The speaker at the spring support group meeting was Dr. J. Julian Zaka from the Respiratory Medical Group and the Contra Costa Sleep Center. He spoke on “Sleep Apnea and Your Heart.”

(Ed note: In the following I will use the term OSA to mean untreated Obstructive Sleep Apnea). Dr. Zaka opened his talk by stating “Intermittent hypoxia and the arousal response associated with OSA are the main factors causing oscillation of the systemic and pulmonary arterial blood pressures, heart rate and cardiac function. These repetitive oscillations contribute to cardiovascular disease.”

There are five cardiovascular disorders involved:
• Systemic Hypertension
• Coronary Artery Disease
• Cardiac Arrhythmias
• Congestive Heart Failure
• Pulmonary Hypertension

There is evidence that OSA may be cause of Systemic Hypertension. Patients with mild OSA appear two times more likely to have it and those with Moderate/Severe OSA appear to be three times as likely. In one study OSA was found in 71% of patients with uncontrolled hypertension compared with 38% in those patients whose hypertension was controlled

HOW DO I STOP CPAP MASK LEAKS?

(Courtesy of cpap.com)

Air leaks are caused by masks that are too big, too old, or just the wrong style for you.

Air leaking into the eyes is usually an indication that the mask is too big (long or wide) as are leaks at the base of the nose. Leaks may also occur under the nose due to facial hair.

As the silicone in the mask cushion ages, it deteriorates and becomes too soft to hold a seal. With many masks, the cushion may be removed and replaced to extend the life of the mask.

When a cushion has softened to the point where it will no longer hold a seal, you may be able to tighten it enough to stop the leaking when you go to sleep, but during the night the seal will loosen and leak.

Mask Leaks may also be caused by the pillow pushing against the mask and changing the position and seal of the mask. There are special CPAP pillows which are designed to minimize the contact of the CPAP mask with the pillow, even when you are sleeping on your side.

How you care for your mask will also prevent leaks. Masks should be washed daily with warm water using a very gentle soap or baby shampoo, and left to air dry. Never use antibacterial soap as it will break down the silicone of the mask cushion. Avoid soaps that include lotion or lanolin which can coat the mask and cause it to lose its seal.

Remember, going to bed with a clean face will improve your seal and protect the lifespan of your mask. The best time to clean your mask is in the morning after use. This removes the oils left behind from your skin which can reduce the lifespan of your mask.
___________________________________

If you have hypertension; limit how much alcohol you drink to one drink a day for women and two for men, limit the amount of salt you consume to less than 1500mg /day, reduce stress, and stay at a healthy body weight.

Evidence also indicates that treatment of OSA with CPAP reduces systemic hypertension in many patients. A decrease of only 2mmHg in blood pressure is enough to significantly reduce cardiovascular risk!

Most people with Coronary Heart Disease have no symptoms until a heart attack. A study of 1651 men over ten years revealed those with severe OSA had a higher incidence of fatal and non-fatal cardiovascular events than untreated patients with mild/moderate OSA. Severe OSA is associated with multiple vascular risk factors. OSA may also exacerbate pre-existing coronary artery disease. OSA is also associated with Nocturnal Cardiac Arrhythmias. Bradyardia and Asystole during sleep, and in some patients during waking hours, are the most prominent and significant rhythm disturbances associated with OSA. Therapy with CPAP abolishes these rhythm disturbances in most patients.

It is well know that OSA complicates Congestive Heart Failure. A study of 700 patients with heart failure revealed 36% had OSA and 40% had central sleep apnea. The increased risk appeared to be highest among men with severe OSA (AHI >30 events per hour). OSA was not associated with heart failure among women!

Sleep apnea if left untreated can lead to a complication of Pulmonary Hypertension. Pulmonary hypertension refers specifically to high blood pressure in the arteries that supply the lungs with blood. High blood pressure damages these arteries, causing them to thicken so that less blood reaches the lungs, even as the heart works ever harder to try to force blood through. Pulmonary hypertension can result in damage to both the heart and lungs.

Dr. Zaka, in conclusion stated, “For patients who have heart failure or related disorders which are complicated by OSA, positive airway pressure (CPAP) may improve cardiac function, blood pressure, excercise capability and quality of life. It is unknown whether positive airway pressure therapy improves heart failure-related mortality in patients with treated OSA.”

