By now, many of us have heard about obstructive sleep apnea (OSA), or just "sleep apnea" as it is commonly referred to in public dialogue. OSA is a condition in which the flow of air pauses or decreases during breathing while you are asleep because the airway has become narrowed, blocked, or floppy. A pause in breathing is called an apnea. Impacts from OSA are widespread, including straight-forward dangers related to reduced oxygen delivery and it's impact on the mechanics of the heart, to less intuitive impacts such as the onset or exacerbation of diabetes, obesity, and mental and emotional health disorders by virtue of secondary mechanisms.The trouble with limiting public discussion of OSA to formal definitions of apneas and their mechanical causes is that many people assume they do not have sleep apnea because they'd KNOW if they stopped breathing during sleep. That is not the case, however. Our body overcomes and even anticipates upper-airway resistance— of which snoring is a prime indicator, by setting in motion repeated patterns of increased neuromuscular vigor around the upper airway to keep the airway open.
The problem is that effort does not always wake you, but it sets in motion adverse effects from OSA, including hypertension, blood sugar problems and cognitive impairment.It is hard to imagine— but true— that repeated bouts of tiny nerve and muscle signals can have such adverse effects on basic health, including driving persistent hypertension, obesity, and diabetes. After all, these episodes may happen literally hundreds of times per night and we may not even be aware of them. Nonetheless, they disrupt our basic sleep architecture, which means that we do not enter deep, restorative stages of sleep. When that happens, more adverse effects ensue for our mental and emotional health.
There are a multitude of options when choosing a home sleep testing solution. While some providers may offer similar equipment and technology (most do not), Home Sleep Health provides a multi-night testing solution that accumulates more data so that our sleep physicians have more to interpret while reviewing your test. You do not sleep the exact same way every night, therefore, it makes sense that we test you more than one night so that we can catch that potential variability. In addition to improved accuracy, Home Sleep Health offers the most convenient and comfortable sleep testing solution on the market with the NightOwl. This device is so small that it simply needs to be taped to your finger and all the data is transferred to us remotely through the testing application you download to your phone. Lastly, you may keep your NightOwl device for future testing at a substantially reduced cost.
Most home sleep testing equipment consists of a nasal cannula, a pulse oximeter that goes on your finger and a chest harness that wraps around your body. While more comfortable that an in-lab test, these tests can still be difficult to sleep with and fairly complicated to set up. In many cases, these tests are required by your physician or sleep lab (when they offer home sleep testing) to be picked up in-person and returned.
While home sleep testing has grown tremendously in popularity over the past few years, in-lab testing continues to be the preferred sleep testing method for many sleep physicians and hospitals systems. The fact is, physicians and hospital systems can bill your insurance or Medicare much more money if they conduct an in-lab test versus a home sleep test. The typical cost of an in-lab test is around $3,000 compared to just a few hundred dollars for a home sleep test. In addition, if you are positive for sleep apnea after an in-lab test, the sleep lab will make you come back in for a second night of testing to determine the settings of your potential CPAP machine for therapy. After a home sleep test, if you are positive for sleep apnea, in most cases you can utilize the newer CPAP machines that auto-titrate to the right settings so you do not have to go back to the sleep lab for a second night to determine your settings.
As much as cost and convenience are heavily favored by home sleep testing versus in-lab testing, comfort is an even bigger reason to utilize an at-home test. As noted in the picture, an in-lab test consists of wires all over your face and body while a stranger (the technician) watches you through a camera the entire night while you try to fall asleep. It is much easier to fall asleep in your own bed.
Oral appliances are an established treatment option for snoring and mild-to-moderate OSA. Oral appliances work by increasing the upper airway space. Appliances are designed to stabilize the anterior position of the mandible and/or to advance the tongue (or soft palate) so that you air can flow unobstructed. Oral appliance therapy is generally well-tolerated, with short term side effects or minor discomfort. Recently, the field of sleep medicine and sleep diagnostics have begun to recognize (through clinical studies) that oral appliances are an additional viable first line treatment to consider for mild to moderate sleep apnea in addition to CPAP. AASM (American Academy of Sleep Medicine considers oral appliance therapy, in tandem with PAP, a first-line treatment option for patients with mild to moderate OSA, or patients that have tried and failed PAP therapy. Dental appliances are thus an important option for patients that have proved intolerant or non-compliant of CPAP therapy.
