Sleep News Archives - Page 2 of 3 - Contra Costa Sleep Center CC Sleep Center BASS

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.
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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.

REVIEW: iPHONE APP ‘Sleep On It’

By Brandon Peters, M.D. (SleepFellow, Stanford University)

One of the most popular of the sleep-related apps (applications) for iPhone, ‘Sleep On It’ works by tracking your movements during the night in order to time your morning awakening. What are the pros and cons of this app?

‘Sleep On It’ relies on your iPhone’s accelerometer to monitor movement. The idea is that you place your iPhone near you in bed and that it will register movements. When you are in deeper sleep, especially REM sleep, it will document this stillness. When you are restless towards morning, drifting into lighter stages of sleep, it will seize on this wakefulness to alert you to get up for the day.

The interface of the app is slick. There are five tabs of controls and information. The first tab offers instructions on how best to place your phone and use the app. Under settings, you can choose an alarm sound (including a favorite song) and set your snooze options. You select a 30-minute period during which you wish to awaken. Then, each night after using it, it creates a summary page that includes a hypnogram (showing sleep stages) as well as your bedtime, wake time, and total and average sleep time. There are also options to share this information by email and Facebook.

‘Sleep On It’ is accurate at tracking the consistency of your sleep schedule. This is similar to documenting your sleep patterns with a sleep diary, and akin to monitoring that is better accomplished with an actigraph. But at a cost of just 99 cents, it is much less expensive than actigraphy.

There are unfortunately drawbacks to the ‘Sleep On It’ app:
• In order to function, the program must run overnight and this will slowly drain your battery. Although it will no doubt vary with your battery’s age, it drained mine by 20% over 8 hours. The instructions recommend that you keep your phone plugged in, which could present a choking hazard should you become wrapped in the cord.
• The accelerometer will pick up any movements, including those of bed partners or pets.
• It brings your phone into the bedroom, and unless you put the phone in flight mode, you will be bothered with calls, texts, and alerts throughout the night.
• The sleep cycle hypnogram (for which the app is named) does not appear to be accurate. If you have a soft mattress pad or other bedding, the accuracy will suffer because movements will be missed.

Therefore, though the ‘Sleep On It’ app is an interesting development in inexpensive application technology that may help us to monitor our sleep, it seems that it is really only accurate to track your bedtime and wake time. It should not be used as an alternative to more sophisticated sleep studies.” (Note: your Editor loaded the app on his iPhone and my evaluation is the same as Dr. Peters…. but it is interesting to play around and see what your pattern looks like)

BATTERY POWER FOR CPAP

The Winter Support Group meeting was devoted to a discussion of “Traveling with your CPAP.” Most CPAP machines now run off “inverters” or “sine-wave generators” which output to the CPAP 12 or 24 volts alternating current (depending on the machine). If you are traveling to a country that provides 220 or 240 volts be sure your power supply input will work on those voltages. If not contact your CPAP supplier.

For those who are RV’ing or camping battery power from your vehicle or an auxiliary battery is required. All of these battery solutions will power a CPAP machine for at least 8 hours and some more.

Each of the manufacturers has a slightly different approach. Here are some websites where you can get specific information:

Respironics
http://sleepapnea.respironics.com/accessories/batterypack.aspx

ResMed (2 sites)
http://www.resmed.com/us/assets/documents/service_support/battery_guide/198103_battery-guide_glo_eng.pdf
http://www.resmed.com/us/products/resmed_power_station_ii/resmed-power-stationii.html?nc=patients

Fisher Paykel
http://www.fphcare.com/userfiles/file/OSAfiles/CPAP/Battery%20Quick%20Reference%20Guide%20PM-185045763.pdf

Battery Power Solutions
http://batterypowersolutions.net/C-444_Power_Pack.shtml

ARTHRITIS PATIENTS NEED MORE SLEEP

Poor quality of sleep is equally problematic as joint pain and limited mobility for many people suffering with arthritis. Sleep disruption appears to be an overlooked consequence of arthritis for many people. People suffering with arthritis need to give more attention to the often dismissed symptom of disrupted sleep, according to results from a national study by researchers from the University of North Carolina at Chapel Hill surveyed 937 Medicare recipients, 65 years old or older.

Most people, if asked to list the symptoms of arthritis, would include pain, stiffness, discomfort, and limited mobility in their response. Fatigue also is recognized as a symptom of many types of arthritis, in the sense of being “worn out” or “lacking energy”. Often overlooked though is the impact of arthritis on sleep.

Study results were reported in the Archives of Family Medicine. About one third of the study participants reported a correlation between arthritis and sleep loss.

