Untreated Sleep Apnea Has Risks

Severe obstructive sleep apnea linked to high blood pressure with medication.

August 17, 2014 / Author: Tara Haelle / Reviewed by: Robert Carlson, M.D. Beth Bolt, RPh

(dailyRx News)  The link between obstructive sleep apnea and high blood pressure has been known among doctors for a while.  But it may be stronger link than most realize.

A recent study found that those with severe obstructive sleep apnea, when not treated, is linked to high blood pressure even when a person is taking blood pressure medications.

The most common treatment for obstructive sleep apnea is continuous positive airway pressure, of CPAP.

CPAP requires that a person wear a mask that pumps air into their airways during sleep.

The study, led by Hameet Walia, MD, of the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, looked at the link between obstructive sleep apnea and high blood pressure.

The researchers studied 284 participants who had untreated moderate to severe obstructive sleep apnea and who are at risk for heart disease or related conditions.

Among those with high blood pressure, the participants were classified in one of three groups:

• having blood pressure under control, with a blood pressure lower than 130/80
• having high blood pressure not under control, higher than 130/80 and not taking blood pressure medications
• having high blood pressure despite taking medications for it

Overall, 62 percent of the participants had controlled blood pressure, 28 percent had uncontrolled high blood pressure and 10 percent had high blood pressure despite taking medication.

Overall, 24 percent of those in the study had severe obstructive sleep apnea.

Then the researchers looked the which of the blood pressure categories the individuals were in based on how bad their sleep apnea was.

They found that having high blood pressure despite taking medications was more common among those with severe sleep apnea than among those with moderate sleep apnea.

While 58 percent of those with severe sleep apnea had uncontrolled blood pressure despite medication, only 29 percent of those with moderate sleep apnea had uncontrolled blood pressure.

After taking into account differences in age, sex, race, weight and history of heart disease, diabetes and smoking, those with severe obstructive sleep apnea had four times greater odds of having uncontrolled blood pressure than those with moderate sleep apnea.

"Among patients with increased cardiovascular risk and moderate to severe obstructive sleep apnea, untreated severe compared to moderate obstructive sleep apnea was associated with elevated blood pressure" despite intensive drugs to control blood pressure, the researchers wrote.

They concluded that this finding suggested "untreated severe obstructive sleep apnea contributes to poor blood pressure control despite aggressive medication."

William Kohler, MD, the medical director of the Florida Sleep Institute in Spring Hill, Florida, said the link between high blood pressure and obstructive sleep apnea has long been established.

"All patients with hypertension should be screened for possible obstructive sleep apnea, particularly those that have uncontrolled high blood pressure," he said.

"Sleep apnea is a significant contributing factor to high blood pressure,"  Dr. Kohler said.  "If it is the primary cause, treating the sleep apnea may allow the person to decrease or actually discontinue their antihypertensive medication."

The study was published August 15 in the Journal of Clinical Sleep Medicine.  The research was funded by the National Heart Lung Blood Institute and the National Center for Research Resources.

One author has received research support from a dozen different pharmaceutical companies, and another has consulted for Saatchi and Saatchi.  Five authors have received research support from Philips Respironics and/or Res Med, and one of these has also consulted for Apnex Medical, Apnicure and Vertex Pharmaceuticals.

Doctors want schools to start later so kids can sleep

MICHELLE HEALY @BYMICHELLEHEALY USA TODAY

America’s pediatricians have a message for school administrators: Let the kids sleep.

The nation’s largest pediatrician group issued a policy statement this past week, just as millions of children are returning to school, calling for high school and middle school classes to begin at 8:30 a.m. or later. The move would be “an effective countermeasure to chronic sleep loss” and the “epidemic” of delayed, insufficient and erratic sleep patterns among the nation’s teens, the group noted.

Many factors, “including biological changes in sleep associated with puberty, lifestyle choices and academic demands,” negatively impact teens’ ability to get enough sleep. Pushing back school start times is key to helping them achieve optimal levels of sleep — 8½ to 9½ hours a night, says the American Academy of Pediatrics statement, which was published online in Pediatrics.

“As adolescents go up in grade, they’re less likely with each passing year to get anything resembling sufficient sleep,” says Judith Owens, director of sleep medicine at Children National Medical Center in Washington, D.C., and lead author of the AAP statement.

