I was excited to order Jaws: The Story of a Hidden Epidemic a few months ago when it first came out, but didn’t get a chance to read it until recently. The two authors complement each other with their very different backgrounds. Dr. Sandra Kahn is a pioneering orthodontist with 22 years of practice, and Dr. Paul Ehrlich is a world-renowned evolutionary biologist. Their basic premise is that that modern humans’ jaws are shrinking, and as a result, our teeth are coming in more crooked and our airways are more crowded than ever. Inspired by the work of Dr. John Mew, they present a convincing argument that there truly is an epidemic that’s not being addressed by the orthodontic, let alone the medical community.
This book is a much more in-depth, and up-to-date description of what I described in my book, Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, which was published in 2008. Coming from an orthodontic and evolutionary biology perspective, the authors add enormous value to enlightening our dental and medical colleagues (and the general public) about the enormity of this problem. One recent and welcoming trend that’s common with the age of the internet is that increased awareness by the general public can oftentimes change the way doctors and dentists practice. It can also drive more interest in research topics and funding for such projects.
The first 3 chapters cover the origins of malocclusion (crooked teeth) from a evolutionary perspective. In particular, they go into great detail about George Catlin’s book, Shut Your Mouth and Save Your Life. Catlin was a civil war era naturalist and painter, who had an interest in painting native Americans in their natural habitats. He noticed that those who kept their mouths closed had broader faces and were much healthier, whereas these who kept their mouths open hand more narrow and long faces, and were much more prone to illnesses. You can see many of his paintings at the Smithsonian museum. They also note that many paleontologists have demonstrated that ancient skulls usually have very good teeth and essentially no dental crowding. No book talking about shrinking faces and smaller airways is complete without mentioning Dr. Weston Price’s classic book, Nutrition and Physical Degeneration. Price was a dentist who traveled the world in the early 1900s, showing that across the board, cultures that ate naturally without modern Western influences had broad dental arches with a full set of teeth, beautiful smiles, and essentially no cavities.
Dr. Brian Palmer, who was my original inspiration and mentor in this areas, documented this finding as well. Kahn and Erlich also liberally cite Dr. Robert Corrucinni, an anthropologist who found that communities with soft diets had higher rates of malocclusion (see podcast interview with Dr. Corruccini). This highlights the importance of how and what we chew determines how our faces grow. These concepts also build on one of the basic tenants of modern dentistry proposed by my medical school anatomy professor, Dr. Melvin Moss, DDS, who proposed the functional matrix hypothesis, which states that facial bone growth is not only influenced by your genes, but also the forces around your jaws, including direction and intensity of muscle forces, as well air pockets surrounding the bones. They finish the introductory chapters with many convincing arguments that there is an epidemic of shrinking faces (and airways) in modern humans, and that there are strong associations with numerous chronic health conditions in the United States.
Chapter 4 delves into how the perception of facial beauty is directly influenced by how well your facial bones develop. It’s no wonder that for the most part, elite athletes have relatively “attractive” faces which stem from more fully developed facial structures and dental development. This leads to more optimal breathing during the day as well as at night, potentially leading to higher levels of endurance or physical abilities. Jaws makes it clear that crooked teeth are only the tip of the iceberg, and not just a cosmetic problem. With an estimated 50 to 70% of children in the US needing braces, this truly is an epidemic that’s hidden under the surface of our medical and dental system’s level of awareness.
Chapter 5 covers early development and oral posture, and how poor development can lead to facial and airway underdevelopment. Bottle-feeding, thumb-sucking, pacifier use, eating soft diets and poor tongue-lip and mouth postures are all potential sources of contribution to our facial shrinking epidemic.
The next chapter brings everything together to culminate in the end result, or the tip of the iceberg called obstructive sleep apnea. Here the authors bring up Dr. Robert Sapolsky’s analogy of the stress response that’s created when a zebra is being chased by a tiger. People with obstructive sleep apnea react physiologically like they are being chased by a tiger all the time, especially when they have breathing obstructions during sleep. Over time, chronic obstructive sleep apnea has been strongly linked to a myriad of health conditions including ADHD, memory problems, heart disease, heart attack, stroke, cancer, sexual dysfunction, and car accidents. The chapter ends with a cursory discussion about jaw surgery (maxillomandibular advancement), uvulopalatopharyngoplasty, tonsillectomy, and CPAP. Disappointingly, there’s no mention of mandibular advancement devices, which are a mainstream alternative to CPAP for mild to moderate sleep apnea, and recommended by the American Academy of Sleep Medicine.
The following chapter (What Can You Do?) describes the fundamental of proper nasal breathing, optimal chewing, and good body posture. In particular, Buteyko Breathing and Good Oral Posture Exercises (GOPex) are described in detail.
The penultimate chapter describes Dr. Kuhn’s philosophy in treating airway disorders with orthotropics (developed by Dr. John Mew in the UK and promoted in the US by Dr. Bill Hang. Listen to interviews with Dr. Michael Mew and Dr. Bill Hang). Orthotorpics (also called forwardontics) is compared to other fields such as orthodontics and dental orthopedists. It’s not surprising that mandibular advancement devices are not mentioned, since orthotropics is fundamentally different from mandibular advancement devices in the way they work. Additionally, orthotropics is available only for children, whereas mandibular advancement devices are indicated for adults only.
The final chapter concludes with a passionate plea for the general dental community to open their eyes to the importance of the airway as they treat patients for routine dental problems. They also advocate for more cross-collaboration between dental, medical and allied health fields, such as myofunctional therapists. Finally, they also are calling on all medical professionals and legislators to place higher value on oral health and screening for breathing-related sleep disorders.
