Growing up angry: How nighttime breathing battles hurt our children: the sleep apnea-ADHD connection

Sleep apnea is not just an adult problem. Far from it. Between 1- 3% of young children have sleep apnea/disordered breathing, and if untreated, can grow up with lasting scars. Habitual nighttime battles for adequate air can set a child up for ADHD sym

By Dr. James E. Metz

Published: Thursday, Apr. 18, 2013 - 2:14 pm

Read more here: http://www.sacbee.com/2013/04/18/5353670/growing-up-angry-how-nighttime.html#storylink=cpy

COLUMBUS, Ohio, April 18, 2013 -- /PRNewswire/ -- People lobbying for gun control may want to consider another culprit in the post-Newtown search for the answer to our unfathomable questions.  In Adam Lanza, with his classic adenoidal face structure, have we overlooked a possible root cause as simple as the very air we breathe…or more accurately, don't breathe?  Failure to free a compromised child's breathing, usually through tonsil and adenoid removal, can have tragic repercussions which extend beyond the life of that individual. 

(Photo: http://photos.prnewswire.com/prnh/20130418/CL97507 )

Parents today tend to view tonsillectomies with skepticism.  Aren't we smarter now than when tonsils were routinely removed for a few stubborn sore throats?   What about our president's well-publicized implications that surgeons fall prey to financial incentives to remove tonsils, limbs and anything else that can be severed?  Shouldn't we be wary? 

Evidence is mounting that if a child's tonsils are causing him or her to snore or breathe abnormally, there are more serious things to be wary of than the knife.   

The politicization of medical decisions is particularly regrettable fallout from Washington's debate over how to control one-fifth of our economy.  After President Obama made his "cash for tonsils" gaffe at a health care overhaul rally, The American College of Surgeons reacted strongly, and rightly so.  Their official statement made it clear that the College still thinks its members take the Hippocratic Oath seriously, and are not knife-happy because of the current reimbursement schedules President Obama promises to convert into a greed-deterring system:  "That remark (that a surgeon's decision to remove a child's tonsils is based on the desire to make a lot of money) was ill-informed and dangerous, and we were dismayed by the characterization of the work surgeons do."

Aside from the insult to physicians, who still rank #2 on Forbes' "Most Respected Professions" list, is it a big deal to raise public doubt about the necessity of tonsillectomies and the motives of those we have traditionally trusted to do the right thing for our children? 

Changing trends in tonsillectomy

Let's start by noting that two generations ago, tonsillectomies were routine, not due to snoring, but due to throat infections.  Tonsillectomies were an inpatient procedure, and over one million American children had their tonsils removed in the 1950's alone!  At that time 90% of tonsillectomies were performed because of recurrent infections, but superior antibiotics and a generally cautionary approach to surgery reversed the tide.   Today, only 20% of the tonsillectomies performed are due to recurrent infection.  80% are due to sleep-disordered breathing, which is the spectrum that extends from primary snoring, which is often benign, through obstructive sleep apnea (OSA).¹

The brain remembers every insult

The message that surprisingly hasn't been shouted from the rooftops is that we have significant evidence that sleep-related breathing disorders are associated with cognitive and behavioral impairment in children (which improve after tonsillectomy).  What, then, if OSA is ignored and the child grows up with these "cognitive and behavioral impairments" becoming firmly rooted?  Do we then have an adult with ADHD, with anxiety or depression, and often some very severe anger issues? 

It is safe to say that ADHD has been routinely misdiagnosed, undertreated and overtreated, and the medical and psychological communities are still stabbing in the dark about root causes and defining physiological characteristics.  The closest we have come to finding these is through PET scans, which have demonstrated abnormal glucose uptake patterns in the brains of symptomatic individuals.   Why that happens and whether the reduced glucose uptake causes symptoms or simply coexists with them is as yet unclear.  

