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I became acquainted with the term “sleep apnea” at an early age when my father was diagnosed with the sleep disorder and was subsequently put on a CPAP (Constant Positive Air Pressure) machine. Before that, he could clear bedrooms with his snoring, the same way an old, flatulent dog can send people fleeing from a room, gasping for breath. It was so bad that, on his annual men’s ski trip, he was forced to sleep alone in what became known as “The Richard J. Pilny Memorial Snoratorium”. The room still goes by the title to this day. 


While I laugh even writing about it, sleep apnea is not a joking matter. It’s actually quite serious, as Doctors Noah and Wind will tell you. Obstructive Sleep Apnea (OSA) causes an array of problems, from something as simple as daytime fatigue, to something a little more stressful, such as erectile dysfunction. Picking up where they left off last month, The Sleep Doctors discuss OSA and what to do if you feel like you suffer from it, or any other rest-prohibiting sleep disorders.   


Dish: Now for sleep apnea.


Dr. William Noah: Ah, the big one.


D: I was reading the signs that you may have sleep apnea—the loud snoring and daytime sleepiness. Are there any other—


WN: Anyone who snores needs to be screened for sleep apnea. If you snore, there’s an 80% chance you have sleep apnea. Eighty percent, that’s pretty high. That mean’s there’s an 80% chance you have a markedly increased risk of diabetes, high blood pressure, heart disease, stroke, and a number of other things. Those are the big killers. But things like gastroesophageal reflux, erectile dysfunction, and cognitive disorders—as far as being able to think clearly—are all linked to sleep apnea. You’re nine times as likely to have an automobile accident when you suffer from sleep apnea. But if you get treated, all those things are resolved. Isn’t that great news?


D: Definitely. How does sleep apnea cause things like diabetes, high blood pressure, erectile dysfunction, and etc.?


WN: What happens is when you have one of these—and by the way, I need to say that sleep apnea is a really bad term because “apnea” is the Greek word meaning “not to breathe”. I mean, you think of an apnea, where someone takes no breath, or no effort to breathe for a period of time: those are rare during sleep studies. What most people have is just decreased airflow. And the sound of that is snoring. Snoring means someone’s choking. You have decreased airflow. People don’t understand that; that’s not a laughing matter, like people make jokes on trips with guys. “Hey, he snored last night!”


So the decreased airflow, if it’s a tiny amount, which is the case about 20% of the time, doesn’t trigger the brain, or arouse the brain, or irritate the brain. Those are the people who just snore and don’t have what we call Sleep Disorder Breathing. But for the other 80% of the people that snore, those events they’re having, those obstructions, are leading their brains to problems. In other words, the brain recognizes the decreased airflow, and it upsets the brain, so it arouses itself out of sleep. And that’s why we have brain waves on patients when we do sleep studies—so we can see the arousals. So when you have enough decreased airflow that it arouses you, that’s a problem. It’s trying to get the muscles in your throat to constrict again. You don’t ever snore when you’re awake, do you? Have you ever known anyone who snores while they’re awake? It’s because the muscles in the throat relax during sleep, and it’s this relaxation, along with some other mechanisms, that causes people to snore. Thus, the brain’s trying to arouse the muscles to constrict again where they won’t snore. So these events are going on over and over. Here’s the big kicker: there’s a neurotransmitter in the brain called norepinephrine; it’s the main awake hormone. And it is released when the brain senses this obstruction. So every time these events occur at night, norepinephrine is being released. Well, norepinephrine is what I’d give you as a critical care doctor if you were in shock. So what do you think happens to your blood pressure if norepinephrine is being released seventy-five times an hour while you’re asleep? You’re blood pressure’s going to be up. But by putting someone on a CPAP, which corrects the sleep apnea, their blood pressure comes down. That makes perfect sense doesn’t it?


D: Yeah.