This book is a valuable addition to a recent surge in books with similar messages, such as Your Jaws – Your Life, Gasp!, Six-Foot Tiger, Three Foot Cage, and the Dental Diet. It’s an excellent review of what causes crooked teeth and narrowed upper airways, leading to a range of chronic conditions, such as headaches, fatigue, weight gain, anxiety, TMJ, as well as complications of untreated obstructive sleep apnea. I highly recommend this book.
What is the little-known problem that’s causing a lot of people to be sick and tired, and that many doctors miss? In this podcast episode Kathy and I discuss how the epiglottis may be the reasons behind your chronic fatigue, anxiety, or headaches. Find out:
Jennifer was adamant that her son’s tonsils were not to be removed. They were 4+ “kissing” tonsils, the size of two golf balls, and he was choking 12 times every hour. I recommended surgery. His mother asked about alternative options. I mentioned CPAP and functional dental appliances as alternative options.
Shaking her head, she asked, “Are there any other options?”
I mentioned that there are studies showing that both acupuncture and tongue exercises were found to lower sleep apnea severity by 50% on average. She did not think her 4 year old could be disciplined enough for tongue exercises and she was not interested in acupuncture.
“What about herbs or supplements? “
I mentioned that I’m not aware of any proven options that I know of that’s published in mainstream sleep or ENT journals.
She also rejected topical steroids, which are found to help somewhat to lessen sleep apnea scores in children.
At this point, I was feeling a bit frustrated, since she was rejecting every option that I had to offer. I finally asked her why she didn’t want to have her daughter’s tonsils removed.
She paused for a few seconds to think, and revealed that she read on the internet that the tonsils are part of the immune system and helps to fight infections.
“If you remove the tonsils, then you can’t fight infections.”
This is one of many such discussions I have with patients every day. In this post, I will describe 7 of the most common myths about sleep apnea surgery, in no particular order.
1. Sleep apnea surgery doesn’t work
This is a common misperception based on generalized results of historical surgery on the soft palate only. The same 40% success rate figure is quoted repeatedly, but this is an old study looking at the traditional version of the uvulopalatopharyngoplasty, or UPPP. We know have much more refined UPPP variations with significantly higher success rates. However, no matter how well you do the palate procedure, you won’t be successful if there are other areas of obstructed breathing that’s not addressed. These areas include the tongue base, tonsils, epiglottis, or the lingual tonsils. Most people will have multiple areas of obstruction.
One commonly cited tool that’s used to predict UPPP success is the Friedman classification, which predicts that if you have relatively large tonsils and a low sitting tongue, and you’re not very overweight, your chances of “surgical success” is about 80%.
Even if you only have only one area of obstruction, doing a standard procedure doesn’t guarantee that the obstruction is completely addressed.
We also know that weight loss surgery, double jaw surgery (maxilla-mandibular advancement, tongue pacemaker surgery or even tracheotomy can have profoundly positive results. So to say that sleep apnea surgery doesn’t work is not an accurate statement. What that statement is really saying is that the patient states that it didn’t work for him or her.
I also have to stress that sleep apnea surgery of any kind must be considered only after trying non-surgical options first.
2. If your tonsils help to fight infections, why take them out?
This is another common misconception that’s used to justify not undergoing tonsil surgery. Yes, the tonsils are a part of the immune system that educates the body. A common reason for taking out the tonsils is due to recurrent tonsil infections. In this case, the tonsils are prone to repeat infections with pain and misery, requiring antibiotics. Applying the logic to leave the tonsils in place just doesn’t make sense.
If you have large tonsils which are aggravating obstructed breathing at night, then the benefits of improved breathing and sleep far outweigh any theoretical benefit to your immune system. Your tonsils make up a small fraction of your body’s lymphatic tissues, such as in in your neck, gut, skin, groins and armpits. When two large lymph nodes in your mouth (tonsils) obstructs your breathing repeatedly at night causing oxygen levels to drop less than 80%, then the benefits of surgery far outweighs any theoretical benefits of leaving them in.
3. Uvulopalatopharyngoplasty (UPPP) causes swallowing or choking problems
Regardless of how well the UPPP works to address sleep apnea, there are always potential risks for any surgical procedure. Bleeding, infections, and anesthesia complications are unusual, but important issues to think about with any operation. In particular to the UPPP, swallowing problems are known complications that are well documented. Fortunately, in the vast majority of cases, even if these symptoms do happen, is usually temporary, lasting only a few days to weeks at most. Rarely, symptoms may last months to years. The most feared long-term side effect of the UPPP operation is what’s called velo-pharyngeal incompetence, when food or air or water leaks up into your nose when you swallow or talk. Taking out too much of the soft palate may prevent proper closure of your soft palate against the back of your throat, leading to something similar to having a cleft palate.
Fortunately, these complications after UPPP surgery are rare, but should be considered in light of the risk to your health if you have severe sleep apnea and can’t tolerate CPAP at all.
4. Uvulopalatopharyngoplasty (UPPP) makes CPAP more difficult or impossible to use
There are a handful of small studies suggesting that a UPPP can make CPAP use more difficult. However, there’s much more recent evidence suggesting the reverse. My personal experience is that even if the UPPP procedure doesn’t result in a surgical “cure” in someone who initially can’t tolerate CPAP, it may be better tolerated after UPPP. One potential explanation for this is my previous description of expiratory palatal obstruction, where the soft palate backs up into the nose causing a sudden blockage, like a valve. This prevents breathing out through the nose, potentially leading to difficulties using CPAP.