One thing that is clear is that a child diagnosed with ADHD will exhibit symptoms that mimic the very natural consequences of other infirmities or unmet physiologic needs -- like quality sleep.  The adult with ADHD is different from the child in that the pattern of behavior --> response to behavior --> negative reinforcement of self-image has been in place since childhood.  Chronic inability to engage in social banter, listen attentively, keep to a calendar and be prompt, plan and organize….all these basic necessities of a civilized lifestyle can be daunting to the adult with ADHD, and the reactions from the world are often emotionally debilitating. 

10 Symptoms of Adult ADHD
1.	Difficulty Getting Organized
2.	Reckless Driving and Traffic Accidents
3.	Marital Difficulties
4.	Extreme Distractibility
5.	Poor Listening Skills
6.	Restlessness, Difficulty Relaxing
7.	Difficulty Starting a Task
8.	Chronic Lateness
9.	Angry Outbursts
10.	Prioritizing Issues

So tonsils are connected with mental health?

Strong correlations have been established and causal relationships are beginning to emerge from the research, but aside from this, there is something very fundamental we know:  breathing matters.  Oxygen matters.  Acute lack of oxygen is a death sentence, a chronic shortage of oxygen is going to lead to a suboptimal life, and the little throats of children have disproportionately large organs around which to negotiate the air they need.   Here's something else we do know:  10% of children snore regularly, and it is estimated that 10-30% of these children have obstructive sleep apnea.^2,3,4,5

But wait - it gets worse!  Untold numbers of children suffer from other upper airway restrictions that mimic OSA but which are not considered a problem by many people in the medical community.   In total, that is a lot of children to put at risk for permanent damage from dysfunctional breathing.

In children who have moderate to severe OSA, the airway is so compromised that the body is in continual "fight or flight" mode, as the primitive brain struggles for oxygen.   A child will snore, repeatedly stop breathing, and then arouse to recover, only to fall back into the cycle.  Not only is there an oxygen deficit, but the "fight or flight" mode causes surges of sympathetic system hormones (adrenaline and cortisol) to be delivered throughout the bloodstream.  In the short term, the child will simply be exhausted, "fuzzy", distracted by day.  Over time, however, as the barrage of hormones habitually attacks the nervous system and organs, permanent changes take place.  Anxiety, depression and other psychological disorders are among the consequences of this unremitting hormonal onslaught.

Disappearing ADHD

In fact, researchers are accruing evidence that much of the behavior we call ADHD is a result of chronic struggle for oxygen from obstructive sleep apnea, and a significant percentage of the time, this is something that can be resolved by tonsil removal.    Multiple studies have demonstrated that ADHD symptoms subside substantially post-surgery, and some studies even indicate that 20-30% of the participants who were diagnosed with ADHD became completely asymptomatic for ADHD.⁶If OSA is caught and treated early, we can mitigate damage and the toll that living with ADHD takes on the psyche.   

The "adenoidal face" reflects childhood struggle

Any dentist, orthodontist or physician can recognize the characteristics of what is called "adenoid facie" – a face that has developed an abnormally long, narrow bone structure due to chronic mouth-breathing over the growth years.  The "dumb look" may belie an intelligence that is often dwarfed or subverted by years of others' negative responses to a tired, forgetful, distracted demeanor.  Loneliness, rejection, failure in others' eyes, eventually converts to anger – at self or others.  

The brain is permanently damaged by the struggle with airway incompetence.  An indelible mark is left.  Generally, only the person's close relationships suffer from the damage, but sometimes a missed diagnosis may have had repercussions way beyond that small circle.  While we will never know the etiology of Adam Lanza's tragic rampage, he exhibits the classic "adenoidal face", and one can't help but wonder if he wasn't, as a child, victim to his own nighttime battles for air, and what kind of impact that made on his mental state over time. 

Spare the knife, risk the outcome

Tonsillectomies are still painful and still carry the attendant risks of major surgery.  However, the risk of morbidity or misplaced trust in a surgeon are very low, and to let fear blind us to the enormous benefits children receive from relieved airways, improved oxygenation, peaceful sleep and potential prevention of long-term mental health problems is far riskier.

What if my child snores or exhibits ADHD symptoms?

A one to two night polysomnic sleep test at a certified sleep laboratory will enable a sleep medicine professional to rule out sleep disordered breathing or recommend surgery (primary recommendation for children), CPAP or oral device treatment.

