In Chapter 8, Section 1, Dr. Park offers great tips on the critical issue of nasal patency. First, he reviews the medical or non-surgical approaches to the problem and then wades deeply into his bailiwick, the surgical interventions. And, we’ll discuss the whole chapter using the same format of highlighting some of his key pearls and occasionally providing our commentary.
Dr Park unequivocally stresses the value of “keeping your nose clean.” He points out one of the most obvious factors, surprisingly overlooked by many sleep physicians; namely, when your nose is closed, your mouth is open. And, he incisively explains that even the use of a full face mask is no fail-safe method when nasal congestion issues are not adequately addressed. As much as his background began as an ENT surgeon, he clearly wants his patients to begin with medical or non-surgical interventions, because they often bring a high rate of success at a cheaper and less invasive cost to the patient.
He describes 7 key factors in evaluating nasal blockage issues, many of which overlap in terms of how they affect nasal breathing and how they are treated. We’ll go through most of these items with brief summaries:
1. Flimsy Nostrils
The thrust of this problem is that your nasal anatomy is just too small to begin with or the walls of your nostrils may not been sufficiently strong enough to let a normal volume of air flow into the nasal cavity. As you can imagine, many possible solutions include external nasal dilator strips and internal nasal dilators. Some of the products he has recommended to his patients include Breathe Right nasal strips, Nozovent, and Sinus Cones. I want to mention here that we have had some recent experiences with the ASO nasal strip brand, a product you can find for example in Wal-Mart sold under the Equate brand name. We have been very pleased with this product because it is so much easier to apply and remove without seeming to cause any skin irritation. We featured these strips in my recent TEDx talk, where we showed some graphics on this brand.
2. Nasal Sprays or Irrigation
The usual approaches with nasal saline and netipot washes including sinus rinse products are described, including a do-it-yourself version of the solution. Dr. Park and I are on the same page here in noting that you can never underestimate the potency of simply cleaning out your nose every day with one of these approaches. I am certain he has seen the same experiences we have observed at our sleep center where individuals literally start sleeping better just by “keeping their noses clean.” The only caveat I would mention is that using irrigations or sprays too close to bedtime may lead to annoying drainage in the back of your throat, which may be a bit vexing if you’re using a PAP device at the time.
3. Avoiding Late Meals
He recommends no further eating about 3 to 4 hours before bedtime, and I believe he is spot on for those patients with tendencies toward reflux (whether they know it or not). However, many people snack at night for many different reasons, some healthy (e.g. diabetics to prevent hypoglycemia during the night) and some unhealthy (e.g. emotional eating to relieve anxiety). Regardless, we both agree that large meals in particular are not a good idea the closer you get to bedtime.
4. Avoid Alcohol Near Bedtime
On this one, we’re in 100% agreement, primarily because scientific evidence clearly notes alcohol worsens your snoring and sleep apnea. Therefore consuming beverages around dinner time is more optimal. Moreover, this timing often produces a relaxation effect that carries over into the evening hours after the alcohol has been metabolized by your body. Drinking a glass of wine at dinner is described by many people as their ritual that helps turn off the mind and getting them into that feeling they can leave daytime worries behind. We call this experience, “finding emotional closure” on the day, which is a potent therapy for insomniacs. The irony that most drinkers know intuitively is that when you drink a lot near bedtime, it will sedate you and put you into deeper sleep, but halfway through the night you go into a mini-withdrawal state from the absence of alcohol, which then leads to constant sleep fragmentation the remainder of the sleep period.
5. Control Your Allergies
The discussion here is extensive and for a PAP user who has never broached this area of treatment, the content provides clear insight into nearly all facets of care needed to aggressively “keep your nose clean.” Two items I would add refer to some research building on the use of nasal allergy drops to supplant traditional immunotherapy (weekly or greater injections for months or years). I know of several patients who are using this newer approach and reporting good results, but my sense is that the technique is not widely accepted or available.
We continue to be impressed with the vast number of OSA/UARS patients suffering from the combination of allergic and nonallergic rhinitis, and the single most common presenting complaint is typically, “I’ve tried nasal steroids and the response was so-so.” We have been using azelastine (Astelin, Astepro) nasal sprays for several years and seen great results. In the past year, we’ve learned from local ENT docs who have also seen great results with ipratropium sprays, the older version being Atrovent, but newer variations of this type of drug may be forthcoming for NAR treatment.
NAR is a very big deal in some proportion of PAP users, because PAP itself involves “wind blowing the face,” a relatively common trigger for NAR. Thus, in the worst case scenario if the NAR diagnosis is not established early on, the susceptible PAP user could develop worse congestion and even sinus inflammation just by initiating treatment with a pressurized air device. In such cases, we react quickly to halt the patient’s use of PAP and initiate either Astelin or Atrovent for a week or two and then retry PAP therapy.
