Changing Your Life... While You Sleep?
Are you done with CPAP? If you answered yes... this information is for you!
A Bad Night’s Sleep Obstructive sleep apnea (OSA) occurs when the airway gets blocked while a person sleeps. A sensation of not breathing causes gasping for air and wakes the person up. “It’s not just the blockage that’s a problem,” explains oral maxillofacial surgeon Dr. Randolph C. Robinson, surgeon-in-chief at Sleep Apnea Surgicure in Denver, Colorado. “It’s also that the patient wakes up, almost at a subconscious level, so that they’re not rested. They go through this cycle through the night. It can adversely affect multiple organ systems.” Stephen D. Ochs, M.D., M.B.A., chief anesthesiologist and medical director at Sleep Apnea Surgicure, further details what happens in patients with OSA. “You will snore and eventually collapse the airway. Therefore you don’t exchange air, and don’t oxygenate your vital organs including your brain, as you should.” “Fortunately nature has seen fit to alert us, even in the unconscious state, that we’re not breathing. You awaken to the extent that you clear your airway, and exchange air in and out. You re-oxygenate your brain, heart, liver, and all vital organs that need oxygen minute to minute.”
No Small Problem Think only a few people are affected by OSA or other sleep problems? Think again. Eighteen million people in the United States suffer from OSA, and 40 million have a chronic sleep disorder, according to surgeon Randolph Robinson, M.D., D.D.S. “Sleep apnea is an epidemic.” It’s been shown that probably one out of five adult men and women in the United States suffer from OSA. And most of those people are unaware. “The majority of our patients are men in their mid-30s to 60s,” comments Dr. Ochs. “They often come here because their wives can no longer sleep with them, due to their snoring or even
choking.” “Symptoms can be as simple as awakening after seven to eight hours in bed and you wake up feeling exhausted,” states Dr. Ochs. “That’s a very common complaint.” What may sound like a small annoyance is extremely serious, he says. “There are tests to determine how often a person’s airway is obstructed. Some may do this every 45 seconds. This over and over throughout night.”
Identifying Symptoms Wonder if you or someone you know may have a sleep problem? Warning signs are relatively straightforward.
• Snore • Wake up choking or gasping for air • Often wake up with a sore throat • Feel tired most days • Experience chronic fatigue, perhaps bordering on depression • Need several cups of caffeine or energy drinks a day to keep going • Boost your energy with energy bars, carbohydrates and sugar • Have experienced significant weight gain over several years • High blood pressure, often resistant to medical treatment • Feeling chronically depressed • Poor job performance issues While these are several indicators you should pay attention to, the real diagnosis is made by a sleep study or polysomnography (PSG), according to Dr. Robinson and Dr. Ochs. Sleep studies are performed in sleep clinics or in the patient’s home. The PSG monitors the heart rate and rhythm, brain waves, breathing rate, chest movements, eye movements, nasal airflow, blood oxygen concentration, blood carbon dioxide concentration, and leg muscle moments.
The Obesity Factor Obesity is one of the most common associations with sleep apnea. This is because extra weight often occurs as excessive soft-tissue under the chin in the throat area. This makes breathing more difficult during sleep and often exacerbates the severity of OSA. Dr. Ochs notes, “This is what medicine calls a comorbidity and creates a vicious cycle.” “You wake up tired, so you eat foods that elevate the blood sugar. These can be white or whole grain bread, donuts, certain cereals, and candy bars–anything that gives a sugar-high.” “The problem is taking more calories in than they burn off; so over a period of time, they gain weight.”
Restorative REM Sleep It’s only been in last 15 to 20 years that obstructive sleep apnea has been researched and publicized, according to Dr. Ochs. Today we’re aware of the integral connection between OSA and the Rapid Eye Movement (REM) dream stage of sleep. REM sleep, where our eyes move back and forth, is very important to psychological and physiologic health. Most important, it’s restorative sleep necessary to help refresh us. “During OSA, you’re disturbing your sleep so you never get into a full REM cycle,” Dr. Robinson explains. Ironically, people who have OSA can move into a REM cycle faster than most people. “However, it’s interrupted, so they start to feel this fatigue.”
