Sleep apnea is the end result of a clash between normal body functioning and anatomy, aided by gravity and the effects of aging. Prompt treatment could prevent multiple medical complications and improve health while reducing the cost of healthcare.
YOU SNOOZE, YOU LOSE YOU SNORE, YOU COULD DIE
A concise, life-saving book for sleep apnea victimsBy EVARISTO P. BADIOLAAuthorHouse
Copyright © 2011 EVARISTO P. BADIOLA, M.D.
All right reserved.ISBN: 978-1-4670-2781-6 Contents
I. Why do we sleep?.......................................................................1II. So, you think snoring is normal.......................................................5III. What is normal sleep?................................................................9IV. What happens during abnormal sleep....................................................25V. Occupational and legal consequences of sleep apnea.....................................35VI. Types of sleep apnea..................................................................39VII. Diagnosis of sleep apnea.............................................................43VIII. Women who snore.....................................................................49IX. Other treatments for sleep apnea......................................................53X. Quality of life after sleep apnea treatment............................................57XI. Impact of sleep apnea treatment on the overall cost of healthcare.....................63
Chapter One
Why do we sleep?
Before we address this question, we need to accept the fact that the human race is part of a bigger warm-blooded species called mammals. All mammals sleep, whether it is a matter of several minutes to hours or even weeks or months. An example is the bear that hibernates during the winter months.
We all need to sleep for lots of reasons. There are external cues in the environment such as the transition from dusk to dawn that makes people start yawning and get ready to sleep. Then, our brains begin to pick up the cue and start secreting hormones or neurotransmitters that make us feel sleepy in preparation for a whole night's sleep.
The question is: why do we sleep? It is not really hard to guess. We need to sleep as a way of recharging and energizing our bodies in order to get ready for the next day. It's like having to plug in a rechargeable battery. This analogy is actually too simplistic.
We need to sleep because we have to. Refusal to sleep is like defying nature. Unfortunately, we do this all the time. That is why we have cities that never sleep like New York, Las Vegas, Chicago, Miami, Los Angeles, and so forth. A lot of us are in a so-called rat race and somebody has to work the midnight shift or our economy could grind into our sudden stop. Thus, we have air traffic controllers, night shift workers such as doctors in emergency rooms, nurses doing graveyard shifts, etc. What do this people do after work? Sleep of course. Otherwise if we don't sleep for days or hours, we could become "zombies" or worse, psychotic. As you know, up to this very day, thousands of sleep deprivation studies have been and are still being performed all over the world. Somehow, the experiments invariably arrive at the same conclusion: lack of sleep for several hundreds of hours has made even normal subjects become delusional and paranoid, experience frightening auditory hallucinations, become dull-headed with significant cognitive impairment as well as demonstrate slurred speech. Laboratory animals deprived of sleep eventually died due to lowered immunity with subsequent overwhelming infections plus total cardiovascular collapse. Hopefully, this answers the question about the need for sleep for now. There is more about sleep in the next two chapters.
Chapter Two
So, you think snoring is normal Let us switch gears for a moment and consider the question: is snoring normal? Isn't it interesting to note that whenever we hear the word snoring, a lot of us chuckle and smile as if snoring is outrageously funny?. Indeed, it does really sound funny. Some people describe the sound of snoring in various ways. Women often snore like a cat purring while men snore like screaming lions. There are also others whose snoring sounds like a steam locomotive with whistling at the end of its cycle. Some men snore like a NASCAR or Formula One car followed by a screeching halt. At this time, they are actually gasping for breath or snorting like a hog before it is slaughtered. Morbidly funny but true, isn't it? We also have heard of reports of wives of snorers complaining of deafness in one ear usually on the side of the snorer. It is true that snoring has actually broken up marriages and has proven itself to be a killer of sex life. So now, you still think that snoring is normal? I don't think so, as you may all know by now.
Snoring is actually the result of the flapping and or vibration of the tissue close to the root of the tongue as a result of partial airway obstruction. Due to a peculiar anatomical construction of the pharynx, the jaw, and the root of the tongue, men and/or women with short necks, small mandibles and oversized tonsils, uvula, and para tonsilar tissues are quite vulnerable to partial upper airway obstruction which we simply call snoring. Don't forget that people with nasal allergy and /or deviated nasal septum snore even more. You may ask how does snoring lead to sleep apnea? Simple. As we get older and the root of the tongue gets heavier and more flabby, this structure aided by gravity begins to close in on the upper airway and lead to complete blockade and thus we have sleep apnea.