6. Exercise Your Nose
I like this instruction because of the general health benefits, but Dr. Park astutely points out that vigorous physical exercise can lead to increase sympathetic nervous system effects on the nasal blood supply. This effect leads to vasoconstriction, which means the clamping down of blood flow, and in so doing, decreases congestion. On the other hand, among patients who report difficulty with exercising, conceivably there are nasal anatomy issues preventing a fuller volume of breathing in which case surgical interventions may be relevant.
7. Lower Stress
While this section is relatively brief, two very important points are brought forward. First, stress or what I prefer to call “emotional tension” or “unprocessed emotional residue” physically causes sufficient tension in your chest cavity to constrict your natural breathing tendencies and produce shallower breathing. Dr. Park points out these changes are not natural and may have their own adverse influences on nasal breathing as well as on the development of nasal congestion. Although not directly stated, this point correlates with second issue related to stress, which is that anxiety itself causes nasal congestion in some people. According to a paper published in the research literature a few years back by Dr. Christian Guilleminault—who discovered UARS—at least as far back as the 19th century doctors were aware of emotional distress interfering with nasal breathing.
This information is very important to so many more sleep apnea patients than most sleep physicians realize. The importance relates to how anxiety and nasal congestion interfere with someone’s efforts to use PAP therapy, which brings us back to the discussion in point #5 above on non-allergic rhinitis. NAR in fact seems to be the culprit in patients having a congestion response to PAP therapy. As PAP therapy is wind blowing in your face, most sleep doctors should know that “wind-triggering congestion,” especially in seasons other than spring or fall, is a fairly reliable marker of NAR.
Thus, lowering stress levels (especially anxiety levels) is valuable for many health reasons, but in particular if you suffer this type of distress-related congestion in which your anxiety triggers a NAR response, you will either need to find relief through the nasal sprays described above or in the some case, you may discover a certain type of emotion-focused psychotherapy will be of value in your ultimate quest to regularly use PAP therapy without congestion.
Next up, surgical interventions to improve nasal airflow.
In Chapter 7, Dr. Park adds “More Helpful CPAP Tips.” He covers several key factors such as cleaning your PAP equipment, travel tips, battery back-ups, situating your device in the bedroom, and how to manage your PAP device in the hospital should you be undergoing surgery. These were covered so well, I have no further comments. In the second half of the chapter, Dr. Park delves into other clinically relevant situations and factors, which we will discuss here, using the same format of highlighting some of his key pearls and occasionally providing our commentary.
1. Re-check or re-calibrate PAP pressures
This area is of great interest, because it raises the question about what to do when the response is changing. Is the machine defective and needing re-calibration to confirm pressure settings are accurate and doing the job they are supposed to do? Or, has something changed necessitating a more thorough analysis with another night in the sleep lab? As you know from past posts, our sentiments lies with returning the patient to the sleep lab, because pressure settings frequently change in most patients, despite the conventional wisdom followed by many sleep specialists and proffered by many insurers that claim settings rarely change and one titration night in the lab is all that’s ever needed. Dr. Park mentions how data downloads with more modern equipment can provide some sense about whether things are running smoothly, but in our experience we find the downloads often provide qualitative information and less commonly offer sufficient information to guide a manual adjustment of settings. No matter how expensive and how inconvenient, the experience of the sleep lab is a much more reliable way to address these problems. Keep in mind, however, that you will find yourself in a struggle either with your own sleep doctor or your insurance carrier, because they often do not appreciate the concept of a dose-response relationship between your pressure settings and your outcomes changing over time. I cannot repeat this enough times: if your response is waning, as Dr. Park declares, it is a big mistake not to return to the sleep center for additional care and nine times out of ten you want to be tested again in the sleep lab.
2. Patients changing their own pressures
This area is another key element in extending care back into the patient’s domain. I believe the vast majority of patients must be trained to adjust their own pressure settings, if for no other reason than so many sleep doctors are stuck in the conventional wisdom that pressure settings are a static process. In reality, pressure settings should be viewed dynamically. I have noticed this issue first-hand in my own use of ASV and ABPAP over the years. There are times where I am literally adjusting settings daily, weekly or monthly to accommodate some change I am noticing in outcomes. There is no reason why patients could not be instructed in this approach to care, and given the resistance to testing in the sleep lab by so many sleep doctors and insurers, this self-care model can also work very well to further enhance the relationships between patients and their DME personnel. The model of health care for the future is clearly heading toward patient-centric and away from doctor or medical system centric. I appreciate that some patients cannot learn to approach their care in this manner, but arguably anywhere from 30 to 60% of PAP users could learn this approach, and it’s just common sense that healthcare systems should be implemented to encourage patients to understand how to gather subjective data about themselves to then make informed decisions about changing the objective pressure settings on their machines.