Curing a Sleepless Night with CPAP For someone diagnosed with OSA, the initial recommended medical treatment is CPAP (continuous positive airway pressure). “Because sleep apnea is caused
Sleeping With a “Bucket of Monkeys” The person diagnosed with sleep apnea isn’t the only one who suffers. So does whoever tries to sleep beside them.
by blockage in back of the throat, the positive pressure of a mask over the face can keep the airway open,” shares Dr. Robinson. Dr. Ochs explains how CPAP works while a person sleeps. “The mask is not unlike what a jet pilot wears. They strap it on their face–it has to be strapped on securely–and it generally covers the nose and/or mouth.” CPAP is successful in the vast majority of patients, according to Dr. Ochs, as long as people use it as prescribed. Therein lies the main problem with CPAP–compliance is not very good. “We know that approximately 65 percent of people prescribed to use nightly CPAP fail to use it over one year,” says Dr. Ochs. “That’s important because CPAP is generally prescribed to be used every night and all night.” Why such low compliance? Dr. Ochs continues, “The majority of our patients come to us already diagnosed and treated with CPAP. They say it’s uncomfortable. Every time there’s a change of position, there’s always a risk the mask will become dislodged. CPAP also can cause teeth to move, chronic sore throat, facial rashes or sinusitis.” Amy Thomas-Blakely of Colorado Springs, shares her experience of sleeping with a husband who suffers from sleep apnea. “Sleep apnea affects us both because of Chris snoring or waking up all night. Starting right after he falls asleep, he wakes up because his body is saying his airway is closing up. “There’s lots of tossing and turning. It’s like sleeping with a bucket of monkeys! And then we both wake up cranky in the morning.” Looking for relief through CPAP, Amy says that also has its downside. “If Chris wears the CPAP mask, there’s so much noise from the machine.
And if there’s no noise, it means he’s stopped breathing.” So ultimately, neither person sleeps well. “It’s also inconvenient. Chris has to sleep on his back. If he rolls on his on side, the mask will come off or the straps will move.” In either case, the CPAP won’t be able to provide oxygen. Chris’ work requires long road trips. CPAP machines also must plug into a wall and recharge their seven-hour battery power, which can be inconvenient for people who travel or work on the road. “CPAP is clunky and you have to wash it out; so it’s a hassle. The cab of Chris’ truck is small, so he’d be dragging around a piece of machinery with nowhere to put it.” Currently, Chris and Amy are sleeping without the machine. “We discovered Chris can tilt his head or put his face downward to reduce his snoring.” For now, Amy says their solution is just learning to live with sleep-apnea interruptions while hoping no related illnesses might later occur.
Surgical Solutions So what’s a sleep-apnea sufferer to do, if CPAP isn’t a good fit? Several surgical treatments may be helpful, including:
• • • • • •
Opening the nasal passage Removing a person’s tonsils Shortening the soft palate Reducing the size of the tongue Moving the chin bone Straightening the jaw
Some of these surgeries have a good effect as far as treating snoring and breathing through the nose, according to Dr. Robinson. However, only the last one has a good track record of “treating sleep apnea in a predictable, curative way.”
The “Get to REM” Solution “The MMA or maxillomandibular advancement surgery has a 90 to 95 percent cure rate, according to Dr. Robinson. “We call it ‘Get2REM.’ Adds Dr. Ochs, “That’s what we accomplish. We get you breathing properly, curing the sleep apnea. This procedure allows people to go into normal sleep cycle, into normal restorative portions of sleep they should get seven to eight times a night.” The outpatient MMA surgery has clinically cured obstructive sleep apnea for several hundred of Dr. Robinson’s patients. Together with Dr. Clark O. Taylor, another associated oral maxillofacial surgeon based in Missoula, Montana, Sleep Apnea Surgicure has successfully operated on over 600 OSA patients the past decade. Performed under general anesthesia administered by Dr. Ochs, MMA takes only about three hours. “Our surgery is very successful,” explains Dr. Robinson, “because it treats three areas at once: the nasal passage, soft palate and back of the throat at the base of the tongue.” He explains, “Cuts are made through the bones, so the bones are broken and then advanced into new position. This pulls the soft palate, chin and tongue forward. Now the airway is open.” Once the lower jaw is advanced, it’s held in position using titanium bone plates. “One question
everyone usually asks is, ‘Is it enough metal to set off the airport detectors?’ “It’s not. They’re also nonmagnetic, so people usually can have MRIs.” The surgery is performed through the mouth, eliminating any incisions on the outside, and the stitches simply dissolve inside of the mouth. Teeth are not held together unless just slightly, with guiding rubber bands for about six to eight weeks. During that time, patients take off the rubber bands to eat a nonchew diet. “They can eat anything from protein shakes and scrambled eggs to mashed potatoes. Whatever suits them,” says Dr. Robinson.