Recent studies have also shown that the soft palate is not the only area of abstraction. The tongue base, epiglottis, tonsils and lingual tonsils can also contribute to OSA, to various degrees in different combinations in different people. Treating the soft palate alone may help some patients significantly, but most patients will need other areas of obstruction addressed as well.
5. Surgery shouldn’t be done for mild sleep apnea or upper airway resistance syndrome (UARS)
I recently reported on a study that we published showing that in symptomatic patients with AHI < 5 (no sleep apnea), 83% are found to have significant multilevel obstruction. This goes along with what we see in patients with UARS, where you can stop breathing 25 times every hour and not have any apneas. This can but much worse than someone with only 5 pure apneas per hour. The prevailing recommendation is to recommend surgery only for people with moderate or severe OSA. My general philosophy is to treat the patient, not the numbers. I routinely offer surgery to people with mild sleep apnea or no apneas at all based on sleep studies.
6. CPAP is always better than surgery
While CPAP is the “gold” standard treatment for OSA, in practice, it doesn’t even reach bronze status. I’ve quoted other experts showing that at the end of one year, only a small fraction of people given CPAP are using it effectively. Everyone will agree that CPAP works but only if you use it. This reminds me of a study in 2004 looking at people with newly diagnosed OSA who were given CPAP or underwent UPPP surgery from 1997 to 2001. By 2002, patients given CPAP were 37% more likely to be dead. This study supports the argument that an inefficient treatment (UPPP) that is 100% compliant can be just as good or better than an efficient treatment (CPAP) that’s not used very often.
7. You need to find a surgeon that has done lots of procedures to be good at it
It’s commonly accepted that the more procedures you perform, the better the surgeon. This concept was popularized by Malcom Gladwell in his book, Outliers, which described Dr. Anders Ericsson’s landmark study. Ericsson, in his book Peak, studied elite violinists at a prestigious music school in Europe. If you extrapolate this finding to surgeons, it’s logical to assume that a surgeon who performs 10,000 tonsils is better than someone who has done only 2000. However, there was one major caveat that was not emphasized in Gladwell’s book: The best musicians not only practiced 10,000 hours, but 10,000 hours of intentional, focused practice. Just performing tonsillectomies over and over again doesn’t make you a better surgeon. It’s a process of constant refinement through external feedback that intentional practice that ultimately makes you fluent and proficient as a master surgeon.
I still see surgeons who have been in practice over 25 years who can perform a routine tonsillectomy, but there’s no skill or finesse involved. Like Hiro in the movie Hiro Dreams of Sushi, a surgeon must constantly strive to improve his or her skills, not just to finish faster, but to have a passion for excellence and an incessant desire to keep pushing the limits even when reaching retirement age. Reinforcing average surgical skills by repeating it 10,000 times will leave you with average surgical skills.
The surgeon’s technical skills are important, but what’s more important is your surgeon’s judgement and clinical expertise. You have to perform the right operation for the right reasons. You also have to experience enough complications to know how to handle them then they occur. in rare situations. If a surgeon tells you that she doesn’t have any complications, run away.
So the next time you have a desire to ask your surgeon the “how many” question, figure out a way to find out how well your surgeon does a particular procedure. It may be challenging to get this information, but if you do your legwork, it’s possible to figure out if you can ultimately trust your surgeon no matter how many procedures were performed.
Jennifer’s mother understood my logic behind why I recommended tonsillectomy. She even agreed with me on all my points. But she admitted that she was uncomfortable in removing something entirely from the throat if it serves a function. We compromised by going ahead with a partial tonsillectomy, which I was comfortable doing, despite the slightly higher rate of possible recurrence. Ultimately, Jennifer did very well after the procedure and her mother was happy with the results.
What if I told you that there’s something in your throat that can block your breathing 20 to 30 times every hour while sleeping, but almost never gets correctly diagnosed. This breathing problem doesn’t show up on formal sleep studies. It’s not sleep apnea or upper airway resistance syndrome, and it’s not asthma.
This breathing problem may be due to a floppy epiglottis. Your first question might be, “What’s an epiglottis?” The Greek prefix epi- means on, over, near, around, or before. The glottis describes your vocal folds and the space between the two folds. The epiglottis is a structure that sits just above your vocal folds, just in front of the back of your tongue (see figure 1). It’s made of cartilage (like your ear) and covered with mucous membranes. It’s thought to protect your airway from food going down your windpipe when you swallow.
Figure 1. Epiglottis
One of the interesting things that I see quite often during drug induced sleep endoscopy is the epiglottis flopping back with each breath in, causing total occlusion. It’s like a one-way valve-like flap. Sometimes, patients can even demonstrate it in the office. When you see it’s quite dramatic (see video below).
This situation is formally called laryngomalacia, which is much more commonly seen in infants. In most cases, children outgrow this problem, but sometimes need surgery. One recent study found that a floppy epiglottis was the most common reason for persistent OSA after adenotonsillectomy in children. For unexplained reasons, we are now seeing much more of this in adults. One possible explanation is because we’re now doing drug-induced sleep endoscopy.
Click the photo above to play video. Jaw thrust at the end of video showing improved airway.
However, here’s my take on why we’re seeing more problems with the epiglottis for the following reasons.
3 Reasons for your floppy epiglottis
1. Shrinking jaws. I’ve commented for over 10 years that human jaws are shrinking, especially in modern, Western countries. This is the main premise of my book, Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. The smaller the jaws, the more narrow the airway due to soft tissue crowding. The epiglottis is attached in the front to the hyoid bone, a c-shaped bone that sits on top of your voice box, and is attached to the lower jaw. So the more recessed your lower jaw, the more your hyoid bone and epiglottis is positioned backwards. This is also why most modern humans can’t sleep on their backs.