Dr. Metz is a Diplomate and Board member of the American Association of Dental Sleep Medicine.  Having treated over 2,500 sleep disordered patients, his outreach to colleagues, physicians and the public is part of his mission to raise health risk awareness and improve treatment for sufferers of TMD and OSA.  He brings a soft-spoken style and visionary approach to educating others in "Medistry" (a term he coined for medically-informed dentistry).  Since shedding 100 pounds in 2004 and alleviating his own case of sleep apnea, Dr. Metz relates readily to those struggling with OSA, obesity and their attendant health problems. 

www.themetzcenter.com

References

1. Head and Neck Surgery web site  http://www.entnet.org, 2013.
2. Newacheck P. W.  Am. J Public Health , 1992.
3. Rosen, C. Sleep, Yale University School of Medicine, 1996.
4. Chang, S., Chae K., J Pediatrics, Oct, 2010.
5. National Sleep Foundation web site  http://www.sleepfoundation.org, 2013.
6. Oguzturk O.  J Clin Psychological Medical Settings, 2012

Contact

Margy Rockwood 614-252-4444 drmetz.margy@yahoo.com

SOURCE Dr. James E. Metz

• Read more articles by Dr. James E. Metz

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Read more here: http://www.sacbee.com/2013/04/18/5353670/growing-up-angry-how-nighttime.html#storylink=cpy

Forty percent of snoring patients are women

4/5/2013 10:30:00 AM

Philippa Lees

We can't point our finger at old, obese men as the only snoring culprits —these days up to 40 percent of patients being treated for snoring are women.

A UK study found the number of women seeking treatment was rising, with drinking, smoking and obesity worsening the problem.

Dr Sean Tolhurst, a respiratory and sleep physician said weight gain is to blame, plus snoring often worsens around menopause.

"Weight gain in the peri- and post-menopausal women is different to weight gain in their pre-menopausal period," he said.

"Post-menopausal women gain weight in a much more male pattern because they don't have the effect of oestrogen. Most of the weight gain that has an impact on sleep apnoea is on the chest and the back of the airway."

Women with large breasts can also have problems.

"To expand their lungs to breathe, they have to lift whatever weight is on their chest up and out," Dr Tolhurst said.

"When they're upright, the extra breast tissue doesn’t make a big difference, but when they are asleep at night, particularly on their back, the extra weight of very large breasts can make a big difference to the amount of pressure they have to generate."

Many women don't realise the broader health and emotional consequences of snoring.

"Snoring has been linked with increased high blood pressure and increased stroke," Dr Tolhurst said.

A study from the Snoring Center in Chicago last year found snoring was causing relationship issues in 30 percent of couples. Forty-six percent of people involved in the study said they would consider breaking up with somebody whose snoring interrupted their sleep.

"It can lead to two tired and cranky patients in the relationship. They feel guilty when one has to move to another room, and can have a negative impact on the intimacy. It's no wonder that that on top of all of life's normal stress is enough to break," Dr Tolhurt said.

"Snoring in women is becoming a really big issue, especially for single women who might be looking for a new life partner — it can be a real deal-breaker for some of them."

But Dr Tolhurst said treatment is often quite simple.

"One treatment is called the Theravent, which is a band aid-looking thing that sits on the outside of the nostril," he said.

"It works by holding up some of the flow when a patient breathes out, which increases the pressure. It's not particularly ugly and can make a huge difference."

A child's snoring is nothing to joke about

SATURDAY, JANUARY 19 2013 04:51

WRITTEN BY JENNIFER RICH

If your child snores, tell your pediatrician. Snoring may be a symptom of an underlying condition that can have serious health consequences later in life.

Even though snoring in children is frequently trivialized and even joked about by family members, it can be a sign of a serious medical problem or condition. 

Many parents will casually report that their son or daughter snores so loudly that they “sound like grandpa” or even “wake the entire house up.” But these casual reports just reinforce the need for practitioners to screen all children at routine visits for a history of snoring and especially those children with large tonsils on physical exam.

