EDUCATION

The mechanisms for the benefits of sleep are still being discovered, but there are metabolic byproducts of the brain that are being cleared at night by the deepest stages of sleep in particular. Such toxins have been shown to accumulate and contribute to a dementia-like clinical picture in animals and is a highly suspected reason for sleep deprivation causing cognitive impairment in humans. In addition, the daytime energy expended by the brain is immense and rest is necessary to prepare the brain for processing during the following day. Sleep dysfunction can manifest as daytime sleepiness with poor concentration, impaired cognitive performance, learning and short-term memory. Psychomotor abilities can be impaired in a similar appearance to alcohol intoxication. While non-REM sleep has been linked with consolidation of memory at night, REM sleep appears connected to perceptual learning, creative problem solving and emotional memory consolidation. The experience of dreaming has been attributed to the release of negative emotions including primitive aggressions, leading to enhanced daytime mood. Finally, a reduction in sleep quantity has been clearly linked with impaired immune function by mechanisms not well understood. Immune surveillance is not only valuable in the fighting of infections, but in the self recognition and destruction of early cancers before they become obviously detectable. Jobs associated with sleep deprivation have been linked to various forms of cancer and the absence of sufficient rest is likely to have played a role.

Sleep studies in a sleep lab involve more sensors, including an EEG (electroencephalogram) that can more definitively distinguish between sleep and wake as well as the different sleep stages. Home Sleep Studies use algorithms based on movement or vascular tone to make estimations with regard to sleep onset and sleep stages without the need for the potentially cumbersome EEG sensors which get glued to the scalp. The EEG however can also identify nighttime seizures. The Full PSG makes use of EMGs (electromyography) to look for spastic movements of the limbs such as in Periodic Limb Movement Disorder or movements during REM which can suggest REM Behavior Disorder (RBD) where someone is attempting to act out their dreams. The Full PSG includes professional EKG (electrocardiogram) monitoring of the heart to look for nighttime arrhythmias. HSATs will typically monitor heart rate at night but only select devices using predictive algorithms can comment on nighttime arrhythmias such as atrial fibrillation. A PSG can also be valuable for titrating CPAP during the second half of a sleep study, where a respiratory therapist can enter the room and try different masks and settings with a real-time assessment of benefit. With the advent of APAP, home titration of CPAP settings can be done by the machine itself and thus remove the necessity of an in-lab sleep study for titration. Finally a Full PSG includes a night vision camera to assist identifying abnormal nighttime behaviors or activities that have gone unnoticed by the patient.

There are many studies which show that sleep in a sleep lab is often of poorer or surprisingly better quality than sleep at home and thus not representative of the true sleep that the patient regularly obtains. Furthermore, people who have been reluctant to get help for their sleep problems (a large population of people) are particularly hesitant to participate in elaborate studies outside the home, observed by a stranger and tethered with numerous uncomfortable electrodes. Sleep Doc LA has been focusing on new technologies to both test in the natural environment and be easy and comfortable enough that representative, natural sleep takes place. These newer devices are better than ever at detecting true sleep, arrhythmias and even sleep stages, once thought impossible to assess outside of a dedicated sleep lab.

Based on the additional sensors of a Full PSG, anytime nighttime seizures are a concern, acting out dreams or unusual nighttime behaviors are suspected, an 'in lab' study is preferrable. Complex cardiac arrhythmia detection or complex CPAP/APAP/BiPAP titration is preferably done in the sleep lab. Conditions such as Narcolepsy, where sleep stage characterization is of highest priority, is usually best done in the sleep lab. At Sleep Doc LA, we are honest about our capabilities and are able to make high quality referrals to dedicated sleep labs when necessary.

Sleep apnea is a condition where the back of the throat collapses during sleep, leading to a disruption in breathing. For some people, the blockage of the upper airway leads to a drop in oxygen levels, however the major problem for most sufferers is that deep sleep is prevented due to these obstructions waking people up. These brief periods of waking-up (microarousals) result in poor quality sleep that contributes to daytime fatigue and a host of associated medical issues including difficult to control blood pressure and a propensity towards irregular heart rhythms. The impairment to quality of life for the sufferer can be considerable, but there can also be challenges for the bed partner who is trying to sleep next to someone with loud snoring and gasping.

Snoring is simply the loud vibration of a sagging soft palate into the airway during sleep. It can be significantly disruptive to the bed partner and may suggest the presence of Sleep Apnea. Sleep Apnea is when that space behind the throat becomes completely obstructed transiently, leading to cessation of breathing and a nighttime arousal. Though significant snoring can be a red flag, suggesting the presence of Sleep Apnea, major airway blocking events can often be the quietest moments in a person's sleep given prolonged periods with lack of sufficient air movement.

