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Thoracic Medicine

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Sleep Medicine

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People diagnosed with depression need to step out for a cigarette twice as often as smokers who are not dealing with a mood disorder. Those who have the hardest time shaking the habit may have more mental health issues than they are actually aware of, research suggests. While the number of Australians who smoke declines, about 40 per cent of depressed people are in need of a regular drag.

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Are you having trouble sleeping, snoring, waking tired or unrefreshed, and becoming excessively sleepy throughout the day? A home based sleep study may be an appropriate option for you. Medicare offers rebates for one (1) home based sleep study per year.

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About one in four Australians are sleep-deprived, and leading sleep researchers came together for the BBC's "Day of the Body Clock" and warned that shunning shut-eye leads to "serious health problems".

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Often times when we can’t sleep or we feel tired throughout the day, there are common “quick fixes” which we use to help us fall asleep easier and give us an extra boost in the morning. However, some of these habits can often be detrimental to your sleep health, affecting you not just at night, but throughout the day as well.

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New research has found that the less we sleep in midlife, the faster our brains can decline and lead to cognitive impairment in old age.

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“What is happening in YOUR sleep?!? How can you really know? Ever thought of using a sleep app? There are some misunderstandings to what data is relevant when using sleep apps so understanding the limitations are IMPORTANT. "It is always recommended to follow up with a sleep study to be sure nothing is missed. “

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What is CPAP?

The most common treatment for OSA is CPAP. This ‘splints’ the airways open. This then normalizes breathing and oxygen delivery to the body and brain. Symptoms associated with OSA can improve markedly.

In stroke patients recent studies indicate CPAP therapy improves stroke outcomes and can shorten hospital days.

How does CPAP work?

photo_mask2

It keeps the airway open by providing a steady stream of air through a mask that you wear as you sleep. PAP machines work by pumping air through a hose to the mask. Masks either fit over the nose or over the nose and mouth. This mask is held in place with straps. Your sleep specialist determines the right level of air pressure for you during an overnight sleep study. To determine the correct pressure for you a sleep study will need to be conducted in a sleep laboratory.

Some people prefer using nasal pillows instead of a traditional mask. These are soft pieces of plastic that are placed directly into the nostrils. A nasal pillows system covers less of your face and may give you more freedom in your choice of sleeping positions.

Several brands of PAP devices are available. Your sleep specialists can recommend for you the best combination of mask and PAP model.

Most people do well with PAP therapy. Others may experience dryness in the nose or feelings of claustrophobia. You can overcome these problems with a few adjustments.

Using a heated humidifier is one of your best options. Some PAP models come with humidifier. Others give you the option of connecting a humidifier to it. You may also be able to overcome nasal dryness by using a saline nasal spray. This solution is a mixture of salt and water. Taking a nasal decongestant or using a chin strap can also reduce nasal symptoms.

A few people have feelings of claustrophobia from PAP treatment. This can be corrected by relaxation techniques given to you by your CPAP consultant. You can also try using a mask that covers less of the face, which should allow you to overcome feeling claustrophobic. Your sleep specialist can help you overcome these feelings.

I need PAP therapy - Where do I begin?

Various PAP machines and masks are available and each person should find the right combination of equipment that works best.  In PAP therapy pressurised air comes through a mask that fits securely over your nose.  Some patients find that PAP works best for them when using a mask that fits over both the nose and mouth or in the nostrils.

Most people first try PAP machines that deliver a continuous positive airway pressure (CPAP).  Some people prefer two-level PAP machines, which deliver more pressurized air with breathing in and less with breathing out.  Self-adjustable PAP will raise pressurised air levels only when apnoea occurs.

Whatever you choose, your PAP machine needs to be carefully adjusted to provide the proper amount of pressurised air during all of your body positions, no matter how deeply you sleep. To determine the amount of air pressure that is right for you a sleep centre will monitor your sleep while you use PAP devices. A sleep centre technologist will monitor and adjust (by small amounts) air pressure from the PAP machine until your apnoea is eliminated. You may need higher pressures during some sleep stages and in some sleeping positions. A sleep technologist is experienced in helping people get used to sleeping with PAP and will work to find the best settings and equipment for you.

Obstructive sleep apnoea can often be controlled completely with a PAP device, but you must use it whenever you sleep. Getting used to sleeping with a PAP machines takes time. While at first you may find it inconvenient or troublesome, you shouldn’t give it up without a good try. It will probably be well worth your effort.

Should I try a CPAP machine?