3. CPAP use during naps?
I agree with Dr. Parks approach here and simply want to reiterate that if you nap for longer than 30 minutes, it is probably worth considering using your PAP especially when you have known cardiac risk factors or frank heart disease. One other point worth stating is that finding yourself napping on a regular basis should raise red flags about whether you are receiving optimal results from your PAP machine.
4. Allergies and PAP use
Dr. Park makes the excellent point that of course you can use your device when you are congested, but you probably won’t get the same results. More importantly, he points out the necessity for paying close attention to your congestion issues and resolving them prophylactically so you can maintain optimal results. At our center, we call this a “zero tolerance policy” and we consistently educate our patients on the need for aggressive maintenance of nasal airway patency.
5. Sleep position while using PAP
Dr. Park’s specific question is whether you can sleep on your side to which he responds in the affirmative. I would like to add that any sleep position works with PAP, but it may take periods of trial and error to find out how to make things work effectively. For some reason, many OSA/UARS patients presume PAP therapy only works properly when you sleep on your back. The irony, of course, is that some patients suffer from airway anatomy obstructions or neck problems either of which makes it impossible to use PAP while sleeping on your back. I cannot even count the number of times I’ve conversed with patients who were surprised when informed they could use PAP on their back, their side, or even on the stomach (prone position). Personally, I worked through these scenarios and found sleeping prone is my best position, and it usually only requires a few extra fairly flat pillows to work with to create the proper effect. At one time, I used a very flat pillow under my chest, but now my most effective system involves one very flat pillow to rest my head upon and then a second flat pillow tucked slightly under the side of the first pillow to raise its angle. This step improves the comfort effects by slightly lifting the back portion of my head so it is higher than my chin, all of which leads to a pleasant feeling of my face sinking into my mask. Although there are special pillows advertised to assist in solving some of these problems, I am persuaded a little ingenuity on the patient’s part can yield excellent results. Nonetheless, many patients benefit from these special CPAP pillows to aid their efforts to sleep on their sides and off their backs.
6. Beards and CPAP
As Dr. Park points out the first step is to use nasal pillows to avoid any problems with facial hair. However, if someone sports a beard, there is a higher probability his chin might be small or recessed, which worsens risks for mouth breathing. So, the number of patients with a beard who can successfully use nasal pillows is probably smaller than the proportion who ultimately need full face masks or chinstraps or both. Then again, for some, using a chinstrap with a nasal pillow might solve these problems. Although we have no experience with beard sealant ointments, we are learning patients have found them most useful in mashing down the beard in such a way the full face mask seals fairly well.
7. Whom do you call for CPAP supplies?
While this question should be a minor one, it actually turns out to be a common source of snafus, thanks to the way the government has interfered with selling CPAP supplies. Because the main players in sleep medicine are the sleep centers and their professional staff combined with the DME companies and their staff, we often find that poor communication occurs between the two groups. The reason the federal government is partially to blame is their creation of rules and regulations not only making it difficult for sleep centers to operate as DMEs, but even more problematically they create so many rules and regulations for DMEs to follow the two groups (DMEs and sleep centers) often find themselves in conflict, because certain information was not passed correctly from one entity to another. Take the example of Medicare patients: if a primary care physician sends a referral to the sleep center for a specific patient, the DME company may not accept it if it does not include the phrases, “referred for sleep testing” or “referred for OSA evaluation” or both. If it states, “referred for sleep evaluation” it might be rejected. We have experienced dozens of instances where a DME returned the referral as incomplete and refused to send in the fax prescription for the PAP device to receive Medicare authorization. This administrative nonsense delays care and occurs on a daily basis, and some of the idiosyncrasies take up more than an hour of staff time for just a single patient. Above all, it is imperative that a patient make a solid connection with staff at the DME to facilitate communication about receiving essential supplies (masks, tubes, headgear, etc.). But, don’t be surprised when the DME informs you some piece of data or a medical note is missing from the sleep center and is holding up delivery of your equipment.
8. Life span of a CPAP device
Most devices last several years. It is not uncommon to meet patients using a device for 5 to 10 years. But here’s a pearl about switching to different devices that often is not appreciated by patients, probably because the information is not passed onto them by their sleep doctors or DMEs. At any point if you are deemed a CPAP failure case, regardless of how short or long you have owned the device, you can switch to another more advanced device, and the insurers will cover the new device. In other words, your efforts to gain a more advanced device will not be rejected if CPAP failure is demonstrated. Most commonly, if you fail CPAP or APAP, you can rapidly qualify for BPAP or ABPAP. And, if you fail these bilevel devices due to central apneas, then you can qualify for ASV modes. This info is critically important for patients to know about, because many sleep centers don’t seem to realize they can move their patients onto a more advanced PAP device and move them rapidly when they are not responding well to CPAP or APAP. There is no time interval that states you must use CPAP for 3 months or 6 months and so on to be declared a PAP failure case. Even in the sleep lab, if you cannot tolerate CPAP, then technically you have failed CPAP and can be switched to BPAP for the remainder of the night, after which you can be prescribed BPAP immediately without having to take a CPAP device home and fail it again.