Insomnia is difficulty getting to sleep or staying asleep, or having nonrefreshing sleep. “Dr. Bones”, a retired rheumatologist, commenting on arthritis and insomnia said, “The insomnia associated with arthritis may be due to chronic pain, arthritis related stress, or one of the many medications required for disease control. In addition, many arthritics are fatigued at bedtime but not physically tired. This is due to reduced physical activity because of joint immobility. Coping with insomnia requires complex treatment including physical reconditioning”.

More attention needs to be paid to the often dismissed symptom of sleeping problems in people with arthritis. Let your doctor know that you are have sleeping problems and explain the problem in detail.

Childrenʼsʼ Sleep

Every living creature needs to sleep to restore brain function. Newborns do not yet have an internal biological clock (circadian rhythm) so their sleep patterns are not related to the night or daylight.

Infants 1 to 12 weeks old usually sleep 15 to 18 hours a day, but only in short periods of 2 to 4 hours irregularly as the baby needs to be fed, changed and nurtured. The baby should be put in crib when drowsy, not asleep. Place baby on the back with face and head clear of blankets and other soft items.

Infants 3 to 12 months old sleep 12 to 14 hours a day and periods of 4 to 6 hours and more regularly in the evening. Establishing healthy sleep habits is important goal. Create a consistent and enjoyable bedtime routine with a “sleep friendly” environment. Encourage baby to fall asleep independently and become a “selfsoother”. Babies have 3 naps and drop to 2 naps a day at 6 months old. They are capable of sleeping through the night after 6 months.

Toddlers 1 to 3 years old sleep 12 to 14 hours a day. Naps will drop from 2 to 1 in the day. Many toddlers experience sleep problems including resisting going to bed, nighttime awakenings, and their ability to get out of bed. Nighttime fears and nightmares are common with the development of the child’s imagination. Toddlers’ drive for independence and an increase in their motor, cognitive and social abilities can interfere with sleep. Daytime sleepiness and behavior problems may signal poor sleep or a sleep problem. A consistent bedtime routine and schedule with consistent, well communicated and enforced limits is essential. A security object such as a blanket or stuffed animal is helpful. Separation anxiety and illness can disrupt sleep. Preschoolers 3 to 5 years old sleep 11 to 13 hours a night and most do not nap after 5 years old. With further development of imagination, nighttime fears are common. Sleep terrors and sleepwalking and sleep talking peak during this time. The child should sleep in the same environment every night in a room that is cool, quiet and dark – and without a TV.

School-aged Children 5 to 12 years old need 10 to 11 hours of sleep. Sleep problems and disorders are prevalent at this age. Poor or inadequate sleep can lead to mood swings, behavioral problems such as hyperactivity and cognitive impairment that impact on their ability to learn in school. Stimulating media and TV programs, the Internet, caffeine products, social activities and the demands of school can interfere with sleep. It is important to teach children about healthy sleep habits and maintain a consistent schedule and bedtime routine. Keep computers and TV out of the bedroom and keep bedroom cool, dark and quiet. Awakening the same time everyday stabilizes the biological clock.

Teenagers 12 to 18 years old still need 8 to 9 hours, however, social pressures, school work, and sports activities all conspire against getting the proper amount and quality of sleep. Many teenagers develop a delayed phase sleep disorder and they stay up way too late and have great difficulty arising in the morning and getting to school. Most teens are chronically sleep deprived and try to “catch up” by sleeping late on weekends. Teens struggle to learn to deal with stress and control emotion – sleep deprivation makes it even more difficult so irritability, lack of self confidence, impaired judgment, and mood swings become even worse with insufficient sleep.

Tips for teenagers (ages 11 to 22):
• Avoid caffeine and nicotine in afternoons. Avoid alcohol
• Avoid heavy studying or stimulating computer games before bed
• Avoid arguing with your adolescent just before bedtime
• Avoid bright light in the evening, but open blinds and turn on lights in mornings
• On weekends sleep no more than 2 to 3 hours late

DR. CHEUNG SPEAKS ON “SLEEP & AGING”

Karin Cheung, M.D.

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.

WHAT WAS NEW AT THE “VENDOR FAIR”

The annual Support Group “Vendor Fair” was held in July and was well attended by members and the medical equipment supply community. The CPAP manufacturers were represented by; Respironics and Fisher & Paykel. Representatives from the Contra Costa Sleep Center and from the Durable Medical Equipment supplier, OxygenPlus, were present to explain their services.

Dr. Peter F. Chase DDS MA also was present at the Vendor Fair this year. Dr. Chase has spoken before the support group on several occasions in the past and is now associated with the Contra Costa Sleep Center specializing in the application of oral appliances for mild/moderate Obstructive Sleep Apnea treatment.