Most people begin with a CPAP machine since it offers a fixed amount of pressurized air at a steady rate. This way they don’t need to worry about, or focus on, adjusting the air pressure.  Many people find this is an adequate approach to help eliminate their OSA symptoms.

Obstructive Sleep Apnoea can often be controlled completely with a PAP device, but you must use it whenever you sleep.

Should I try C-Flex or EPR or two-level PAP?

If you have trouble breathing out against the continuous air pressure of CPAP, modern devices incorporate a comfort function that can be enabled. This allows a slight pressure drop only when you breathe out and can make your breathing feel more natural.

If you cannot tolerate CPAP devices at all, a two-level PAP machine may help you. These machines, called BPAPs, sense when you breathe in and out and deliver one pressure of air when you breathe in and lower pressure when you breathe out. In some more severe or complex cases, these machines are required for effective treatment.

You should consider using BPAP if you find that the air pressure with CPAP feels too high or that you are working too hard to breathe out. A lower pressure when you breathe out may feel more natural to you, particularly if you are using a fairly high air pressure when you breathe in. In general, BPAP machines are larger, heavier and more expensive than CPAP devices.

If you were not tested in the sleep laboratory on a BPAP device, you will probably need another sleep study to determine the correct air pressure for you.

Should I try self-adjustable PAP?

PAP devices raise the air pressure only when they sense problems with breathing. By increasing air pressure intermittently, it is believed that PAP treatment of sleep apnoea may be made more comfortable and effective. If air pressure-related complaints limit your use of CPAP or BPAP, you should consider asking your doctor about self-adjustable PAP device.

Alternative OSA Treatments.

Lifestyle changes

Some behaviours or habits can make OSA worse. For some people, certain changes in behaviour can reduce or end sleep apnoea. Talk with your sleep specialist or another qualified healthcare professional. See if one of these options might work for you.

Losing Weight and Exercising Regularly

Weight loss may be the most helpful treatment for overweight people who suffer from OSA. Consult your doctor before trying to lose weight. He or she can make sure that your weight-loss programme is both safe and effective. Your programme should combine a healthy diet with regular exercise.

A doctor should confirm that you no long have OSA once you reach your desired weight. Then it is important to maintain that weight. Otherwise, snoring and breathing problems are likely to return when you gain weight again.

Quitting Smoking

Smoking irritates your mouth and throat. Recent evidence suggests that this might make snoring and sleep apnoea problems occur during sleep. Talk with your doctor to find a safe and effective way to quit smoking.

Avoiding Alcohol and Sedatives

Even one glass of wine just before bed can worsen your snoring and sleep apnoea. You should avoid drinking alcohol for at least four hours before bed. Alcohol and sedative medications can cause the muscles in your throat to relax more than usual. This can cause sleep apnoea to occur. Alcohol and sedative drugs also make it harder for the brain to “wake up”. This means that episodes of sleep apnoea will last longer and will be more dangerous. These are some examples of sedative drugs:

  • Sleeping pills
  • Muscle relaxants
  • Some anxiety medications
  • Some pain medications

Your sleep specialist can help you modify your use of sedatives and alcohol.

Sleeping on your side or stomach

Sleeping on your back allows gravity to pull on the soft tissues at the back of your throat and neck. This causes the airway to narrow or collapse completely. Sleeping on your side or stomach might improve your breathing. This change in behaviour is called “sleep-position training”.

Sleep-position training can occur in several ways. The simplest approach is called the “tennis ball technique”. It involves sewing a pocket into the back of your pyjama top. You then insert a tennis ball into it. They help when you start to roll onto your back during sleep. The pressure from the balls will cause you to roll back to your side. Strapping a foam wedge to your back can produce the same result. You can also buy a device with an alarm that alerts you when you roll onto your back. Sleep-position training may not help all people with OSA. It is best to consult with your sleep specialist to see if it might work for you.

Medical Therapy

Oral Appliances

These devices look much like sports mouth guards. They keep the airway open by holding the tongue or jaw forward. This increases the airway space behind the tongue. They can be effective for people who have mild to moderate OSA. A licensed dentist who is trained in dental sleep medicine can custom fit the oral appliance. This will give you the best results.

Surgery

An operation may be an option if there is a physical cause for your OSA that surgery can correct. You may also want to consider surgery if more conservative treatments fail to control your sleep apnoea. Make sure you have a realistic understanding of the expected success rate for any surgery you consider. Your sleep specialist should also inform you of all possible risks and side effects. An operation can be an effective treatment for some people. But it is not the right choice for everyone.