10. Summary Points
The main takeaway from the anecdotes Dr. Park mentions in this section is that patients who are diligent and resourceful are more likely to become successful users. Without Dr. Park saying so, I would point to the opposite conclusion in which patients who have a more dependent style of coping with life in general and who lose their momentum in the face of just the slightest roadblock often fail to achieve optimal results with PAP. In fact, these are the patients who give up entirely, return their devices or simply give the PAP machine a comfortable burial site in their closets. This problem is ubiquitous in sleep medicine, and the insurers have caught on, because they know that unless someone makes a conscientious effort to tie up all the loose ends, CPAP failure is looming close at hand. From their point of view, that is when finances are a primary focus, it makes good business sense not to pay for a device when someone won’t or can’t use it. And, all these points go back to Dr. Park’s initial imperative: you really must find a way to want to use PAP and once you find the way, you need to maintain your willpower in maintaining your use. My only caveat in all these philosophical ruminations about PAP is that lots of folks, who might be categorized as in a gray zone halfway been super conscientious and highly dependent personalities, are among the many that if given the chance to use advanced PAP would most assuredly find the way and the will to move forward to stay the course.
In this episode, we have Mr. Roger Price, who has more than five decades of experience and qualifications in multiple areas of human health, giving him a unique background and ability to ‘see the big picture’, as well as to spearhead the integration of previously unconnected disciplines into a Functional Health Program. He is internationally recognized as “The Man who connected Dentistry, Sleep and Breathing.”
In this interview, we discuss:
What is the link between children’s teeth and the way they sleep?
How did modern humans change the rules of life?
How we changed our diets and feed our babies to make things worse
Why the AHI is not a reliable measure of sleep quality
In Chapter 6, Dr. Park addresses the top 15 questions he is asked most frequently or which arose in the past five years during his extensive work interviewing experts in the field and in his own teleseminar series Ask Dr. Park. We’ll list each of these topics, note Dr. Park’s pearl, and where relevant add a pearl of our own.
1. Dry Mouth
Switching to a full face mask or applying a chinstrap are good options, and we would add that a substantial proportion of patients must use them simultaneously. We have also found RemZzzs mask liners solve the problem in some cases when the individual rests their lips against the bottom and wider half of the liner. Dr. Park also points out the necessity how for finding the correct humidification level for some cases of dry mouth.
2. Mask Leak
He covers many key points here, some usually not conveyed to patients, such as how masks can actually be worn too tightly and paradoxically cause leaks. He also mentions that leak can occur in the hose or the device itself, so these areas must be checked. As above, we would mention that mask liners can decrease leak, but one must learn to apply them with great precision as in some instances they can exacerbate leak. Last, he mentions how facial hair issues frequently must be addressed by shaving, but we have recently heard about CPAP beard sealants in use, but we have no first-hand experience with this approach.
3. Device Noise
Check for leaks and confirm your CPAP machine works properly. If it didn’t make noise previously and just started doing so, you might need your DME company to check it out. Ear plugs are recommended as a last resort, and I would add it is important to find the right decibel level usually 32 to 33 for the best results. Recently I found excellent ear plugs with a 33 rating at Walmart, and which have a smooth surface to avoid irritating the skin inside your ear. I don’t use earplugs because of the noise of the machine, but instead, the whine of the device is too high-pitched, and earplugs blunt this specific noise issue.
4. Mask Coming Off
In this one there is a lot to discuss, although for starters Dr. Park does a good job of explaining the mechanical aspects of properly hanging or otherwise situating the tubing so it does not become tangled, which then could lead to inadvertent leverage on the connection between tube and mask. In our clinical experience, such events are rare, though certainly plausible depending upon how your equipment is setup.
The more likely problems that lead to masks coming off are related to patients removing it unknowingly, and the most likely trigger for removal is the patient experiences a breathing event or a series of breathing events for which PAP has not effectively treated, usually due to the wrong pressure settings. The converse situation also arises where the patient is receiving too much air either objectively due to settings too high or subjectively because the patient cannot tolerate the settings. These scenarios are so common in clinical sleep medicine, they often lead to CPAP rejection for obvious reasons. It is therefore crucial to discuss with the patient the likelihood of these situations so that critical short-term adjustments can be made to yield immediate relief. Or, the patient needs to return to the sleep lab pronto to sort out the difficulties. A major complicating factor is observed in patients with leg jerks, as this disorder of excessive movement also interferes with the stability of the mask seal and, in and of itself, may lead a sleeping patient to reach for the mask to adjust it or yank it off.