Let's go back to the funny part of snoring. A lot of us become pleasantly annoyed when we hear or see someone snore. Often, we would rather leave him alone while he snores his life away. What if he or she stops breathing? For fear of the poor snorer dying suddenly, the suffering spouse would often elbow him to wake him up and make him breathe again. Single men or women who snore don't have that luxury of having the so-called bruised rib syndrome. So what happens? Either their brain wakes them up or they die in their sleep!
Chapter Three
What is normal sleep? Normal sleep is free, unobstructed sleep. That means that while we are in this temporary state of unconsciousness called sleep, we should breathe freely: no obstruction, no snoring. Not only that. The length and quality of sleep are equally important. Sleep is both a function OF and FOR the brain. Let me clarify this. The brain is more than just a computer. It is a complicated but living piece of machinery that controls our thinking as well as our emotions. The reason why sleep is a function of the brain is because it is the brain that actually controls the need as well as the mechanics of sleep. The brain appears to be a bag of soft and fragile-looking tissue protected by a thick skull and placed right on top of our body. It consists of billions of overlapping and highly integrated neurons with specific functions one of which is the creation and control of the process we call sleep. In turn, sleep helps the brain (as well as our body) recharge and rejuvenate itself. As you know, we spend one third of our lives sleeping. It is then hard to underestimate the importance of sleep.
We have defined what normal sleep is but we also need to understand what happens during normal sleep by looking at EEG or brainwave patterns. Before, the early sleep researchers used to classify sleep stages: as alert wakefulness with predominance of beta waves which are usually low amplitude but fast waves, alpha waves which are present when a person is relaxed and drowsy with eyes closed, stage I with theta waves, stage II with predominance of sleep spindles and K complexes, and finally delta sleep stage which consists of high amplitude slow waves. They also found out that the brainwave during dreaming (mostly REM sleep) resembles the awake stage. They called this: REM sleep consisting of random and fast saw tooth waves. REM means rapid eye movement and this is where most of our dreaming happens. The other important EEG pattern is the non REM sleep wave, as you will find out later in this chapter. You must remember that dreaming occurs also in non REM sleep but we rarely remember those dreams upon awakening.
The illustrations below will attempt to explain the different sleep stages.
There is another way of classifying sleep and this is according to the respiratory pattern. The first one is N1 sleep wherein there is regular breathing mixed with periods of slow breathing (hypopneas) and fast breathing (hyperneas). N3 sleep is usually stable and with regular frequency and amplitude of breathing. The last but not the least is REM sleep (see above) which is characterized by highly irregular respiratory rate as well as volume of respiration. This is where central apnea or periodic breathing could happen.
Now, let's look at what happens during normal sleep which we need to divide into REM as well as non-REM sleep. Before going further, we need to understand the difference between sympathetic and parasympathetic activity. Sympathetic activity occurs mostly during the awake state and is triggered during an emergency, the so-called life and death situation in which during this time brain chemicals such as the catecholamines dopamine, epinephrine, norepinephrine and to a limited extent acetylcholine are secreted. These chemicals are called into play during this emergency situation. On the other hand, the parasympathetic nervous system activates the so-called life preserving function of the body and secretes mostly acetylcholine involved in the "rest and digest" functions. Therefore, sympathetic stimulation results in increased heart rate and elevation of blood pressure, reduced motility of the stomach and intestines, reduced urine output, reduced salivation and mucus production, and finally relaxation of the bronchial smooth muscles. You will probably understand now why epinephrine injections can be life-saving in cases of laryngeal spasm and anaphylactic shock from bee or wasp stings. Parasympathetic activity, on the other hand does exactly the opposite.
Going back to the subject of REM and NREM sleep, we can now understand that even though there is some sympathetic activity in (phasic) REM sleep—consisting of rapid eye movements and muscle twitches, there is actually more predominance of parasympathetic activity in both types of sleep. Sleep is a life preserving function and therefore, the sympathetic or emergency alert system places no significant role here. As you will find out later, abnormal sleep disorders specifically sleep apnea, invariably leads to the undesirable activation of the sympathetic nervous system with all its attendant consequences.
Next, let's talk about the factors that drive us to breath while asleep. As we know, we need both oxygen and carbon dioxide to live. Through a complex process, two oxygen atoms combine with one carbon atom to form carbon dioxide which regulates the body pH, meaning acidity or alkalinity critical for survival. Somehow, we have to get rid of excess carbon dioxide by exhaling it. At the same time, the amount of dissolved CO2 in our blood is the body's first line of defense against the tendency to stop breathing when we are asleep. In other words, increasing amounts of CO2 controls breathing by stimulating chemo receptors located in the medulla oblongata and pons region of the brain. An example is hyperventilation during and after strenuous exercise. While awake, we are also able to control our breathing in a voluntary manner (cortical or behavioral) but when we sleep, we have to completely rely on metabolic control, that is, the amount of CO2 present in the blood that affects the respiratory centers in the base of the brain.