It is important that a report of snoring is not only when a child has seasonal allergies or is sick with a cold to be considered persistent. Almost 80 percent of children will snore when they are congested with a cold or allergies and this is predictable, normal and not pathologic.

When there is a report of persistent snoring even without congestion, then further testing and evaluation is important and indicated. This is because a child’s snoring can be an early sign of obstructive sleep apnea. OSA is a complicated condition but essentially, a child’s snoring is an audible sign that there may be multiple, short, 2-3 second episodes of apnea (stopped breathing) during sleep. All children continue breathing normally between these episodes, but their sleep is interrupted.

When snoring is a sign of OSA and remains untreated or unaddressed for years, it may lead to cardiac problems (primarily right heart enlargement), in early adulthood. But long before any heart problems potentially arise, snoring and OSA are frequently associated with some of the following symptoms and signs: gasping or snorting during sleep, prolonged nocturnal enuresis (bedwetting), chronic mouth breathing with sleep, daytime somnolence (sleepiness) even after a full night’s sleep, and even behavioral and attention problems.

If your child has persistent snoring with or without some of these other signs, then after initial pediatric evaluation and exam, a referral to a pediatric ear-nose-throat specialist may be needed. A pediatric ENT can use a flexible endoscope to check for hypertrophy — enlargement — of a child’s adenoids and tonsils. Enlargement of tonsils and adenoids is the most common cause of persistent snoring in children.

So, once snoring has been confirmed by both a practitioner and specialist to be a sign of OSA, what is the next step(treatment)? Rarely, when the swelling of the tonsils and adenoids is mild, intranasal steroids at bedtime used for 4-6 weeks can decrease swelling and minimize snoring. But the majority of the time, the gold standard and definitive treatment for OSA is surgery to remove the tonsils and adenoids.

In summary, because of the proven available treatment and clear significant health consequences of OSA, it is important for parents to always mention their child’s persistent snoring at any pediatric office visit.

Jennifer Rich, MD is a board-certified pediatrician and is an associate professor of pediatrics at Albert Einstein College of Medicine, of which she is an alumna. She continued her pediatrics residency at the same institution and went on to serve as chief resident at the Children’s Hospital at Montefiore. Rich has a special interest in the prevention and treatment of childhood obesity, medical education and biomedical ethics. She is a physician at Peconic Pediatrics in Riverhead.

Is snoring more dangerous to your heart than smoking?

Tuesday, February 05, 2013 by: David Gutierrez, staff writer

(NaturalNews) People who snore are at higher risk for cardiovascular disease than smokers, the overweight, or people with high cholesterol, according to a study conducted by researchers from Henry Ford Hospital in Detroit and presented at the 2013 Combined Sections Meeting of the Triological Society in Scottsdale, Ariz. The study has been submitted for publication to the journal The Laryngoscope.

"Snoring is more than a bedtime annoyance and it shouldn't be ignored," lead author Robert Deeb said. "Patients need to seek treatment in the same way they would if they had sleep apnea, high blood pressure or other risk factors for cardiovascular disease."

Scientists have known for some time that the sleep disorder known as a obstructive sleep apnea - in which a collapse of the airway in the throat causes snoring and cessation of breathing during sleep - significantly increases a person's risk of cardiovascular disease and other serious health problems. Yet until now, there has been no evidence suggesting that even in the absence of obstructive sleep apnea, snoring itself might be a risk factor.

The researchers reviewed medical data on 54 patients between the ages of 18 and 50 who did not have sleep apnea and who had participated in a diagnostic sleep study at the hospital between December 2006 in January 2012. All the participants had completed a survey about their snoring habits and had undergone a test known as a carotid artery duplex ultrasound.

This procedure measures the thickness of that critical artery's two inner layers, known as "intima-media thickness." Thickness of these two layers is considered an early sign of carotid artery disease, and can be used to detect and track the progression of atherosclerosis, or hardening of the arteries. Atherosclerosis can deprive the brain of oxygenated blood, leading to stroke.

Snoring not "benign"

The researchers found that people who snored had a significantly higher carotid intima-media thickness than people who did not snore. No such difference was found between smokers and non-smokers or people who did and did not suffer from diabetes, high blood pressure or high cholesterol.