5. Allergic to Mask
Dr. Park makes a number of knowledgeable statements on this issue, and we concur with his recommendation to try mask liners. We would also add consideration for the Dream Weaver series of mask, which are made from cloth. Though these masks are difficult to fit properly and are often prone to leak, the company has worked diligently through the years to solve these issues, and their product has proven miraculous for select patients unable to use any other mask system.
6. Chest Soreness
I am glad Dr. Park mentions this issue, not because we see it frequently, because we do not. Rather, the severity of the problem is sufficient to cause CPAP rejection. We like his idea to switch to bilevel, but even with such changes we have not always seen improvement. Our current model is to put the patient on ibuprofen for two to four weeks during the adaptation period and then gradually taper off the medication to see whether the chest soreness persists. In several cases, this approach solved the problem, but in a few cases we have seen nothing work, after which patients might switch to OAT.
This issue is near and dear to my heart, since I’ve spent the past two nights providing interventions and coaching for two severely claustrophobia patients in our sleep lab. At some point, I hope to film a mock session demonstrating how we approach this problem. Here, I’ll go through the main principles for helping patients overcome the problem. First, we start out by clarifying whether the patient is reporting claustrophobia due to the mask or the pressurized air or both. Most people report both, but when probed, greater than 90% report the pressurized is the worst part of the problem, because they feel as if they are “drowning in air.”
This comment serves as the perfect segue as it opens up a discussion on the nature and experience of claustrophobia. The patient recognizes instantly that the main complaint of claustrophobia is one cannot get enough air, or there’s a feeling of being unable to catch one’s breath. These clarifications help the patient recognize the irony involving a diagnosis of sleep-disordered breathing in which one also cannot get enough air. The follow-up comment of course is that pressurized air is designed to give you enough air. Just this single insight shifts patients into a new mindset, because they are almost obliged to realize that PAP claustrophobia isn’t anything like the claustrophobia of being locked in a closet or smothered with pillows (two of the most commonly reported childhood experiences causing a claustrophobia disorder). Most patients accept this new perspective, which facilitates a transition to re-defining PAP claustrophobia.
Now, we broach the topics of “control of breathing” and “attention amplification,” the latter of which in a nutshell means CPAP delivery of its unnatural pressurized flow of air will instantaneously cause the patient to pay so much attention to the sensation of the new and awkward air flow, it actually makes the sensation more intense (amplifies). Most people who already suffer from anxiety (claustrophobia is an anxiety disorder) are particularly sensitive to this amplification response. And, as the uncomfortable feelings grow in intensity, you guessed it the patient pays even more attention to the feelings such that the sensation’s intensity becomes intolerable. Ultimately, the patient tries to control his or her breathing cycle, believing that synchronization with the machine’s pressure delivery will somehow resolve the problems. This “control of breathing” response invariably makes the problem worse.
This process is exactly what occurs in greater than 90% of patients who are reporting claustrophobia due to pressurized air. Once they acknowledge this process, patients become open to the third and curative intervention they themselves can introduce into the equation. This final step is called imagery distraction. Simply put, when you put CPAP on, you must avoid thinking about the mask or the pressure by instead delving into your mind’s eye as if you were daydreaming to picture pleasant images and memories, for example your most recent and pleasurable vacation. Shielded within this visual mental space, it is virtually impossible to engage in attention amplification or control of breathing, because you are distracted by something far more interesting and pleasurable. Most patients can immediately feel some relief from this distraction, and more advanced patients will quickly connect the dots to realize they have tremendous control over these problems if they choose to rapidly find a way to ignore the mask and the pressure. Though it should go without saying, it is nearly impossible, physiologically or psychologically, to adapt to PAP therapy by trying to harmonize your breathing with the PAP air delivery cycle.
Although we concur with Dr. Parks’ recommendation to consider assistance from either a behavioral sleep specialist or a psychotherapist who works with claustrophobic patients, the routine described above can be learned by any competent and motivated sleep technologist. In the two instances of my experience this week, I was working with two newly trained sleep techs at our center. I used this methodology simply by chatting with the patient over the phone for about 10 minutes while the sleep tech listened in. Both patients were ready to call it quits and bolt from the center. Yet, after the brief conversation both patients spent the night using a modified PAP-NAP procedure to engage them periodically in efforts to go back and forth with and without the mask to attempt the imagery distraction. The first patient did not fare so well, only trying out the technique for a few minutes during the night. The second patient who actually appeared to suffer from more severe claustrophobia not only remained most of the night, but at one point was able to use PAP therapy for 3 straight hours. Only time will tell as to whether each of these patients will be able to make the effort to go forward with PAP.