2. Our bones and cartilage are getting weaker. Osteoporosis, which is much more common now than decades ago, doesn’t just start when you turn 65. It’s a result of problems that starts when you are born. Perhaps even before you are born, due to the your mother’s health status during pregnancy. This is just conjecture, but based on my interpretation of the published research on the detrimental effects of glyphosate on bone formation, it’s also likely to affect proper cartilage development. This is evidenced by a higher rate of lax and hypermobile joints in our children, as well as higher rates of broken bones. Glyphosate can prevent optimal bone formation by altering chondroitin sulfate synthesis in your cartilage and bones. This may be due to glyphosate’s ability to bind essential minerals such as manganese, which is a metal that’s required for the enzymatic reaction for producing optimal bones and cartilage.
3. Fluoride. Adding fluoride to our drinking water has been hailed as a public health success story. However, there are tomes of studies showing that even small amounts of fluoride may have detrimental effects on brain and bone development. For example, adding fluoride to drinking water to rats given braces showed significantly less widening. Other studies suggest less quality bone development when exposed to fluoride. Any toxin, chemical, or even lack of oxygen during development that diminishes optimal jaw and hyoid bone growth may predispose to a floppy epiglottis.
A combination of less forward jaw growth and weakened cartilage can potentially lead to the epiglottis flopping back with each inhalation during sleep, causing frequent arousals from deep to light sleep. These obstructive episodes are usually too short to be picked up as an apnea or hypopnea on sleep studies.
How to diagnose and treat a floppy epiglottis
So far, the only way to formally make a correct diagnosis is to undergo sleep endoscopy, where your airway is observed during light sedation in the operating room. It can occur by itself or along with other areas of obstruction such as the soft palate, tonsils or tongue base. Pushing the lower jaw forward during sleep endoscopy (similar to using a mandibular advancement device) helps most of the time, but not always.
Then what’s the solution? A mandibular advancement device may help, but the only only way to know if it is going to work is to try it. The jaw thrust maneuver during sleep endoscopy (shown in video above) can guide you on whether is may be a good idea. The ideal way of treating this is to either grow your jaws using advanced orthodontic or functional appliance options. These options may help in theory, but it can take up to two years, with no guarantees. Jaw surgery is another option but not feasible or practical for most people. The only treatment that works relatively quickly is to trim a portion of the epiglottis, or attach it to the back of the tongue base with a stitch. Like many sleep apnea procedures, it works most of the time, but not always, depending on how severe the epiglottis obstruction or if there are other areas of obstruction.
The greatest concern for removing the epiglottis is aspiration, where food goes down your windpipe. Although it’s possible in theory, I have yet to see it in my practice. I perform about 2 to 3 such cases every month. More up to date research suggests that swallowing problems are not as much of a concern than previously thought.
Finding the right surgeon
It’s likely that if you approach an ENT surgeon about this possibility, you may get mixed reactions. Not every ENT surgeon performs sleep endoscopy. There are also widely differing opinions on how to address a floppy epiglottis. Even if you’re sure that you feel like that there’s a flap inside your throat that’s keeping you from getting a good night’s sleep, you’ll likely get a get a puzzled look from your physician or surgeon. This has been reported to me by a number of of my patients, who usually don’t have sleep apnea confirmed on sleep studies, but are extremely tired and suffer from severe anxiety. CPAP usually won’t work since you can’t breathe in due to the valve-like effect.
More often than not, a floppy epiglottis is seen along with multiple other areas of obstruction. All these areas must be addressed as well using any of the options mentioned above for the floppy epiglottis. If you suspect that you may have a floppy epiglottis, you may have to do some leg work and find an ENT surgeon who is open to this possibility, as well as being comfortable with various treatment options. I have a pediatric neurologist who sends me many of his patients with headaches, but only mild or no sleep apnea confirmed by sleep study testing. Oftentimes, when I treat the floppy epiglottis, the headaches improve significantly or go away completely.
In an upcoming article, I will describe another valve-like process that can happen in your throat, but during exhalation.
Continuing with our review of Totally CPAP, written by Dr. Steven Park, this next section discusses implementing a program for CPAP therapy success. Dr. Park has developed a very interesting seven-step, seven-day program to help someone integrate all the major instructions from the book. His goal is to enhance your first week of efforts to use the PAP machine, although as you will read below, the focus is more on the seven steps and not actually seven consecutive days. And, he begins quite rightly with the question, “Where do I even start?”
His first step is all about “Education and Goal Setting.” He believes individuals should start with a sleep journal to track various data points such as how much you are sleeping with the mask, how you feel the morning after and related themes connecting CPAP effects to your sleep. Obviously, this step involves more than just one night or day, but the idea behind it is to capture data to provide feedback to create realistic expectations and appropriate goals.
I’m not a big fan of sleep diaries/journals, although they certainly have their place in treating insomnia. And, I certainly appreciate Dr. Park’s perspective here and believe this approach will work for a certain segment of CPAP attempters, particularly those who tend to be well-organized and function in an orderly, rational way when approaching tasks. My concern is that an extremely large proportion of CPAP attempters do not react rationally to PAP therapy. Instead, many people are highly reactive to it, exhibiting an almost exclusively emotional response. Now, when you imagine all the possible emotional experiences associated with PAP therapy, there is no question fear, anxiety, guilt, embarrassment, and shame could individually or in combination thwart any efforts to use the device. In the worst case, the emotions converge into a traumatizing, impossible to forget adverse experience after which many patients drop out immediately, never to revisit PAP following the very first encounter.
