Replies to This Discussion

Permalink Reply by Steven Y. Park, MD on May 5, 2009 at 10:23pm

Comparative anatomists and evolutionary biologists have stated that speech and language development was ultimately detrimental to humans. The upper airway serves three functions: breathing, swallowing and speech, in order of importance. But if the ability to speak overdevelops, then the other two have to suffer. This is why humans have so many problematic issues with breathing and swallowing.

As I describe in my book, Sleep, Interrupted, as part of my sleep-breathing paradigm, the voice box had to descend to a position below the tongue for us to have complex speech and language, creating a gap between the soft palate and epiglottis, called the oropharynx. Only humans have a true oropharynx. So by definition, we all have various degrees of breathing problems, especially at night, when our muscle relax in deep sleep.

We were doing fine until a radical change in our diets (from organic, off the land, ocean or mountains to processed foods and refined sugars) and possibly with the addition of bottle-feeding. Dentists tell us that our jaws are getting smaller and we have much more dental crowding, which leads to airway narrowing.

So in answer to your question, I think yes as well. Sleep apnea doesn't happen all of a sudden then you're middle aged or overweight. It's been developing over years or decades. But a sleep-breathing problem has been there since you were young. Lesser degrees of obstruction and arousal but not severe enough to be called sleep apnea occurs almost routinely. But if you have too many of these micro-arousals that don't meet the definition of an apnea, then your entire physiology and biochemistry changes. An imbalanced involuntary nervous system wreaks havoc on your body. You'll have various degrees of depression, anxiety, GI problems, urinary and reproductive issues, recurrent infections, and even cancer and Alzheimer's. I can't say that a sleep-breathing problem is the sole cause of all these conditions, but it can definitely aggravate all these conditions, if you're already predisposed. I explain this more fully in my book.

Yes, there are reports of CPAP curing everything, from sleep-walking to cluster headaches to rhythmic movement disorders to irritable bowel syndrome to frequent trips to the bathroom at night. If CPAP doesn't work, then dental appliances and even surgery can make huge differences. I've seen amazing things happen with all three modalities. Unfortunately, by the time obstructive sleep apnea is discovered, in most cases, it's too late. Some damage has already been done. Sleep apnea set up an increased inflammatory state in your body as well as making you more susceptible to blood clots in various areas of your body.

If you have a very large clot from your heart or your carotid artery, then you'll have the classic stroke. But if you have microscopic areas of brain damage over many years due to inflammation and clotting, then slowly but surely, you'll have symptoms later on in your life. A recent specialized brain imaging study showed that sleep apnea patients have multiple areas of brain damaged tissue, all over the brain. Another study showed a much higher incidence of "lacunar infarcts" in sleep apnea patients. Imagine how even a very small clot or stroke in critical areas of your brain could lead to neuromuscular problems, hormonal imbalances, memory problems, and even central respiratory drive problems.

I could go on and on about all the various links between sleep-breathing problems and various medical conditions, but I'll stop here. Sorry for the lengthy reply.

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Permalink Reply by RockRpsgt on May 6, 2009 at 3:28am

Thanks for the insight Dr. Park

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Permalink Reply by Ron Sowell on May 6, 2009 at 9:42am

my point, exactly. If I had gone in with symptoms of a heart attack I'll bet I would have been sent immediately for a work up. But central sleep apnea - I don't think the doctors really understand how dangerous it is. Or maybe, again, I am just an insurance code!

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Permalink Reply by Dave on May 7, 2009 at 12:17am

Dr. Park,

You said 'If CPAP doesn't work, then dental appliances and even surgery can make huge differences.' It seems you are implying that dental appliances are not as good as CPAP as a general statement. Can you clarify?

Thanks
David

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Permalink Reply by Steven Y. Park, MD on May 7, 2009 at 4:59pm

Dave said:

Dr. Park,

You said 'If CPAP doesn't work, then dental appliances and even surgery can make huge differences.' It seems you are implying that dental appliances are not as good as CPAP as a general statement. Can you clarify?

Thanks
David

CPAP should be the first line treatment for obstructive sleep apnea. Ideally, with good counseling, follow-up and support, most people do well. In the real world, this is not necessarily the case. There's a lot more that we physicians as well as DME vendors can do to improve CPAP effectiveness (I hate the word compliance—this word tends to place blame on the patient if things don't go well). However, if you've done everything possible to try CPAP, and if you're looking at other options, then for selected people, oral appliances and surgery are good alternatives. But just like CPAP, these other options have to be applied appropriately and for the right reasons with good follow-up and support. In the real world, this doesn't happen all the time, either.