SEVERE OSA TIED TO CANCER RISK

Lack of oxygen from disrupted rest may be to blame
(extracted from Science News, May 21, 2012)

Untreated Obstructive sleep apnea, a disorder linked to heart disease and depression, may heighten the risk of cancer as well. A two-decade study shows that people with severe sleep apnea could be four times as likely to die of cancer as people without the condition.

The findings were unveiled May 20 at a meeting of the American Thoracic Society in San Francisco and will appear in an upcoming issue of the American Journal of Respiratory and Critical Care Medicine.

Sleep apnea results in disruptions of breathing which rob cells of needed oxygen, a condition called hypoxia. This may underlie the cancer link, says study coauthor Javier Nieto, a physician and epidemiologist at the University of Wisconsin– Madison.

(Based on) a long-term sleep study that began in the early 1990s. The 1,522 participants, who were age 30 to 60 at the start of the study, underwent an overnight sleep examination at the outset. Those tests showed that 59 people had severe sleep apnea.

By November 2011, after a median follow-up of 18 years, those with untreated severe apnea were 4.8 times as likely to have died of a cancer-related cause. Severe sleep apnea is defined as having an air interruption “every other minute or more,” Nieto says.

The effect of using nighttime breathing devices called CPAP machines to control apnea was unclear, since some apnea patients but not all began using them at various times during the study.

Depression and Sleep

(Courtesy of the National Sleep Foundation)

Feeling sad every now and then is a fundamental part of the human experience, especially during difficult or trying times, and is something we all experience. In contrast, persistent feelings of sadness, anxiety, hopelessness and disinterest in things that were once enjoyed are symptoms of depression. Depression is not something that a person can ignore or simply will away. Rather, it is a serious disorder that affects the way a person eats, sleeps feels and thinks. The cause of depression is not known, but it can be treated.

The relationship between sleep and depressive illness is complex – depression may cause sleep problems and sleep problems may cause or contribute to depressive disorders. For some people, symptoms of depression occur before the onset of sleep problems. For others, sleep problems appear first. Sleep problems and depression may also share risk factors and biological features and the two conditions may even respond to some of the same treatment strategies.

Insomnia is very common among depressed patients. People with insomnia have a ten-fold risk of developing depression compared with those who sleep well. Depressed individuals may suffer from a range of insomnia symptoms, including difficulty falling asleep (sleep onset insomnia), difficulty staying asleep (sleep maintenance insomnia), unrefreshing sleep, and daytime sleepiness. Obstructive sleep apnea (OSA) is also linked with depression. People with depression were found to be five times more likely to suffer from sleep-disordered breathing (OSA is the most common form of sleep disordered breathing). The good news is that treating OSA with continuous positive airway pressure (CPAP) may improve depression; a Study of OSA patients who used CPAP for one year showed that improvements in symptoms of depression were significant and lasting.

In many cases, because symptoms of depression overlap with symptoms of sleep disorders, so there is a risk of misdiagnosis. For example, depressed mood can be a sign of insomnia, OSA or narcolepsy. Restless legs syndrome (RLS), a neurological condition that causes discomfort in the legs and sleep problems, is also associated with depression.

Many children and adolescents with depression suffer from sleep problems such as insomnia or hypersomnia (excessive sleepiness) or both. They are also more likely to suffer from weight loss, impaired movement, and anhedonia (an inability to feel pleasure). A study which focused on children aged 11 to 17, found a strong association between negative mood and sleep problems. Among adolescents who reported being unhappy, 73% reported not sleeping enough at night.

Depression affects all types of people from all over the world, but certain people are more likely than others to develop depression. Among older adults, higher rates of depression and sleep problems may be explained in part by higher rates of physical illness. Among women, motherhood and hormonal changes throughout the life cycle (menstruation, menopause) may contribute to higher rates of depression. Among women and older adults, higher rates of depression may also be explained by higher rates of insomnia in these groups.

Seasonal affective disorder (SAD), also known as “winter depression,” is one type of depression. SAD is believed to be influenced by the changing patterns of light and darkness that occur with the approach of winter. Circadian rhythms are regulated by the body’s internal clock and by exposure to sunshine. When the days get shorter in autumn, circadian rhythms may become desynchronized and trigger depression. For most people with SAD, depressive symptoms resolve in springtime with increasing hours of daylight. when the days lengthen out.

Living with depression can be extremely difficult. Depression not only affects the way a person feels and thinks but research suggests that it is also associated with serious chronic health problems such as heart disease. If you are experiencing symptoms of depression, it is very important to seek treatment as soon as possible.