Which brings us to Dr. Park’s second step, “Practice, Practice, Practice,” which I believe is the best first step for a sizeable number of patients. Here, Dr. Park and I agree that a hierarchical desensitization approach is optimal for many patients, but many DME programs may not be set up to accommodate patients. Specifically, he writes about the hypothetical scenario where a patient could receive just the mask first and practice wearing it in various settings throughout the day to deal with this issue straightaway before the person ever attempts to experience pressurized air coming through the mask. Practically, a person could fill their prescription for the mask, tubes, and PAP device, but simply work on the mask issues first.
My only objection to the instructions is the notion a person could fall asleep with the mask on when it’s not hooked up to the machine. I see the idea behind it, because if a person could fall asleep with the mask on, it may give them confidence the process is progressing well. The problem arises when you might have a breathing event once sleeping, since no pressurized air is flowing; then, you wake up gasping for breath with a mask stuck on your face. Such a scenario would not only be traumatizing, but it also connects the wrong dots in which the individual would experience the mask as somehow triggering the breathing event. Thus, I would never recommend someone falling asleep with a mask on, unless they want to sit upright in an easy chair and doze off briefly.
In step three “Apply Pressure,” Dr. Park brings up some excellent experiential points when you start using the pressurized airflow. Not only does he want you to learn to distract yourself from the sensations, he also wants you to experience some of the side-effects of PAP so you won’t be surprised by them in the middle of the night. I really like his idea to intentionally open your mouth as well as intentionally move the mask around so you experience the sensations associated with leak, that is, leaks through mouth breathing or leaks through the mask itself. These steps are sound ideas to make you aware of some of the major barriers to successful PAP use.
A key point in this step is the problem of anxiety or claustrophobic tendencies when breathing out against pressurized air. As you know from our work, these side-effects are unacceptable, which is our rationale for switching patients to bilevel modes as soon as possible. Dr. Park’s comments suggest that a certain number of patients will report these experiences, but he expects these side-effects will abate if the patient proceeds slowly. We do not find such outcomes to be so common, but we accept that others might presume we give up on CPAP too quickly. Nonetheless, I believe patients should be informed about bilevel up front so they can request a quick comparison while in the sleep lab or at the DME, after which I would predict the vast majority would choose dual pressure (BPAP) over fixed pressure (CPAP).
Step four is where Dr. Park has his patients begin using CPAP to sleep. I want to reiterate here that while Dr. Park and I have different opinions on aspects of his first three steps, the overarching theme of his initial steps are exceptionally well-crafted, because they are all about effective preparation. So many people feel as if PAP therapy is thrown at them not only in chaotic fashion, but worse they feel the “use it or lose it” stress right from the get-go. Dr. Park’s system, like some of the strategies of Classic SleepCare, encourages you to slow down and learn about the process and put your toe in the water and try to feel what’s going on before you jump in the deep end of the pool. Regrettably, so many sleep professionals do not offer this approach, which is why I want to single out Dr. Park’s wisdom and commend him for integrating his approach into a book where PAP users will learn that slow and steady wins the race.
This section on “Sleeping with CPAP” is succinct and focuses on two main points. First, did you notice any problems using the device? If so, then track them for future discussions with sleep professionals, or ideally see if you have enough information and skill to solve them yourself. I like his recommendation to leave the mask on when you must get up at night to use the bathroom, but I would add the caution you might want to practice walking back and forth twice, that is, once with the lights on and once with the lights off to determine how safely you can navigate the trip. Some full-face masks clearly interfere with your line of sight; moreover, if you are sleeping with another person, you may not be able to turn on the lights in the middle of the night.
His second point is about your ratings of the sleep experience and any side-effects from using it, for example taking the mask off in your sleep, waking with a dry mouth, and most importantly how well did you sleep. Many of these factors require immediate attention because their persistence may be so aggravating you quit using the device. For example, dry mouth can become quite exasperating, and the solution is not to drink more water, but often means you’re going to need to try a chinstrap or a variant to hold your mouth closed. Yet, lots of people refuse to use a chinstrap, or if they are motivated to pursue it, they may discover lengthy delays in trying to get their sleep doctor to write the prescription and send it to the DME, after which there might be further delays if the DME cannot readily dispense what’s needed. Such a scenario would demonstrate the classic negative conditioning influences that emerge when PAP experiences are unpleasant or disturbing. Would you want to keep trying your CPAP device for a week or two while you wait for the chinstrap? All the while waking up with a dry mouth that’s so problematic you are beginning to develop sores inside your oral cavity? Or, should you stop using CPAP even though you were beginning to experience some clear-cut improvements in the quality of your sleep?
As you can imagine, a risk-rewards interplay drives most decision-making in this process. In the worst case, however, the dry mouth means you’re mouth breathing and therefore a sizeable leak is occurring that diminishes the necessary pressurized air. As a result, this leak allows apneas and hypopneas and flow limitations to return from the lack of air pressure. In other words, not only do you experience a dry mouth, but your sleep remains fragmented and of poor quality. We would not expect this patient to continue using the device while waiting for the chinstrap. But, what if the patient doesn’t recognize the connection between all these factors? In fact, this lack of knowledge occurs frequently, thus setting up patients for failure, because no one may have connected the dots for the patient so he or she could solve the problem immediately.