There's no ideal way of treating obstructive sleep apnea. Each method has its' advantages and disadvantages. With very few exceptions, I almost rarely recommend surgery unless they've honestly tried CPAP and/or a dental device first. However, treatment must also be individualized, and the only way to do this properly is to get to really know the patient well and try to understands his or her wants and needs. This means you have to spend a lot of time with the patient.

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Permalink Reply by BeeAsleep on May 7, 2009 at 5:32pm

Thank you so much for the wonderful post. SO much great information!!!!

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Permalink Reply by Steven Y. Park, MD on May 7, 2009 at 9:47pm

David asked me why I think CPAP is the first line therapy for sleep apnea, as opposed to going with a dental device first. That's a great question. We have the most data out there showing the effectiveness of CPAP for treating sleep apnea. Whether or not the patient is able to benefit from it is a whole other matter. The American Academy of Sleep Medicine did state that oral appliances for sleep apnea may be considered as a first line treatment option for snoring and mild to moderate sleep apnea, in addition to CPAP. These are overly broad definitions and don't take into consideration individual patient considerations such as anatomy, nasal congestion, or financial resources. For example, someone with 4+ kissing tonsils and a relatively small appearing tongue should probably not use a dental device, since the tonsils will obstruct his or her breathing even with the dental device in place. Someone with severe nasal congestion shouldn't even consider a dental device either until the nasal congestion is fixed. You can argue for a full face mask, which is a good idea, but compliance issues are worse than with a nasal interface. In this patient with 4+ kissing tonsils, tonsillectomy alone may also be a good first line option (many children fit into this category).

So in answer to your question, CPAP is still the gold standard treatment option, despite all its' limitations and problems. All other options will be compared to CPAP. On a practical level, if a patient tells me that he doesn't want to use CPAP at all, then we'll go to a dental device, assuming he has the right anatomy.

One last logistical reason why I usually recommend CPAP first is that if the patient can't tolerate it, you can document that the patient was not able to use CPAP, which makes it much more likely that the insurance carrier will cover for either a dental device and as a last resort, surgery. Since most dentists that deal with these devices don't take any insurance, it's another hurdle for the patient. Although in theory, most insurances do cover for oral appliances, but the patient may be responsible for out of network fees, and other responsibilities like deductibles or coinsurances. Typically, the patient will have to be reimbursed by the insurance company. Different dentists also handle this differently.

Maybe we can talk about the pros and cons of surgery in a later discussion (it's a long one).

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Permalink Reply by susan mccord on August 4, 2009 at 1:07pm

Dr. Park, I find your remarks absolutely fascinating! I'm a 67 year old female and have been really pretty healthy all my life. I thought! Besides the not-unusual surgeries, I've been depressed and had sleep problems for many, many years. The last time I KNOW I slept well was when my children were young. They're now 47 and 43. I was diagnosed with CAD 10/05, have one LAD stent and a second LAD blockage that's positioned so it can't be stented. It's being managed via Rx. My cardiologist, Carl Rouch, has probably saved my life a second time, because he's the one who sent me for a neuro eval due to excessive exhaustion. That led to dx of severe sleep apnea, which I'm now trying to deal with. I've done some research and find links between apnea, depression, heart disease, diabetes, inflammation, on and on. I think you are absolutely right that apnea may be at the root of MANY of our serious illnesses today. All the conditions I mentioned are ALSO linked to each other. There's so much we don't know yet. I was surprised to note your comment on organic food. Do you recommend that? The guy I'm seeing now is on a totally organic diet, grows his own food, shops at a co-op, etc. He's 67 and healthy as can be. Sure makes me wonder.....glad to have your input on here. I'm wondering if you're the holistic MD I used to hear my cancer patients rave about in support group.....
-Susan McCord P.S. Where can I buy your book?

Steven Y. Park, MD said:

Comparative anatomists and evolutionary biologists have stated that speech and language development was ultimately detrimental to humans. The upper airway serves three functions: breathing, swallowing and speech, in order of importance. But if the ability to speak overdevelops, then the other two have to suffer. This is why humans have so many problematic issues with breathing and swallowing.