The manufacturer’s emphasis this year was on redesigned and more comfortable nasal pillows and masks in addition to state of the art software controlled CPAP machines. Respironics exhibited their new unique in shape “GoLife” nasal pillows custom designed for both men and women and their “TrueBlue” gel nasal mask as well as their “System One” intelligent CPAP machine.

Respironics “GoLife” Nasal Pillows

More information on the Respironics product line can be found at their website: http://respironicssleeptherapysystems.respironics.com/ Fisher & Paykel was present to describe the three new “Zest” Range nasal masks designed to fit better, feel lighter and be easier to use.

Fisher & Paykel “Zest” nasal mask

More information on the “Zest” Range nasal Masks and Fisher & Paykel’s full range of “ICON” clinical therapy solutions on their website: www.fphcare.com/osa/cpap-solutions.html Although unable to attend this year’s Vendor Fair, ResMed, also has a full line of nasal pillows, masks and system solutions. Information can be obtained at their website: http://www.resmed.com/us/index.html

30 YEARS AGO CPAP WAS INVENTED!

Thirty years ago Dr. Colin Sullivan, an Australian pulmonologist studying the problem of airway collapse, hit on CPAP as a possible solution. Here, (extracted), is how he described it in the Lancet 1981;1:862-65. “One afternoon we were setting up for a nighttime study on a patient with severe OSA who was to have a tracheotomy. He was participating in a series of nightly studies before and after the procedure to measure breathing while he was asleep.

The patient was eager to know if there was anything else that might work. I suppose I was thinking out loud, looking at the mask and all the tubing sitting around for the experimental procedure, when it occurred to me that putting pressure in the upper airway might just hold it open.

Dr. Colin Sullivan PhD, BSc(Med),MB FRACP
Professor of Medicine at Sydney University

The patient was keen to give it a try, and so we started searching around for equipment that we could use. We had large bore tubing into which we cut holes for the nasal prongs (pillows) to fit.

Our next problem was finding a blower to create an appropriate pressure. We had a blower we used to calibrate the Fleish pneumotach (airflow measuring device) and thought that might work. In hours, the first CPAP device for OSA was born.

We were very tentative going into this, not knowing what would happen, how the patient might respond or even if we might ‘blow the patient up.’

What we weren’t prepared for was how quickly and easily we were able to unblock the upper airway obstruction. As we turned the pressure up, the obstruction disappeared, and the patient went immediately into REM (sleep). We then reduced the pressure and recreated the classic obstructive pattern. Turning the pressure up again relieved the obstruction. After a few runs of switching the apnea on and off by changing the pressure level, we realized what a fantastic physiological tool we now had to study obstructive sleep apnea and mechanisms.

However, it wasn’t obvious to me at this stage that this could be a long-term treatment for the patient. Although we had planned to use the pressurized system for just a short time during that first night, the impressive response in terms of sleep quality and respiratory, as well as the patient’s tolerance to it, made me decide to continue on for the whole night. After all, just because it worked for five minutes, it didn’t mean it would work for five hours You have to remember, (in 1981) we knew the airway was collapsing, but no one knew why. Was this passive collapse, or was it an active response? I reasoned that if what we were seeing was a reflexive response, then the patient would adapt to the continuous pressure over time. On the other hand, if it was a physical problem of passive collapse, then CPAP would act as a splint and no adaptation would be seen. I realized that we could answer that question by the end of the night so we continued with pressurization. And we had an extremely satisfied and rested patient next morning. The results we saw were absolutely clear-cut, and I knew right away that the upper airway obstruction was a passive process by how easy it was to unobstruct the airway.”

The First CPAP Machine (1981)

….. and thus was born the device that has benefitted the one in every 15 people worldwide who suffer from Obstructive Sleep Apnea.

Gender Differences Of Sleep Disordered Breathing

Many studies have shown that men have more sleep disordered breathing problems than women. The one study showed that men had 3 times more sleep apnea than women when compared for Body Mass Index (BMI).

It is known that obesity is a risk for sleep apnea and accounts for 80% of male patients, but 20% of patients are thin or normal weight. Women have less sleep apnea with obesity for unclear reasons, but obesity is still an important risk factor for women also.

It is also known that a larger neck circumference also has more risk for sleep apnea in both men and women. If men have greater than 18 inch collar size, they will more likely to have sleep apnea. If women have a greater than 16 inch collar they will more likely to have sleep apnea.

The upper airway mechanics and muscle tone are important for maintaining an open airway during sleep. Men experience more airway obstruction and collapse than women. Men do have a longer airway length and this may allow for more obstruction. Even though women have smaller upper airways, they have more favorable airway mechanics than men.

Pre-menopausal women appear to be protected as are post-menopausal women with hormone-replacement therapy. After menopause, the risk of obstructive sleep apnea increases in women by 4-fold. This marked increase compares to almost as much as males of the same age.