In the best-case example, the sleep quality is improving no matter what the side-effects, so the patient remains highly motivated to maintain the momentum. Later at follow-up, which could occur 30 to 90 days later, the patient is reporting various gains from continued use of CPAP, but he or she also now has the chance to discuss the side-effects in the context of real progress being made. When these side-effects are effectively managed, further gains are achieved.
Which brings us to Dr. Park’s fifth step for “Troubleshooting.” This section is very short, because Dr. Park wants you to refer to the Part II of his book, chapters four through eight, which provide an enormous amount of troubleshooting information, and which will now make even more sense as you have begun your experience with CPAP. The most important and powerful statement in this section is the following, “Communicate with your DME or sleep physician ASAP.” Truer words were never spoken. Basically, my variation on this theme is to inform patients, “If something’s wrong, then something’s wrong.” You are not supposed to feel pain or side-effects or discomfort, even though there might be some unpleasant sensations in the early adaptation. Nonetheless, I tell my patients at my sleep clinic in New Mexico to be finicky, because no one will ever adapt to PAP therapy if it hurts or causes consistent periods of discomfort. You are not going to adapt to this pain or discomfort, so why give it more than one or two nights to determine? This problem must be fixed ASAP.
Among the patients who struggle more with the process, I may have to give them a bit more information that they may not enjoy hearing, but which can at least enlighten them enough to know why things aren’t going well or might take longer than anticipated. The monologue goes something like this:
“You appear to be suffering from at least five factors that are going to interfere with your getting a good response to PAP. In no particular order, you cannot get the mask to seal well, you are mouth breathing, psychologically you have not adapted yet to the foreign and sometimes threatening sensations of pressurized air, you haven’t really embraced the idea of PAP yet, because you are still suffering some embarrassment issues about having to use it. Compounding all these factors, we cannot be certain yet whether you are suffering an independent leg movement disorder or not.”
Undoubtedly, all this information cannot be given to certain patients who would be overwhelmed. On the other hand, a fair proportion of patients appreciate knowing that their sleep professionals, technologists and doctors truly understand the barriers they face.
In Dr. Park’s sixth step, “Modify and Try Again” he is mostly reiterating how important it is to continue troubleshooting, because there are so many little tweaks that might be needed. By paying attention and solving each of these problems, things should continue to improve on a nightly basis. A major emphasis here, which I strongly endorse, is the need to reevaluate whether you’ve got the right mask or not. Unfortunately, there has been a great deal of flak targeting full face masks, but in reality, a huge proportion of patients are ultimately going to need to switch to the FFM for numerous reasons, one of which Dr. Park points out regarding any sort of nasal breathing difficulties.
He also mentions the importance of returning to the care of a sleep technologist where you might be able to undergo a desensitization program. He also mentions our PAP-NAP procedure, which is available at some sleep centers around the country. At this point, we would add the use of the laboratory for a retitration study, including our REPAP protocol, because so many patients just cannot get over the hump of the PAP experience itself. They not only need more coaching, but more importantly they need more experience using PAP under the skilled direction of a technologist where the troubleshooting is literally nonstop for your entire study.
In Dr. Park’s seventh step, “CPAP Success,” he makes a few points I might disagree with, but again his overarching approach to the problem of CPAP adaptation appears much more comprehensive and therefore likely to be successful than most efforts I have seen written about in other books, research articles or blogs. When he remarks that most people will get the hang of things in that first week, I am not sure whether he is talking about his own personal experience with his clinical population or whether he is making a prediction about what will transpire if you follow his steps. In our clinical and research experience, we believe one of the two largest problems leading to early dropouts are that CPAP is the wrong device for nearly all the patients who fail CPAP, and they should have been switched to BPAP or other more sophisticated technology within one or two weeks of their initial struggle with CPAP.
The second largest obstacle relates to the first: when someone is not given the chance to use an advanced PAP mode such as BPAP, ABPAP or ASV, their chances continue to dwindle for long-term adaptation and regular use. At my sleep center, we have repeatedly conducted quality assurance statistics, and I am pleased to say that on every occasion where we looked at 100 consecutive patients who filled their PAP prescription, that is, got a device and started using it, 85% to 92% were using the device 6 months later. Ever since changing my system to regularly prescribe our patients ABPAP and ASV more than 98% of the time, we have conducted this in-house evaluation and arrived at the same results each time.
Notwithstanding, Dr. Park makes the corollary observation that, “don’t think it’s [a good response] going to last forever.” He delves into this phenomenon in several ways including whether your device and equipment are being properly cleaned, whether you’ve gained weight, whether other intercurrent health factors are affecting your sleep, and of course the process of aging, which can also worsen your sleep apnea. He points out the absolute necessity for vigilance about your sleep quality. Are your results being maintained at the level of your most optimal benefits, whenever you achieved this benchmark? Are you suddenly noticing a bit more fatigue in the afternoons; are you a bit more irritable in the evening and snapping at your spouse or children? Or are you suffering an increase in trips to the bathroom at night?
How you monitor this information is a big deal. Dr. Park quite rightly recommends his sleep journaling ideas, which are a smart strategy for individuals who might let things slide. On the other hand, the larger problem arises among some individuals with sleep problems as well as many medical professionals outside of sleep medicine, both of whom tend to still disrespect the value of sleep. In such circumstances, you may not naturally harken back to recall what things were like before you used PAP therapy and your regular doctors may not remind you of your past symptoms. If so, you may then point your finger at something else to explain the slippage in your results, like a medication side-effect, or you are stressed out, or you are squabbling with your boss. All of these factors are valid reasons for worse sleep at some level, but the very first item on this agenda could be to check whether your response to PAP is fading, which more often than not is the primary troublemaker.