As I describe in my book, Sleep, Interrupted, as part of my sleep-breathing paradigm, the voice box had to descend to a position below the tongue for us to have complex speech and language, creating a gap between the soft palate and epiglottis, called the oropharynx. Only humans have a true oropharynx. So by definition, we all have various degrees of breathing problems, especially at night, when our muscle relax in deep sleep.

We were doing fine until a radical change in our diets (from organic, off the land, ocean or mountains to processed foods and refined sugars) and possibly with the addition of bottle-feeding. Dentists tell us that our jaws are getting smaller and we have much more dental crowding, which leads to airway narrowing.

So in answer to your question, I think yes as well. Sleep apnea doesn't happen all of a sudden then you're middle aged or overweight. It's been developing over years or decades. But a sleep-breathing problem has been there since you were young. Lesser degrees of obstruction and arousal but not severe enough to be called sleep apnea occurs almost routinely. But if you have too many of these micro-arousals that don't meet the definition of an apnea, then your entire physiology and biochemistry changes. An imbalanced involuntary nervous system wreaks havoc on your body. You'll have various degrees of depression, anxiety, GI problems, urinary and reproductive issues, recurrent infections, and even cancer and Alzheimer's. I can't say that a sleep-breathing problem is the sole cause of all these conditions, but it can definitely aggravate all these conditions, if you're already predisposed. I explain this more fully in my book.

Yes, there are reports of CPAP curing everything, from sleep-walking to cluster headaches to rhythmic movement disorders to irritable bowel syndrome to frequent trips to the bathroom at night. If CPAP doesn't work, then dental appliances and even surgery can make huge differences. I've seen amazing things happen with all three modalities. Unfortunately, by the time obstructive sleep apnea is discovered, in most cases, it's too late. Some damage has already been done. Sleep apnea set up an increased inflammatory state in your body as well as making you more susceptible to blood clots in various areas of your body.

If you have a very large clot from your heart or your carotid artery, then you'll have the classic stroke. But if you have microscopic areas of brain damage over many years due to inflammation and clotting, then slowly but surely, you'll have symptoms later on in your life. A recent specialized brain imaging study showed that sleep apnea patients have multiple areas of brain damaged tissue, all over the brain. Another study showed a much higher incidence of "lacunar infarcts" in sleep apnea patients. Imagine how even a very small clot or stroke in critical areas of your brain could lead to neuromuscular problems, hormonal imbalances, memory problems, and even central respiratory drive problems.

I could go on and on about all the various links between sleep-breathing problems and various medical conditions, but I'll stop here. Sorry for the lengthy reply.

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Permalink Reply by wallace j smith jr on August 4, 2009 at 4:03pm

heres one for you any chance it could also be related/connected to being born premature? i much to the dismay of my mom wet the bed until i was almost ten i used to sleep so deep and snore soo loud my mom would have to come upstairs and try to flip me over which i guess used to atleast muffle the snoring...as to your connections of depression and hypertension i beleive your right .. i think we alll know that we need proper sleep for our body to "repair itself" so it would stand to reason that alot of things could be attached to osa my personal ones are type 2 diabetes, hypertension, i did have depression but that went away with continued successful treatment

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Permalink Reply by Steven Y. Park, MD on August 4, 2009 at 4:20pm

Susan,

The main message of my book is how everything is connected when it comes to sleep apnea. You can order it at www.sleepinterrupted.com.

Yes, it's important to eat organically, but these days, it's hard to know who to trust. Even organic milk is not truly organic since vitamins are artificially added and further, it's homogenized and Pasteurized. These things don't happen in nature.


susan mccord said:

Dr. Park, I find your remarks absolutely fascinating! I'm a 67 year old female and have been really pretty healthy all my life. I thought! Besides the not-unusual surgeries, I've been depressed and had sleep problems for many, many years. The last time I KNOW I slept well was when my children were young. They're now 47 and 43. I was diagnosed with CAD 10/05, have one LAD stent and a second LAD blockage that's positioned so it can't be stented. It's being managed via Rx. My cardiologist, Carl Rouch, has probably saved my life a second time, because he's the one who sent me for a neuro eval due to excessive exhaustion. That led to dx of severe sleep apnea, which I'm now trying to deal with. I've done some research and find links between apnea, depression, heart disease, diabetes, inflammation, on and on. I think you are absolutely right that apnea may be at the root of MANY of our serious illnesses today. All the conditions I mentioned are ALSO linked to each other. There's so much we don't know yet. I was surprised to note your comment on organic food. Do you recommend that? The guy I'm seeing now is on a totally organic diet, grows his own food, shops at a co-op, etc. He's 67 and healthy as can be. Sure makes me wonder.....glad to have your input on here. I'm wondering if you're the holistic MD I used to hear my cancer patients rave about in support group.....
-Susan McCord P.S. Where can I buy your book?

