Family support increases CPAP therapy in patients, new study says

Posted by David O. Volpi, MD, PC, FACS

Attention families of people with obstructive sleep apnea (OSA): you can make a positive difference when it comes to your family member’s use of a Continuous Positive Airway Pressure (CPAP) machine to treat their OSA.

According to new research published in May in the American Academy of Sleep Medicine’s journal, Sleep,    married people with OSA, or those living with a partner, showed better use of their CPAP machine after the first three months of treatment than OSA sufferers who were single.
Additionally, those who rated their family relationship quality as higher also showed better adherence to CPAP therapy.  The results were adjusted for potential confounding factors including age, gender, and body mass index.

Here’s a refresher on what OSA is, and how CPAP therapy can help: When you fall asleep, your muscles relax, and the soft palate at the back of the throat can sag. When this happens, the upper airway can become obstructed, causing the soft palate and uvula to vibrate, causing snoring.

When the airway is completely obstructed, breathing stops for a period of time, until the body is jerked awake in reaction. This is obstructive sleep apnea. OSA can cause interrupted breathing hundreds of times a night, usually around 20 seconds per pause.

This paused breathing causes waking through the night, preventing deep, restorative sleep. This often leads to a host of problems, from daytime sleepiness and reduced job performance, to hypertension, heart disease, mood, and memory problems.

A CPAP machine helps this condition by pumping a continuous flow of air into the nasal passages — via a mask worn at night — keeping the airway open, and preventing or greatly reducing snoring and paused breathing.

In addition to improving paused breathing and reducing snoring, CPAP treatment also reduces systemic inflammation, a common side effect of OSA. Systemic inflammation is inflammation of blood vessel tissues caused by foreign elements, such as pathogens or damaged cells.

Despite its effectiveness, the problem with CPAP therapy is that the patient has to wear an oxygen mask while they sleep at night. Many people find this uncomfortable, so they don’t wear it and subsequently don’t get the benefits of OSA treatment they need.

In an effort to increase CPAP therapy adherence, this study is great news. Family support from loved ones can increase a patient’s treatment and benefits.

If you or someone you know is considering or struggling with CPAP treatment, a qualified sleep specialist can recommend the correct CPAP machine, or one of the many non-surgical in-office treatments. Visit the eOs sleep apnea treatments page for more information.

Read the full study,  “Family support may improve adherence to CPAP therapy for sleep apnea.”

New study links sleep apnea with higher risk of osteoporosis

By David Volpi, M.D., P.C., F.A.C.S. 

Women and older Americans, take note. There’s new research showing that obstructive sleep apnea (OSA) may raise the risk of osteoporosis, particularly in women or older individuals.

OSA is the most common form of sleep apnea and occurs when a person’s airway becomes blocked, causing repeated, brief interruptions in breathing during sleep. If it goes untreated, OSA can cause myriad health problems, including stroke, cardiovascular disease, heart attacks, and now we learn, osteoporosis.

Osteoporosis is a condition that causes bones to gradually thin and weaken, leaving them susceptible to fractures. About 2 million fractures occur each year due to osteoporosis, and of the estimated 8.9 million Americans affected by osteoporosis, at least 80% are women, according to the International Osteoporosis Foundation.
The results of the OSA-osteoporosis study were published April 15 in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism (JCEM). For the study, the researchers looked at the medical records of 1,377 people in Taiwan diagnosed with OSA between 2000 and 2008. They then compared those records with around 20,000 people of similar age and gender who did not have OSA.

Over the six years of research, the researchers noticed that people with OSA were 2.7 times more likely to be diagnosed with osteoporosis, and the risk was highest among women and older people with OSA.

One of the study’s main authors is Kai-Jen Tien, MD, of Chi Mei Medical Center in Tainan, Taiwan. Tien commented, “Ongoing sleep disruptions caused by obstructive sleep apnea can harm many of the body’s systems, including the skeletal system. When sleep apnea periodically deprives the body of oxygen, it can weaken bones and raise the risk of osteoporosis.

While the study only indicated a link between OSA and osteoporosis, it did not prove if one condition causes the other. That said, I applaud the research team’s efforts in bringing to light the fact that untreated OSA has far-reaching effects in the body, compromising even the skeletal system. I echo Tien’s advice that, “As more and more people are diagnosed with obstructive sleep apnea worldwide, both patients and health care providers need to be aware of the heightened risk of developing other conditions. We need to pay more attention to the relationship between sleep apnea and bone health so we can identify strategies to prevent osteoporosis.”