Much still needs to be learned about disordered breathing during sleep and the search goes on.

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!

The National Sleep Foundation President writes on the Air Traffic Controller Sleep issue in an open letter. Those who have experienced sleep apnea and sleep deprivation can agree with his concerns.

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!

In use in Europe for sometime, and in the U.S. since 2004 as a treatment for snoring, the Pillar® procedure for palatal implants was given FDA approval in February 2004 as a treatment for mild to moderate cases of sleep apnea. However, a wide range of opinion exists in the medical community concerning its long-term value for obstructive sleep apnea treatment. Currently, Medicare may only provide limited coverage and most private health insurance do not cover the Pillar® procedure treatment costs of aprox. $2000 and up.

In the procedure, three small bars made of a soft polyester material are implanted into the roof of the mouth. After a month or two, as the body responds to the foreign substance by forming fibrous tissue around it, the palate becomes stiffer, making it less likely to collapse into the airway during sleep.

Since the mechanics of sleep apnea are complicated, involving the uvula, pharynx, tonsils, and tongue as well as the palate, the Pillar® procedure is not a cure-all. It is not indicated for use in the severely obese, defined as people with a Body Mass Index over 30. People who meet the weight criteria still might not be good candidates for the procedure, depending on their oral anatomy. Data from the clinical trials prior to FDA approval indicate that in about 50% of the cases of mild to moderate OSA, the procedure results in a “cure”. An additional 25% of OSA patients experience a reduction in apneas.

An authoritative and current view of the Pillar® procedure is contained within the text, “Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults” printed in the medical journal, SLEEP , Vol. 33, No. 10, 2010, on page 1412: “4.3.7 Palatal Implants: Palatal implants may be effective in some patients with mild obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable. There is limited research that adequately assesses the efficacy of palatal implants for the treatment of OSA. One RCT (randomized controlled trial) and 2 case series met the criteria for inclusion in the review and suggest marginal efficacy. Overall, this (data) represents very low quality evidence. This is a new treatment option that has emerged since the previous practice parameter. While this procedure may be an alternative mode of therapy for mild OSA, at the present time it is difficult to predict if it will be ultimately be found to be a reliably effective intervention.”

CONCLUSION: The Pillar® procedure is the newest in an array of surgical procedures for the treatment for obstructive sleep apnea. Therefore it has been well advertised and has captured media attention due to its seeming simplicity and one-time “cure-all.” However, the selection by the patient of the appropriate option for sleep apnea treatment should always be based on the recommendations of a knowledgeable Sleep Specialist.

LOWER PG&E RATE FOR CPAP USERS

PG&E has a financial assistance program for residential customers that have special energy needs due to certain qualifying medical conditions. PG&E considers CPAP as “life- support medical equipment.” As such, it qualifies for these reduced electricity rates.

Eligible customers may receive a “standard” Medical Baseline quantity of approximately 500 kWh of electricity at a lower rate. A member of the Support Group states, “After registering with PG&E as a CPAP user, I am saving several hundred dollars per year from my electricity bill.”

To obtain these rates, you must submit a form signed by your doctor. Information on the “Medical Baseline Program,” instructions and the application forms can be obtained from PG&E or their website at; www.pge.com/myhome/customerservice/financialassistance/medicalbaseline/index.shtml Fill out the form and mail it to your Respiratory physician for signature along with a stamped envelope addressed to PG&E. You may wish to follow up with PG&E to see how your approval is going. Eventually, your monthly PG&E bill should indicate that you are getting the medical baseline rate, which will be lower.

SLEEP & AGING TALK

At the Winter meeting of the Support Group, Dr. MacDannnald addressed the group on the subject of Sleep and Aging.

Dr. MacDannald addresses the Support Group

Pointing out that “severe daytime sleepiness at any age almost certainly indicates a sleep disorder,” he went on, “it is mistakenly thought of as part of the normal aging process.”

Sleep disordered breathing has the same symptoms and effects on the body in the elderly as well as in sleep apnea patients; snoring, daytime sleepiness, heart disease, hypertension and cognitive impairment. There are a number of age-dependent risk factors for sleep disordered breathing in the elderly; increased body mass, decreased muscle strength, increased airway collapsibility, decreased thyroid functions, decreased lung volume and decreased central respiratory drive. Dr. MacDannald offered the following 7 tips for older adults to reduce the effects of aging on sleep;

– Get regular exercise.
– Limit naps to one per day for no more than 30 minutes.
– Increase your light exposure by taking a walk in the afternoon or early evening.
– Check medications for effect on sleep.
– Avoid alcohol, caffeine and nicotine.
– Limit liquids in the evening.
– Keep regular hours for going to bed and arising.

