More than 18 million Americans have obstructive sleep apnea, which is a potentially life-threatening condition that can cause someone to stop breathing during sleep, sometimes dozens or even hundreds of times each night. If not treated, sleep apnea can cause serious health complications.
It is estimated that four out of five of all moderate to severe cases of obstructive sleep apnea go undiagnosed. But what is sleep apnea? How does someone know they have it? Sleep apnea is basically when someone has a period during sleep where they quit breathing, or a shallow breath, which is called a hypopnea, both of these cause the oxygen to go down and very quickly our brain senses something isn’t right and arouses us from a deeper to a lighter level of sleep, so we resume breathing. These repeated arousals can tip us into irregular heartbeat, especially atrial fibrillation, which can lead to blood pressure and heart problems.
Sleep breathing issues, and especially obstructive sleep apnea, can be dangerous to your health. During this podcast, Board-certified ENT and Sleep Medicine Physician Phil Lee, MD talks through how to recognize the problem, and how best to get tested and, if needed, treated for it.
Welcome to Mason City Docs on Call, a podcast series with North Iowa specialists who educate us about how to stay healthy. I’m your host, Carol Gifford.
More than 18 million Americans have obstructive sleep apnea, which is a potentially life-threatening condition that causes you to stop breathing during sleep, sometimes dozens or even hundreds of times each night. If not treated, it can cause serious complications for your health. It is estimated that four out of five of all moderate to severe cases of obstructive sleep apnea go undiagnosed. With us today is Dr. Phil Lee, a board-certified ENT and sleep physician at the Mason City Clinic, who will help us understand how and why sleep is very important to our overall health and how to diagnose and get treated for sleep breathing disorders. So welcome to the program, Dr. Lee.
Good morning.
So, tell us why is sleep so important to our health?
Well, sleep is restorative and without it we don’t function well. Most adults need in the range of seven to eight hours of sleep and without it, we just don’t function well. Unfortunately, a lot of people during their working years don’t have enough time for sleep and try to get by, especially during the week, on four to six hours and catch up on the weekend, and not really doing the best they can.
So in the introduction, I talked about obstructive sleep apnea. So, define it for us in sort of medical terms and who suffers from it the most.
So, sleep apnea simply means that we stop breathing with sleep. 97 or 98% of sleep apnea is obstructive in nature, meaning the throat tissues collapse together and obstruct the airway. In a few percent, it’s central apnea where the brain doesn’t tell us to breathe and that’s a rarity. But obstructive sleep apnea is the vast majority. And in general, as we sleep, our muscles relax, allowing the tissues of the throat and especially the tongue, the palate, the uvula, and the tonsils to collapse together, leading to snoring and periods of obstruction where we don’t move air.
And so when you’re normally just falling asleep, don’t all of those, your tonsils and your throat, that just naturally relaxes? Like what’s the difference between falling asleep and your throat relaxing versus obstructive sleep apnea?
So in all of us, as we fall asleep, our muscles relax and allow the tissues to collapse together. In REM sleep, our muscles are actually paralyzed, other than our breathing muscles and the little muscles that move the eyeball to account for the rapid eye movements for which REM is named. And so there will be greater collapse. And the best analogy I can give you is think of moving air through a collapsible tubing. And depending on the size and the structural characteristics, it may collapse, and if the throat is big enough and sturdy, it will not collapse. But if there’s some narrowing of the airway and then with sleep and the relaxation of the muscles, the airway can collapse. Things that can make it worse are obesity, alcohol, not breathing adequately through the nose, sleeping on our back are all part of this.
So when people are coming into your office, what are they saying in terms of their symptoms that may suggest to you they could have sleep apnea?
Well, by far the most common is the bed partner coming in and telling how much they snore. And men by far are more snorers than the women. In general, probably 60 to 70% of men will snore. Women may be 40 to 50% and children may be in the range of 20%. But the usual presenting symptom that comes is snoring. Now beyond that, when the bed partner starts talking about periods where the patient quits breathing at night, and then when we start hearing about tiredness during the day despite an adequate amount of sleep, and especially when there are associated heart issues, high blood pressure, atrial fibrillation or other irregular heartbeat, heart attacks, strokes, this all is related to obstructive sleep apnea.
So does obstructive sleep apnea create some of these heart issues or if someone has heart issues already, does sleep apnea make it worse?