Read the full study, “Osteoporosis Risk Heightened Among Sleep Apnea Patients.”

Poor sleep doubles risk of heart failure hospitalizations

By David O. Volpi, MD
 
If you or someone you love has a heart failure condition, not sleeping well can double the likelihood of being hospitalized, according to new research by the European Society of Cardiology.

In April, the European Society of Cardiology presented a study at EuroHeartCare 2014 showing that poor sleep doubles hospitalizations in heart failure patients. EuroHeartCare is the official annual meeting of the Council on Cardiovascular Nursing and Allied Professions (CCNAP) of the European Society of Cardiology (ESC).

The lead author, Dr. Peter Johansson, is a heart failure nurse at the University Hospital of Linköping, Sweden. He explained, "Sleep is important for everyone and we all have to sleep to feel good. We know that sleep problems are common among patients with heart failure, but until now there was no data on whether poor sleep persists over time and how that relates to hospitalizations."

The researchers studied 499 patients hospitalized for heart failure. During the initial hospitalization, they collected information on their physical functioning, mental health and sleep. They were then asked a simple but important question: "Was your sleep restless?"
After 12 months, the researchers recorded the number and cause of unplanned hospitalizations and assessed the patients’ quality of sleep again. They found that 215 patients—43 percent—said they slept restlessly when they were initially hospitalized. And nearly one-third—30 percent—still experienced sleep problems 12 months later.

The take away for the researchers was that patients with continued sleep problems were twice as likely to be hospitalized during the follow up period than those without any sleep problems, and their risk doubled for all-cause hospitalizations and cardiovascular hospitalizations.

Per the results of the study, Dr. Johansson was spot on in his message to the public:
"Our study shows that some patients with heart failure have chronic sleep problems and this more than doubles their risk of unplanned hospitalizations—it underlines the impact that sleep can have on health.”

He added, "Patients may have poor sleep hygiene, which means they do things that prevent them from getting a good night's sleep. These include drinking coffee or too much alcohol late at night, having a bedroom that is too hot or too cold, or having upsetting conversations before going to bed."

And kudos to Dr. Johansson for also addressing the importance of attentive healthcare professionals, "Patients who say they consistently have poor sleep should be taken seriously, and we need to ask all our heart failure patients whether they sleep well and if not, find out why."

Poor sleep patterns and sleep habits have reached epidemic proportions in our nation, yet getting quality, restful sleep is exactly what we need to help us feel alert and stay healthy. If you are having trouble sleeping, please get checked out by a qualified doctor—especially if you have a heart failure condition.

Read the full study, “Poor sleep doubles hospitalizations in heart failure patients.”

Significant connection found between sleep apnea and diabetes

Written by David Volpi, M.D., P.C., F.A.C.S.

It’s no secret that sleep apnea can lead to a long list of medical conditions, and worsen existing ones. Medical experts are now adding diabetes to the list. According to a new study published in February on the American Diabetes Association’s Diabetes Care website, sleep apnea can worsen Type 2 diabetes in some patients.

Sleep apnea is a potentially life threatening sleep disorder that’s caused when the muscles of the throat collapse during sleep. Obstructive sleep apnea (OSA) is the most common type of sleep apnea and also the most serious because it causes the soft tissue in the palate, throat, or tongue to “obstruct” the flow of air as a person struggles to breathe while they are asleep.

It’swell known that sleep apnea can greatly increase the risk of Type 2 diabetes. But according to Dr. Babak Mokhlesi, author of the new study and the director of the Sleep Disorders Center at the University of Chicago, sleep apnea can worsen blood sugar control in people with Type 2 diabetes because it disrupts the deepest stage of sleep, known as rapid eye movement, or REM.

For the study, Dr. Mokhlesi and his team studied patients with sleep apnea. The participants experienced apneic episodes during REM sleep. While obstructed breathing usually occurs throughout the night in sleep apnea patients, Mokhlesi and his team found that apneic episodes during the REM phase of sleep had the most detrimental effects on long-term blood sugar control.

In a New York Times article, Mokhlesi commented, “Most REM sleep occurs in the early morning hours before waking. But research shows that many patients remove their CPAP mask in the middle of the night because it can feel uncomfortable. As a result, their apnea is more likely to go untreated during REM sleep, a time that may be particularly important for anyone with diabetes.”