DR. CHEUNG SPEAKS ON “SLEEP & AGING”

Dr. Karin Cheung spoke at the Fall meeting of the Support Group on the subject of “Sleep & Aging” and had the rapt attention of the group (except during the 8:16PM small earthquake). She is a specialist in Pulmonary and Sleep Medicine, is in private practice in Walnut Creek and on the medical staff of the Contra Costa Sleep Center.

Dr. Cheung opened with the remark, “We need consolidated, restorative sleep to function in a safe efficient and effective way, for cognitive social and physical performance, for emotional enhancement and relating well with others, for learning and memory consolidation, and for the prevention of health problems.”

“Sleep changes with normal aging,” she said. Insomnia can effect older people, Obstructive Sleep Apnea can occur, Restless Leg Syndrome may disrupt sleep, and medications prescribed can change sleep patterns.

The elderly typically say about their sleep;
• Time in bed increases
• Number of awakenings increase
• Total sleep time decreases
• Time to fall asleep increases
• More dissatisfaction with sleep
• More tired during the day
• More frequent napping

Dr. Cheung stressed, “Severe Daytime sleepiness at any age almost certainly indicated a sleep disorder.”

A number of factors affect sleep with aging; Circadian Rhythm disorders (i.e. effecting the biological timing of sleep) and Advanced Sleep Phase Syndrome (e.g. go to bed early in the evening 6:00–8:00 p.m. and wake up very early in the morning 1:00–3:00 a.m.), Obstructive Sleep Apnea, Medical illness, stimulants, Medications, and Dementia.

Snoring increases with age – about 40% of the U.S. adult population snores. BUT Obstructive Sleep Apnea, which in middle age affects 4% of men and 2% of women, increases for those over age 65 to 28% of men and 24% of women. This is a serious health risk!

She then expanded on the causes of Insomnia in the elderly citing; stress, depression, anxiety, physical illness, acute or chronic pain, caffeine intake, irregular schedules and poor bed habits, Circadian Rhythm disorders, and drugs, alcohol and nicotine ingestion.

“Making matters worse,” she said, “Older people may take a number of medications that may adversely affect sleep. They drink coffee too late in the day. They drink alcohol to speed sleep onset but it leads to disruption of sleep later in the night. And smoking can cause stimulation and result in insomnia and disrupted sleep.” She offered the following tips for older adults to enhance sleep:

• Exercise
• Limit naps to 1 a day for less than30 minutes
• Take a walk in the late afternoonor early evening to increase bright light exposure
• Check Medications for side effects
• Avoid alcohol, caffeine, nicotine
• Limit liquids
• Keep regular hours
• Practice good bed habits.

In summary, Dr. Cheung said, “Sleep is a basic biological need that is essential to our health, performance, safety and quality of life. Sleep deprivation has serious negative consequences. Establish healthy sleep practices prevents sleep problems from arising and promotes optimum sleep. Signs and symptoms of sleep difficulties need to be identified and discussed with your doctor.

REPLACING YOUR CPAP MASK

(based on an article in CPAPStore.com)

The silicone rubber cushion, the part that goes over your nose on a nasal or full face mask and the part that goes up the nose with a nasal pillow is replaceable without needing to replace the frame and headgear.

Some manufacturers design their mask so that you can replace about every part on the mask. The leaders in this field are ResMed followed by Philips Respironics, Fisher & Paykel, and DeVilbiss.

The most critical part of an interface is the cushion. That is the silicone rubber part that goes over the nose or over the nose and mouth in a full face mask.. Because the cushion comes in contact with the skin in order to seal, the silicone can be affected by the body oils and other skin secretions. If you wash your face and mask cushion before you put on your mask, the cushion will last eight to fourteen months, possibly even longer. The better care and maintenance you give your mask, the longer it will last.

At some point the cushion will begin to get soft and mushy. It will start being hard to keep the cushion from leaking. This is when you need to replace the cushion. You can find replacement cushions on many websites (CPAP Supplies/Mask Cushions) or from your Durable Medical Equipment (DME) supplier. You will need to know which mask you have and the size of the cushion you are using. That information is printed or embossed on your mask cushion. Different manufacturers place it in different places. Some even put the specific part number on the cushion. Just look close and you will find it. Your users manual should contain a schematic to aid you in ordering parts or you can find one on the manufacturer’s website. By replacing the cushion on your mask, it will respond like a new mask. The payoff is, you don’t have to readjust your mask and you save a lot of money. On top of that, you don’t have to have a prescription to replace mask parts.

