The Comparison of CPAP and OA in Treatment of Patients with OSA

Li W, Xiao L, Hu J.

Respir Care. 2013 Jan 3

A systematic review and meta-analysis was performed to compare the outcomes of oral appliances (OA) with those of continuous positive airway pressure (CPAP) in treatment of patients with obstructive sleep apnea (OSA). Relevant studies were retrieved from the following electronic databases up to and including September of 2012: MEDLINE, PubMed, EMBASE, and Central Register of Controlled Trials. The main variables were epworth sleepiness scale (ESS), health-related quality of life, cognitive performance, blood pressure, apnea and hypopnea index (AHI), arousal Index (AI), minimum saturation (Min SaO2), rapid eye movement sleep, % (REM%), treatment usage, side effects, treatment preference and withdrawals.

Fourteen trials were finally included in this review. The investigators results demonstrated that the effects on ESS, health-related quality of life, cognitive performance, and blood pressure of OA and CPAP were similar. Besides, pooled estimates of cross-over trials suggested a significant difference in favor of CPAP regarding AHI, AI, and Min SaO2, while pooled estimates of parallel-group trials showed a significant difference in favor of CPAP regarding AHI and REM%. Moreover, OA and CPAP yielded fairly similar results in terms of treatment usage, hours/night in cross-over trials and, hours/night, nights/week in parallel-group trials), treatment preference, side effects and withdrawals.

The authors concluded that CPAP yielded better PSG outcomes especially in reducing AHI than OA, indicating that OA was less effective than CPAP in improving sleep disordered breathing. However, similar results from OA and CPAP in terms of clinical and other related outcomes were found, suggesting that it would appear proper to offer OA to patients who are unable or unwilling to persist with CPAP. 

Metro-North to Require Sleep Apnea Evaluation.

Notes from Dr. Norman Blumenstock

Train engineers need to be test now on the Metro North trains.

http://abclocal.go.com/wabc/story?section=news/local/northern_suburbs&id=9512820#

Eyewitness News

NEW YORK (WABC) -- A new Metro-North directive would require the 350 engineers who work for the railway to be evaluated in the coming months for sleep apnea.

Earlier this month, the National Transportation Safety Board revealed that the engineer, William Rockefeller suffered from a severe form of sleep apnea in a derailment late last year. The incident left four people dead and dozens injured.

Mike Doyle, general chairman of the Officials with the Association of Commuter Rail Employees union, told Eyewitness News in a statement that, "recognizing that an undiagnosed sleep disorder likely was a major contributing factor to the tragic accident ... our organization is working with Metro-North to establish a program to help identify engineers who may suffer from the same medical condition."

MTA chief spokesman Adam Lisberg said there are still a lot of questions about the screening and that it will be extended to all safety-sensitive personnel. "We haven't agreed on what to do in the program," he said. "We're working on plans for addressing sleep apnea for critical safety personnel, but have no final plans yet for what we'll do."

Dr. Steven Feinsilver, of Mount Sinai, is an expert on sleep disorders. He applauded the move, but warned that screening for sleep apnea is easier said than done.

Feinsilver said the best testing is an overnight sleep study which can be a "relatively complicated thing to do."

"It's a serious public health problem. It's a common disease," he said.

How Snoring Can Cause Weight Gain

Notes from Dr. Norman Blumenstock

This is true especially if the snoring is related to obstructive sleep apnea.

Dr. Donald M. Sesso, For Philly.com/Health

Posted: Tuesday, April 22, 2014, 4:14 AM

As a sleep specialist, my patients often ask about the relationship between snoring and weight gain. The National Center for Biotechnology Information (NCBI) has demonstrated that obesity is a risk factor for snoring and sleep apnea and that snoring may cause weight gain or the inability to lose weight.

The relationship between snoring and weight gain is linked to alterations in our metabolism, increased appetite and decreased energy expenditure. In other words, snoring and fatigue from interrupted sleep make us hungrier and less active- and both lead to weight gain. It may also explain why some people have difficulty losing weight despite attempts to modify their diets. Bed partners of snorers may be at risk of weight gain, too. If you are not sleeping because of your partner’s snoring, the resulting fatigue may be the reason you’ve become inactive and packed on weight.

Snoring and weight gain should not be ignored as the combination may cause life-threatening health conditions. Fortunately, both can be treated with simple changes that include: sleeping on your side, avoiding alcohol before bed, and getting 7-8 hours of sleep each night. Be aware that snoring could also be a sign of sleep apnea, so consult a sleep specialist for the treatment option that is best suited to you.