I applaud the efforts of Dr. Mokhlesi, and echo his comment regarding the importance of properly using a CPAP mask for the treatment of sleep apnea. If you’re having trouble with your mask, or just not using it, see a qualified sleep disorder doctor and get sized for a new, quieter, and more comfortable one. There are different CPAP masks and units on the market, so don’t settle for living uncomfortably, or going without proper treatment.

Read the full study titled, “Association of Obstructive Sleep Apnea in Rapid Eye Movement Sleep With Reduced Glycemic Control in Type 2 Diabetes: Therapeutic Implications.”

Can nasal surgery help CPAP therapy?

Written by David Volpi, M.D., P.C., F.A.C.S.

This month’s blog is for anyone who has obstructive sleep apnea (OSA) and is having trouble using—or refusing to use—a Continuous Positive Airway Pressure (CPAP) machine while sleeping.

CPAP machines help nighttime interrupted breathing by pumping a continuous flow of air into the nasal passages, keeping the airway open, and preventing or greatly reducing snoring and paused breathing. Still, many people are uncomfortable wearing the CPAP mask at night. Some feel claustrophobic or claim it causes dry mouth, nasal congestion and/or skin irritations.

There are two points I want to make about CPAP machines. One is: realize there are different types of masks and machines available, so take the time to choose one that’s right for you. Choose a small, quiet machine with a comfortable mask that fits you well. A heated humidifier attached to the CPAP machine can reduce throat dryness. Also, adjust titration so the CPAP pressure isn’t too high.

The second point I want to make, is that for some patients with nasal obstruction, a nasal surgery called septoplasty may help make CPAP therapy easier when combined with the above suggestions. An article in the January 2014 issue of The Laryngoscope  explains this first-of-its-kind study.

In response to the difficulty many OSA patients have using CPAP—what doctors call “problematic nonadherence”—three researchers wanted to find out if septoplasty, a surgery for nasal obstruction, would improve CPAP use and effectiveness.

For the study, head researchers Justin Poirier MD, Charles George MD, FRCPC, and Brian Rotenberg MD, MPH studied 18 patients over a six month period. Their average age was 52, 15 were males, and three were female. All the participants had been diagnosed with OSA, were prescribed nasal CPAP, yet were unable to tolerate CPAP treatment mostly due to nasal obstruction and a deviated septum.

The patients underwent septoplasty surgery with inferior turbinoplasty to improve breathing and sinus drainage. Following the surgery, data was collected regarding the patients’ CPAP usage per night. Patients were also asked to fill out the Nasal Obstruction Symptom Evaluation (NOSE) Scale questionnaire on how their post-surgery nasal obstruction felt.

The results of the study were encouraging. Before surgery, average patient CPAP usage was 0.5 hours per night. Pre-surgery NOSE Scale questionnaire data averaged 16.1 among the patients, with a maximum possible score of 20.

After surgery, the mean nightly CPAP usage was 3.9 hours per night (significant difference compared to preoperative data at P < .05). And the NOSE Scale score decreased to 5.4 (significant difference compared to preoperative data at P < .05).

In summary, the results show improved CPAP compliance rates following septoplasty surgery in OSA patients with documented nasal obstruction. That said, it’s important to keep in mind that septopasty surgery should be considered conservatively and for appropriate patients. Nasal surgery is not a cure-all for OSA, but along with CPAP and/or other therapies, could make a positive difference in easing OSA-related symptoms. Further, the results of this study offers some written proof of the effectiveness of septoplasty surgery for nasal obstruction and OSA treatment.

If you have been diagnosed with OSA, or are suffering from snoring and sleep issues, I urge you to get evaluated by a qualified ear, nose, and throat doctor. Some common symptoms of OSA include snoring, paused breathing during sleep and excessive sleepiness during the day. Increased blood pressure is another sign you may have sleep apnea.

Untreated OSA can result in poor sleep (for you and your partner), lack of focus, increased cardiovascular disease, and even death. So please get checked out. There are multiple options and minimally invasive techniques available today to treat OSA and other sleep disorders.

Read the full article entitled, “The effect of nasal surgery on nasal continuous positive airway pressure compliance” in the January 2014 issue of The Laryngoscope.

Say Hello to the Neurostimulator—an Alternative to CPAP Machines

I’ve been a practicing ear, nose, and throat specialist for more than 20 years, and one thing I know for certain about my obstructive sleep apnea (OSA) patients is—they have to do the treatments in order to get better.

The problem is that some OSA patients who would benefit from Continuous Positive Airway Pressure (CPAP) machines can’t or won’t use it because they find it uncomfortable, even though CPAPs have proven to be very effective in increasing oxygen flow and reducing apneic events that result in snoring.

