Why am I tired all the time? What is causing my high blood pressure? Why can’t I lose weight? I get these questions on a daily basis in my clinic. Many of you have probably asked the same questions. You know something is not quite right, but you are just not sure what it is. When presented with chronic problems, I like to look for the underlying cause of those issues. While the list of conditions that can cause fatigue and obesity is extensive, I always like to start by looking at that crucial activity that consumes most of our day: your sleep.

If you are not sleeping well, then you cannot live well. Sleep is the most important activity that you can do to heal, to grow and to prepare for the following day. Sleep is free, its available to everyone every night, and it comes in unlimited supply. However, millions of people suffer from sleep disorders that inhibit them from accessing this wonderful resource. The CDC reports that 70 million Americans suffer from sleep disorders. That’s 21% of Americans who are not operating to their full potential due to lack of sleep.

What Is Sleep Apnea?

Sleep apnea is one of the most common sleep disorders seen in adults, it can go undiagnosed for years and has deadly consequences. Sleep apnea is a disorder that prevents your body from breathing appropriately while you are sleeping. There are two kinds: obstructive and central. Obstructive sleep apnea occurs when your throat collapses at night and prevents your lungs from ventilating appropriately. Central sleep apnea occurs when your brain fails to send signals to your diaphragm to ventilate on their own. Both kinds of sleep apnea prevent you from achieving good quality sleep. When your lungs don’t ventilate, your body’s oxygen saturation drops. And when your O2 drops, your body notices it, in an emergent way.

Low oxygen levels stress you out. Your body doesn’t like it. When your body senses those low oxygen levels, it goes into panic mode, and your adrenal glands secrete cortisol. Cortisol is the stress hormone that can save you in an emergency, but can wreak havoc when secreted for an extended period of time. Cortisol secretion causes something called microarousals. Microarousals pull you out of REM sleep in order to get you to start breathing again. Breathing is a good thing of course, but when you sacrifice your REM sleep in order to start breathing again, then you are not getting good quality sleep.

What Are The Effects Of Sleep Apnea?

There are numerous symptoms that can come from sleep apnea. Some occur right away, and some take years to develop. These immediate symptoms include snoring, morning headaches, fatigue, waking up feeling unrested, insomnia, nighttime awakenings, anxiety and more. And these are just the symptoms that you can notice on a daily basis. Sometimes patients are asymptomatic, meaning they have no immediate symptoms at all.

Hypercortisolism

Sleep apnea can cause a lot of other problems that you may not notice for a long time. The first set of problems come from the effect of prolonged elevation in your body’s cortisol levels. As I mentioned above, the body’s stress reaction tells your adrenal glands to crank out the cortisol. In response to cortisol, your body elevates your heart rate and your blood pressure. It can cause you to gain weight or make it impossible to lose weight even with aggressive diet and exercise. It promotes inflammation of all kinds which can increase your risk of heart disease and cancers in the future. Elevated cortisol places unnecessary stimulation on your heart. The most common cardiac problem from sleep apnea is atrial fibrillation. A-fib comes from hyperactivity in the top chambers of your heart, which causes quivering of the chambers, and inefficient pumping of blood to the rest of the body. Lack of sleep from sleep apnea is one of the leading causes of low testosterone and erectile dysfunction and can even accelerate early dementia.

Hypoxia

The next set of problems comes from prolonged hypoxia, or low oxygen levels. When your body detects prolonged low oxygen levels, it sends a message to your kidneys. Your kidneys respond by secreting a hormone called erythropoetin or epo. Epo then travels to your bone marrow and tells it to start cranking out more hemoglobin. Hemoglobin is the molecule that carries oxygen to the rest of your tissues. So sometimes, in patients with undiagnosed sleep apnea, the first sign of the disease that we discover is an elevated hemoglobin level. Elevated hemoglobin can cause brain fog, itchy skin, shortness of breath, and even blood clots if the level elevates high enough.

When the lungs detect low oxygen levels, the pressure in your pulmonary artery rises. This causes a disease called pulmonary hypertension. This is different from normal high blood pressure, in fact, its much worse. Pulmonary hypertension puts undue pressure on the right side of the heart. Like any pump under stress, those high pressures can eventually cause the right ventricle to fail or can cause pressure to back up into the inferior vena cava and cause profound swelling in the legs.