Excess weight and sleep apnea

According to the Centers for Disease Control and Prevention (CDC), more than 35% of adults 20 years and older are overweight. In addition, more than two-thirds of obese patients have obstructive sleep apnea (OSA), which poses a major health risk. We commonly notice weight gain in our abdomen or buttocks, but fat tissue can also deposit in our neck, tongue and airway. It is believed that excess fat deposits in the neck can change the size and shape of our airway and make it smaller.

Furthermore, fat in the neck and throat can displace muscle tissue and result in less muscle tone in the airway. These changes cause the airway to become weaker and more likely to collapse. The end result is snoring and sleep apnea.

Are you at risk for sleep apnea?

One simple method to determine if you are at risk for having sleep apnea is to check your shirt collar size. It has been shown that men with a collar size larger than 17 inches (16 inches for women) are more prone to snoring and sleep apnea.

Q&A: Have questions about sleep disorders, snoring and sleep apnea? Ask Dr. Sesso

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Dr. Donald M. Sesso, Director of the Pennsylvania Snoring and Sleep Institute, is the only triple certified sleep apnea surgeon in the tri-state area and specializes in the surgical treatment of obstructive sleep apnea and sinus disorders. He is a Board Certified ENT Otolaryngologist in Head and Neck Surgery, Facial Plastic Surgery, and Sleep Medicine.

Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: A Report of the American Academy of Dental Sleep Medicine

Notes from Dr. Norman Blumenstock

In response to the demands of an emerging profession to set standards of care, the Board of Directors of the American Academy of Dental Sleep Medicine (AADSM) brought together leaders in the profession to develop the definition of an effective oral appliance for the treatment of sleep disordered breathing based on current research and clinical experience. On February 15-17, 2013, a consensus conference was held in Tampa, Florida. Fifteen leaders in the profession used the modified RAND/UCLA Appropriateness Method to craft an empiric definition of an effective oral appliance with emphasis on purpose, physical features and function. A definition was developed and in March 2013 was accepted by the Board of Directors of the AADSM.

The purpose of this report is twofold. First, it presents a systematic review of all available level one and two literature (based on Oxford Centre methodology) to validate the accepted definition of an effective oral appliance. Second, this report details the processes employed and clarifies inclusion and exclusion rationale.

Future research, improved methods, and innovations in biomaterials will continue to advance the profession of dental sleep medicine. This definition provides a foundation and framework to guide both future investigations and current treatment of individuals with sleep disordered breathing.

Citation:

Scherr SC, Dort LC, Almeida FR, Bennett KM, Blumenstock NT, Demko BG, Essick GK, Katz SG, McLornan PM, Phillips KS, Prehn RS, Rogers RR, Schell TG, Sheats RD, Sreshta FP. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. Journal of Dental Sleep Medicine2014;1(1):39–50.

Sleep Apnea Boosts Risk of Pneumonia

Notes from Dr. Norman Blumenstock

Sleep apnea appeared to confer a higher risk for future pneumonia, possibly in a severity-dependent manner.

The risk was even higher among patients who received CPAP therapy.  No mention of oral appliances in this study.

A study published in the Canadian Medical Association Journal (CMAJ) titled “Sleep apnea and risk of pneumonia: a nationwide population-based study” analyzed evidence to determine the risk of pneumonia in patients with obstructive sleep apnea.

Researchers explored the risk of incident pneumonia among adults with sleep apnea, either with or without the need of CPAP therapy. According to the article, from January 1, 2000, researchers identified adult patients with sleep apnea from the Taiwan National Health Insurance Research Database. A control cohort without sleep apnea, matched for age, sex and comorbidities, was selected for comparison. The two cohorts were followed until Dec. 31, 2010, and observed for occurrence of pneumonia.

Click below for abstract.

http://www.cmaj.ca/content/186/6/415

CMAJ reports that of the 34 100 patients (6816 study patients and 27,284 matched controls), 2,757 (8.09%) had pneumonia during a mean follow-up period of 4.50 years, including 638 (9.36%) study patients and 2119 (7.77%) controls.

“Kaplan–Meier analysis showed a higher incidence of pneumonia among patients with sleep apnea (log rank test, p< 0.001),” writes CMAJ editors. “After multivariate adjustment, patients with sleep apnea experienced a 1.20-fold (95% confidence interval 1.10–1.31) increase in incident pneumonia. The risk was even higher among patients who received CPAP therapy. Interpretation: Sleep apnea appeared to confer a higher risk for future pneumonia, possibly in a severity-dependent manner.”

Click below to access full study.

http://www.cmaj.ca/content/186/6/415.full.pdf+html

Train engineer suffered from severe sleep apnea

Notes from Dr. Norman Blumenstock:

An investigation shows the train engineer who was at the controls of a fatal commuter train crash in New York in December suffered from "severe" sleep apnea.