Chronic sleep loss in children and adolescents “can, without hyperbole, really be called a public health crisis,” Owens says.

Among the consequences of insufficient sleep for teens, according to the statement:

Increased risk for obesity, stroke and type 2 diabetes; higher rates of automobile accidents; lower levels of physical activity; increased risk for anxiety and depression; lower academic achievement, poor school attendance; increased dropout rates; and impairments in attention, memory, organization and time management.

According to U.S. Department of Education statistics, approximately 43% of the over 18,000 public high schools in the U.S. have a start time before 8 a.m.; 15% started at 8:30 a.m. or later.


1 in 5

Adolescents getting nine hours of sleep on school nights

45%

Percentage of adolescents sleeping less than eight hours

Source: 2006 National Sleep Foundation poll

Untreated snoring in kids may lead to heart disease: expert

Notes from Dr. Norman Blumenstock
Is your child's snoring a sign of sleep disordered breathing

TNN | Aug 26, 2014, 10.51PM IST

Kanpur: Does your kid snore while sleeping at night? If the answer is `yes', you should immediately consult a doctor, as it can be a symptom of sleep breathing disorder, a more serious underlying problem that can affect your child's physical and mental well-being, an expert revealed during the third day of IMA CGP.

Dr JC Suri from New Delhi, said that sleep breathing disorder is most common among kids between 2-18 years of age. "This problem is seen in about 5% of children between this age group. The biggest reason being excessive growth of tonsils and adenoid in the back of the throat. Major symptoms of the disease include snoring, irregular sleep, increased aggressiveness, change in attitude etc.

Children who are chronically sleep deprived may be prone to problems with attention behavior, learning and mood. If not treated on time the disorder can take shape of chronic heart disease. With the advancement of science today we have developed ways to cure the disease without operating the child," the doctor said.

Dealing with snoring helps both partners

Notes from Dr. Norman Blumenstock
"Laugh and the world laughs with you. Snore and you sleep alone"

Unlike high blood pressure or blood sugars, snoring is unique in that it causes problems not just to the person with the issue, but to both partners. As a result, 25 percent of married couples state that they sleep separately because their partners snore. Besides sleeping alone, it can also adversely affect our health. For-tunately, there is a lot that can be done to turn down the noise, improve our relationships and maintain our best health.

Dr. Nina's what you need to know about snoring to improve our sleep, relationships and health:

Why all that noise? A partial obstruction of our breathing passages can cause our respiratory structures to vibrate when we breathe. The vibration results in the harsh sound that we call snoring. To get a better understanding of this, try to create a snoring sound so we can feel the vibration.

What can cause a partial obstruction?

•When we are overweight, extra fatty tissue accumulates not just on our waist and hips, but also along our breathing passages.

•Drinking, smoking and certain medications can cause our airway muscles to relax, making them more likely to vibrate when breathing.

•With age cometh wisdom, narrowing of our throats, and decreased airway muscle tone.

•Nasal deviation and sinus problems can narrow our breathing passages.

•Sleeping flat on our backs can cause our tongue or other fleshy structures to relax and block our airways.

•And some of us are just built with long uvulas (the funny looking dangly thing), large tongues or narrow throats.

Is snoring the same as obstructive sleep apnea (OSA)? No. When we snore, we are breathing but the noise we hear is due to a partial (not total) obstruction; there is movement of air. OSA means that our breathing has stopped temporarily due to complete breathing obstruction and there is no movement of air. This causes us to wake up and is often accompanied by a loud snort or gasping sound. Over time, the repeated sleep interference and drops in oxygen levels can result in a number of ill effects on our health.

What are some ill-effects that can occur from OSA? OSA may be dubbed the "not-so-quiet" culprit of a number of chronic and dangerous health conditions. Studies have shown that it can increase our risk for stroke, heart disease, acid reflux, car accidents and other injuries, mental health issues and weight gain. In other words, we cannot ignore the warning sounds.

What can I do if I snore? Losing weight, quitting smoking and avoiding heavy meals and alcohol at night are some lifestyle changes that can literally put a stop to the noise. For some, sleeping on our sides, performing throat strengthening exercises or "clearing" our nasal passages by humidifying the room or using nasal sprays may do the trick.