Weight-loss is considered an important adjunct treatment option for OSA. The AASM (American Academy of Sleep Medicine) has recently emphasized that over time PAP use may drop in favor of weight loss, but they also stress that weight-loss is not initially emphasized (as a primary option) by physicians. Weight-loss is effective for OSA, however, weight-management efforts do not retain a sustained track record when evaluated five-years past significant weight loss; although bariatric surgery fares better than commercial diet programs in this regard.
OSA is potentially amenable to surgical intervention when specific anatomic features are present in the candidate. Three principle anatomic regions of potential collapse during sleep in patients with OSA include the nose, the palate, and the base of the tongue. Each region can be surgically restructured on its own or in combination when warranted. Soft tissue can be removed and the maxilla and mandible may be repositioned forward to expand the posterior airway space.
PAP THERAPY : Positive Airway Pressure (PAP) devices are the first line treatment option recommended by the American Academy of Sleep Medicine (AASM) for OSA. Through the medium of a mask over the nasal, oral, or oronasal interface (nose, mouth or both), PAP devices create apneumatic splint (air support) to open the upper airway that is prone to collapse during apneic events. PAP may be delivered in continuous (CPAP),bilevel (BiPAP), auto-titrating (APAP) or adaptive servo ventilation (ASV) modes. PAP is the standard treatment recommended for moderate to severe OSA and is a primary option for mild OSA. Although PAP is the standard recommended clinical treatment modality for OSA (but not the only one), it requires proper introduction and education on the part of the Durable Medical Equipment (DME) provider, and an open mindset on the part of the patient. This is an extremely important dialogue, as PAP compliance statistics are generally poor, hovering at or just above 50%.
It is a well-known fact in the industry that compliance numbers can rise significantly with a proper introduction to a suitable interface. Nonetheless, the dialogue remains two-sided. If the patient's attitude has been skewed by irresponsible marketing of non-PAP commercial devices or social interactions that reflexively bias the individual against "sleeping with a mask", then PAP compliance will be an up-hill challenge. Based on the track record of PAP relative to some other forms of therapy for moderate to severe cases of OSA, it is recommended that you give PAP a serious accommodation effort for the initial week after you have been prescribed the device if your physician has prescribed PAP. Once adapted,76% of AASM survey respondents reported the quality of their sleep to be good to very good post treatment versus only 7% before (n=506). The same survey also disclosed that 41% of respondents were finally diagnosed with severe OSA and 43% were moderate even though the initial physician's assessment had 62% mild, 30% moderate and only 8% severe.
At any given time, over forty percent of us report difficulty getting to sleep or staying asleep during attempted sleep periods. Despite the huge numbers that these percentages imply, individuals with clinical insomnia form a much smaller subset of those reporting insomnia. So what about all of those highly frustrated individuals reporting insomnia that do not meet the criteria of a clinical insomnia subclass? It turns out that if they were put through a systematic process, many would show indications of other common sleep disorders in tandem with maladaptive beliefs and behaviors associated with sleep. Some would, indeed, present with clinical insomnia. The process of addressing insomnia complaints requires first ruling out other common sleep disorders with overlapping symptoms. This includes obstructive sleep apnea (OSA), restless legs syndrome (RLS), periodic limb movement disorder (PLMD) and many other possible disorders. If any of these disorders are suspected they must be addressed as a priority even while continuing the investigative process of identifying OTHER contributions to insomnia, such as medication use, hyper arousal, circadian mistiming, or maladaptive behaviors. In practice— all of the components that contribute to insomnia, including other medical conditions, should be addressed.