Updated: Tuesday, April 8 2014, 08:17 AM EDT

http://www.wwmt.com/shared/news/features/national/stories/wwmt_-train-engineer-suffered-severe-sleep-apnea-7403.shtml#.U0a5nq1dVuC

NEW YORK (NEWSCHANNEL 3) - An investigation shows the engineer who was at the controls of a fatal commuter train crash in New York in December suffered from "severe" sleep apnea.

A report from the National Transportation Safety Board says William Rockefeller didn't know he suffered from the condition.

The report also says he took an antihistamine the day of the crash because of a respiratory infection.

The train was speeding when it hit a curve and jumped the tracks, killing four people.

An official cause of the crash has yet to be determined.

Sleep Loss May Cause Brain Damage and Accelerate Onset of Alzheimer’s, Two New Studies Show

Notes from Dr. Norman Blumenstock:

Two more studies on the dangers of sleep deprivation and obstructive sleep apnea.

April 03, 2014 

Visit the Mercola Video Library

By Dr. Mercola

Could poor sleeping habits cause brain damage and even accelerate onset of Alzheimer's disease? According to recent research, the answer is yes on both accounts.

According to neuroscientist Dr. Sigrid Veasey, associate professor of Medicine and a member of the Center for Sleep and Circadian Neurobiology at the Perelman School of Medicine, this is the first time they've been able to show that sleep loss actually results in the loss of neurons.

A second study also suggests that if you sleep poorly, you're at increased risk for earlier onset of severe dementia.

Sleep Loss Linked to 'Massive Brain Damage'

 The first study in question, published in the Journal of Neuroscience,1, 2, 3 found that sleep is necessary for maintaining metabolic homeostasis in your brain. Wakefulness is associated with mitochondrial stress, and without sufficient sleep, neuron degeneration sets in.

The research also showed that catching up on "sleep debt" on the weekend will not prevent this damage. To reach their conclusion, the researchers submitted mice to an irregular sleep schedule similar to that of shift workers.

Inconsistent, intermittent sleep resulted in a remarkably considerable, and irreversible, brain damage—the mice actually lost 25 percent of the neurons located in their locus coeruleus,4 a nucleus in the brainstem associated with arousal, wakefulness, and certain cognitive processes. As reported by Time Magazine:5

"The scientists believe that when the mice slept inconsistently, their newer cells would create more sirtuin type 3, a protein meant to energize and protect the mice. But after several days of missing sleep, as a shift worker might, the protein creation fell off and cells began to die off at a faster pace."

Chronic Sleep Disruption May Trigger Alzheimer's Onset

In a similar vein, research published in the journal Neurobiology of Aging6suggests that people with chronic sleep problems may develop Alzheimer's disease sooner than those who sleep well. According to lead author Domenico Praticò, professor of pharmacology and microbiology/immunology in the university's School of Medicine:7

"The big biological question that we tried to address in this study is whether sleep disturbance is a risk factor to develop Alzheimer's or is it something that manifests with the disease."

Using mice bred to develop Alzheimer's, the researchers exposed one group of mice to 12 hours of light and 12 hours of darkness, while another group was exposed to 20 hours of light and only four hours of darkness. This lack of darkness significantly reduced the amount of time the mice slept.

At the end of the eight-week long study, the mice that slept less were found to have significantly poorer memory. Their ability to learn new things was also impaired—despite the fact that the two groups of mice had about the same amount of amyloid plaque (a hallmark of Alzheimer's) in their brains. According to Dr. Praticò:

"We did observe that the sleep disturbance group had a significant increase in the amount of tau protein that became phosphorylated and formed the tangles inside the brain's neuronal cells...

Because of the tau's abnormal phosphorylation, the sleep-deprived mice had a huge disruption of this synaptic connection. This disruption will eventually impair the brain's ability for learning, forming new memory and other cognitive functions, and contributes to Alzheimer's disease."

Since both groups of mice were bred to develop Alzheimer's but the sleep deprived group developed these dementia-related problems sooner than the others, the researchers believe that poor sleep acts as a trigger of pathological processes that accelerate the disease. The researchers concluded that "chronic sleep disturbance is an environmental risk factor for Alzheimer's disease."

Previous research, published in the journal Science,8 has also revealed your brain removes toxic waste during sleep through what has been dubbed "the glymphatic system."9, 10, 11, 12, 13 This system ramps up its activity during sleep, thereby allowing your brain to clear out toxins, including harmful proteins linked to brain disorders such as Alzheimer's.