The damage to the carotid artery may come from trauma and inflammation caused by the vibration of chronic snoring, the researchers speculated.

"Our study adds to the growing body of evidence suggesting that isolated snoring may not be as benign as first suspected," Deeb said. "So instead of kicking your snoring bed partner out of the room or spending sleepless nights elbowing him or her, seek out medical treatment for the snorer."

A 2012 study published in October 2012 in the American Journal of Obstetrics found that women who began snoring during pregnancy were significantly more likely to develop hypertension.

The Ford researchers are now planning to conduct a long-term study to see if people who snore suffer from a higher rate of cardiovascular events.

"Snoring is generally regarded as a cosmetic issue by health insurance, requiring significant out-of-pocket expenses by patients," Deeb said. "We're hoping to change that thinking so patients can get the early treatment they need, before more serious health issues arise."


Learn more: http://www.naturalnews.com/038955_snoring_smoking_heart_health.html#ixzz2PPvWTaiG

Snoring Isn't Sexy Member, Dr. Norman Blumenstock of Monroe Township, NJ Named as Chair of Accreditation Committee of the American Academy of Dental Sleep Medicine

PRESS RELEASE

Dr. Norman Blumenstock, a general dentist in Monroe Township, NJ whose practice provides

oral appliance therapy for snoring and sleep apnea, has been appointed, by the Board of

Directors, chair of the Accreditation Committee of the American Academy of Dental Sleep

Medicine.

Dr. Norman Blumenstock, a general dentist in Monroe Township, NJ whose practice provides oral appliance therapy for snoring and sleep apnea, has been appointed, by the Board of Directors, chair of the Accreditation Committee of the American Academy of Dental Sleep Medicine (AADSM).

"Being appointed as chair of the Accreditation Committee is a distinct honor that carries great responsibility."said Dr. Blumenstock. "I will do everything I can to maintain the high standards set by the American Academy of Dental Sleep Medicine and thank the Board for this appointment."

In the words of the AADSM: "The mandate of the accreditation committee is to maintain the accreditation standards and processes, as approved by the board of directors, for dental sleep medicine facilities. The committee is responsible for monitoring these standards and processes making recommendations to the board of directors for changes as needed. The committee will recommend to the board of directors accreditation status for dental sleep medicine facilities."

The American Academy of Dental Sleep Medicine is the premier professional organization for dentists who provide oral appliance therapy for snoring and sleep apnea. AADSM Accreditation is a voluntary process created to evaluate and recognize competency and delivery of optimal care to dental sleep medicine patients.

Dr. Blumentstock can be reached for comment at his office at 410 Spotswood Englishtown Rd. in Monroe Township, NJ, by phone (732) 251-7766 or by email (staff@centraljerseydental.com).

About Snoring Isn't Sexy, LLC

Snoring Isn't Sexy, LLC was founded in 2008 by Laurence I. Barsh, DMD, a dentist who has been involved with sleep medicine since 1992 and who now devotes full time to educating the public about dentistry's role and responsibility in the recognition and management of snoring and sleep apnea. Dr. Barsh and the dentists associated with Snoring Isn't Sexy, LLC feel strongly that management of sleep-breathing disorders is a shared responsibility of both the medical and dental professions.

Snoring Isn't Sexy, LLC consists of independently owned and operated affiliated offices. Visit

http://www.SnoringIsntSexy.com for a directory of all participating dentists or our dedicated Facebook page at http://www.facebook.com/findsleepapneadentist

Published August 13, 2012 - http://www.prweb.com/releases/2012/8/prweb9780507.htm

Living with Sleep Apnea

Living with sleep apnea can be a real challenge, not only for the sufferer but the for the loved ones who share the same bed and/or room.

Family members or bed partners are usually the first ones to notice the snoring. They are normally the first ones to recognize their loved one stops breathing while sleeping. It is essential for people with sleep apnea to get medical help. Sleep apnea sufferers are at higher risk for car crashes, work-related accidents, and other medical problems due to their sleepiness.

