By Laura Freeman
It doesn’t take years for a sleep disorder to kill. Aside from its lethal effects on heart disease, stroke, hypertension and other chronic killers, the death it brings isn’t always gradual. It can happen in an instant, when a moment of sleepy inattention on a work site turns into tragedy, or when a drowsy driver drifts into oncoming traffic.
“Sleep is fundamental to health and a major influence on the course diseases will take,” UAB Sleep Lab director Patricia Patterson, MD said. “In addition to arrhythmias and heart failure, there is an association with metabolic disorders including diabetes and obesity. Some research also suggests a disturbance in immune response when sleep disorders remain untreated.”
Although suspicion of sleep apnea is the most common reason physicians refer patients to the sleep lab, the range of sleep disturbances is broad.
“Insomnia is common these days,” Patterson said. “Sometimes it’s related to short-term stress. Disturbances in circadian rhythm, like working a night shift, can also be factors. Or it could be a matter of sleep hygiene, in which case it can be improved by cutting back on caffeine late in the day, increasing morning light, and avoiding blue light before bedtime. However, long-term insomnia may have neurological aspects.”
Restless legs, sleep walking and other movement disorders also put patients at risk and warrant investigation. Problems such as night terrors can have both sleep and psychological or neurological components and may need a multidisciplinary approach to resolve.
“Sleep apnea usually presents with symptoms like persistent fatigue even on waking, frequent urination, difficulty with concentration, irritability, daytime sleepiness and possibly an irritated throat,” Patterson said. “Most sleep apnea patients are likely to be overweight and older. Obesity is a chicken and egg situation. Losing weight can reduce the severity of apnea, but apnea is associated with higher levels of hunger hormones, lower levels of satiety hormones, and fatigue that reduces activity, all of which makes losing weight harder. However, the good news is that the reverse is also true. Treating apnea can help make those stubborn pounds easier to lose.”
The gold standard of care for obstructive sleep apnea is positive air pressure therapy (PAP), which may be prescribed in the form of CPAP, bi-PAP or automatic APAP, depending on breathing patterns.
“The air pressure acts like a stent to keep the airways open,” Patterson said. “We prescribe a range of pressure levels depending on the severity of the disorder. Most PAP equipment can be set at low pressure and gradually be ramped up as the patient falls asleep. It can be at full prescribed pressure during deep sleep when muscles relax and airways are more likely to collapse. Instead of patients having to repeatedly come near wakefulness to breathe, the pressure protects the airway and they continue in deep sleep.
“During sleep studies, we connect electrodes to monitor brain activity and sensors to follow the heartbeat and breathing. This gives us plenty of data for a clearer picture of what is happening. Apnea is measured in events per hour, which means the number of times breathing either stops, is delayed or becomes too shallow to supply enough air. If there are more than five events per hour, the patient may need treatment.
“There are other possible interventions, including raising the head of the bed or stacking pillows in a wedge to allow more upright sleep. We might also teach patients to sleep on their side rather than their back, and may include a side sleeper pillow to support the neck.”
There are also oral devices and chin straps to maintain a better airway position and prevent the jaw from dropping and the tongue from falling back. If unusually large tonsils, nasal polyps or other obstructions are found, the patient may be referred for a surgical consult.
“We like to get patients setup with a Bluetooth app that offers coaching to help them resolve common issues and stick with it,” Patterson said. “Even if patients are unable to continue PAP therapy, there is always something we can do. For example, we now have an implantable device that stimulates the tongue during sleep so it doesn’t fall back and block the airway.
The FDA has also just approved the Eli Lilly weight loss drug Zepbound (R ) (tirzepatide) to treat moderate to severe sleep apnea. The weekly injectable is the first medication approved to treat the disorder. In placebo controlled trials, subjects lost an average of 20 percent of their body weight. Negative breathing events were reduced by 29 per hour in patients also using CPAP therapy and 25 per hour in patients using the medication alone.
What Doctors Can Do
Getting PAP Ready
Helping patients identify related health issues and resolve them can greatly improve the odds for success.
“If patients have chronic sinus congestion, allergies, reflux or other problems that impact their breathing, resolving them can open up a wider choice of equipment options. Being able to use a nasal pillow mask rather than a full face mask could be easier for patients with beards, sensitive skin, unusual facial structure or claustrophobia. They can also use the oral devices to help with nose breathing and avoid a dry throat from a mouth that falls open,” Patterson said.
“When muscle aches, joint and back pain or stress and anxiety make sleeping more difficult, dealing with them makes it easier to fall asleep rather than lying there hurting and frustrated.”