WN: Well, norepinephrine is also counter-regulatory to insulin, meaning that it does the opposite of insulin. In other words, where insulin makes your blood sugar go down, norepinephrine makes your blood sugar go up. So if you’re having norepinephrine released all night, you’re blood sugar’s going to be elevated all night, which also means your insulin is going to be elevated all night, as well. And if your insulin levels are elevated night after night after night, you’re going to become insulin resistant, which is Type 2, or adult diabetes. And that’s why we know putting patients on CPAPs drops their blood sugar and what we’d call the hemoglobin A1C. It’s the measure of how you’re blood sugar’s been over three months. We’ve had it out about thirty years. So that level drops almost a whole point when patients are put on a CPAP, which is better than most diabetic medications. That’s why the International Federation for Diabetes came out a few years ago and recommended that all diabetics be screened for sleep apnea. Because, first of all, 86% of overweight adult diabetics have sleep apnea. So if you diagnose sleep apnea, you can reduce their blood sugar without adding medication with side effects in a large number of patients.


D: And without surgery.


WN: Well, surgery doesn’t work very well with sleep apnea, anyways. The other thing: I got all these guys taking Viagra. You can’t believe how much these erectile dysfunction (ED) meds are taken. Of course, that’s why you see the ads all the time. Well, the ED meds are making their sleep apnea worse, which is in turn making the ED worse, because what causes most of the ED is sleep apnea untreated. There are studies out of Portugal, and there are studies in mice—don’t ask me how they tested ED in mice—that showed that 75% of the men in Portugal, and the mice, had ED. And when they treated them with CPAP, or corrected the abnormality in the mice study [laughing], they resolved the ED. That’s huge.


Now, I’ll tell you, the makers of Cialis and Viagra don’t want you to know that.


D: Of course not. So when should a person consider having a sleep study done? What signs would tell them to do it?


WN: Well, we don’t recommend sleep studies; we believe patients need sleep doctors, not sleep studies. You have all these fly-by-night centers everywhere wanting to get all the doctors to send their patients for sleep studies. A sleep study is only as good as the doctor who reads it and the doctor who evaluated the patient before. Most patients have multiple sleep disorders at one time. And so to us, the sleep study is a very minor part of the evaluation. What matters is them seeing a board certified expert, like me or Dr. Wind, who’ll go through a thorough and extensive history of them to find out what’s going on with them. And in many of the cases we don’t do sleep studies. They don’t need one; we can solve the problem without it. But other doctors are here just to make money, just to do things, so they want to do sleep studies. And we strongly disagree with that. In fact, at the new Nashville office, we’re not going to have a sleep lab. We’ll let them go with whatever sleep lab they want to; we’ll order it and get it arranged. But it’s a minor part. What they need is a sleep doctor who understands what’s going on and makes sure it’s cured. And that’s key because none of the primary physicians are trained in it. No one is.


D: So what you’re saying is go to a sleep doctor, not a—


WN: Don’t ever go for a sleep study from a regular doctor. Go see someone who’s an expert in sleep medicine and get a thorough evaluation. Then if you do need a sleep study, have that person evaluate your sleep study once they have all your history with them. Then they can make a proper interpretation. We don’t treat people based on their sleep study; we treat them based on their history. The study’s just part of it for those patients that need one. And that’s a huge difference. Most places will do a sleep study on you, then they’ll talk about what you need to do so they can make more money from you.


The problem is, there are so many guys and girls out there who are doing sleep medicine part time. They’re not well trained; they’re not boarded; or they’re not serious. They’re doing neurology, or pulmonology, or something else; and they reading sleep studies to make a little extra income. The key is: are you really a sleep doctor? Is your goal to correct and fix all their sleep disorders, and not just sleep apnea? And that’s what our group is different about.


BW: Sleep is all we do. That’s an important thing. We have accredited sleep centers; we’re board certified; we’re passionate about it; and we’re devoted to doing sleep medicine and sleep medicine only. It’s not a side job to make a little more income. / Issue 127 - September 4726
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