Hypoxemia or low oxygen levels in the blood, is the second (and last) factor that controls our breathing. If our CO2 receptors are knocked out or become unresponsive we could still breath if the chemo receptors sensitive to low O2 levels, are present. This is the reason why administering pure O2 to patients with COPD or emphysema could theoretically make these patients stop breathing.
What happens to our cardiovascular system in normal sleep? That depends on whether we are in REM or non-REM sleep. During REM sleep our heart rate, blood pressure, and cardiac output are reduced. The same thing happens during tonic REM sleep (absence of rapid eye movements but still with fast, small amplitude waves on EEG). It is only in phasic REM sleep when, due to some sympathetic activation the heart rate, BP, and cardiac output go up momentarily. This happens also during awakenings. Therefore, it is common for nocturnal systolic BP to be 10% less than awake BP. The correlation here is that cardiac events (such as angina or heart attack) and dangerous arrhythmias (e.g. irregular heartbeats) can be quite common during nighttime hours and the early morning up to 11 AM. The reason is due to the sympathetic activation during phasic REM sleep. In sleep apnea, this probably is amplified several times over.
During sleep, our digestive or gastrointestinal tract generally slows down. That means salivary production, swallowing reflex, gastric acid secretion, and motility of the intestines all go down. This explains why people with sleep apnea with increased sympathetic nocturnal activity, suffer from acid reflux or GERD which occurs due to increased acid secretion and gastric motility causing the stomach acid to regurgitate back up to the esophagus. This is in addition to the negative pleural pressure in the lungs compared to the positive pressure in the abdominal cavity.
In normal sleep, we rarely have to go to the bathroom to urinate. Why is this? Because due to the usually present parasympathetic activity during sleep, the kidneys tend to reabsorb water due to reduced glomerular filtration and increased rennin release especially during NREM sleep. Renin is by the way a part of the renin-angiotensin-aldosterone system involved in the regulation of BP the increase of which is a sympathetic function with the regulation of fluid balance. Thus, the opposite is true-people with sleep apnea often wake up many times to go to the bathroom and their BP's and heart rates are elevated.
Have you ever wondered why tall people don't snore as much as those who do? That is because growth hormone is secreted during normal sleep, specifically N3 or NREM sleep (the deepest part of sleep). As you know, GH is not just essential for the growth spurt during puberty. Not only does it stimulate growth and cell reproduction, but it is also important in the repair and regeneration of the cells and body tissues. However, this doesn't mean that GH is all that important specially if secreted in high amounts or synthesized as HGH used and abused by athletes as performance-enhancing drugs. If GH is secreted also in high amounts by the anterior pituitary gland after the epiphyseal plates have fused during or after puberty, it can lead to gigantism or acromegaly which paradoxically results also in obstructive sleep apnea.
There are many other hormones implicated in normal sleep. We have prolactin which increases during N3 sleep and is reduced during REM sleep. Thyroid stimulating hormone increases during wakefulness as well as the hormone histamine. There is a curious sounding hormone called hypocretin which keeps us alert and awake during the day. On the other hand, adenosine makes us sleepy if we did not have a good night's sleep. Parathyroid hormone increases during sleep. Cortisol levels more associated with the circadian rhythm than sleep, begin to rise about two hours prior to awakening. It is important to remember that N3 sleep suppresses cortisol secretion while prolonged awakenings could actually increase it. This fact is implicated in the causation of diabetes. The hormone melatonin begins to go up during the evening hours and reaches its peak between 2 and 5 AM after which it starts to decline and is ultimately suppressed by light exposure. One particular topic not to be neglected by men who snore and have erectile dysfunction, is the fact that the secretion of testosterone is increased during normal sleep and reaches its peak levels 90 minutes prior to the first REM period. Thus men who suffer from sleep apnea have been found to have low testosterone levels. The opposite is true among women with polycystic ovarian syndrome in which high testosterone levels could put them at risk for obstructive sleep apnea.
Now let's talk about diabetes and weight gain. Despite some increase during early sleep, insulin levels generally go down during normal sleep although they are still comparatively higher during NREM sleep. Therefore, if you don't have normal sleep your insulin levels become persistently high and subsequently you develop insulin resistance leading to type II diabetes. In addition, those with sleep deprivation (leading to EDS or excessive daytime sleepiness) have high insulin resistance as those with narcolepsy (EDS secondary to idiopathic deficiency of hypocretin).
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Excerpted from YOU SNOOZE, YOU LOSE YOU SNORE, YOU COULD DIEby EVARISTO P. BADIOLA Copyright © 2011 by EVARISTO P. BADIOLA, M.D.. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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