BEWARE THE SLEEPY TRUCKER

According to Overdrive magazine (March 2010), a magazine of the trucking industry, “an estimated 28 percent of truck drivers suffer from mild to severe sleep apnea, but less than half of those with the disorder are being treated for it, experts say. Nearly 42 percent of drivers are overweight and considered prone to having the disorder.” The National Transportation Safety Board is drafting regulations that would require those diagnosed with sleep apnea on the required physical to utilize CPAP in order to retain their license.

High Altitude Issues

In California, most of the population leaves near sea level elevation so we do not experience any difficulties traveling from one point to another. However, if one goes to altitude, adjustments are needed to accommodate to the higher altitude with lower atmospheric pressures and less available oxygen. Even though there is 21% oxygen concentration in our air clear up to an altitude of 70,000 feet, the available oxygen diminishes in direct proportion to the atmospheric pressure. For example, the following elevations have the associated partial pressures of oxygen available:

Altitude	Air Pressure	Partial Pressure of Oxygen
Sea level	765 mm Hg	160 mm Hg
3,000 Feet	686	144
6,000	613	129
9,000	547	115
15,000	423	91
20,000	352	74
40,000	141	30

Donner Summit on Interstate 80 is 7058′ above sea level and therefore has 19% less available oxygen than at sea level. Most commercial airplanes pressurize their cabin pressures to the 8,000 foot level. If cabins were not pressurized, passengers could start losing consciousness at 18,000 feet.

When one travels to the mountains 8,000 feet or above quickly, they may experience acute altitude sickness, especially if they do not consume enough water, exercise too vigorously, or drink alcohol.

The mild to moderate symptoms are:
• Headache
• Fatigue
• Dizziness or light-headedness
• Difficulty sleeping
• Loss of appetite
• Nausea or vomiting
• Rapid pulse
• Shortness of breath

More serious symptoms are:
• Bluish discoloration of the skin
• Chest tightness or congestion
• Crackling breathing
• Confusion
• Coughing up blood
• Decreased consciousness
• Difficulty walking

If the serious symptoms develop then one must go down to a lower altitude by at least 1,500 feet. If one is unconscious, then one should go to the lowest altitude possible or be treated in a pressure chamber.

Prevention is the key. Drink plenty of liquids and avoid alcohol in the first two days. Avoid vigorous activities in the first two days and stay rested. Your physician may be able to prescribe a medication to reduce the chance of acute altitude sickness. Patients that use CPAP machines must also make accommodation for altitude in order to receive sufficient pressure at altitude. Most new machines have a built in altitude adjustment to 10,000 feet and will automatically adjust. Older CPAP machines must be raised to a higher treatment pressure. Ask your dealer if you are planning a vacation to high altitudes.

For any number of reasons your CPAP mask has gradually been getting out of fit. It’s pretty normal since people’s body and faces change occasionally if not from time to time. This really is nothing to be alarmed about since it is pretty normal for every CPAP mask user. If you are finding that your mask has been too tight or has been slipping as you sleep and by the time you wake up has been removed or become uncomfortable – here are some tips to help you in refitting the mask:

(1) Readjust the mask straps

The beauty of good CPAP masks is that the straps are always adjustable. All you need to do is adjust and readjust the straps and the buckles when needed. You will find that the more you do this, the better the mask will fit. Since the straps are adjustable, you would not find it difficult to resize the mask itself to make things more comfortable for you.

(2) Replace the Straps

If you find that the straps are already adjusted to their limit but still has not become the most comfortable that it could be, what you can do is replace the strap for a larger size or a smaller size. Either way, the new straps are going to be adjustable and will fit to your needs more. You can also opt for another kind or type of strap since there are a lot to choose from. You can choose to replace it with over head straps and the like, choose to your liking!

(3) Use strap guards

Now, if you find that you have already secured the smallest or largest straps and still find it to be uncomfortable, you can use strap guards to that effect. While the strap guards are used to avoid getting markings on your face, you can also use it to adjust the fit. It’s all about adjusting, fitting and readjusting again. Be patient and do not be hesitant in asking for assistance!

NO REST FOR THE AIR TRAFFIC CONTROLER!