The usual informative and responsive Question and Answer Session followed Dr. MacDannald’s presentation.

AMBIEN SAFE TO TAKE WITH TREATED SLEEP APNEA

If you and your physician have determined you need a sleep aid, Ambien is safe to take with Obstructive Sleep Apnea as long as your Sleep Apnea is being treated with CPAP. Although Ambien is a CNS (Central Nervous System) depressant and could slow down the body’s normal reaction to an apnea episode, the CPAP machine will overcome the apnea and quickly restore the airway to normal.

MOUTH LEAKS

Although breathing through the nose with the mouth closed would seem perfectly normal, studies have shown that 1/3 of the people using CPAP can not seal their mouths when sleeping and therefore leak air when using a nasal mask or nasal “pillows” thereby reducing the effectiveness of their treatment. In these cases a full face mask, which covers the mouth, will correct the problem.

THE DATA CARD

The Data Card is the most recent and useful. It is analogous to a memory card in a digital camera. All new machines should now have a removable memory card to track their treatment successfulness. The Data Card is provides a vital measure of patient benefit since it will track treatment performance every night that the machine is used. We ask every patient to please bring their Data Card every time they come in for a follow-up appointment now. The Data Card will indicate whether there are still significant problems. Some other innovations are:
– The machines have gotten small and quieter, and more transportable.
– There are many more enhancements
– Humidifiers used to be extra, but now are included
– Patient can now have a ramp function, so instead of starting right out on their fully prescribed treatment pressure, the machine will gradually ramp up the pressure to the goal pressure, if desired.
– There is a C-Flex setting, to drop pressure during exhalation, if desired.
– There is a much greater variety of mask sizes and configurations
– There are more options of headgear
– There are more manufacturers
– There are automatically adjusting machines that deliver the only the amount of pressure needed during the night to prevent apneas/hypopneas
– There are Bi-level machines now for those patient that are unable to breathe against a high pressure when they exhale.
– There are machines now for those patient that a plagued with central sleep apnea syndrome

There are Data Cards now to not only record how much the machine is being used but whether the patient is still experiencing apneas or hypopneas, and how many. We always wish for good memories.

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.

ANNUAL VENDOR FAIR SHOWS WHAT’S NEW!

Once again the summer support group meeting was devoted to the annual vendor
fair showcasing what’s new in CPAP equipment. This year Matt Chirco of Oxygen Plus led the meeting. Three vendors were present this year; ResMed, Philips/ Respironics and Fisher & Paykel.

ResMed

Laurie Messerling from ResMed provided information on their award winning new S9 series of CPAP machines, their feather-light Swift FX masks and their new Mirage ConvertAble masks that give a choice of two mask cushions, the long proven Mirage Activa™ LT or Mirage SoftGel, on one frame.

ResMed S9™ CPAP Mchine

The new S9 series CPAP machines offer greater quietness through a new motor which virtually eliminates noise, Intuitive design combines with novel user-friendly control knob (think BMW), climate control which adapts to environmental conditions providing optimal humidity and preventing dreaded rainouts, small diameter air tubes that are the lightest available , a new detection algorithm that differentiates between obstructive and central sleep apneas and responds appropriately, delivers optimal therapy at the lowest necessary pressure. and compliance management for patients and clinicians alike to monitor therapy. Learn more at: www.resmed.com/us/

Respironics

Doug Lockwood from Philips/Respironcis enlightened the group on their “Intelligent Solution” which includes “Flex” CPAP machine technologies and ComfortGel Blue masks.

Respironics System One™

This system provides humidity control and dry-box technologies with resistance control permitting the use of virtually any mask, advanced event detection to measure all of the sleep parameters of Obstructive Sleep Apnea (OSA) as well as detecting symptoms beyond classic OSA, and a sophisticated data and reporting system for compliance management. More information can be found at: www.respironicssleeptherapysystems.respironics.com/

Fisher & Paykel

Rachelle Tracey of Fisher & Paykel Healthcare showed the group their new ZEST Range of nasal masks that fit better, feel lighter and are easier to use. When coupled with their F&P ICON family of CPAP machines offer a wide variety of solutions.

The Fisher & Paykel ICON™ Auto CPAP machine

The F&P ICON™ AUTO provides: humidity and comfort technology, autoadjusting pressure for personalized treatment during sleep, and SensAwake™ Technology for pressure relief during awake states. It even includes; includes a digital clock, alarm and music playing capabilities to enhance patient adaptation to CPAP therapy alarm together with a one-touch navigation knob. You can learn more at: www.fphcare.com/osa.html As is the normal practice for Support Group meetings, a valuable Question & Answer session concluded the evening hosted by Matt Chirco and ably assisted by Bill Stohl of Timberlake Respiratory Care.

