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Mea culpa--sleep apnea.

I was setting out to visit my father as I did on a monthly basis. He lived 100 miles away and the journey usually took me about two hours on the highway. Half way there I began to feel sleepy. I drove into a rest area and had half an hour's sleep. I thought I was tired because I have been working long hours in my office.

The following month the same thing happened but this time the tiredness occurred after only driving 40 miles. I managed to overcome the tiredness by making two stops at rest areas and having half an hour sleep each time.

My wife who was away for two months to be with my daughter in Florida during her childbirth came back home. I met her at the airport and although she was pleased to see me, she looked concerned. The next morning I asked her if there was something worrying her. She said that she did not wish to embarrass me but she noticed that I had gained weight. I stood on the scale and to my surprise, I had gained 30 pounds in two months. She also noted that I had been smoking almost a pack of cigarettes a day. She then said that she could not sleep the previous night as I was snoring loudly. The next day she said, "I watched you sleeping and you almost stopped breathing for 30 seconds every time. I got scared and nearly woke you up to see if you were alright." I said to her that I had been feeling tired lately and also I had not been sleeping well. By then I was getting up in the night two to three times to go to the bathroom.

I decided to consult my primary care physician. His diagnosis was that I was suffering with an enlarged prostate. My blood pressure was 190/110. All my blood work came back normal except for my PSA which was 7 ng/mL. I was immediately referred for a biopsy of the prostate. My urologist offered to do the test in his office (without general anesthesia). This was a painful experience, but I felt it was worth it, especially when the result came back as "benign prostatic hyperplasia." Being reassured I felt that I would now sleep better.

One month later, my nocturnal sleeplessness had gotten worse. I also became more sleepy during the day and had to disappear for half hour short naps. I began waking up almost every hour to go to the bathroom and even though I felt tired, I could not go back to sleep not even with my eyes shut. I consulted my primary care physician again who said there was nothing to worry about and that I was working long hours. Being a physician myself, I was not satisfied with his diagnosis and researched my symptoms on the Internet. To my surprise, my symptoms seemed to point out to "Sleep Apnea."

I referred myself to a sleep apnea consultant who checked me in for a polysomnogram. I was admitted at 9 pm and the technician wired me up with EEG leads and an oximeter. By the time I took the test, my condition had deteriorated to the point that I was waking up every two hours. Half way through the test at about 3 a.m., the technician came in and fitted me with a CPAP mask; soon after I fell into a deep sleep and had to be awakened at 7 a.m. I was surprised to find out that I slept for four hours without waking up. The consultant told me that the diagnosis was what I feared, I have sleep apnea. She pointed out that during the night I had 172 apneic attacks lasting one to two minutes at a time. My oxygen saturation had dropped at times to as low as 72% saturation. She prescribed a CPAP machine and strongly advised me to lose weight.

What Is Sleep Apnea?

In sleep apnea, the patient spends more time in "light sleep" than in deep sleep with rapid eye movements (REM sleep). Brief pauses in breathing occur that jolt the patient out of his sleep. Chronic sleep deprivation results in daytime sleepiness, lack of concentration and increased risk of accidents. Over time, the patient develops serious health problems such as right sided heart failure, hypertension, stroke, diabetes and weight gain. There are three types of sleep apnea:

* Obstructive sleep apnea is the most common type of sleep apnea. It occurs when the soft tissue at the back of the throat relaxes during sleep and blocks the airway. This often causes loud snoring.

* Central sleep apnea is a much less common type of sleep apnea and involves the central nervous system. The brain fails to signal the muscles that control breathing. People with central sleep apnea seldom snore.

* Complex sleep apnea is a combination of obstructive sleep apnea and central sleep apnea.

Most patients don't know they have sleep apnea as they are unaware they are having apneic attacks or snoring. A bed partner will usually notice these symptoms:

* Loud and chronic snoring

* Choking, snorting, or gasping during sleep

* Long pauses in breathing

* Daytime sleepiness, no matter how much time you spend in bed

Other common signs and symptoms of sleep apnea:

* Waking up with a dry mouth or sore throat

* Morning headaches

* Restless or fitful sleep

* Insomnia or nighttime awakenings

* Going to the bathroom frequently during the night

* Waking up feeling short of breath

* Forgetfulness and difficulty concentrating

* Moodiness, irritability, or depression

Children can develop obstructive sleep apnea. The most common cause is large tonsils. Their parents notice loud continuous snoring, bedwetting, perspiration at night and increased episodes of night terrors. They may have changes in daytime behavior such as:

* Hyperactivity or inattention

* Developmental and growth problems

* Decrease in school performance

* Irritable, angry, or hostile behavior

* Breathing through mouth instead of nose

Not everyone who snores has sleep apnea, and not everyone who has sleep apnea snores. The diagnosis is usually made with daytime fatigue, sleep deprivation and daytime sleepiness. The American Sleep Apnea Association provides the following quiz:

* Are you a loud and/or regular snorer?