Washington, DC, April 28, 2011— “Americans are justifiably concerned by the recent spate of incidents involving air traffic controllers who fell asleep on duty. But now that the FAA/DOT has outlined the steps it intends to take to address this problem – minor tweaking of the controllers’ work/rest schedules combined with a threat of stricter disciplinary action against offending controllers in the future – the public’s response ought to escalate from concern to alarm.

This is because the announced changes amount to tokenism – gestures more likely to assuage public anxiety than to meaningfully reduce fatigue in air traffic controllers. For example, although it is true that extending the time off between shifts (from 8 to 9 hours) will probably result in more sleep (which is good) it will not result in adequate sleep (the amount of sleep necessary to sustain normal alertness during the night shift). Prior research shows (and common sense dictates) that a significant portion of the 9 hour break will be devoted to commuting, eating, personal hygiene, socializing with family, etc. If the FAA was truly serious about optimizing alertness in air traffic controllers, and if the policy makers based their decisions on scientific evidence, the time off between shifts would have been extended to at least 12 hours – and scheduled napping would now be encouraged during work shifts, rather than prohibited.

Likewise, prior sleep research (and, again, common sense) suggest that the threat of more severe punishment will have no beneficial effect on alertness. Those air traffic controllers who fell asleep did not do so because they were not properly motivated to maintain wakefulness. They fell asleep because they had a significant, physiological need for sleep. And they probably didn’t even realize they were falling asleep – sleep onset can be insidious. (Think about it. If sleep onset was not insidious, would anyone ever fall asleep while driving an automobile?) Also, it should be pointed out that both the airline industry and the FAA have known about this problem for decades. In 1981 the National Transportation Safety Board (NTSB) published a special investigative report on air traffic controller fatigue. However, the recommendations outlined in that report were essentially ignored – and classified as “Closed—Unacceptable Action” in 1989. Since then, the NTSB (which is the congressionally-mandated special investigative body charged with determining causes of transportation accidents) has issued more than 80 new fatigue-related safety recommendations. Care to guess how many of these have been implemented?

History is replete with accidents resulting in human death and injury caused by sleepy transportation workers, and the NTSB routinely cites air traffic controller fatigue in its findings.

Unfortunately, given the inadequate response to the recent incidents, we can expect more sleep and sleepiness – fatigue related errors and accidents involving air traffic controllers in the future.”

Signed,
Thomas J. Balkin, Ph.D.
Chairman, Nat’l Sleep Foundation

A WEARABLE CPAP

“Transcend” is a new, wearable, sleep apnea therapy system manufactured by Somnetics, LLC, a privately held Minnesota-based medical device company. It is FDA/FAA/ TSA approved and weighs approximately 0.8 pounds and is about the size of a 12oz. package of coffee beans. It designed to fit comfortably on the head, uses a short hose and is vibration-free. When used with a battery pack, “Transcend” lets the user rise without removing the device. It uses a small, disposable hygienic heat moisture exchanger (HME) in place of a chamber humidifier found with traditional CPAPs. The HME captures moisture from the patient’s exhaled breath, which provides warm, moist air. The use of HME technology instead of a chamber humidifier requires a lower amount of power and provides a full night’s use with humidification — even when using the optional battery pack. Transcend provides the normal range of therapy pressure and all of the features of a full size CPAP machine including; memory, ramp feature and altitude compensation to 8,000 feet..

Transcend and its accessories are available for sale from a number of retailers. More information and dealer names are available at: www.mytranscend.com You can also see a short “You Tube” film about it at: www.youtube.com/watch?v=1gOGw_b94o

WEIGHT LOSS & SLEEP APNEA

Recognition, evaluation and treatment of Sleep Apnea Syndrome (SAS) has evolved greatly in the last forty years since first described in the medical literature. In the first 17 years the only effective treatments were weight loss and tracheostomy; both were effective, but weight loss has always been difficult to achieve and maintain. Tracheostomy was not acceptable to many patients.

In 1984 the CPAP machine was invented and introduced for patient treatment. CPAP is now the main-stay of effective treatment for SAS and made enormous improvement in the quality of life for patients. CPAP can provide immediate relief of the symptoms and reduce the dangerous bodily effects of un-treated SAS. However it is important to get beyond the “quick Fix” that CPAP provides. For the majority of patients that is long term weight loss.

Approximately 80% of persons with SAS are substantially overweight and need make long term life style changes to work towards their ideal body weight.

Weight loss and increased physical activity require a commitment to healthy eating and age appropriate exercising.