Obviously, reconnecting with your DME or sleep center resources is critical in these times as well as working with online support groups, such as this blog site at Classic SleepCare. Online support may prove pivotal for many patients, because you can lay out precise details in print about your struggles with PAP, after which several commenters who might be more experienced than you will delve into a range of solutions. However, even with all this support, professional or otherwise, you still have to realize that identification of a problem must begin with you, which means you must develop reliable metrics to assess your experiences over the course of months and years.
Unfortunately, one of the leading metrics that far too many patients want to rely on is the data coming from their machines. Sadly, much of this data is misleading, inaccurate, or downright distracting from what’s going on in your actual sleep period. Take for example the AHI numbers. Suppose you have seen a decrease down to say 2 events per hours (AHI =2). Would you be satisfied? We teach our patients to respond, “heck, no.” Why wouldn’t an AHI of 2 be a good thing? It is good, but it’s not predictive. If you continue to show an AHI of 2, you are probably continuing to suffer a lot more flow limitations, but you might never see these events until you go into your sleep center or call/see your DME to capture a full data download. Thus, you could see an AHI of 2 but no matter how you feel, you might think to yourself that “this must be as good as it gets.”
Another common misconception would be leak values. Many manufacturers use symbols like smiley faces to let you know you had a good night with low or no meaningful leak. I cannot count the number of times the smiley face was giving the wrong information to the patient, because unequivocally, all leaks not related to natural ventilation of CO2 is a bad leak. In contrast, PAP machines are often calibrated in some ways to allow for a certain level of leak with the understanding the machine somehow compensates for this problem. In our experience, this compensation does not lead to an optimal response. How do we know this point to be true? Easy. We have witnessed more than 1000 patients whose leak was NOT zero (yes, not big fat 0…we’re not kidding) but instead suffered leaks ranging from 4 to 100 liters of air per minute. In nearly all these cases, when we could work the system to bring the leak down to 0 or let’s say less than 2, the patient always felt better, even if the starting leak was in the 4 to 10 range, which many sleep professionals for some reason think is acceptable. We cannot guarantee every patient can attain zero leak, but we strive for it and encourage patients to strive for it too, because all the evidence points to their receiving a better response with no leak whatsoever.
I would like to mention sometimes I can register 0 leak for months on end and other times the leak runs between 2 and 8 liters per minute. There is no question in my mind that zero leak correlates with a better night of sleep.
This wraps up Dr. Park’s ‘seven steps program’ in Chapter 9, from which I believe many CPAP users will benefit. In his final chapter of the book, which I hope to review next, he pulls together several areas to help individuals with poor results as well as those who might need to consider different options beyond PAP.
In the second half of Chapter 8, Dr. Park focuses on the surgical options for the three most common conditions causing nasal congestion that might not be relieved by the medical options we discussed in Section 1 of this post: deviated septums, swollen turbinates and flimsy nostrils.
Septal Deviation and Septoplasty
Dr. Park begins with a discussion on how the septum or midline structure that separates the nostrils into two openings has a cartilage portion in the front and a bony portion in the back. When the septum is crooked for whatever reason, you may be more susceptible to a stuffy nose, and a septoplasty (to straighten the septum) may improve the stuffiness. However, you might also possess a crook septum and not have a stuffy nose, so there is no requirement to undergo surgery on your nose in such circumstances.
Dr. Park describes a very interesting theory about the origin of deviated septums. The conventional wisdom is that the septum becomes crooked following trauma, usually during delivery at birth or getting punched or knocked in the nose later in life. However, in this newer theory, in a nutshell, anatomical development of the jaw and dental structures are shrinking in modern society due to dietary and other influences, which changes the nasal cavity in such a way that the normal septal development must occur in a smaller space than normal. As a result the septum “buckles” and becomes crooked.
In Dr. Parks’ own words with some paraphrasing, here is a more detailed description:
“….jaws are shrinking due to what and how we eat….Soft foods, bottle-feeding, thumb-sucking, pacifier use, prematurity and nasal congestion…are all factors in crooked teeth….Crooked teeth means your jaws are not big enough to hold all your teeth….in some cases, the roof of the mouth doesn’t drop down normally, leading to narrow dental arches, resulting in smaller oral cavity size and crowding inside the mouth….Inside your nasal cavity, if the floor of the nose (the topside under which is the roof of your mouth) does not drop down, the nasal septum cannot grow properly and buckles from the limited space….The nostrils in turn will be pressed closer to the midline, leading to greater risk of collapse when breathing in.”
Dr. Park next describes the basics of a septoplasty, but without a diagram or other graphic to follow along, it was a bit difficult to follow the narrative, and I would not want to attempt to retrace his steps as I possess no surgical background. A main theme of this section is that the surgery must be done well, otherwise various side effects may occur; and at our center, we have noted that many patients with deviated septum repairs still demonstrate persisting septal deviations years later. It is also not a rarity for the surgery to fail and then be repeated within the next year, so we resonate a great deal with Dr. Park’s main point that the surgery must be done very well to get things right.
Post-surgery, your expectation should be that some immediate improvement in nasal breathing can occur in as little as 2 to 5 days, but the total healing process may take weeks or months, during which there will be ups and downs due to crusting, swelling, bleeding, and the need to evacuate the debris in a very gentle manner as well as managing the regular mucus build-up. Final, healthy scar tissue that situates things in their proper place could take weeks to months before benefits are maximized. Pain-wise most patients do well with over the counter pain killers.