Steven Y. Park, MD said:

Comparative anatomists and evolutionary biologists have stated that speech and language development was ultimately detrimental to humans. The upper airway serves three functions: breathing, swallowing and speech, in order of importance. But if the ability to speak overdevelops, then the other two have to suffer. This is why humans have so many problematic issues with breathing and swallowing.

As I describe in my book, Sleep, Interrupted, as part of my sleep-breathing paradigm, the voice box had to descend to a position below the tongue for us to have complex speech and language, creating a gap between the soft palate and epiglottis, called the oropharynx. Only humans have a true oropharynx. So by definition, we all have various degrees of breathing problems, especially at night, when our muscle relax in deep sleep.

We were doing fine until a radical change in our diets (from organic, off the land, ocean or mountains to processed foods and refined sugars) and possibly with the addition of bottle-feeding. Dentists tell us that our jaws are getting smaller and we have much more dental crowding, which leads to airway narrowing.

So in answer to your question, I think yes as well. Sleep apnea doesn't happen all of a sudden then you're middle aged or overweight. It's been developing over years or decades. But a sleep-breathing problem has been there since you were young. Lesser degrees of obstruction and arousal but not severe enough to be called sleep apnea occurs almost routinely. But if you have too many of these micro-arousals that don't meet the definition of an apnea, then your entire physiology and biochemistry changes. An imbalanced involuntary nervous system wreaks havoc on your body. You'll have various degrees of depression, anxiety, GI problems, urinary and reproductive issues, recurrent infections, and even cancer and Alzheimer's. I can't say that a sleep-breathing problem is the sole cause of all these conditions, but it can definitely aggravate all these conditions, if you're already predisposed. I explain this more fully in my book.

Yes, there are reports of CPAP curing everything, from sleep-walking to cluster headaches to rhythmic movement disorders to irritable bowel syndrome to frequent trips to the bathroom at night. If CPAP doesn't work, then dental appliances and even surgery can make huge differences. I've seen amazing things happen with all three modalities. Unfortunately, by the time obstructive sleep apnea is discovered, in most cases, it's too late. Some damage has already been done. Sleep apnea set up an increased inflammatory state in your body as well as making you more susceptible to blood clots in various areas of your body.

If you have a very large clot from your heart or your carotid artery, then you'll have the classic stroke. But if you have microscopic areas of brain damage over many years due to inflammation and clotting, then slowly but surely, you'll have symptoms later on in your life. A recent specialized brain imaging study showed that sleep apnea patients have multiple areas of brain damaged tissue, all over the brain. Another study showed a much higher incidence of "lacunar infarcts" in sleep apnea patients. Imagine how even a very small clot or stroke in critical areas of your brain could lead to neuromuscular problems, hormonal imbalances, memory problems, and even central respiratory drive problems.

I could go on and on about all the various links between sleep-breathing problems and various medical conditions, but I'll stop here. Sorry for the lengthy reply.

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Permalink Reply by Dan Lyons on August 4, 2009 at 6:19pm

Dr. Park,

This recent article was published concerning the organic foods and indicates that they are no more healthier than regular foods. The only difference is they cost more.

The study conducted by the London School of Hygiene and Tropical Medicine, commissioned by Britain's Food Standards Agency (FSA) and published in the American Journal of Clinical Nutrition

http://news.yahoo.com/s/afp/20090731/hl_afp/healthenvironmentbritai...

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Permalink Reply by Banyon on August 4, 2009 at 7:16pm

I have thought for a few years now that we eventually will find out that SDB is our biggest health condition affecting well over 50% of the population. It could be that it is the root cause for more deaths than any other condition.

If it is true that women tend to see a worsening of SDB later in life (postmenopausal) than men, then SDB could be a major factor in the shorter lifespan of men compared to women.

Regarding "Comparative anatomists and evolutionary biologists have stated that speech and language development was ultimately detrimental to humans."

I find this statement a little amusing. I don't deny that speech and language development was detrimental to the anatomy of humans. But as far as the total human experience, surely speech and language contribute greatly to our lives?

On the other hand, mom always told us, "What you leave unsaid will do much less damage than what you say." :):)

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