MYTHS AND FACTS ABOUT SLEEP

(from the National Sleep Foundation)

There are many common myths about sleep. We hear them frequently, and may even experience them far too often. Sometimes they can be characterized as “old wives tales,” but there are other times the incorrect information can be serious and even dangerous. The National Sleep Foundation has compiled this list of common myths about sleep, and
the facts that dispel them.

1. Snoring is a common problem, especially among men, but it isn’t harmful. Although snoring may be harmless for most people, it can be a symptom of a life threatening sleep apnea, especially if it is accompanied by severe daytime sleepiness. People with sleep apnea awaken frequently during the night gasping for breath. The breathing pauses reduce blood oxygen levels, can strain the heart and cardiovascular system, and increase the risk of cardiovascular disease. Snoring on a frequent or regular basis has been directly associated with hypertension. Men and women who snore loudly, especially with pauses in the snoring, should consult a physician

2. You can “cheat” on the amount of sleep you get. Sleep experts say most adults need between seven and nine hours of sleep each night for optimum performance, health and safety. When we don’t get adequate sleep, we accumulate a sleep debt that can be difficult to “pay back” if it becomes too big. The resulting sleep deprivation has been linked to health problems such as obesity and high blood pressure, negative mood and behavior, decreased productivity, and safety issues in the home, on the job, and on the road.

3. Turning up the radio, opening the window, or turning on the air conditioner are effective ways to stay awake when driving. These “aids” are ineffective and can be dangerous to the person who is driving while feeling drowsy or sleepy. If you’re feeling tired while driving, the best thing to do is to pull off the road in a safe rest area and take a nap for 15-45 minutes. Caffeinated beverages can help overcome drowsiness for a short period of time. However, it takes about 30 minutes before the effects are felt. The best prevention for drowsy driving is a good night’s sleep the night before your trip.

4. Teens who fall asleep in class have bad habits and/or are lazy. According to sleep experts, teens need at least 8.5 – 9.25 hours of sleep each night, compared to an average of seven to nine hours each night for most adults. Their internal biological clocks also keep them awake later in the evening and keep them sleeping later in the morning. However, many schools begin classes early in the morning, when a teenager’s body wants to be asleep. As a result, many teens come to school too sleepy to learn, through no
fault of their own.

5. Insomnia is characterized by difficulty falling asleep. Difficulty falling asleep is only one of the four symptoms generally associated with insomnia. The others include waking up too early and not being able to fall back asleep, frequent awakenings, and waking up feeling unrefreshed. Insomnia can be a symptom of a sleep disorder, a medical or a psychological/psychiatric problem, and can often be treated. When insomnia symptoms occur more than a few times a week it impact s a person’s daytime functions.

6. Daytime sleepiness always means a person isn’t getting enough sleep. Excessive daytime sleepiness is a condition in which an individual feels very drowsy during the day and has an urge to fall asleep when he/she should be fully alert and awake. The condition, which can occur even after getting enough nighttime sleep, can be a sign of an underlying medical condition or sleep disorder causing poor quality sleep, such as narcolepsy or sleep apnea. Daytime sleepiness can be dangerous and puts a person at risk for drowsy driving, injury, and illness and can impair mental abilities, emotions, and performance.

7. Health problems such as obesity, diabetes, hypertension, and depression are unrelated to the amount and quality of a person’s sleep. Studies have found a relationship between the quantity and quality of one’s sleep and many health problems. For example, insufficient sleep affects growth hormone secretion that is linked to obesity; as the amount of hormone secretion decreases, the chance for weightgain increases. Blood pressure usually falls during the sleep cycle, however, interrupted sleep can adversely affect this normal decline, leading to hypertension and cardiovascular problems. Research has also shown that insufficient sleep impairs the body’s ability to use insulin, which can lead to the onset of diabetes. More and more scientific studies are showing correlations between poor and insufficient sleep and disease.

8. The older you get, the fewer hours of sleep you need. Sleep experts recommend a range of seven to nine hours of sleep for the average adult. While sleep patterns change as we age, the amount of sleep we need generally does not. Older people may wake more frequently through the night and may actually get less nighttime sleep, but their sleep need is no less than younger adults. Because they may sleep less during the night, older people tend to sleep more during the day. Naps planned as part of a regular daily routine can be useful in promoting wakefulness after the person awakens.