Well, I think both. I think both. So when we have a period where we quit breathing, which is an apnea or a shallow breath, which is called a hypopnea, both of these cause the oxygen to go down and very quickly our brain senses something isn’t right and arouses us from a deeper to a lighter level of sleep so we resume breathing. And it’s these repeated arousals that will tip us into irregular heartbeat, especially atrial fibrillation, leads to blood pressure issues and heart issues.
So how does someone properly get diagnosed for sleep apnea?
So you need a sleep study and up until five or 10 years ago, this meant going to the sleep lab and having an overnight sleep test and we’re asking people to go sleep in a place that isn’t their bed, it isn’t their bedroom, and then attached a number of wires, and often they don’t sleep very well. And in-lab testing tends to be a bit expensive, so insurance doesn’t like that. So it has really transitioned in recent years to home testing and home testing can be done in the patient’s bed in their bedroom. And I think in general they sleep better.
Now there are limitations with home testing and specifically with home testing, we don’t know sleep time. We have recording time; we don’t have sleep time. And so if we do a home test and it is positive for sleep apnea, we can act upon that result and treat the patient. However, if the home test does not confirm a diagnosis of sleep apnea, we cannot with certainty rule out sleep apnea. It is possible they don’t have sleep apnea or it’s possible they just didn’t sleep well and we miss the diagnosis.
So if they aren’t diagnosed with sleep apnea in a home test, but you still sort of suspect they might have sleep apnea, what would you suggest then?
Well, there are a couple of options. One would be to repeat the home test and sometimes the second night when they have more of a sense of what’s going to happen there, they will sleep better and we might confirm the diagnosis. But the best answer would be to say that we would ask for an in-lab sleep test.
So once you get a positive result for sleep apnea, what are the treatment options?
So I think the gold standard is CPAP, which stands for continuous positive airway pressure. It’s a device about the size of a shoebox that will sit on a table next to your bed attached with a hose and then a mask that can cover your nose and mouth called a full face mask, or a nose mask that just goes over the nose. And the CPAP delivers just enough air pressure to keep the tissues from collapsing together. It’s nothing more than some air pressure at an appropriate pressure. Many people think it’s delivering oxygen and it is not. It’s just appropriate air pressure to keep the airway open.
And so that’s the gold standard. I’m assuming there’s different treatments depending on how severe the apnea is?
Exactly. And so CPAP is good for all degrees of severity of the sleep apnea. And we should back up and talk about a couple definitions first. So when we talk about sleep apnea, how many events per hour qualify for sleep apnea? So we’re looking throughout the night, how many times do you quit breathing or have a shallow breath, which is called your apnea-hypopnea index? Zero to four is normal, five to 14 is mild apnea, 15 to 30 is moderate, greater than 30 is severe. So for all levels of severity, CPAP is appropriate. Now for mild to moderate apnea, there is a device called the oral appliance or mandibular advancement device. And this looks like a football player’s mouth guard, and it is fashioned by your dentist and it is adjustable. And when it is worn, the lower jaw is pushed forward in relation to the upper jaw and the tongue is attached to the lower jaw so we’re pulling the tongue forward. And that’s how it works.
And for mild to moderate apnea, the mouthpiece device is equivalent to CPAP. Now in and of itself is not without some side effects. As we pull the jaw forward, we can sometimes move the teeth and I’ve had a few patients that have stopped using it because of that. Some people will get teeth pain with this and then some people will get jaw joint pain. But it can be a terrific alternative, especially for the younger patient. So that works out quite well.
And then for I would say more severe cases, a mouth guard or an oral appliance is really not something you would recommend, right?
Well, it’s not first line therapy and yet if there’s a patient that will not use CPAP, then it’s absolutely better than doing nothing.
Got it. So I have heard about a procedure that you’re doing here in Mason City called Upper Airway Stimulation. I think the brand name is Inspire.
Correct.
And tell me a little bit about that and who would be a candidate for that kind of procedure?
So if you take a large group of patients that have sleep apnea and they have been advised to use CPAP, at best 50% will stick with CPAP long term for any number of reasons. So we know there’s a large group of patients that are untreated. And over the years in the ENT world, we have tried a variety of procedures to help with sleep apnea. And we can do things like make the nose more patent, we might remove tonsils and such, but we don’t have a good little operation to reduce the size of the tongue and yet still have it function to speak and move food around. And so Inspire is a new procedure in which we stimulate the tongue with each breath to move the tongue forward and open the airway.
