:36] do at WellWell and What the Health.

Certainly going to the academy, because we don't want to pretend we're the experts. We may be knowledgeable, but you're an expert. The point is, what do they do now? If someone wants to say, you I really, this is fascinating. I know I'm snoring. No, I'm not sleeping. Well, what are the next steps?

What do you want people to do or take away?

Andrew: I think having that conversation with their provider, and especially if they have symptoms, don't be afraid of it. And I tell people just, oh, I don't want to go through the expense or see a doctor regarding it. I tell you, you will save far more money [00:28:12] understanding your disease state, and many studies have shown that.

It's more cost effective for a patient's health to be identified for a problem, treat that problem, before seeing a specialist, let's say that being stated, what we want you to do is explore the symptoms.

Hopefully this podcast will help you identify some of those symptoms that have led to that discovery. Recognize that having a sleep study is very easy now and that it's accessible, not as expensive, and if it helps you identify the problem, you can then [00:28:48] go on to the road of recovery. And not all treatment is CPAP.

That there are a number of other therapeutics. Although CPAP is the standard of care for symptomatic sleep apnea with moderate to severe disease, it is also, and has been attributed with the longest data that we have for improving outcomes. It is still not for everybody. So, we have mild disease patients can Possibly receive other therapeutics like oral appliances, like I mentioned, and [00:29:24] moderate to severe patients, CPAP.

So don't be afraid of the treatment either. So have that conversation, explore the symptoms, be tested and try to achieve a better, healthier sleep apnea lifestyle.

Living with Sleep Apnea: Personal Experiences and Advice

John Salak: Now, final question, because everybody's going to ask this. How do you sleep?

Andrew: I sleep well. No, I'm just kidding. No I don't believe it or not, I try to live according to the words, so I exercise in the

John Salak: All right.

Andrew: My room temperature's cool. I don't have a TV in the room, and we [00:30:00] don't allow cell phones,

John Salak: Okay. All right.

Andrew: Now my 15-year-old will have issues with that,

John Salak: Okay. All right. That's fair enough. Dr. Naiman, thank you very much. This is great. Certainly people should visit the American Academy of Sleep Medicine to get more information. You are of course associated with the Academy's Public Safety Committee.

And we advise everybody to be proactive at everything they do. It's the best way. So, thank you for your time and your insights. And we hope we can have you back at some other time and talk about some other issues related to this.

Andrew: Thank you, John.

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Conclusion and Final Thoughts

John Salak: Okay, everyone listening should be a little more awake when it comes to [00:31:12] sleep apnea's causes, dangers, symptoms, and treatments.

Obviously, it's a problem we can't sleep on, if you forgive the pun. As always, it's important to recognize potential symptoms in yourself or a loved one and to get in front of the problem. So, first off, Be on the lookout for symptoms like snoring and chronic fatigue. Also, understand that men are more likely to suffer from the problem than women, and so are those who are overweight.

But that doesn't mean that women or lean individuals are not at risk. Ultimately, and most importantly, if you're concerned [00:31:48] about yourself or a loved one, see a doctor and get tested either at home or in rarer cases through a sleep lab. It's also important to keep yourself informed through people like our guest on this episode.

We, of course, want to thank Dr. Andrew Neiman for his time and insights, and we'd like to recommend connecting to the American Academy of Sleep Medicine as a starting point to learn more about the problem. Again, that's the American Academy of Sleep Medicine. Well, that's it for this episode of What the Health.

I hope you enjoyed it [00:32:24] and that you'll listen to more of our upcoming program. Thanks again.