When should I see a doctor? When lifestyle changes do not work; we experience daytime drowsiness; or we gasp or choke while sleeping. Our doctors will take a complete history and perform a physical exam. Based on the findings, he or she may order a radiology imaging or sleep study to determine the cause and best treatment. One option is a CPAP (pronounced cee-pap) machine. This device blows pressurized air into a mask that covers our mouth and nose in order to keep our airway open while sleeping. In some cases, a dental appliance may be used to prevent our lower jaw or tongue from blocking airflow. It may be necessary to undergo surgery to remove tissue or correct abnormalities in order to increase the size of our airway.

Although snoring may cause us to sleep alone, we can solve the problem by coming together. I was once told, "Teamwork divides the task but multiplies the success." Dealing with the problem head on will reap rewards to both our relationships and health. So, let's breathe easier and not wait to exhale.

Dr Nina Radcliff, of Galloway Township, is a physician anesthesiologist, television medical contributor and textbook author. Email questions on general medical topics to her at drninaradcliff@aol.com

Putting your kids back on a sleep schedule for school

Home News Tribune 08/26/2014 / By Susanne Cervenka 

Dina Margulies is planning to enjoy every last bit of summer with her three children before they head back to school. 

What’s getting less thought, however, is getting back on a sleep schedule for school. They’ll probably go to bed a little bit earlier, Margulies said.

Key word: probably.

“We have routines, but life just kind of pops up where you have to bend it,” she said.

It’s a common predicament families find themselves in this time of year. Summer brings with it more flexible schedules to take on more leisurely activities as well as more sunlight to enjoy them.

That also can do a number on our sleep routines.

“The problem is sunlight is one of the strongest cues to tell our bodies where it is in the 24hour clock,” said Dr. Carol Ash, medical director for sleep medicine at Meridian Health. “The natural tendency is to go to bed later, get up later and we have the flexibility to do so.”

With fall and the new school year approaching, it can take some time to get back on a normal sleep pattern.

Getting enough sleep can be crucial to students performing well in the classroom. Children of all ages need sleep for the energy and for the ability to focus and concentrate to do well in school, according to the National Sleep Foundation. 

Sleep is critical 

And lack of sleep can make itself known through behavioral problems and learning difficulties. 

“We don’t understand and appreciate how critical sleep is to your health,” Dr. Carol Ash, medical director for sleep medicine at Meridian Health, said. 

Falling off a sleep routine, even if it is common during the summer, isn’t exactly good for us, Ash said. Our bodies still need the same amount of sleep regardless of when the sun goes up and down in the summer. “It really isn’t helpful for them. We think, ‘The kids, they worked so hard, they earned the right to have fun,’ ” Ash said. “It’s like saying, ‘Brushing your teeth is a lot of work. Why worry about brushing your teeth this summer?’ ” Even if families did fall off their normal sleep habits, they can get back to it gradually, Ash said. And now is the time to do it. 

Do it now 

It can be difficult to abruptly move our wake up times an hour or so earlier. Instead, Ash suggests parents start getting their children to bed 15 minutes earlier until they are on track to get up on time for school. Children may need some coaching to get back to waking up at school time. So think about planning a couple of fun early-morning events in the days before school starts to give them a reason to want to get out of bed earlier, Ash said. 

Fair Haven mother Stacey Strandberg said she lets her four children stay up later in the summer, going to bed at 9 p.m. or 10 p.m. compared to 8 p.m. or 8:30 p.m. during the year. But as school approaches, Strandberg said she gradually starts ending activities, such as trips to the beach or the pool, a little bit earlier so the family can start getting ready for bed earlier. Annual activities at the end of summer help signal for her children that school is starting soon and makes it easier for them to get back to the earlier bed time. Fair Haven Fair is the last summer hurrah for the Strandberg children. They typically get their teacher assignments on the first day of the fair, Strandberg said. And, when they see their friends, they get to talk about school in a positive way. “In Fair Haven, there’s a sense of excitement at that time of year,” she said. At home, Strandberg said she and her husband also talk to their children about all of the fun aspects of heading back to the classroom: walking to school, ordering school supplies that will be waiting for them at their desk and getting new backpacks. 

“They know what’s expected of them. If you want to wake up earlier and have a great day at school, you have to go to bed earlier,” she said. 

Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together?

Notes from Dr. Norman Blumenstock

Should sleep apnea be considered in the company of obesity, diabetes, and cardiovascular disease? Researcher Salim R. Surani makes the case in a recent article titled “Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together?” recently published in the World Journal of Diabetes.

To Read This Article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058742/pdf/WJD-5-381.pdf

Prospective multicenter cohort study of obstructive sleep apnea (OSA) patients treated with a custom-made mandibular repositioning device (MRD)

Notes from Dr. Norman Blumenstock
This recent French study shows the benefits of oral appliance therapy.

August 22, 2014 / By Marie-Françoise Vecchierini, MD

Editor's note: Dr. Marie-Françoise Vecchierini is a recent recipient of an American Academy of Dental Sleep Medicine (AADSM) 2014 Clinical Excellence Award.
Obstructive Sleep Apnea (OSA) has numerous and significant comorbidities, so its treatment is essential. Mandibular Repositioning Devices (MRD) are recommended as primary treatment for patients with mild-to-moderate OSA. Because very few studies have specifically assessed the long-term efficacy of MRDs in OSA patients who are noncompliant with continuous positive airway pressure (CPAP), my research team conducted a study on 312 patients (71% men; 53+/-12 years old), offering MRD treatment and determining the long-term efficacy of a custom-made computer aided-design (CAD)/computer-aided manufacturing technology (CAM).
ADDITIONAL READING | 'Captain, permission to come aboard' -- getting the team on-board with OSA therapy
Study participants
The inclusion criteria were severe OSA patients with an apnea-hypopnea index (AHI) >30 or patients with a 5<AHI<30 and severe sleepiness. All patients had no dental or articular contraindications, and no previous MRD treatment. From this criteria, three subgroups were identified according to AHI value (14% of patients with 5<AHI<15, 44% with 15<AHI<30, and 42% with AHI>30).
ADDITIONAL READING | Hidden dental dangers of undiagnosed obstructive sleep apnea
Research parameters
Successful treatment was defined as a decrease of at least 50% of the AHI and complete response was achieved for an AHI<5 or <10. Mean mandibular advancement was 7 +/- 2 cm, 75% of the maximum advancement, after 2+/-1 titration visits.
Results
In the three- to six-month follow-up, AHI decreased significantly from 29+/-15 to 11+/-10, 84% of patients had a ≥ 50% reduction in AHI, and AHI<10 was achieved in 63%. Among the patients with severe OSA, 60% were effectively treated and 40% were completely cured.
Additional results of the study are as follows:

• SpO2 parameters significantly improved in each subgroup of patients
• Epworth Sleepiness Scale decreased significantly from 12+/-5 to 8+/-5
• Clinical symptoms, including loud snoring, nocturnal polyuria, and libido disorders, were all improved
• Quality of life and fatigue scores improved significantly from the baselines scores
• No significant change in sleep duration but a slight improvement in sleep latency, slow wave sleep, and REM sleep duration
• The mean use of MRDs was 6.7 hours per night and 6.6 days per week
• Side effects were reported by 21% of the patients, including gum irritation or pain (9.5%), dental or periodontal pain (8%), and temporomandibular joint pain or stiffness (7%)
• The rate of occlusion change or mobility was low (2%), and 8% of the patients stopped the treatment early as a result of side effects
• By looking for predictive factors of treatment success through univariate and multivariate regression analysis, less abdominal obesity and Class II malocclusion were found among the patients
• Significant predictive factors for complete MRD effectiveness were lower AHI or higher maximal jaw protrusion capability

Conclusion
In conclusion, an MRD offers an excellent compliance rate among patients and provides significant improvement in patients’ OSA symptoms, AHI, and quality of sleep. A custom-made MRD is an effective therapy for patients with mild to severe OSA that can be used successfully in patients who refuse or are not compliant with CPAP.


Marie-Françoise Vecchierini, MD,
is a member of the American Academy of Dental Sleep Medicine (AADSM), the American Academy of Sleep Medicine (AASM), and past president of the French Sleep Medicine and Research Society. Dr. Vecchierini also received two awards at the 2013 AADSM Annual Meeting in Minneapolis for her study on the follow-up of a large cohort of OSA patients intolerant to CPAP and treated by MRD.