Now to do this, we need three things. Number one, we need a current sleep test showing an apnea-hypopnea index between 15 and 65. And so that’s moderate to severe apnea. We need a body mass index somewhere in the range of 32 to 35, and that is dependent on the insurance company. And then we need a patient that has tried CPAP and the point is we should not be operating on people that can be treated with a non-surgical intervention. So these people need to have tried CPAP and then if they fail CPAP, then Inspire is an option.
And so for the patients that have been treated with Inspire after qualifying as you just described, what have the results been so far? I mean, have you heard from patients and how they feel after the treatment?
Absolutely. And so after the implantation, they are activated four to six weeks later. And what that means is that’s the day that we start using their Inspire device and find the appropriate voltage. And so on that day, we’re looking for the voltage that moves the tongue adequately and it’s probably where they start is not going to be their final voltage. And think of starting to lift weights. If you went to the gym and went to the heaviest weights to begin with, your muscles would be so sore, you don’t want to go back for a few days. Similarly, the tongue is a muscle and if we stimulate it too much, it can literally be sore the next day and people don’t want to turn it on the next night.
And so we start at a low voltage and once a week we ask the patient to move up their voltage and then somewhere down the road, two to four to six months after they are using it and getting good results based on their bed partner’s response to snoring and quitting breathing, we’ll actually do a sleep study in the lab where somebody is trained to adjust the Inspire. And that’s when we find out exactly what is their best voltage.
So when we think about CPAP, when you follow along patients on CPAP, an ideal result is we bring that apnea-hypopnea index down to zero to four. A good result is we make it 10 or less. And then an acceptable result is we reduce the original apnea-hypopnea index by 75%. So those are the CPAP guidelines. Nobody has similar guidelines such as that for Inspire, but the Inspire company has what they call the green pathway or the yellow pathway. And the green pathway, we’re happy with what’s going on, the patient is happy. And to be on the green pathway, there has to be a minimum of four hours of usage per day and we have to have reduced the apnea-hypopnea index to 15 or less. So that’s the minimum.
Now we make every effort to make it better than that, and my goal is always to get it under 10. And I would try to make it as good as we might get with CPAP. But remember, this is a group of people that would otherwise not be treated. And so sometimes we don’t make it as good as the CPAP can do, but at least they’re getting some treatment. Now on activation day, we find the appropriate voltage to move the tongue and we ask the patient to work up from there. And in 90% of the patients it’s very easy and they just move up and we find that final voltage and they stick with it. There’ll be a rare person that can’t move up because it’s uncomfortable. And so there are a lot of parameters we can adjust.
And for example, when we started this process, I was under the impression that while we’re taking a breath, we’re constantly stimulating the nerve to push the tongue forward. No, that’s not correct, because if you do that continuously, the nerve fatigues. So it’s little bursts of energy, actually 90 millionths of a second, 33 times per second is the default setting. So we can widen that pulse interval, we can change the number of times per second. And then we have four different electrode configurations all programming things, not requiring more surgery. But that’s my job to make the best possible result.
So Dr. Lee, if someone suspects or if someone’s bed partner suspects that they may have sleep apnea, what’s the best next step for them? Should they go see their primary care physician? Should they come see you at the Mason City Clinic or one of your colleagues in ENT? What’s the first thing they should do?
Well, either of those options is fine and many of the primary providers do start the process. And what we need to document for the insurance company to get a sleep test is that there is snoring, that they quit breathing, they’re tired during the day. And then if we can add to that that there is some associated heart issues, especially high blood pressure or heart disease or history of stroke, insurance will pay for a sleep study. And so it can get started in their primary provider’s office or they can come and see us and then we would review the sleep study and then talk about treatment options.
Okay. Well, thank you so much. I mean, sleep apnea really is a very serious condition. I think we didn’t know a ton about it even 10 years ago, certainly 20 years ago. And also the connection to some more serious issues, the heart issues you’re talking about. So thank you for this education and thank you for being on the program.
You are welcome.
Thank you for listening to Mason City Docs on Call. For more episodes, go to mcclinic.com/radio-podcasts.
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