By pumping cerebral spinal fluid through your brain's tissues, the glymphatic system flushes the waste, from your brain, back into your body's circulatory system. From there, the waste eventually reaches your liver, where it's ultimately eliminated. So it's quite likely that sleep affects your brain function and your risk of degenerative diseases such as Alzheimer's in more ways than one.

Elderly Women Are Twice as Likely to Develop Alzheimer's Than Breast Cancer

Being aware of the links between sleep and Alzheimer's onset may be particularly important for women, as they are at greatest risk for the disease.14According to the 2014 Facts and Figures report issued by the Alzheimer's Association,15 women over the age or 60 have a one-in-six chance of developing Alzheimer's—nearly double the risk of men, who have a one-in-11 chance. Even more disturbing, a woman's chance of developing Alzheimer's is twice as great as her risk of developing breast cancer!

Since there's no cure, and no truly effective treatments, taking steps to prevent Alzheimer's becomes paramount. And it seems clear that sleeping properly is one important factor to take into consideration. For more information about Alzheimer's prevention, please see my previous article "How to Prevent Alzheimer's Disease—A Neurologist Speaks Out."

How Light and Dark Affects Your Sleep

Fortunately, there are many ways to improve your sleep, thereby helping to reduce any risks to your brain health. Maintaining a natural rhythm of exposure to sunlight during the day and darkness at night is one crucial foundational component of sleeping well. This was addressed in a recent interview with Dan Pardi (@dansplanhealth), a researcher who works with the Behavioral Sciences Department at Stanford University and the Departments of Neurology and Endocrinology at Leiden University in the Netherlands.

The reason why light is important is because it serves as the major synchronizer of your master clock. This master clock is a group of cells in your brain called the suprachiasmatic nuclei (SCN). As a group, these nuclei synchronize to the light-dark cycle of your environment when light enters your eye. You also have other biological clocks throughout your body, and those clocks subsequently synchronize to your master clock.

Most people in Western societies spend the larger portion of each day indoors, which essentially puts you in a state of “light deficiency” as outdoor light is far more intense than any indoor light fixture. Meanwhile, most people are exposed to too muchlight in the evening, at a time when the natural light has faded.

To maintain healthy master clock timing, aim to adjust your light exposure to a more natural light rhythm, where you get bright light exposure during the day and limited blue light and bright light exposure once the sun sets. Pardi recommends getting at least 30-60 minutes of outdoor light exposure during daylight hours, in order to “anchor” your master clock rhythm. The ideal time to go outdoors is right around solar noon but any time during daylight hours is useful.

Research also shows that exposure to bright room light before bedtime suppresses melatonin production in 99 percent of individuals. This can effectively rob you of sleep by masking sleepiness, as this hormone influences what time of day or night your body thinks it is - regardless of what time the clock on the wall displays - and because it’s one of several key biochemical signals that stimulate sleep onset and maintenance.

Shift Workers Are Particularly Vulnerable to Accidents and Disease

One of the worst things you can do to disrupt your body clock is engage in regular night shift work. I realize many people may not be able to avoid night shifts once they've chosen certain professions, but it is vital to understand that when you regularly shift your sleep patterns, you are in fact seriously compromising your health and longevity—in more ways than one. For example, in a study16 of nurses, researchers from the Harvard School of Public Health revealed that a woman's risk of type 2 diabetes rises according to how many years of night-shift work she has completed. Even working a night shift periodically for three years increased diabetes risk by 20 percent, and this increased with time.

The lack of sleep, or poor sleep that comes with shift work and jobs where you're working double shifts or other erratic schedules also makes you far more vulnerable to accidents. The recent subway train accident at Chicago's O'Hare airport17 is a perfect example In this case, more than 30 people were injured, and the accident caused an estimated $6 million in property damage. . I was born and grew up in Chicago and this is the airport I regularly use.  According to the Associated Press18:

"The operator of a Chicago commuter train that crashed at O'Hare International Airport acknowledged she dozed off before the accident and had also done so last month when she overshot a station platform, a federal investigator said Wednesday. Before the crash, the operator had been running trains on the nation's second-largest public transportation system for just two months.

In Monday's accident, which injured more than 30 people, she woke up only as the eight-car train jolted onto the platform and barreled up an escalator leading into the airport. The accident occurred around 3 a.m., as the driver was nearing the end of her shift. The woman had an erratic work schedule and investigators were looking to see if that played a role in her evident fatigue... [T]he operator was an extra-board employee, meaning she filled in to cover shifts for regular employees and her hours varied from one day to the next."