9. During sleep, your brain rests. The body rests during sleep, however, the brain remains active, gets “recharged,” and still controls many body functions including breathing. When we sleep, we typically drift between two sleep states, REM (rapid eye movement) and non-REM, in 90-minute cycles. Non-REM sleep has four stages with distinct features, ranging from stage one drowsiness, when one can be easily awakened, to “deep sleep” stages three and four, when awakenings are more difficult and where the most positive and restorative effects of sleep occur. However, even in the deepest non-REM sleep, our minds can still process information. REM sleep is an active sleep where dreams occur, breathing and heart rate increase and become irregular, muscles relax and eyes move back and forth under the eyelids.

10. If you wake up in the middle of the night, it is best to lie in bed, count sheep, or toss and turn until you eventually fall back asleep. Waking up in the middle of the night and not being able to go back to sleep is a symptom of insomnia. Relaxing imagery or thoughts may help to induce sleep more than counting sheep, which some research suggests may be more distracting than relaxing. Whichever technique is used, most experts agree that if you do not fall back asleep within 15-20 minutes, you should get out of bed, go to another room and engage in a relaxing activity such as listening to music or reading. Return to bed when you feel sleepy. Avoid watching the clock.

Q & A AT APRIL SUPPORT GROUP MEETING

Dr. Fred Nachtway fields a question

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 of Oxygen Plus

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

Respironics “Easy Life” CPAP 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.

CPAP AND A STUFFED UP NOSE

(some research by the editor)

One of the most frequent complaints of CPAP users is of nasal congestion during, or immediately after, using CPAP. An examination of this problem proved it is far more complex as to the cause and solution than first imagined.

There have been only a few studies of this specific problem but these suggest that CPAP itself is not the culprit and, in fact, CPAP results in a reduction in nasal resistance 2 to 3 hours after commencing use due to the mechanical splinting effect and/or reduction of vascular fluid in the nasal membrane.

Therefore the cause of nasal congestion must be due to something else. Chief among the causes identified are; mouth breathing, the change to a more recumbent posture (i.e. lying down), nasal dryness, allergy, the “rebound” caused by the use of decongestants, or Rhinitis/Sinusitis. Examining each of these potential causes of congestion may offer a clue as to what your individual problem is and what steps can be taken to achieve relief.

Mouth breathing is known to increase nasal obstruction and can be alleviated by the use of a chin strap or switching to a full-face mask.

A recumbent posture normally causes a slight increase in nasal resistance. If lying down with CPAP causes nasal congestion to the point making it difficult to breath through the nose this would tend to indicate a pre-existing nasal obstruction or structural physical problems with the nasal passages may be the cause. If the stuffiness goes away when you remove your mask and get up the problem is most likely postural. In any case an examination of your nasal passages by a physician is in order. Nose drops (see the section following) may help but rely on your physicians recommendation.

Nasal Dryness can be a cause of irritation and resulting swelling of the nasal passages. The solution can be as simple as squirting a saline solution (e.g. Ocean brand) into each nostril before putting on your CPAP mask and again several times during the day. If this doesn’t work than investigate with your physician and CPAP supplier the addition of a humidifier to your CPAP machine.

Allergies can cause inflammation and can cause difficulty breathing. Over-The- Counter (OTC) allergy medications treat the symptom (i.e. inflammation) not the cause (allergy) and even then only for a little while. You need to talk with the physician who is treating your allergy and they need to know that you use CPAP and the breathing problem you are having.

“Rebound” caused by the use of decongestants is perhaps one of the commonest “self-inflicted” causes of nasal inflammation. Most of the OTC decongestants are designed for short-term use to decrease congestion and they will cause inflammation if used over extended periods. Beware the “OPXs” – look at the ingredients on the package and avoid those containing the following: Oxymetazoline (e.g. Afrin), Phenylephrine (e.g. Neo-Synephrine) and Xylometazoline (e.g. Sudafed or Sinex). They will all cause “rebound” nasal irritation. Your physician can prescribe one of several nose drops that can be safely used for extended periods without causing inflammation or “rebound” in the nasal passages. One of these is the antihistamine Azelastine (e.g. Astelin). Rhinitis/Sinusitis is really a fancy name for inflammation of the nose and/or nasal passages. Anything that irritates the nose can cause rhinitis. Changes in weather, such as temperature, humidity, and sudden barometric pressure changes often aggravate an already inflamed nose. Many systemic diseases can also impact rhinitis. The most common cause is allergies, but diabetes, high blood pressure, and many medicines can be also effect rhinitis. Treatment first involves getting a diagnosis of the cause of the Rhinitis.

Treatments vary from avoidance of offending substances such as; smoking, symptomatic OTC medicines known to contain an irritating decongestant (see above section on “rebound) and prescriptions with similar ingredients. Reducing or eliminating Rhinitis can be a difficult process to resolve alone. What may be tolerable to one not using CPAP may not be tolerable for one on CPAP. Again you need work with a physician with complete knowledge of your problem.