* Have you ever been observed to gasp or stop breathing during sleep?

* Do you feel tired or groggy upon awakening, or do you awaken with a headache?

* Are you often tired or fatigued during wake-time hours?

* Do you fall asleep sitting, reading, watching TV or driving?

* Do you often have problems with memory or concentration?

If the patient has one or more of these symptoms, they are at higher risk for having obstructive sleep apnea.

Risk factors for obstructive sleep apnea:

* Overweight

* Male

* Related to someone who has sleep apnea

* Over the age of 65

* Black, Hispanic, or a Pacific Islander

* A smoker

There are other physical factors that can cause obstructive sleep apnea such as deviated septum, nasal congestion, thick neck or enlarged tonsils.

Like obstructive sleep apnea, central sleep apnea is more common in males and people over the age of 65. However, unlike obstructive sleep apnea, central sleep apnea is often associated with serious illness, such as heart disease, stroke, neurological disease, or spinal or brainstem injury.

The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans were affected by at least moderate sleep apnea. It also estimated that in middle-age, as many as nine percent of women and 24 percent of men were affected, undiagnosed and untreated.

The Stanford Center for Excellence in Sleep Disorders Medicine achieved a 95% cure rate of sleep apnea patients by surgery. Maxillomandibular advancement (MMA) is considered the most effective surgery for sleep apnea patients because it increases the posterior airway space (PAS). The main benefit of the operation is that the oxygen saturation in the arterial blood increases. In a study published in 2008, 93.3.% of surgery patients achieved an adequate quality of life based on the Functional Outcomes of Sleep Questionnaire (FOSQ). Surgery led to a significant increase in general productivity, social outcome, activity level, vigilance, intimacy, and intercourse. Overall risks of MMA surgery are low.

Resolving Mea Culpa

Having my diagnosis confirmed, I decided to take matters into my own hands and resolve Mea Culpa. I declined surgery and resorted to using my CPAP machine on a daily basis. Other behavior changes:

1. Losing weight--I decided to lose weight by cutting out all carbohydrates and exercising more often.

2. Quit smoking--By keeping my nasal passages clear, I began to breathe better. Excessive use of nasal dilator sprays were harmful to my nasal mucosa but I found the occasional use of Flonase (steroid) spray was extremely beneficial. Saline nasal spray was occasionally helpful.

3. Avoiding late night eating with heavy meals--my acid reflux disappeared.

4. Avoiding alcohol, sleeping pills and sedatives before bedtime

5. Avoiding caffeine drinks such as coffee or strong tea before going to bed.

6. Sleeping on one side to avoid gravity on my tongue at the back of my throat.

7. Using a humidifier with the CPAP machine avoided dryness of the throat. The CPAP machine generates air pressure at a set rate as measured by polysomography. It helps to keep the patient's airways open during sleep. The newer models have variable flow of pressure and are connected to a humidifier which produces warm air.


I now sleep 6 to 8 hours a night. I can drive 6 hours without falling asleep. My blood pressure is 120/70. My oxygen saturation is around 95%. I am able to concentrate on my work. Thanks to my CPAP.


(1.) "Sleep Apnea: What is sleep Apnea?" NHLBI: Health Information for the Public. U.S. Department of Health and Human Services. 2009-05. Retrieved 2010-08-05.

(2.) "Sleep Apnea: Who is at Risk for Sleep Apnea?". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services.

(3.) Sullivan CE, Issa FG, Berthon-Jones M, Eves L. (April 1981). "Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares". Lancet 1 (8225): 862-5.

(4.) Vennelle M, White S, Riha RL, Mackay TW, Engleman HM, Douglas NJ (February 2010). "Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea" Sleep 33 (2): 267-71.

(5.) Lee W, Nagubadi S, Kryger MH, Mokhlesi B (June 1, 2008). "Epidemiology of obstructive sleep apnea: a population based perspective" Rev Respir Med 2 (3): 349-64

(6.) Lye KW, Waite PD, Meara D, Wang D (May 2008). "Quality of life evaluation of maxillomandibular advancement surgery for treatment of obstructive sleep apnea". Journal of Oral and Maxillofacial Surgery 66 (5): 968-72.

Sol. Goldenberg, FRCGP, MSc, RMA
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Author:Goldenberg, Sol.
Publication:AMT Events
Date:Sep 1, 2013
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