Many patients can completely return to normal with substantial weight loss and have no signs of SAS.

Other benefits of weight loss and increased activity are:
– reduced blood pressure
– reduced heart attacks
– reduced strokes
– reduced diabetes mellitus
– reduced blood clots
– reduced load on bones & joints
– improved energy levels
– improved body image

These are concepts that we all know, yet we choose to rationalize and ignore then through denial. Everyone needs to make these commitments regarding weight loss and exercise. It is not just for someone else!

SCIENTISTS TO ZAP TONGUE TO STOP SLEEP APNEA

(from AP 12.28.10)

Scientists are testing whether an implanted pacemaker-like device might help Sleep Apnea patients keep their airways open by zapping the tongue during sleep. As one of the main causes of obstructive sleep apnea is that the tongue and throat muscles relax too much during sleep, stimulating the nerve that controls the base of the tongue with a mild electric current during sleep will enable it to stay toned as during waking hours.

Three companies are developing implants and one plans to start actual patient studies early in 2011.

SUPPORT GROUP 17 YEARS AND STILL GOING STRONG!

The first formal meeting of the Sleep Apnea Support Group of Central Contra Costa Country was held in January 1994. Your editor was diagnosed with a “Severe Case of Obstructive Sleep Apnea” shortly thereafter and joined the group in July of that year. . In 1996, my 2nd retirement allowed me the time and the first issue of “The Sound Sleeper” was published. As of this reading there have been 56 issues containing 210 articles of interest (hopefully!).

It is time to catch our breath and remind ourselves where we have been and the road we have traveled. The Sound Sleeper will continue as long as there are those interested in reading it. The Doctors MacDannald and Cohen have contributed to “The Physician’s Corner” and Support Group members have contributed articles, ideas for articles and questions in need of answer. To those of you who have been with us from the beginning kudos for your perseverance! To those just coming on board – we hope to make your journey more pleasant!

NEW CPAP MACHINES GO HIGH TECH

The very first Sullivan CPAP machine (circa 1985) was a large, noisy device that could deliver a pre-set pressure continuously to the patient. It was robust but totally lacking in intelligence.

With the development of Bi-PAP, air delivered through a mask could be set at one pressure for inhaling and another for exhaling. But still no real intelligence.

For almost a decade this was it and the manufacturers concentrated on quieter machines and more comfortable masks.

The breakthrough in intelligence came with the application of the microprocessor to CPAP. This enabled the CPAP machine to detect breathing abnormalities as they start to occur and react in a preventative manner rather than merely correcting what has already taken place. All of the major manufacturers now offer various types of intelligent CPAP algorithms in addition to the normal “ramp-up.”

As an example here is what ResMed’s CPAP machines now provide in what they call Expiratory Pressure Relief (EPR) and Auto Set Technology. Expiratory Pressure Relief (EPR) maintains optimal treatment for the patient during inhalation and reduces the delivered mask pressure during exhalation by up to 3cm H2O.

Auto Set Technology (AST) recognizes that the treatment pressure required may vary due to changes in sleep state, body position and airway resistance. With AutoSet mode, the device provides only that amount of mask pressure required to maintain upper airway functioning.

The device analyzes the state of your upper airway on a breath-by-breath basis and delivers pressure within the allowed range according to the degree of obstruction. The AutoSet algorithm adjusts treatment pressure as a function of three measured parameters: inspiratory, flow limitation, snore, and apnea. When you are breathing normally, the inspiratory flow measured by the device is a function of time showing a typically rounded curve for each breath.

As the upper airway begins to collapse due to Obstructive Sleep Apnea, the shape of the inspiratory flow-time curve changes.

Snoring is sound generated by vibrations of the walls of the upper airway. It is often preceded by flow limitation or a partial obstruction of the airway.

The AutoSet algorithm detects both obstructive and central apneas. If an apnea occurs, the device responds appropriately. An obstructive apnea is when the upper airway becomes severely limited and/or completely obstructed. AutoSet generally prevents obstructive apneas from occurring by responding first to flow limitation and snoring. If an obstructive apnea occurs, the device will respond by increasing pressure.

During a central apnea, the airway will remain open, but there still is no flow. When a central apnea is detected, the device responds appropriately by logging the event but not increasing pressure.

The detection of these changes in breathing are detected and analyzed instantly by the micro-processors and the appropriate CPAP machine response is delivered. Significant improvement in the number of apneas experienced results. (your editor has noted approximately a 50% reduction in apnea/hypopneas recorded). [Charts and descriptions courtesy of ResMed.]