8. Sinus and Ear Pain
I defer to Dr. Park, a board certified ENT and sleep specialist as he points out that persistence of this particular set of symptoms may require a visit to an ENT physician.
9. Stomach Bloating (aerophagia)
Dr. Park hits nearly all the right notes on this one, pointing out how applying a chinstrap, adding an expiratory pressure relief mode, or switching to bilevel can solve aerophagia. He writes a lengthier and detailed explanation on the problem of reflux triggering air swallowing that is spot on and indicates the dual need to not only treat the reflux with appropriate treatments, but also to appreciate that treatment of OSA/UARS itself may help reduce reflux. Although research is rare on the role of leg jerks in aerophagia, at our center untreated periodic limb movement disorder is the single most frequent cause of the stomach bloating, and we can only theorize that the leg jerks somehow trigger the patient to swallow, presumably due the leg jerk triggering arousal activity. Remarkably, about 80% of patients treated for leg jerks who reported co-occurring stomach bloating noted the immediate cessation or at least a large decrease in aerophagia with successful treatment of the leg jerks.
10. Stuffy Nose
Dr. Park promises a more lengthy discussion of this topic in Chapter 8 where among other approaches he delves thoroughly into surgical interventions. Here he recommends the usual treatments for nasal congestion, including unique aids such as nasal dilator strips and assorted products that fit into the nose to dilate the nostrils. In our clinical experiences, where we have observed a great deal of nonallergic rhinitis in OSA/UARS patients, we are very high on the use of nasal sprays beyond the typical steroid nasal inhalers such as Flonase, although we understand that some nasal steroid products like Sensimist and Budesonide seem to deliver the drug in a different sort of aerosol that might prove more effective than standard sprays in the treatment of allergic rhinitis. However, for nonallergic rhinitis we have seen fantastic results with Ipratropium (Atrovent) or Azelastine (Astelin). These drugs may go under various brand names, but we highly recommend them in patients who are failing nasal steroid sprays, because such individuals almost invariably suffer both allergic and nonallergic rhinitis.
11. Weight Gain on PAP
Like Dr. Park, we have seen numerous patients gain or lose weight on CPAP or experience no change at all, and we concur with the recommendation to start an exercise program when your energy levels start to improve with PAP therapy. Likewise, evaluating and refining your diet and dietary intake is always advisable for someone with concerns about obesity. The only addition we make here is the recognition of a key psychophysiological factor that occurs once you start PAP. More energy for some people may induce a great desire for exercise and potential weight loss or improved fitness. However, some people the increase in energy appears to alter the patient’s appetite. Thus, psychologically if you are someone who notices your appetite increasing with your newfound energy, do not be surprised if you gain a few pounds or more.
12. I can’t fall asleep (with PAP)
Dr. Park mentions the standard sleep hygiene approach to insomnia as well as the need for sedatives in select cases. He also mentions the use of his mask acclimatization exercises, such as reading with the mask on to overcome any anxiety. Our clinic makes use of these strategies, but we tend to focus more on the use of the same imagery distraction technique described above to treat claustrophobic tendencies. In fact, mental imagery often catalyzes brief “dreamlets” otherwise known as hypnogogic imagery, which typically occur as you are falling asleep. Many patients have informed us over the years that spending time in the mind’s eye can serve as an extremely rapid way to induce sleep onset. So, it’s actually a two-for-one where you learn to ignore the mask and pressure while simultaneously moving your mental landscape towards the Land of Nod.
13. Pressure Too Strong
Dr. Park mentions the use of the ramp, which is invaluable advice for PAP beginners and may be required for several weeks or months for some patients. Switching to advanced PAP therapy is also recommended because dual pressures provide expiratory pressure relief. It is this particular problem that has led us to cease prescribing CPAP in general unless forced to by an insurer. Because comfort is such a critical factor in PAP therapy adaptation, we want to see the patient gain a comfortable experience as soon as humanly possible.
Dr. Park has a box insertion in this section that once again highlights his precision approach to sleep medicine. He points out that two areas of obstruction may also interfere with one’s use of PAP and thus lead to further problems, which no doubt could exacerbate problems with both falling and staying asleep. The first area is the soft palate tissue (that rests behind the roof of your mouth) and the second area is the epiglottis (this tissue closes over your windpipe to prevent respiratory aspiration when swallowing food). Given his extensive work with the endoscopy tool, he reports that certain patients suffer unexpected closures of the airway when the soft palate or the epiglottis functions improperly. In his experience, surgical intervention is the key to resolving such issues. I have to admit it makes me wonder how many CPAP failure cases never received such a thorough ENT evaluation.