According to the AASM it is not advised to address insomnia complaints by asking your physician to prescribe a sleep aid for long-term use without addressing the many factors that contribute to delayed sleep onset or poor sleep quality in general. Chronic insomnia complaints should be referred to a sleep specialist to evaluate, or a process that can be taken up by a sleep specialist. A sleep specialist has at their disposal a much wider range of options and evaluation tools designed to address the multiple components that cause clinically significant sleep disturbances. The key is to treat all the components. The American Academy of Sleep Medicine (AASM) clinical guidelines for the evaluation and management of chronic insomnia consider behavioral treatment options, such as Cognitive Behavioral Therapy for Insomnia (CBT-I), to be a first line treatment option. CBT-I is a combination of component behavioral therapy interventions, including therapeutic protocols derived from (1) sleep restriction therapy, (2) stimulus control therapy, (3) relaxation based interventions, (4) congnitive strategies and (5) sleep hygiene education.
Factors that require evaluation and management include: a hyper arousal tendency, excessive worrying or rumination, poor sleep habits, and poor sleep scheduling.Although CBT-I connotes a psychotherapeutic approach, an effective CBT-I program must address the vicious cycle that links the cognitive realm of disruptive thoughts about sleep, with the physiological underpinnings of sleep that become altered over time.AASM clinical guidelines for the management of chronic insomnia also emphasize that sleep medicines do not provide sustained improvement after their discontinuation. Pharmacological interventions such as benzodiazepine receptoragonist medications (sleep meds) were once considered the primary first-line treatment option but now CBT-I is gaining traction with validation studies and clinical guidelines that discuss it as one of the preferred treatments for insomnia. Because over-the-counter medications or herbal and natural substances are not verified in scientifically validated studies for long-term use in chronic insomnia cases CBT-I is currently the only 'natural' treatment modality that has undergone validation in scientific studies for long-term efficacy. CBT-I may be offered by appropriately credentialed therapists in a face-to-face setting, or as part of a self-paced online set of interactive modules.
We all intuitively associate poor sleep with irritability, but we don't normally associate sleep with our basic emotional wellbeing and stability. Apart from its ability to alter our mood, we don't consider our emotional life to be actually constituted, in part, by sleep quality. Our daytime experiences impart the principle material for that constitution. Forus, everything meaningful is embedded within an emotional or feeling-based core. One of the basic functions of sleep is to prune the massive clutter of information entering our brain on any given day, and to firm up the far reaching associations that are important for intelligence, dexterity, creativity, and memory.
That very same process is at play addressing our emotional life. We tend to forget that a great deal of emotional processing has to occur in order for our brain to establish the important facts to remember and incorporate into our mind daily. During sleep, the brain needs top rune out not only irrelevant connections, but a massive amount of competing relevant ones. How does it do it? To some degree, by the emotional relevance of the experience. But that means that the brain must re-create the ability to absorb new emotional information the next day. If it does not, it gets bogged down by previous emotions. They begin to take on a life larger, and usually more negative in tone if they are not adequately processed during sleep. They become highly volatile and off-balance. Thus we become volatile and off-balance.
One of the functions of REM sleep and associated with dream mentation is the process of stripping-out the highly charged emotional aspects of experiences bound for learned-associations and memory, so that we do not constantly relive the strong emotions. The goal is to remember the important connections to the emotional association, not to constantly relive the turmoil. The emerging details of this fundamental role of emotional processing during sleep have profound implications for the very robust association between sleep and depression, mood-disorders, and anxiety disorders.Like many issues related to the clinical evaluation of sleep, current evidence is turning over long held notions that traditionally considered most sleep disorders to be purely secondary to other medical and psychiatric conditions. Increasingly, are evolution in practice is underway whereby sleep processes are understood to beat the center of many mechanisms. Nowhere is this bi-directional relationship more apparent than in the realm of mental health. It is absolutely crucial to address basic cognitive and emotional wellbeing with a clearly defined and systematic sleep evaluation. Sleep disorders, including clinical insomnia, are highly correlated with a whole range of mental disorders. It is not the purview of the sleep specialist, and certainly not a sleep diagnostic provider, to suggest expertise in the clinical practice of mental health. However, it is increasingly recommended throughout the field of sleep medicine that health professionals treat sleep disorders in tandem with mental disorders. Both aspects are now considered "primary" clinical disorders.