Even though some people learn to sleep through someone else's snoring, it is important to recognize a condition like sleep apnea that could be life threatening. Living with sleep apnea is not the only option.

Call Dr. Blumenstock today to find out which solutions we may have for you. Now accepting Medicare and Medical Insurance.

The Battle for Oral Appliance Legitimacy | Sleep Diagnosis and Therapy

The Battle for Oral Appliance Legitimacy

If you’re living in a fox hole, CPAP is highly inconvenient. Army physicians took this simple truth and turned it into a study that has buoyed the case for adjustable oral appliances.
CPAP compliance can be challenging under ideal conditions. Add the dust, sand, and lack of electricity under combat conditions, and therapy adherence can be virtually impossible.
Major Aaron B. Holley, MD, FACP, ran an ICU unit in Afghanistan for 6 months where he treated combat-related injuries. He saw the harsh Arab landscape firsthand, a place where proper sleep is not a priority. Even in cases of clearly identified sleep apnea, most troops could not afford to give up pack space for CPAP devices and batteries.
Back home at Walter Reed National Military Medical Center (WRNMC), Bethesda, Md, Holley and Lt Col Christopher J. Lettieri, MD, FACP, FCCP, FAASM, continued their work to improve sleep for veterans. They believed that if oral appliances (OAs) were as effective as they were convenient, they could ultimately contribute to a stronger fighting force.
Lettieri, Holley, and additional colleagues attempted to find the answer to this question, ultimately publishing research in the December 2011 issue of CHEST. The study, titled Efficacy of an Adjustable Oral Appliance and Comparison With Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome, confirmed excellent results among mild to moderate sleep apnea sufferers.
Accidents and Explosions
Not surprisingly, the quality of sleep among soldiers can be a shambles during combat deployment. Explosions and less-than-ideal sleeping arrangements are unavoidable, but combined with sleep apnea can be even worse. “We know that most injuries are not battle related,” says Lettieri, a co-author of the study. “We have accidents, and if soldiers are sleep deprived, they are going to lack focus and be more prone to accidents.”
It’s a problem on U.S. roadways, but the stakes are even higher when lethal machinery is mixed in. “If you are driving a 40-ton tank around, you can’t afford to make bad decisions,” adds Lettieri, program director, Sleep Medicine Fellowship, WRNMC. “Research shows that chronic low-level sleep deprivation impairs reasoning, decision-making, and slows reaction time. You don’t want that in a combat-deployed troop.”
Beyond the obvious benefits of reduced accidents and convenient placement in a ruck sack, they found that even post traumatic stress disorder (PTSD) may be affected by poor sleep. “We have all these guys coming back with PTSD, and we broke it down into guys who were injured, and those who were not,” explains Lettieri. “Among guys who did not sustain a combat injury, almost universally they had some underlying sleep disorder.”
“When I was over there, we were sleeping next to an air field,” adds Holley. “It’s the nature of deployment that you don’t get a fixed and regular sleep schedule. Even if you take out PTSD and the anxiety of being subjected to mortars and rockets, you still have a situation where people are getting disturbed and fragmented sleep at best.”
Between 2004 and 2006, the Walter Reed sleep clinic gave out oral appliances and CPAP to service men and women on active duty. “When they went to a place without electricity, it would cause problems and sometimes even prevent some people from being able to go overseas,” explains Holley. “The dusty dirty environment made CPAP too difficult to keep clean. Filters in the machines were frequently going down and having problems.”
Large Pool Yields Better Findings
Armed with findings from one of the largest patient populations to date, Army researchers found that adjustable OAs are nearly as effective as CPAP treatment for patients with mild to moderate OSA, and are more effective than fixed oral appliances—particularly in patients with moderate to severe OSA.
“Historically, CPAP has been the primary treatment for OSA, but only half of patients tolerate this therapy,” says Lettieri, an Army medical director, and the chief of Sleep Medicine in the Pulmonary, Critical Care and Sleep Medicine Department at WRNMMC. “This new data offers a fresh look at adjustable oral appliances as an initial treatment for OSA in both the military and civilian sectors.”