14. Skin Irritation
Some of this material has already been addressed regarding mask leak because the tighter you pull the headgear the more marks on your face. We concur with his recommendations for mask liners as the major intervention. He mentions PadaCheek, and we have also had great success with RemZzzs.
15. Water Leaking into Mask (rainout)
This area is tricky and Dr. Park makes several recommendations, but the bottom line is this problem often requires a great deal of finesse to sort out, so I strongly encourage our patients to return to our center or their DME to take the proper steps regarding changing the humidification (manual vs auto), understanding the principles of the room temperature impacting the water temperature in the chamber of the heated humidifier, and the use of various external contraptions such as hose wraps or blankets to find the right combination of steps to solve the problem. We also want the patient to be highly informed on the topic, because as seasons change and heating and air conditioning are switched out every year, rainout can often re-occur. Rainout itself is usually more annoying than a serious side-effect, although some people will experience a rush of water into their nose while lying down, which is more than just uncomfortable. More commonly rainout will awaken you from sleep either because of the dripping of water into your mask and nose, or because it can cause a high-pitch whine. With this level of complexity, visiting your DMD or sleep center is an essential step for many patients.
Of my three boys (ages 18, 15 and 9), only the youngest has major food allergies. He is sensitive to all nuts, milk, soy, tropical fruits, and gluten. In addition, it seems like every other of his classmates have not only similar issues, but various other health problems that are endemic in our young children today. We fed all three boys the same way. So what’s the difference?
In preparing for my recent talk at the Greater New York Academy of Prosthodontics, I came across a research article detailing the high cost of pesticides and herbicides in leading to human and animal disease. In particular the researchers argue that the dramatic rise in the use of the herbicide and weed-killer glyphosate over the past 20 years may have led to facial skeletal changes in white-tailed deer in Montana. In particular, they use the term brachygnathia superior, which is another term for maxillary hypoplasia, or underdeveloped upper jaws. They also detailed significantly higher rates of various other health problems in animals and human infants based on hospital discharge information.
Take a look at the online article and scroll down to look at all the graphs showing higher rates of various health conditions for newborn humans in relation to higher levels of glyphosate. One proposed mechanism is due to glyphosate’s ability to interfere with Vitamin A processing. Be warned. Once you start reading more about the sad state of our food supply, your anxiety and outrage levels will go up.
While at a recent birthday party that I attended with my son for one of his friends, I noticed significant dental crowding and open mouth posture for the vast majority of his friends. There are likely a number of other reasons why our children’s teeth are coming in more crowded and crooked than in past decades. The above mentioned study didn’t measure human children’s dental dimensions, but it’s likely that if measured in five to ten years, there may be significant crowding with more narrowed airways.
If you have children, did your dentist tell you that your child may need braces?
In this podcast episode, Dr. Barry Rafael joins us to talk about integrative orthodontics and his mission to teach patients, parents, and professionals about Airway-Related Oral Dysfunctions and treatment alternatives.
In this 62 minute interview, Dr. Rafael will reveal:
When children should be checked for airway dental disease
The ADA position paper on the role of dentists in sleep disordered breathing
My friend and colleague Dr. Barry Krakow just gave an eye-opening TEDx talk recently. He talks about complex insomnia, which is commonly seen in men and women who keep waking up in the middle of the night. Dr. Krakow explains why this happens and why you have to go to the bathroom when you do wake up.
Why do you wake up at night? | Barry Krakow | TEDxABQ - YouTube
Here are 7 of these reasons below. Please listen to the recording to find out more.
1. You can’t control your breathing when you’re sleeping 2. You don’t know you’re not breathing well 3. You can’t control your sleep position or posture at night 4. Not all breathing is equal 5. The oxygen myth: Lack of breathing, not lack of oxygen 6. Despite high levels of oxygen in your bloodstream, it may not reach certain areas of your body under stress 7. Stress-Breathing Paradox
My family and I recently suffered a miserable cold that would not go away for over 2 weeks. It started off with a stuffy nose, which then developed into a prolonged chronic cough. Thankfully, everyone is now fine, except for a few lingering symptoms. During the peak of my cold, I had trouble sleeping because of my stuffy nose, so I had to resort to using Afrin nasal decongestant in addition to using NyQuil at night. One particular night, I felt something unusual: As I tried to breathe out through my nose, I felt a sudden complete blockage, so I had to breathe out through my mouth. This happened a few more times, until I switched my sleep position from my back to the left side.
The next morning, I realized that I had just experienced expiratory palatal obstruction (EPO), something that I’ve written extensively about in past blogposts. In brief, EPO occurs when due to excess or redundancy of the soft palate, the free edge of the soft palate (the flap of muscle that connects to your uvula, the small finger-like projection hanging down the middle of the back of your throat). In my case, because of inflammation in the back of the nose, my soft palate became swollen to the point that it led to a sudden flap-like closure as I tried to breathe out through my nose.