The main risks from the surgery are infections and bleeding, but these problems are not very common. Careful follow-up by the surgeon can usually rectify these issues and insure no further consequences. Despite the high success rates for septoplasty, nasal congestion may return in some patients. Dr. Park points out the three most likely problems causing the persistence of congestion in these circumstances: (1) the septal repair was not aggressive enough; (2) the turbinates are swollen and need attention; and (3) the problem of flimsy nostrils.
Turbinates and Turbinoplasty
The turbinates are “like wings on the sidewalls of the nasal cavity.” They function to regulate airflow, moisturize the air, and also warm the air you breathe in, all of which improve the comfort and sensations of breathing. However, when turbinates swell up, the sensation turns into congested, stuffy or blocked feelings. Inflammation, irritation, and infection can all induce swelling in the turbinates. Even more subtle changes in weather, including variations in temperature, barometric pressure, and humidity can influence the swelling in the turbinates.
In this section, Dr. Park explains how the turbinates are particularly susceptible to changes from the non-allergic or vasomotor rhinitis problem that we’ve discussed in several prior posts. And, he notes that acid reflux can also trigger the same problems, that is, engorgement of the turbinates ultimately leading to excessive mucus production. The result is a congested, stuffy or runny nose.
Last, turbinates are also part of the nasal cycle, the change in the insides of the nasal cavity that can sometimes be experienced as an easier or more difficult period of breathing. The turbinates can increase in size in alternation between left and right sides every few hours. You may or may not notice these changes, but if you suffer from a deviated septum on one side and the turbinate enlarges on that same side, you have a greater chance of feeling the restricted airflow during that interval.
In beginning the discussion of turbinate surgery, I was very pleased to see Dr. Park’s direct approach to the problem of “empty nose syndrome” where the inferior turbinates are completely eliminated from inside the nose. While this condition is much rarer than in previous times, I have met patients with this condition, and it can prove psychologically debilitating. Due to the sensory capacities built into the turbinates, the empty nose syndrome not only can lead to problems with nasal congestion, but in some cases, the individual feels unable to obtain a full breath on inhalation. I was very fortunate in the 1980s to talk about a patient with Dr. Eugene Kern, who first wrote and talked about this condition. A very good friend of mine had experienced the full removal of her turbinates and developed severe anxiety problems in the aftermath. She visited Dr. Kern to eventually obtain the correct diagnosis of empty nose syndrome. You can learn more on Dr. Kern’s video.
As Dr. Park notes, we now know that turbinates play a vital role in respiratory physiology and that a certain degree of nasal resistance is required in order for the individual to experience “proper breathing.” Therefore, surgery is now directed at preserving this external turbinate tissue by focusing on shrinking procedures as opposed to surgical resection.
Dr. Park then describes various shrinkage procedures starting with a few that can be completed in a doctor’s office and then moving onto several inpatient procedures that require inpatient care involving general anesthesia. Again, not being a surgeon I will leave these details for when you read Dr. Park’s book. Following the surgery, Dr. Park points out a fact I had never heard previously, which is that turbinate procedures are usually not painful and do not require pain meds.
Debris, crusting, and mucus all are a part of the healing process, which takes weeks or longer, and it is imperative to be very cautious in evacuating material too forcefully from the nose after the surgery. Using nasal rinses are a preferred approach to assisting in the clearing of junk from the nose. Again, like with nasal septum surgery, bleeding and infection are major but rare side-effects. And as before, turbinate surgery failure occurs when the procedure may have been too conservative, there is a persistent nasal septal deviation or you suffer from flimsy nostrils.
As we noted earlier, the 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. For some, this problem is their natural anatomy, while for others past nasal surgery may have weakened how the nostrils are functioning when trying to inhale. In this section of the book, Dr. Park provides 3 steps to self-diagnose the problem:
Look in the mirror and watch the openings in your nose when you take a deep breath in; if the sidewalls collapse, that’s the problem.
Place a fingertip next to the nose on each side and gently pull up the skin towards the outer corner of the eye. If breathing in is noticeably easier, it also suggests this problem.
You can perform a similar #2 experiment by using the handle end of Q-tips, placing one in each nostril and gently lifting up and sideways. Again, noticeably improved breathing suggests this problem of flimsy nostrils.
Prior to surgical interventions, Dr. Park reminds us that this collapsibility may also be aggravated by the previously described problem of nasal congestion due to allergic or non-allergic rhinitis. Therefore, it is imperative to address beforehand any aspects of the congestion that might respond to appropriate medical treatments.
The basic rhinoplasty procedure that Dr. Parks describes for flimsy nostrils involves the addition of a small piece of cartilage onto the current flimsy sidewall cartilage that is causing the problem. This surgery is called the open rhinoplasty approach. Another way is to work directly inside the nose to examine and realign the internal cartilage, which then produces a “mild nose-lift” effect. A third possibility involves nasal valve repair.
Overall, this chapter of the book was the most detailed for the obvious reason surgical interventions were discussed. My sense is that many sleep doctors and patients are unfamiliar with much of this detail, so I believe many people would benefit from this information. Though I am not surgically-minded, I share the same sense as Dr. Park regarding the value of nasal surgery to make PAP easier to use. In fact, Dr. Park closes the chapter with a story about a man who had been struggling with CPAP until he underwent septoplasty, turbinoplasty, and nasal valve repair. After the procedure, his CPAP pressures needed to be lowered, and his response to treatment was much better, including a better adjustment to the lower settings and less episodes of mouth breathing. As Dr. Park highlights, many patients currently struggling with CPAP often benefit from a nasal evaluation from a skilled ENT physician. And, I would add that all of this information is equally relevant to individuals who forego CPAP and use the OAT dental device instead.