Knowing What To Expect
Unless patients have experience with an issue like insulin-dependent diabetes, they may be surprised by how much their success in the early weeks depends on their own daily efforts to get to know their equipment and how to use and maintain it.
“It’s very much a learning process where patients learn by doing. Facial structure and their particular combination of health issues are unique to each person. Using PAP consistently every night is how they identify what works for them, what needs to be better, and where to go for suggestions on different aspects of customizing the therapy so it works for them.
“Like learning to ride a bike or play the piano, practice and persistence help. Making your therapy fit you is also like having a suit custom tailored. You can start with a great design, but it’s the custom touches, one by one, as you make small adjustments to fit your body that make the difference.
“It takes a daily effort, but the rewards are worth it. As you sleep better and your health improves, you’re going to feel so much better.”
Help Patients Understand What’s At Stake And Why They Shouldn’t Give Up.
Unsupported, failure rates can be high. But understanding why they are investing the effort can help patients stay motivated when challenges come.
As one patient put it, “There are times in the early morning when I can’t stop the whoopee cushion air leaks or can’t find a comfortable position and I could gladly toss my mask out the nearest window. What keeps me coming back every night to try again is knowing I don’t want dementia or to put my family at risk in a wreck, or for my grade three kidney disease to progress to grade four and become dialysis dependent. That would be a lot more confining than a mask. So every night, I’m back trying again and gradually learning what works for me.”
Tips From PAP Patients
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“Be good to yourself. Refill your humidity chamber every morning or when you first get home so you don’t have to do it when you’re sleepy. Instead of struggling with a gallon of distilled water, every week when you clean your machine, fill seven bottles with a premeasured amount. Filling to slightly below the mark on the chamber usually works best. Mine is easier if I turn the chamber on the side and mark a fill line with a permanent marker.”
“Set up a comforts kit in a basket or bin by the bed, and designate a place for each item so you can find it in the dark. Check to make sure there is plenty of everything when you reset your humidity chamber. You don’t want to find you’re out of tissue, saline nose spray or dry eye ointment when you need it.”
“Check YouTube for manufacturer videos, reviews and tutorials on your specific equipment. That’s how you learn about features you didn’t realize were there and get ideas on what to do if something new comes up. Also check the comments posted. You’ll find great ideas from other users. Just remember every face is different. The perfect mask for one guy may be wrong for someone else
“To get sleep study electrode glue out of your hair, mix half dishwashing liquid and half deep conditioner plus a few drops of warm water. Massage it in, cover with a steaming towel for a few minutes, then double shampoo and follow with a conditioning treatment.”
“If your machine has a seal test setting, try it lying on your side. As the pressure ramps up, you’ll get a better sense of whether the straps need to be adjusted.”
“If you wake up feeling you can’t breathe, the pressure may be keeping you from breathing out enough so you can breathe in. Try pursing your lips and blowing, then take a deep breath. Try to resist the impulse to tear your mask off or you may have to put it back together again in the dark.”
“Try your mask in daylight. Memorize how the straps fit together, and look for touch landmarks so you can put it back together again in the dark. Also learn how to reconnect the plastic nose piece and silicone pillow if it pops out. You don’t want to be stranded wondering what to do if you have a light sensitive bedmate.”
“Moisturize in the morning, not at night. Or if you must, wipe the skin surface where it meets the mask. If it’s giving you rude leak sounds, wipe the silicone pillow, too.”
“Since I started CPAP, I don’t have to go to the bathroom as often. But it has been helpful once a night to turn off the mask, go to the bathroom, get a sip of something to drink, use the saline nose spray, then reposition the mask and turn on the machine, letting it gradually ramp up to pressure as I go back to sleep.”
“Keep a notebook and pen by the bed. If you get congested, write what you ate or what allergens you might have come into contact with the day before. If you have had problems, try to write a simple description while you remember. Examples--“Upper left strap rubbing felt tight on cheek,” or “Lower right seal leaking when I roll over to the other side.” Having a starting point for troubleshooting helps you swat the little aggravations so they don’t continue to bother you.”
“If you’re having trouble getting to sleep, don’t just lay there waiting or every itch, twitch and circular thought will drive you to frustration. I set up playlists of audiobook, soft music and podcasts that are interesting enough to be distracting but boring enough to let me fall asleep. YouTube lets you set up playlists by topic, but listen—don’t look at the blue light. I’m learning a lot about archeology and astronomy. If you’re stuck without a playlist, remember your favorite places and relive vacations. Remembering and imagining are so close to dreaming.”