It seems self-evident to assume that the link between poor sleep and weight-gain has to do with the lack of energy and motivation to engage in physical activity, as well as the association between short sleep and our sweet-tooth cravings the next day. But contrary to our intuitions about the seemingly passive role of sleep, poor sleep engages a cascade of processes that actually set in motion pathophysiological processes that often lead to insulin resistance, diabetes, blood sugar instability, increased fat storage and other adverse metabolic effects. These processes create a snowball effect that make it ultimately impossible to sustain a healthy lifestyle despite our self-proclamations aimed at marshaling 'willpower'— or admonitions from Hollywood-style trainers on TV. You don't need a "Drill-Sergeant"— you need to understand your sleep patterns in greater detail.
It is simply a natural function of the human form to be physically active. Physical activity is, in fact, a consistent product that many of our core physiological processes anticipate by their very nature. Two consequences arise from this relationship. First, a lack of activity has profound consequences on basic normal metabolic functioning. Secondly, the consequent flip-side of the fact that human physiology anticipates consistent physical activity is the observation that the human movement system is highly efficient.
What does this basic two-sided relationship mean? It means that the common notion that exercise is merely a weight-loss tactic is entirely and radically wrong-headed. A lack of physical activity has basic implications far outweighing simply a tendency for weight-gain. Activated muscle is required to retain insulin and blood-sugar health, independent of the goal that we often hear for exercise ;i.e., "burning calories". Skeletal muscle serves as a vast reservoir for utilizing insulin-mediated blood sugar. This is not a trivial role for' normal' activated muscle, as the alarming rate of pre-diabetes and diabetes disclose in the unnatural state that is the modern sedentary lifestyle. In addition to basic cardio metabolic functioning— stress management, emotional health, and increased protection against neurodegenerative disorders remain equally "basic" to the function of consistent physical activity.
The energy available to you from your diet undergoes dramatic changes when you engage inconsistent exercise. But all exercise is not the same, and fuel availability isnot simply on or off. The details are important, both for the performance athlete and for the person interested in exercise only as part of a health-management program. Many fitness advocates do not appreciate the fundamental relationship between the body's fuel use dynamics, and the dietary and sleep patterns that impact performance. It is not simply about marshaling available energy for exercise, it's about understanding which energy stores are tapped into for everyday living. For example, when sleep is altered, lean muscle tissue is preferentially torn down, as opposed to the fat we want to burn. This has been demonstrated even for young, healthy athletes who exercise consistently. Poor sleep impacts fuel-use dynamics. Moreover, even a modest shift in our basic circadian rhythm— which underlies the orchestration of our basic sleep-wake cycle and all of the associated hormones that dictate our energy and performance— can impact our mental and metabolic performance significantly.
Sleep quality includes more than just time asleep. It includes the depth and quality of the specific stages of sleep that the brain orchestrates in a precise sequence throughout the night, known as sleep 'architecture'. It includes all the downstream effects of the hormonal and neuronal activity that these stages set in motion. It includes a necessary match between the circadian timing of these events and the day-night cycle, as well as the social and work schedules we impart to this timing. Circadian rhythm shifts and mismatches between our "master" clock and peripheral body tissue cells has been identified recently as a serious cause of the hormonal imbalances that contribute to metabolic syndrome. Restorative brain and cardiometabolic processes must occur with proper timing or emotional and cardiovascular stress will inflate. Aside from the physical performance of the athlete and serious fitness enthusiast, performance means overall wellbeing to the employee, and economic wellbeing to the employer.
In the same manner employers and employees alike used to value an individual's ability to "soldier on" at work even when sick, so also, pathological sleepiness and poor sleep quality barely registered as a legitimate concern from both the employer's and employee's vantage. In fact, 'weariness' has traditionally been viewed as a sign of hard work. That perspective has been dramatically altered in recent years. Individual worker productivity increasingly translates into the business bottom-line.Just as it makes more sense today to stay home and take care of yourself when you are sick (and don't infect everyone else), so also, quality sleep and other positive lifestyle behaviors are understood to translate into lower long-term health care costs and higher productivity. Moreover, safety in the workplace is highly correlated with sleep quality. In the end, the impacts of sleep apnea alone have been projected to cost our nation nearly $100 billion/yr according to The American Academy of Sleep Medicine (AASM). What are the costs to you, your family and your employer that cannot be quantified?
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