The military is interested in the potential of adjustable OAs, also called mandibular advancement devices, as alternatives to CPAP systems since some active duty service members deploy to remote environments where electricity is not always available. In these cases, reliance on CPAP may result in duty restrictions or separation from service. “Adjustable OAs would eliminate duty assignment limitations associated with CPAP, allowing soldiers to travel to remote areas as needed,” adds Lettieri.
The study in CHEST evaluated and compared results of overnight sleep studies in which patients used adjustable OAs or CPAP devices. Researchers found that a significantly higher percentage of patients using an adjustable OA experienced successful reduction of their AHI score to below five apneic events per hour, compared to past reports (62.3% versus 54%).
In most research trials of oral appliances, patients receive oral appliances after they have already failed with CPAP.  It amounts to a selection bias because patients have already failed, and researchers often never really know why they failed. “We thought our data set was unique because a fair proportion of our patients did not fail CPAP since they were given both at the same time,” explains Holley. “The problem with doing this in the real world is you run into cost limitations. It is not cheap to do either of these therapies individually, never mind giving both to everyone up front. This is true in the military or civilian world.”
Changing Perceptions
Holley contends that physician “CPAP followers” are fairly devoted, tending to favor the humidification features of the modality. “Some docs are comfortable with what they are comfortable with, regardless of the evidence, even when it is compelling,” laments Holley. “It takes time to change people’s minds. How much will change with this study is hard to say. I would hope we have at least shifted the thought process and debate so that pulmonologists like me are more likely to not automatically go to CPAP for mild to moderate. It really does work just about as well as CPAP for people who have mild to moderate disease.”
Lettieri and Holley believe the study will (and should) contribute to a shift toward considering OAs earlier in the patient experience. More comparisons with CPAP are necessary, but Holley admits it can be difficult to level the playing field. “CPAP is electronic with a smart card that records compliance,” he says. “We know exactly how well it’s working. The struggle with studying oral appliances is that you must rely on self reporting from patients as to how much they use it. We can prove that oral appliances work, but the next thing to prove is if patients actually wear them more than CPAP. We suspect they do, but we have yet to prove it.”
Building the case is something that Lettieri is content to do. As a 40-year-old physician in a relatively young field, he has seen awareness grow exponentially, and he has helped the military change its perceptions. At Walter Reed, the size of the sleep lab has doubled in recent years and the staff has tripled. Consults have gone from 70 per month to often 70 in a day.
In a culture where sleep deprivation is part of the culture, Lettieri admits that raising awareness has not always been easy. “When I enlisted, the recruiting slogan was ‘We do more by 9:00 a.m. than most people do all day,’” he muses. “We get up early and operate at night. There is a sleep-when-you-can mentality. Americans as a whole keep shortening their average sleep time at night. Since the 1970s, we have about 1.3 hours less per night. The military is even worse.”
SIDEBAR: Military Intelligence
As program director of the Sleep Medicine Fellowship at Walter Reed National Medical Center, Bethesda, Md, Lt Col Christopher J. Lettieri, MD, FACP, FCCP, FAASM, has seen the evolution of sleep medicine. In a culture where sleep deprivation is often considered a badge of honor, the 40-year-old Lettieri has succeeded by educating top brass and soldiers alike with a powerful message: Well-rested soldiers are more effective in the field of battle.
Nowadays, the sleep lab at Walter Reed is a full-fledged sleep disorders center that is recognized as a center of excellence. In addition to pulmonologists, neurologists, pediatricians, and even psychiatrists are applying for fellowship training. Sleep Diagnosis & Therapy sat down with Lettieri to talk about the explosion in sleep awareness and the implications for the military.
How tough is it to get proper rest in the military?
Lettieri: If you are talking about deployment, your sleep quality gets worse because you go from the relatively quiet environment to sleeping among a bunch of other people. There is more noise, radios, helicopters, explosions, and the constant stress.
Is sleep apnea more or less common in the military population?
Lettieri: Sleep apnea is common in general, and it’s common in the military. Even though we tend to be younger and more physically fit, we still have a lot of sleep apnea.
Why is that?