How Do You Diagnose Sleep Apnea?

The only way to diagnose sleep apnea is to perform a sleep study. Some of you may remember (or may have had) a sleep study being done in the basement of the local hospital. You would check-in the evening of the test and get hooked up to monitors. You would then drift off to sleep with a proctor watching you from a control room (my grandfather actually worked as a sleep study proctor). Needless to say, patients did not love this experience. In fact, many patients reported not being able to sleep under such circumstances.

Thankfully, we now offer at home sleep studies, which are much easier and more comfortable to complete. My company uses a device called a Watchpat to conduct at home sleep studies. You pick it up from the office and take it home the night of the study. When you are ready to sleep, you put on the finger probe, the smart watch and the chest sensor that comes with the kit. Once turned on, you can go to sleep undisturbed and the device monitors your sleep until taken off in the morning. Several parameters are monitored by the device including oxygen levels, limb movements, your sleep position and your respirations. All of this data is used to make a diagnosis of sleep apnea.

How Do You Interpret Sleep Study Results?

Sleep apnea is classified into mild, moderate and severe. We use a number called an apnea-hypopnea index (AHI) to classify your degree of sleep apnea. The AHI is the number of times you stop breathing or under breath per hour. An AHI of 5 or less is considered normal. An AHI of 5-15 is mild, 15-30 is moderate and >30 is severe. I have patients who had an AHI of >100 before, meaning they stopped breathing a couple of times every minute. No wonder they felt terrible! The sleep study also tells us if you are hypoxic or not. Hypoxia occurs when your pulse oxygen level drops below 90%. Your oxygen level can drop to dangerously low levels when sleeping if you have untreated severe sleep apnea.

How Do You Treat Sleep Apnea?

Once sleep apnea is diagnosed, we need to get it treated in order to prevent these symptoms and long term effects from occurring. Most patients with a new sleep apnea diagnosis should meet with an ear nose and throat surgeon (ENT) for an evaluation. The ENT can evaluate your throat and upper airway to see if an operation could cure or significantly improve your sleep apnea. Some patients with sleep apnea may have a single section of the airway that collapses to cause sleep apnea. If this single section of your airway could be fixed with an operation, then sleep apnea could potentially be cured without any other treatments. An ENT can perform a procedure called a drug-induced sleep endoscopy, or DISE for short. This is an outpatient procedure done in the OR. The anesthesiologist will knock you out with a sedative, like propofol for about 20 min. While you are sleeping, the ENT surgeon can put a camera into your nose and then advance that camera down your throat to evaluate your airway while you are sleeping.

CPAP Mask

The most common way to treat sleep apnea is with a mask. This is called continuous positive airway pressure (CPAP). The mask is connected to a machine with a tube. The positive air pressure coming from the mask prevents your airways from collapsing. Most machines that we use today will auto-titrate, meaning they can sense the proper amount of air pressure needed to keep your airways open. If your sleep apnea causes severely low oxygen levels at night, then we can also connect an oxygen tube to the machine to provide extra O2 while you sleep. There are numerous mask sizes, fits, and styles that you can try in order to find the one that provides the most comfort when you sleep.

Oral Appliance

You can also treat sleep apnea with an oral appliance. This is like a mouth guard that keeps your jaw in an open position overnight. This is less effective than a mask and can’t deliver supplemental oxygen like a mask can, but some people prefer it because it is simpler.

Inspire

A new implantable device just received FDA approval for the treatment of sleep apnea. This device is called Inspire and it is implanted in your chest like a pacemaker. Once activated, the device stimulates the muscles of the throat to contract in order to keep your airways open while you sleep. I consider this a rather aggressive treatment, and it only recently received FDA approval, so I hesitate to recommend this for everyone. However, as more patients try this option, we may find that this will be the future standard of care for sleep apnea treatment.

Sleep apnea is underdiagnosed in the USA. You can suffer from it for years before knowing you have it. Oftentimes, patients are only diagnosed with sleep apnea after damage has already been done. Many of the secondary effects of sleep apnea are treated without finding out the root cause of those problems first. If you have any of the symptoms I discussed above, then talk to your doctor about getting a sleep study. If you have already been diagnosed with sleep apnea, make sure you are treating it aggressively, and look into some new options if your current treatment is not right for you.

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