A viral infection like the common cold is a major reason that can cause swelling in your upper airway, leading to various degrees of narrowing. But there are a number of other reasons that can cause inflammation and swelling, anywhere from your nose to your voice-box. The more narrow your upper airway due to having a smaller mouth, the more symptoms you’ll feel with any degree of inflammation and swelling. Contrary to popular belief, the upper airway is not a rigid tube that connects your nose to your voice box. Instead, there are multiple points of narrowing and widening, along with multiple areas that can cave inwards even during normal sleep. The mucous membranes lining your nose and throat can swell significantly when irritated by these 7 factors, leading to poor breathing and poor sleep:
1. Viral infections. This is probably the most common form of irritation to the upper airway. Most viral infections are self-limiting and go away within a few days. Unfortunately, there’s no treatment for the common cold. You’ll have to treat your particular symptom (mine was nasal congestion). Needless to say, staying well hydrated and getting enough sleep are vital to faster healing.
2. Bacteria. Bacterial infections are relatively uncommon. The two areas that are most susceptible are the throat and sinuses. It’s important to remember that in the vast majority of situations, what may feel like an infection is usually not due to bacteria. This is why in general, antibiotics are not recommended as first line therapy. Oftentimes, other factors such as weather changes, or even a sinus migraine can feel like a “sinusitis.” In the throat, acid reflux is a common reason for throat “pain” or discomfort.
3. Allergies. The list of potential allergic irritants is very large. Most commonly, pollens, dust and animal dander are the biggest culprits. The first thing to do is to avoid these irritants if you know what’s causing your allergies. Nasal saline irrigation can be used to flush out your nasal cavity and also act as a mild nasal decongestant, so you can breathe better. Over-the-counter allergy medication and then a consultation with an allergist are other options.
4. Food. Your upper airway can be sensitive to certain foods as well. The most common food allergy is dairy. A simple dairy elimination diet can be a good option to consider. Sensitivity to wheat and other grains with gluten can indirectly affect your upper airway by causing inflammation in your gut. Other foods can trigger sinus migraines (see #5).
5. Environmental or neurologic. In general, not being able to sleep efficiently due to obstructive sleep apnea or upper airway resistance syndrome (UARS) can heighten your nervous system, causing your nose (and body) to ever-react to weather changes (mainly pressure changes), migraine triggers (certain foods such as chocolate, aged cheeses, MSG and red wine), smoke, chemicals or fumes.
6. Acid reflux. One expected consequence of OSA or UARS is that vacuum forces created during obstructed breathing episodes will bring up small amounts of normal stomach juices in your throat. What most people don’t realize is that these juices can also reach your nose, sinuses, middle ears, and even your lungs. It’s not only acid that comes up, but also bile, bacteria and digestive enzymes. Pepsin, a digestive enzyme, is found in middle ear, sinus and lung fluid in people with infections. Stomach juice can be a major irritant in your nose and your throat. One more thing to remember is that having a stuffy nose will cause more of a vacuum effect in your throat, which can potentially lead to more obstructed breathing and more reflux episodes. This is one reason why some premenopausal women experience throat pain just before their periods, due to lower progesterone levels leading to lower upper airway muscle tone.
7. Dental crowding with crooked teeth. This may not fit with the previous 6 sources of inflammation, but having a smaller mouth can predispose you to more inflammation of the upper airway. Going back to #6, repeated partial or total obstructed breathing can suction up your stomach juices into your throat. Some of the most common symptoms that result are chronic throat clearing, post-nasal drip, coughing or hoarseness. This is also why most people with smaller jaws can’t sleep on their backs, since the tongue or soft palate can fall backwards due to gravity. Additionally, if you have a small mouth, you’ll also have a small nasal cavity (leading to breathing problems due to a deviated nasal septum and flimsy nostrils), and more narrowed sinus passageways, which predispose you to sinus problems with even simple allergies or colds.
Due to modern man’s shrinking faces and epidemic rates of dental crowding, it’s not surprising that we are all more sensitive to normal substances in our environment. Yes, there are probably more toxic chemicals in our environment and food supply, which can literally “rev-up” the immune system, but having a smaller airway can also heighten the immune system, due to the chronic state of physiologic stress. At the other extreme, obstructive sleep apnea is known to cause massive amounts of systemic inflammation, as evidenced by much higher levels of CRP, amongst many other documented inflammatory markers.
For all the reasons mentioned above, this is why I always tell my patients to avoid eating 3-4 hours before bedtime, and to make sure you’re able to breathe optimally through your nose. If you’re not already doing these two things, you may be missing out on the potential for a much better night’s sleep.
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