OK, so it might not get you on the golf tour, but I have used many tactics to get folks living a healthier life by getting their sleep disordered breathing under control, so why not appeal to their desires for superority among their golf buddies?

Dr. Smith: I read 2 or 3 of these every day, and rarely do they resemble each other. However, I can help with some of the acronyms and numbers even without seeing the study.

AHI: Stands for the Apnea-Hypopnea Index. Very simply, this means the number of times you stop (or significantly hinder) breathing for at least 10 seconds every hour. These “events” can be due to an obstruction or due to your brain’s respiratory center being a bit lazy.

RDI: This stands for Respiratory Disturbance Index. There is some controversy here, but generally this number is derived from adding the RERAs to the AHI. So, the RDI should always be higher than the AHI.

RERA: Respiratory Effort Related Arousal. These do not need to last 10 seconds, but they are related to an obstructed breathing effort that created a sleep arousal. If you have many RERAs but a low AHI, this is called Upper Airway Resistance Syndrome (UARS)

ODI: Oxygen Desaturation Index. This is generally considered to be the number of times per hour that your oxygen became desaturated at least 4%. This usually occurs concurrently with or shortly after a respiratory (breathing) interruption, or apneic event.

If you (or anyone) would like to know more about the numbers or acronyms on your sleep study, just let me know. There are far too many possiblities to list them here.

Excess weight can be sleep related

Dr. Smith: If your snoring has elevated into a more dangerous condition called sleep apnea, that is indeed true. (Only a sleep study can give you this information) There are various theories, most of which have sketchy research behind them, but what we know is that the link is real. One thought revolves around the hormones leptin and gherlin. Leptin tells you when you are full, while gherlin tells you to eat. When you don’t get proper sleep due to sleep apnea, leptin levels drop, gherlin levels rise and you keep eating. Many ask me if there are leptin pills available, but I’m afraid these are not yet on the market. They may be close, using a medication meant for diabetes to hold the leptin, but all they have been able to do is help keep weight off once it has been lost. Having said that, it’s a long way from FDA approval, so in the meantime, just eat less and exercise I’ll post other theories on weight gain due to snoring and sleep apnea in future blog posts.

Dr. Dmith:
1. From Sleep and Breathing (When we remove obstructions and anatomically reorient the mandible, we can be surprised at the benefits)

The aim of the present study was to investigate the effect of a mandibular advancement device (MAD) for the treatment of sleep apnea (SA) on plasma brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF), and health-related qualify of life (HRQL) in patients with mild to moderate stable congestive heart failure (CHF). Seventeen male patients aged 68.4±5.5 with an apnea–hypopnea index (AHI) 10 were equipped with an individually fitted MAD. SA was evaluated using a portable respiratory multirecording system before and after the initiation of treatment. Eleven patients completed follow-up and were evaluated after 6 months of treatment. The AHI reduced from 25.4±10.3 to 16.5±10.0 (p=0.033) compared to baseline and mean plasma BNP levels decreased from 195.8±180.5 pg/ml to 148.1±139.9pg/ml (p=0.035). SA-related symptoms, e.g., excessive daytime sleepiness, were also reduced (p=0.003). LVEF and HRQL were unchanged. We conclude that SA treatment with a MAD on patients with mild to moderate stable CHF appears to result in the reduction of plasma BNP levels. Further studies to investigate if the observed reduction in BNP concentrations also result in improved prognosis are warranted.

2. From articles like this one, it becomes clear that a) Obstructions that create a decrease in respiratory motor output will b) decrease respiratory drive, leading to c) CSA. Therefore, anything that removes obstructions, such as a MAD, can improve CSA.

3. Additionally, OSA leads to arousals, which leads to hyperventilation, which leads to hypocapnia, which leads to a decreased respiratory drive, which leads to CSA. So, control OSA with a MAD, and you can lessen the likelihood of CSA manifestation.

Dr. Smith: Yes, there is more and more literature coming out showing that not only can mandibular advancement devices improve obstructive sleep apnea, but they can have a positive effect on central sleep apnea as well.

From articles like this one, it becomes clear that a) Obstructions that create a decrease in respiratory motor output will b) decrease respiratory drive, leading to c) CSA. Therefore, anything that removes obstructions, such as a MAD, can improve CSA.

Additionally, OSA leads to arousals, which leads to hyperventilation, which leads to hypocapnia, which leads to a decreased respiratory drive, which leads to CSA. So, control OSA with a MAD, and you can lessen the likelihood of CSA manifestation.

Dr. Smith: Excellent questions! I’ll address each numerically.
1. Most sleep centers are well equipped to handle children’s sleep studies, so if you suspect sleep apnea in your child, a study would be a good idea.

pediatric sleep room at Comprehensive Sleep Medicine

If they prefer no sleep study, I would suggest an allergist first, to rule out any allergens that could be disrupting the immune system, creating an inflammatory process that swells the pharyngeal tissues. It’s also a good idea to find an ENT with good knowledge of the child’s airway and the negative developmental changes that can occur when the airway is restricted during growth.