Lettieri: Some of it is anatomic, but a lot of it has to do with chronic low level sleep deprivation. You lose your ability to maintain tone of your upper airways. Back when I was a fellow, I did a research study called, “Obstructive Sleep Apnea Syndrome: Are We Missing an At Risk Population.” Across America, most people thought about sleep apnea in the 55 year-old overweight guy snoring in your waiting room. But really you see it in younger, thinner people. And if you don’t think about it, you’re going to miss the diagnosis.
Are physicians outside of the sleep realm starting to think about sleep apnea outside of the stereotypical patient categories?
Lettieri: With some of my prior research, and in a lot of the lectures I do now, I am trying to get people to think about it in the less typical person, such as the younger girl with chronic headaches and depression. Or the young guy who has unexplained fatigue and ADHD. I’ve always thought we had a lot of it in the military because of this chronic low level sleep deprivation.
Are there examples among fit combat soldiers?
Lettieri: We have had young, active duty guys who get diagnosed with sleep apnea. If it is toward the earlier part of the war, what do you do with them? You cannot bring CPAP in the theater with you. If you’re living in a fox hole, where are you going to plug it in?
Are CPAPs possible at the larger bases?
Lettieri: Even with the more mature theaters we have now, where everybody has laptops plugged in and lamps, you still can’t plug in a CPAP. The Central Command that runs the war said you can’t bring it.
So what do you do now? You’ve got a young guy, and if you tell him he has sleep apnea, he may be out of a job. The alternative is oral appliances.
When did oral appliances emerge as a viable alternative?
Lettieri: A couple of years ago, when we started this, oral appliances were largely considered an alternative to CPAP. You could consider oral appliances if they had a really mild disease, or really hated CPAP.
What do you with young guys who have severe disease?
Lettieri: You can’t say, ‘Well you’re out of the army.’ So we pushed the envelope way beyond what was accepted, because we didn’t want anyone to be forced out of the Military because of sleep apnea” At one point, we had more experience with oral appliances than most of the country combined. We had to get this message out, so we published two papers almost back to back.
Why did you focus so much on the oral appliances?
Lettieri: We did it largely to conserve the military fighting strength. On one hand, we want to find alternatives to CPAP, because while it is great, lots of people don’t like it.
Across the country, it’s a constant battle with better adherence. You can say that with all medical care, but the difference with CPAP is it has an integrated compliance monitoring device. So we look at this thing and we can tell exactly when the person used it. Some people abandon therapy, and roughly only half of people on CPAP have regular use of their therapy. That’s terrible.
CPAP may be great, but if people aren’t going to use it, we’ve got to have another treatment option. For us on a more personal note, we also have to maintain the fighting strength. We must be able to send people into combat.
You don’t diagnose sleep apnea, and then let soldiers go out with an untreated medical disorder. That is not good for anybody. In that case, you are taking very sleepy people and putting them in harm’s way, and you’re going to see more accidents.
How effective are oral appliances?
Lettieri: Nothing’s perfect by any means, but even half of the people with severe disease got what we considered to be adequate therapy. It depends on where you draw your line in the sand.
“We use strict criteria for what we consider to be effective therapy.  It would be hard to argue with this criteria, so most people would have to agree that adjustable oral appliances work.” If we realize that only half the people are actually using their CPAP anyway, then you’re no worse off. Even if CPAP were completely effective, half the people are not going to use it.
What do you think of non adjustable or fixed devices?
Lettieri: The problem is that you get one shot to fix them. We found that they are OK, but only for really mild disease. Anyone with moderate to severe, you need adjustable. And these are ones you can titrate, just like you do when adding a higher dose of a medication or a range of pressures with CPAP. Adjustable ones ought to be used, and are probably more cost effective in the long term because more people get adequate therapy.
What do you think of tongue control devices?
Lettieri: These are essentially suction bulbs affixed to your tongue that pulls your tongue forward. They really don’t work well—maybe for very mild disease they can be adequate. Most patients find them uncomfortable and they are not used much in clinical practice.

Originally Published At ... http://www.sleepdt.com/the-battle-for-oral-appliance-legitimacy/