If you currently work nights, I would strongly suggest trying to switch your hours, or at the very least restrict your night shift duty to a couple months at a time. This will at least give your body a chance to readjust in between. If it is not possible for you to avoid working the night shift, you can somewhat counter the health effects by keeping to a schedule. By being consistent, your body's clock will eventually adjust to your sleep/wake cycle, and this is LESS damaging than if you constantly change shifts and expect your body clock to adjust.

Next, although day sleeping makes it much more challenging to create a dark environment, it is essential that you make your bedroom pitch-black, even if you're sleeping at noon, as exposure to light squelches the production of melatonin. Even the dim glow from your clock radio could be interfering with your ability to sleep -- and more importantly, your long-term health.

Other Helpful Tips to Improve Your Sleep

Besides maintaining a natural circadian rhythm, there are a number of additional ways to help improve your sleep if you're still having trouble. Below are half a dozen of my top guidelines for promoting good sleep. For a comprehensive sleep guide, please see my article "33 Secrets to a Good Night's Sleep."

1. Avoid watching TV or using your computer at night—or at least about an hour or so before going to bed—as these technologies can have a significantly detrimental impact on your sleep. TV and computer screens emit blue light, similar to daylight. This tricks your brain into thinking it's still daytime, thereby shutting down melatonin secretion. Under normal circumstances, your brain starts secreting melatonin during something called dim light melatonin onset. If the light in your environment doesn't dim, because of multiple artificial light sources, melatonin won't be released and this affects sleep timing, quantity, and quality.
2. Sleep in darkness. Remember, light can disrupt your internal clock and your pineal gland's production of melatonin. Refrain from using night-lights, cover up your clock radio, cover your windows — I recommend using blackout shades or drapes, or use an eye mask—and don't turn on a light if you have to go to the bathroom at night. You don't need to sleep in complete darkness. The intensity of light needs to be at a certain level (different levels depending on the spectrum) to suppress melatonin production. Complete darkness is probably best however.
3. Keep the temperature in your bedroom no higher than 70 degrees F. Many people keep their bedrooms too warm. A reduction in core body temperature is a part of the sleep-initiation and sleep maintenance process. A room temperature that is too warm or too cool can prevent your core temperature from lowering to its ideal place for good sleep. Aim to keep your bedroom temperature between 60 to 68 degrees, and identify the best room temperature for you through trial and error.
4. Take a hot bath or shower 30 min before bedtime. The hot bath increases your core body temperature, opening up the blood vessels in your limbs. When you get out of the bath, heat can leave your body easily (if the room temperature is cool), abruptly dropping your core body temperature, making you drowsy and ready for great sleep.
5. Check your bedroom for electro-magnetic fields (EMFs). These can disrupt your pineal gland and the production of melatonin and serotonin, and may have other negative effects as well. To do this, you need a gauss meter. You can find various models online, starting around $50 to $200. Some experts even recommend pulling your circuit breaker before bed to shut down all power in your house.
6. Move alarm clocks and other electrical devices away from your bed. If these devices must be used, keep them as far away from your bed as possible, preferably at least three feet. This serves at least two functions. First, it can be stressful to see the time when you can't fall asleep, or wake up in the middle of the night. Secondly, the glow from a clock radio can be enough to suppress melatonin production and interfere with your sleep. Cell phones, cordless phones and their charging stations should ideally be kept three rooms away from your bedroom to prevent harmful EMF's.

Sleeping Well Is Part of a Healthy Lifestyle Plan

In summary, if you want to get good sleep, you have to have properly aligned circadian rhythms. If you don’t, aspects of your waking/sleeping system will be working at the wrong time. The ramifications of this go far beyond daytime sleepiness, as the research discussed above can attest to.

So first and foremost, make sure to get daylight exposure, ideally around solar noon, for at least half an hour or more each day. A gadget that can be helpful in instances when you, for some reason, cannot get outside during the day is a blue-light emitter. Philips makes one called goLITE BLU. (You can find it on Amazon19 for less than $150.) It's a small light therapy device you can keep on your desk. Use it twice a day for about 15 minutes to help you anchor your circadian rhythm if you cannot get outdoors.

Then, in the evening, dim environmental lights and avoid the blue light wavelength. Use blue-blocking light bulbs, dim your lights with dimmer switches and turn off unneeded lights, and if using a computer, install blue light-blocking software like f.lux.20 Also keep in mind that digital alarm clocks with blue light displays could have a detrimental effect. Last but not least, when it's time to go to sleep, make sure your bedroom is very dark. I recommend installing blackout shades for this purpose. A far less expensive alternative is to use a sleep mask to avoid disrupting your melatonin production and circadian rhythm.