2. Tonsils (palatine – the ones you can see, out of 4 sets) should only be removed if the cost-benefits are weighed appropriately. Studies show that tonsillar tissue helps in creation of T-Cells, which are important for cancer prevention. However, if they are impeding the airway, and if inflammatory processes have been addressed, I would have them removed. Remember, the child does have 3 other sets. Oh, and one more thing. The adenoids are FAR more likely to be obstructing the child’s airway, so THIS set of tonsils should be studied by the ENT, if anything! The ENT’s organization has a set of guidelines for when they will remove tonsils. They can be found here. Finally, yes, most will “outgrow” large palatine tonsils and adenoids. Actually, the tonsillar tissues usually shrink, unless there are inflammatory processes present. The usual suspect is a mouth breather, who has to use the tonsils to trap pathogens as they enter the oral cavity. Without the valuable nose filters, which are set up to do this job with regularity and expertise, the tonsils take on this arduous responsibility, and become enlarged to house the many bad guys. This can be seen in the “pocked” tonsils with “crypts”. Does that conger up a lovely thought?

3. Can snoring in children cause ADHD? You bet. Email me or comment here if you would like to read some studies. Additionally, a Johns Hopkins study showed that children with OSA average a 16 point drop in I.Q. What parent wants this?

Dr. Smith: Of course! Hypothyroidism leads to OSA (obstructive sleep apnea) AND CSA (central sleep apnea), but not vice versa.
1. It leads to obesity
2. Decreases respiratory drive (CSA)
3. It creates swelling of tongue and other pharyngeal tissues
4. Weakens breathing muscles

Dr. Smith: OK, here are some articles, Ross.
1. http://ajrccm.atsjournals.org/cgi/content/full/163/6/1294 (not compared to CPAP)
2. SLEEP 1995;18:501-10 Oral Appliances For The Treatment Of Snoring And Obstructive Sleep Apnea: A Review
Summary: This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee’s parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea.
3. http://findarticles.com/p/articles/mi_hb4345/is_3_35/ai_n29337679 (compares to CPAP)
4. http://www.journalsleep.org./ViewAbstract.aspx?pid=26465 Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review
Abstract:
We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.
Citation: Ferguson KA; Cartwright R; Rogers R et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP 2006;29(2): 244-262.

5. http://www.springerlink.com/content/j4w6r21256314131/fulltext.pdf Review of oral appliances for treatment of sleep-disordered breathing
Abstract Between 1982 and 2006, there were 89 distinct
publications dealing with oral appliance therapy involving a
total of 3,027 patients, which reported results of sleep studies
performed with and without the appliance. These studies,
which constitute a very heterogeneous group in terms of
methodology and patient population, are reviewed and the
results summarized. This review focused on the following
outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea
index or respiratory disturbance index), ability of oral
appliances to reduce snoring, effect of oral appliances on
daytime function, comparison of oral appliances with other
treatments (continuous positive airway pressure and surgery),
side effects, dental changes (overbite and overjet), and
long-term compliance

Prior to having kids, I was a pretty deep sleeper. My mom used to say that I could sleep through World War III and never even know it. Once kids came along, though, I started waking up at the drop of a hat. Now, I’m lucky to sleep throughout an entire night without someone or something disturbing my slumber.

It started out with my husband being the sole snorer in the family. It used to be just when he slept on his back. Now, it’s whether he’s on his back, his side, or standing on his head — it makes no difference. To give him credit, he has tried to rectify the situation by testing out the Breathe Right strips, the mouth sprays, etc., but, unfortunately, nothing seems to work. I, too, have tried to better the situation by nudging him, yelling at him, and even kicking him in the night, of course to absolutely no avail. I have finally resorted to wearing those stupid foam ear plugs each and every night to block out the noise.

And, wouldn’t you know, my other little man in the house has now followed in the footsteps of his father. Over the past couple of years, my son has become a mouth breather. Translation: the kid saws logs like nobody’s business at night. I can often hear him all the way down the hall even though his bedroom door is closed. My mom made me ask the pediatrician about it to see if he might have a problem with his adenoids. The doctor said that he really doesn’t recommend removing them unless sleep apnea is involved. He definitely doesn’t seem to stop breathing in his sleep — I’ve listened intently on many occasions. He’s got a steady and very excruciating rhythm going on with his snoring.

So, why is it that men are typically the ones who snore? My daughter doesn’t snore, and I certainly don’t either. Am I really doomed to stuff foam in my ears for the remainder of my nights? I don’t want to become like Lucy and Ricky and sleep in two different beds! I guess I just answered my own question — foam forever it is….

Dr. Smith: Don’t know where you live, but you should not take either your husband’s, nor your little man’s snoring lying down, and get some help. If your husband is now snoring regardless of sleep position, this has almost certainly elevated to obstructive sleep apnea, and if you don’t know the complications related to this, feel free to read all about them on my web site.

As far as your son, mouth breathing is not healthy, and can mean his adenoids are swollen. When this happens, he is forced to breathe through his mouth, which swells the tonsils even more. It also causes some structural changes in his mouth over time, as his upper arch begins to narrow, the roof of his mouth rises up, and before you realize it, there is even MORE constriction of the nasopharynx, and he becomes a permanent obligate mouth breather.

So, for your husband’s health, energy level, weight complications, etc.., get him some help. For your son’s future, get HIM some help. Let me know if I can help guide you somewhere.