Several benefits make the Get2REM procedure especially desirable. Patients: • Can go home the day after surgery, saving them significant cost • Usually lose 10 to 12 pounds during the specialdiet phase of recovery • Experience minimal pain, bruising or swelling • Return to work after about 2 wks • Resume mild exercise in two weeks and their regular workout routine in about four weeks
Dr. Randy Robinson
Patients tell Dr. Robinson that the difference in their breathing and sleeping is almost immediate. “They take a breath after surgery and say their airway is more open. It also helps them when they work out and when they’re running. It’s a huge change for them.”
MMA, Historically Speaking Dr. Paul Tessier, a world famous maxillofacial surgeon based in Paris, developed and refined the surgical techniques for breaking the bones and moving them into new positions for correcting facial deformities. As that process evolved, they discovered, “We’re actually opening the airways of these kids that have facial deformities,” explains Dr. Robinson. “From there, it was realized, that for patients who have OSA, partially due to fact that their face may be too small both in the upper jaw and in the lower jaw, they now can benefit from this type of surgery.” Dr. Robinson is one of only a few surgeons in the country who perform this procedure. He actually trained in Paris under Dr. Tessier, who is considered the father of cranial facial surgery. “I’m passionate about this procedure and how can help people,” he says.
Facing Fear Is Life-Changing A lot of people will avoid getting treatment out of fear. “If someone suspects they have sleep apnea,” stresses Dr. Robinson; “it can affect their life in a serious way. “From heart disease to diabetes, to obesity and respiratory problems, it’s very serious. They should get it checked.” Adds Dr. Ochs, “I
Dr. Steve Ochs
can’t urge you enough, if you think you may have it, get tested. It is a preventable disease. By treating it, we can generally reduce the risk of developing all the other adult disease processes that are leading to early death in this country.” Dr. Ochs says these include diabetes, which will increase risk of heart disease and stroke; chronic depression, weight gain and obesity. Risk of sudden death also is higher across all parameters if you have sleep apnea. “So we’re not only talking about longevity here, but also quality of life. I am passionate about people being diagnosed and properly treated,” Dr. Ochs emphasizes. While Dr. Robinson agrees, he acknowledges that the financial consideration also is an important one. “For most patients, OSA is due to a medical condition, so it should be covered under major medical insurance. Our office will help with that determination.” Ultimately, sufferers of sleep apnea should look into the many possible solutions for their problem. “MMA is one solution, but it’s not for everyone,” says Dr. Robinson. And then he concludes, “The patient has to realize the value of what can be accomplished by MMA, our proprietary Get2REM surgical procedure. “It can be life-changing.” In its 2012 Sleep in American poll, the National Safety Foundation noted, “train operators and pilots report the most sleep dissatisfaction.” Statistics expose how numerous transportation accidents have related to sleep deprivation or sleep apnea:
Transit Industry. Chicago O’Hare train derailment, March 2014. Under investigation for possible driver sleep deprivation. Airline industry. Air India, 2010. The pilot’s snoring can be heard on an audio recording. Air France 2010. The pilot reportedly only slept one hour the night before flying. Train Industry. Two trains collide, Michigan 2001. Engineer’s and conductor’s fatigue said to be due to untreated OSA. Shipping Industry. Exxon Valdez 1989. Documented statement says, “It’s clear the entire crew suffered from fatigue.” Truck Industry. 100,000 accidents and 1,550 fatalities a year due to sleep deprivation. It’s estimated that 20 percent of all truck-car collisions are caused by sleepdeprivation or sleep apnea. Congress and the National Transportation Safety Board (NTSB), which oversees commercial truck drivers, are working on regulations requiring testing for OSA. “It’s estimated that 40 percent of all commercial truck drivers are at risk of sleep apnea with a 60 percent overall incidence of overweight or obesity,” notes Dr. Ochs.
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