In conclusion, the benefits of CPAP to your overall well-being outweigh any efforts required to make its use uninterrupted and effective. A little analysis on your part, working with your physician and equipment provider can, in most cases, solve the problem of your stuffed up nose.

A stuffy nose is not caused by CPAP and abandoning CPAP will not cure a stuffy nose!

“OBSTRUCTIVE SLEEP APNEA – A REVIEW”

Support Group Meeting and gave a comprehensive review of Obstructive Sleep Apnea; causes, concerns, and alternative treatments to a small but interested audience (the weather outside was frightful!). His conclusion said it all, “Sleep Apnea is an important medical disorder that warrants active investigation by means of clinical evaluation and sleep studies. Treatment is essential, not only to improve the symptoms that include daytime sleepiness, but also to prevent the development of serious cardiovascular complications. Effective treatments exist that include behavioral, medical and surgical means. Dramatic improvement in patient wellbeing can result.”

A wide-ranging Question and Answer session with the doctor followed.

Dental Health and Teeth Grinding (Bruxism)

(from Web-MD)

Most people probably grind and clench their teeth from time to time. Occasional teeth grinding, medically called bruxism, does not usually cause harm, but when teeth grinding occurs on a regular basis the teeth can be damaged and other oral health complications can arise.

Why Do People Grind Their Teeth?
Although teeth grinding can be caused by stress and anxiety, it often occurs during sleep and is more likely caused by an abnormal bite or missing or crooked teeth.

How Do I Find Out if I Grind My Teeth?
Because grinding often occurs during sleep, most people are unaware that they grind their teeth. However, a dull, constant headache or sore jaw is a telltale symptom of bruxism. Many times people learn that they grind their teeth by their loved one who hears the grinding at night.

If you suspect you may be grinding your teeth, talk to your dentist. He or she can examine your mouth and jaw for signs of bruxism, such as jaw tenderness and abnormalities in your teeth.

Why Is Teeth Grinding Harmful?
In some cases, chronic teeth grinding can result in a fracturing, loosening, or loss of teeth. The chronic grinding may wear their teeth down to stumps. When these events happen, bridges, crowns, root canals, implants, partial dentures, and even complete dentures may be needed.

Not only can severe grinding damage teeth and result in tooth loss, it can also affect your jaws, result in hearing loss, cause or worsen TMD/TMJ (temporal mandibular dysfunction), and even change the appearance of your face.

What Can I Do to Stop Grinding My Teeth?
Your dentist can fit you with a mouth guard to protect your teeth from grinding during sleep. If stress is causing you to grind your teeth, ask your doctor or dentist about options to reduce your stress. Attending stress counseling, starting an exercise program, seeing a physical therapist, or obtaining a prescription for muscle relaxants are among some of the options that may be offered.

Other tips to help you stop teeth grinding include:
• Avoid or cut back on foods and drinks that contain caffeine, such as colas, chocolate, and coffee.
• Avoid alcohol. Grinding tends to intensify after alcohol consumption.
• Do not chew on pencils or pens or anything that is not food. Avoid chewing gum as it allows your jaw muscles to get more used to clenching and makes you more likely to grind your teeth.
• Train yourself not to clench or grind your teeth. If you notice that you clench or grind during the day, position the tip of your tongue between your teeth. This practice trains your jaw muscles to relax.
• Relax your jaw muscles at night by holding a warm washcloth against your cheek in front of your earlobe.

Do Children Grind Their Teeth?
The problem of teeth grinding is not limited to adults. Approximately 15% to 33% of children grind their teeth. Children who grind their teeth tend to do so at two peak times — when their baby teeth emerge and when their permanent teeth come in. Most children lose the teeth grinding habit after these two sets of teeth have come in more fully. Most commonly, children grind their teeth during sleep rather than during waking hours. No one knows exactly why children grind their teeth but considerations include improperly aligned teeth or irregular contact between upper and lower teeth, illnesses and other medical conditions (such as nutritional deficiencies, pinworm, allergies, endocrine disorders), and psychological factors including anxiety and stress.

Grinding of the baby teeth rarely results in problems. However, teeth grinding can cause jaw pain, headaches, wear on the teeth, and TMD. Consult your dentist if your child’s teeth look worn or if your child complains of tooth sensitivity or pain. Specific tips to help a child stop grinding his or her teeth include:
• Decrease your child’s stress, especially just before bed.
• Try massage and stretching exercises to relax the muscles.
• Make sure your child’s diet includes plenty of water. Dehydration may be linked to teeth grinding.
• Ask your dentist to monitor your child’s teeth if he or she is a grinder.

No intervention is usually required with preschoolage children. However, older children may need temporary crowns or other methods, such as a night guard, to prevent the grinding.