But thankfully, medical advances are happening almost weekly, and so it is with sleep apnea diagnosis and treatment. One study that has me particularly excited recently appeared in the New England Journal of Medicine.  It was also written about in The New York Times by Catherine Saint Louis.

Inspire Medical Systems, based in Minneapolis, Minnesota, has developed a something called the neurostimulator to treat OSA. The pacemaker-like device is surgically implanted in the chest, and at night, the device sends regular electric impulses to a nerve inside the jaw. These electric impulses cause the tongue to move forward during inhalation, opening up the airway, improving air flow and reducing breathing pauses. 

Inspire Medical Systems funded a study to test the neurostimulator. Doctors surgically implanted remote-controlled neurostimulators in 126 patients, and activated them at night as the patients slept. After one year, patients experienced a marked decline in breathing pauses—from 29.3 episodes per hour to nine per hour, on average. Dangerous drops in blood oxygen levels also declined, from 25.4 per hour to 7.4 per hour, on average. At one year, 86 percent of patients said they use the neurostimulator on a daily basis, and two of the 126 patients stopped using in at night. Sleep apnea worsened in about 20 patients using the device, but doctors are not yet sure why.

The second phase also showed indications that the neurostimulator is effective in OSA treatment. In 46 patients who showed that the treatment was helping their OSA after one year, some were told to continue with the therapy or have it withdrawn for one week. Not surprisingly, those who continued the neurostimulator therapy showed little change in the number of breathing pauses per hour or drops in blood oxygen levels. But in the patients no longer using the therapy, the number of breathing pauses increased sharply, from 7.6 per hour to 25.8 per hour, on average. And the episodes of blood oxygen level drops rose from 6 per hour to 23 per hour, on average.

While more research and study is needed, the results are truly encouraging that upper airway neurostimulator therapy may soon be an effective and welcome alternative for OSA treatment, especially for those patients who have difficulty with CPAP masks and machines.

Read the full article entitled, “Upper-Airway Stimulation for Obstructive Sleep Apnea” in The New England Journal of Medicine.

Sleep Better — Get Smart about Your Smartphone

By Dr. David O. Volpi, M.D.

Smartphones, iPads, and other personal electronic devices are great ways to communicate and entertain ourselves, but they may also be negatively impacting the quality and quantity of our sleep.

As personal electronic devices have become more ubiquitous, the bright-light emitting screens that allow the use of mobile devices in dimly lit rooms have become a more common reason for sleep disruption, whether users realize it or not.

Why is that? Melatonin is a hormone produced by the pineal gland at night and when it is dark. It is a “timer” that tells the body that it is nighttime, and time to go to sleep. Exposure to light at night, such as that in the brightly-lit screens of many personal mobile devices, can interfere with melatonin, the hormone that helps control our sleep and wake cycles.

But rest easier: New research from the Mayo Clinic in Scottsdale, AZ explains a way to reduce the impact of electronic devises on sleep cycles.

Lois Krahn, M.D., a psychiatrist and sleep expert at the Mayo Clinic and co-author of the study said, “In the old days, people would go to bed and read a book. More commonly, people go to bed and they have their tablet on which they read a book or newspaper or look at material. The problem is it's a lit device, and how problematic is the light source from the mobile device?"

That question prompted Dr. Krahn to wonder, is the light from screens always a negative factor for sleep?" To find out, Krahn and his colleagues experimented with two tablets and a smartphone in a dark room, using a meter on its most sensitive setting to measure the light the devices emitted at various settings when held various distances from a person's face.

They discovered that when the brightness settings were lowered and the devices were held just over a foot from a user's face, it reduced the risk that the light would be bright enough to suppress melatonin secretion and disrupt sleep.

Explains Krahn, “We found that only at the highest setting was the light over a conservative threshold that might affect melatonin levels. If it's at the mid setting or at a low setting, it's bright enough to use."

The new Mayo Clinic research, which was presented in June at SLEEP 2013, the 27th annual meeting of the Associated Professional Sleep Societies LLC, in Baltimore, Md., also suggests things you can do to help prevent screen light from interfering with melatonin and affecting sleep.

These tips include dimming the smartphone or tablet brightness settings and holding the device at least 14 inches from your face while using it.

Other general tips include moving the TV and computer out of the bedroom, or at the very least, do not watch TV or work on the computer to bedtime.

With so many electronic distractions in our lives, it's important to re-claim the bedroom for its intended purpose: rest, relaxation, and sleep.