Nasal Operations

Nasal surgery removes blockages in the nose. It can also repair a deviated septum. The septum is the bony divider between the two nostrils. A bent septum can block the flow of air through your nose. These operations may be one part of an overall plan to treat sleep apnoea. They tend to be used along with other forms of treatment or other operations. Nasal surgery by itself rarely cures OSA.

Laser-assisted uvulopalatoplasty (LAUP)

This procedure is used mainly for the treatment of snoring. The surgeon uses a laser to remove part of the soft palate and uvula. The uvula is the soft lump of tissue that hangs down in the back of the throat. The surgery takes place during several sessions in a doctor’s office. This technique may be helpful for snoring. You need to be aware that it rarely succeeds in treating OSA.

Uvulopalatopharyngoplasty (UPPP)

This operation involves removing the uvula, the tonsils and part of the soft palate. It is helpful for less than 50% of people who undergo the operation. But not all of them are cured. Side effects may include:

  • Severe throat pain
  • Nasal-sounding speech
  • Liquids backing up into the nose when you swallow

Maxillomandibular Advancement (MAS)

This surgery involves cutting the upper and lower bones of the jaws. This moves them both forward. General anaesthesia is used for the operation. The surgery requires a hospital stay of a few days. After the operation the jaw is wired shut to hold it in place for about four weeks. A liquid diet is required and weight loss often results. Once the wires are removed you may need orthodontic work to realign the teeth so they fit together properly.

This treatment is time-consuming and expensive, but its results are positive for many people. It works best for people who are born with a jaw that is either smaller than normal or that is set too far back.

Provent Therapy

Disposable adhesive dots that contain a one way valve are taped over the nostrils at night. Each adhesive dot is recommended for one only use. You can buy Provent® in boxes of 10 days ($37) or 30 days ($110) worth of adhesive dots. You can purchase Provent directly from our CPAP clinic.

Tracheostomy

This surgery is rarely used to treat sleep apnoea. It is performed only in severe cases of OSA when all other options have failed. It involves the recreation of a small surgical opening in the throat. The opening is located in the windpipe below the larynx. The tracheostomy bypasses any obstructions in the throat. This allows air to flow freely into the lungs while you are sleeping. The opening is covered during the day and normal breathing and speech resume.

Medications and Alternative Treatments

Using only medications to treat snoring and OSA has limited benefits. They may be most useful for treating mild sleep apnoea. They may also be one part of an overall treatment programme.

Nasal Sprays

Over the counter nasal sprays that help clear the nasal passages can be habit forming. They should be used for only a few days. Prescription anti-allergy nasal sprays might improve OSA by helping to unblock the nose. You should be aware that it takes days or weeks for the spray to work. By themselves, nasal sprays do not fully control OSA. Nasal sprays tend to be ineffective if there is a permanent nasal blockage. This may be caused by a deviated septum or other abnormality.

Decongestants

Oral medication to relieve nasal congestion may help you breathe better through your nose. But they are rarely a successful treatment for sleep apnoea. They also can make it hard for you to fall asleep and stay asleep.

Oxygen

This treatment can help correct the low oxygen levels in the blood that sleep apnoea causes. But oxygen treatment rarely prevents sleep apnoea from occurring. It is sometimes used along with PAP therapy.

Alertness promoting medications

Modafinil is a medication that stimulates the brain to help you stay awake. It is used to treat some causes of excessive daytime sleepiness. Some people with OSA may remain sleepy during the day even if their PAP treatment is successful. If there is no other identifiable cause of this sleepiness, then taking modafinil is an option to improve alertness. Some people with OSA have mild elevations in their blood pressure when taking modafinil. It is important to monitor your blood pressure while you are taking the medication.

Follow up care

A sleep specialist in an accredited sleep centre can help you achieve long-term success with your OSA treatment.  This will improve your health and overall quality of life.  It is important for you to have regular follow up appointments with your sleep physician.  This will allow him or her to confirm the ongoing success of your treatment.

OSA may become more severe as you age.  A change in your weight can also affect your sleep apnoea. Even if surgery has initially corrected OSA, the problem may return later.  Snoring or struggling with daytime sleepiness again may indicate that your sleep apnoea has returned.

If you are using PAP to treat your OSA then your first follow up appointment should be shortly after you start using PAP at home.  This will ensure that you get off to a good start.  Ongoing follow up will then help you maintain this success.

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