SLEEP APNEA IMPACTS REACTION TIME LIKE ALCOHOL

(from Stanford University’s On-line Report) In a study involving 293 patients, researchers at the Stanford Sleep Disorders Clinic and Research Center, concluded that people who were tired because of mild to moderate sleep disturbances performed about as poorly in a NASA developed test of reaction times as subjects who were legally drunk.

213 patients were recruited with mild to moderate (untreated) sleep apnea and their reaction times were compared with 80 subjects who had slept well the previous three nights. Members of the later group took the reaction time test sober to provide baseline data and then gradually got drunk and performed the test three additional times once at a blood alcohol level of 0.057%, again at 0.08% and finally at 0.083%. (0.08% is the legal limit for driving a car in California).

Comparing the two groups on seven measures of reaction time –including averagetime, maximum time and average of ten fastest times – – showed a surprising degree of impairment in the apnea patients. On all seven measures, their results were worse than those of the drinking group at a blood alcohol level of 0.057%! On three measures, the Sleep Apnea patients scored as badly or worse than the drinkers who were legally drunk (0.08%).

Reaction times for those with 0.057% blood alcohol level were 263 milliseconds, at 0.08% it was 276ms. The untreated Sleep Apnea patients averaged 266ms!!!!!!

Surgery & Sleep Apnea

Patient diagnosed with sleep apnea should always inform their anesthesiologist and surgeon that they have sleep apnea so that extra precautions can be taken both during surgery and in the post-operative recovery period. Sleep apnea patients take longer to recover from the anesthetic and may have more dangerous airway blockages with anesthesia. Patients require pain relief medications and sedatives following surgery and these agents as well as anesthesia medications all depress breathing and increase collapsibility of the airway in the back of the throat, especially behind the tongue. If the treating physicians are aware of sleep apnea ahead of time then precautions can be taken throughout the care period to insure that the patient is safely taken care of. Patients with known sleep apnea are much less of a challenge than the undiagnosed sleep apnea patients. Undiagnosed sleep apnea of course is a major risk factor for complications with surgery and anesthesia. Approximately 80% of persons with sleep apnea are still not diagnosed so when they present for surgical procedures, they are at increased risk for complications and more prolonged and unanticipated care. Anesthesia physicians are much more attuned to sleep apnea nowadays and ask the STOP-BANG questions.

S – snoring

T – tiredness during the day,

O – observed sleep apnea & interrupted breathing

P – pressure elevation of the blood

B – body weight excess

A – age older

N – neck size larger

G – gender is male.

The more a person has these findings the higher the risk for sleep apnea and the more cautious the care should be. Hopefully, awareness in the community will continue to increase and more patients will be diagnosed and get the benefit of treatment.

Q & A AT APRIL SUPPORT GROUP MEETING

Dr. Fred Nachtway, a Pulmonary Disease specialist in the John Muir Physician Network led an evening of Questions & Answers at the Spring (April) Support Group meeting. One of the advantages of the Sleep Apnea Support Group is interfacing in an informal setting with specialists in the field. Questions ranged from CPAP equipment to the four sleep stages to the advantages and disadvantages alternative treatments for Sleep Apnea.

Link Between Acid Reflux and Sleep Apnea Challenged

ScienceDaily (Apr. 13, 2010) — New research in Wisconsin suggests that a link between Gastroesophageal Reflux (GER) and obstructive sleep apnea (OSA) may not exist. Researchers from the Medical College of Wisconsin studied the sleep events of nine patients with GER without OSA, six patients with OSA but without GER, 11 patients with OSA and GER, and 15 control subjects. Although GER is thought to be induced by decreasing intraesophageal pressure during OSA, study results showed that esophageal pressures progressively increased during OSA. The incidence of GER during sleep in patients with OSA and GER did not differ from the remaining three groups. Researchers speculate that OSA may not induce GER or other reflux events

“WHAT’S NEW” AT SUPPORT GROUP MEETING

Matt Chirco, the owner of Oxygen Plus, Inc. presented to the Support Group some of the latest in CPAP technology. Here he illustrates the new Respironics “EasyLife” CPAP mask to the Support Group. Matt said, “The ‘EasyLife’ is ideal for avoiding irritation at the bridge of the nose. (see article below).

The Medicare schedule is the minimum period allowed for reimbursement.
* “Conventional Wisdom” is based on widely accepted Patient/DME experience assuming proper care of the equipment.

RESPIRONICS NEW “EASY LIFE” MASK

Philips Respironics named their new mask “EasyLife.” The “EasyLife” nasal mask nearly eliminates the need for manual mask adjustments. Its lightweight design features a unique dual-cushion construction – the inner cushion creates an instant, selfadjusting seal, while the outer cushion provides comfortable support. The only manual steps necessary are the headgear adjustments. The Forehead pad adjusts automatically – eliminating a fitting step- and requiring minimal headgear force. Only four parts: mask frame, headgear, outer support cushion, inner seal cushion. Angled exhalation micro ports make operation quieter and redirect exhaust air away from the bed partner. Outer support cushion lets the mask rest lightly and comfortably against the face, eliminating the risk of over-tightening the headgear. Inner seal cushion creates an instant, selfadjusting seal.

If you are using an “EasyLife” or have tried it and would like to offer a “firstperson review” please e-mail me your comments at; r.b.griff@sbcglobal.net. If you wish to remain anonymous I will print your comments and credit them to “Sleepless in Walnut Creek.”

WHAT IS CENTRAL SLEEP APNEA?

An Apnea occurs when a person has no airflow at the nose or mouth for 10 seconds or longer. The most common form of Sleep Apnea is Obstructive Sleep Apnea and a person has interrupted breathing due to airway blockage in the back of the throat, and usually the obstruction is behind the tongue. The person never stops trying to breathe during these breathing interruptions, and sometime there is gasping. In contrast, Central Sleep Apnea occurs when a person does not even try to breathe, but lies motionless until a breathing pattern begins again. One such type is called Cheyne-Stokes Breathing (CSB) pattern and notable by alternating cycles of deep breathing and cessation of breathing and is usually associated with such conditions as congestive heart failure, kidney failure, stroke or other brain disorders.

Central sleep apnea (CSA) occurs when the brain does not send the signal to breathe to the muscles of breathing. This usually occurs in infants or in adults with heart disease, cerebrovascular disease, or congenital diseases, but it also can be caused by some medications and high altitudes. Under normal circumstances, the brain monitors several things to determine how often to breathe. If it senses a lack of oxygen or an excess of carbon dioxide in the blood it will speed up breathing. The increase in breathing increases the oxygen and decreases the carbon dioxide in blood. Some people with heart or lung disease have an increase in carbon dioxide in their blood at all times.

If present, treatment of the underlying disorder often improves central sleep apnea. For example, descending to a low altitude is effective in treating high-altitude periodic breathing. Similarly, instituting dialysis is often effective for Cheyne-Stokes breathingcentral sleep apnea (CSB-CSA) due to kidney failure or optimizing medical treatment for heart failure. Heart transplantation will resolve CSB-CSA due to end-stage heart disease.

Up to 20% of central sleep apnea cases have been suggested to resolve spontaneously. If the patient is not symptomatic, observation may be the only appropriate step. This may be the case in patients who have central sleep apnea during sleep-wake transition, patients without significant oxygen desaturation, or in those who experience central sleep apnea during continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea.

No clear guidelines are available on when or whether to treat central sleep apnea in the absence of symptoms, particularly when central sleep apnea is discovered after an overnight sleep study (polysomnography – PSG) is performed for another reason. Clearly, when the symptoms are present, treatment is warranted. The decision to treat should be made on an individual basis.

Central sleep apnea may occur in premature infants (born before 37 weeks of gestation) or in full term infants. It is defined as apneas lasting more than 20 seconds, usually with a change in the heart rate, a reduction in blood oxygen, or hypotonia (general relaxation of the body’s muscles). In infants CSA usually occurs with prematurity or other congenital disorders. Central sleep apnea can be diagnosed with a sleep study or overnight monitoring while the patient is in the hospital. Central sleep apnea in children is not the same thing as sudden infant death syndrome (SIDS).

In infants, central sleep apnea is treated with an apnea alarm. This alarm monitors the infant’s breathing with sensors and sounds a loud noise when the infant experiences an apnea. The alarm usually wakes the infant and the parents. Most infants usually “out-grow” the central apnea episodes, so the alarm monitoring is stopped after the episodes resolve. In infants with other congenital problems, apnea monitoring may be needed for a longer period.

Since Central Sleep Apnea usually occurs in adults with other medical problems, it is best to discuss this with your doctor.