Long term medical effects of sleep apnea include the persistent elevation of cortisol (the stress hormone) which is associated with high blood pressure, obesity and elevated blood sugar, all of which impact health and survival. Epidemiologic studies have shown an increase in cardiovascular mortality as well as an increase in death from all causes. The full extent of the damage caused by sleep apnea on the body is not totally understood, however, a disproportionate percentage of stroke, heart attack, heart failure and heart arrhythmia patients have been found to have the diagnosis, especially in the most severe cases. One aspect of sleep apnea that is underemphasized is that sufferers can have significant daytime sleepiness which can impact safety through impaired judgement. This condition is especially dangerous in the operation of heavy machinery and other precarious devices.

Sleep apnea is like having a door that closes several times an hour inside a sufferers upper airway. Oxygen may be low as a consequence because the flow of air is disrupted. Just giving oxygen at night 1) doesn't mean that the extra oxygen will reach the lungs due to the aforementioned blockage of air flow and 2) a major part of the damage that sleep apnea causes to the body is the disruption of sleep caused by nighttime gasping. Oxygen alone does not fix these respiratory disruptions.

Because the major pathology of sleep apnea is the disturbance of upper airway flow to the lungs, restoring the patency of the upper airway at night is the mainstay of therapy. As the muscle tone diminishes with deeper stages of sleep, the small space in the back of the throat collapses and the major anatomical structures surrounding that airspace include pharyngeal muscles, the soft palate and the tongue. Some treatment modalities include exercises to strengthen the pharyngeal muscles, devices which pull the tongue forward or improve tongue muscle tone and minor surgeries that reduce the size of the soft palate. Treatment depends on a specific individual's anatomy, however the most effective treatment for severe sleep apnea that doesn't involve significant surgery is CPAP or APAP. These are devices which push just enough air into the back of the throat to prevent the airway from collapsing and thereby restoring the patency of the upper airway. Despite numerous advertisements for sleep apnea therapies that appear as "easy" solutions and as a CPAP or APAP alternative, very few therapies can result in enough benefit to treat those sleep apnea sufferers that are categorized as "severe" as CPAP or APAP.

CPAP applies "continuous positive airway pressure" which is a single specified numerical airway pressure prescribed by a Sleep Physician to eliminate a patient's sleep apnea. APAP is "automatic positive airway pressure" where the machine's algorithm attempts to detect a blocked airway, titrating the pressure until the blockage is eliminated. With APAP, the Sleep Physician can give the machine a range of pressures which allows these 'smart' algorithms a better chance to find successful settings. Because the degree of airway collapse fluctuates at night based on the different sleep stages, the self titrating APAP devices can adapt better throughout the night than CPAP.

This is an important development in the understanding and classification of sleep apnea severity. Traditionally, AHI has been used to diagnose people's sleep apneas and definitionally, it consists of the number of apneas and hypopneas per hour of sleep. An apnea is the cessation of airflow for at least 10 seconds and a hypopnea is reduced airflow with at least a 4% drop in oxygen. The problem with the AHI classification, is that many people don't quite meet this older criteria for diagnosing sleep apnea (shorter duration of blockages or preserved oxygen levels during events) yet they had frequent respiratory disruptions that were clearly harming the quality of sleep. The RDI is the apneas + hypopneas + other respiratory disturbances per hour. This flexibility allows the clinician to review the data and help make an important diagnosis of Sleep Apnea when certain arbitrary thresholds are not met. This also puts a premium on having a sleep study reviewed by a capable and discerning physician to help make the appropriate diagnosis. That is a necessary level of detail that Sleep Doc LA provides.

A lot of this practice was built around my experiences with patients' CPAP failures. Sometimes people can't use and will never be able to use CPAP, however, that was an unusual event when the introduction to CPAP is done right. What is the right way to do CPAP?: The mechanism and benefits need to be explained clearly and thoughtfully. The mask and machine need to be of quality design and function rather than cheap and generic alternatives. Close follow-up with access to the physician is necessary to help address problems. The patient needs to be taught the various user settings and set-up options including humidification settings and potential alternative mask types and sizes. Occasionally medications or other therapies are needed to treat patient medical issues that interfere with CPAP use including nasal congestion and comorbid anxiety and insomnia. The data generated by the CPAP/APAP device needs to be completely read (waveform analysis) to truly validate that the right settings and options are being used. It is helpful in identifying difficult to recognize factors that are interfering with use. This is a critical step to getting CPAP right that I rarely see done in other sleep clinics. CPAP options change over time as the patient has changes in their upper airway with age and fluctuations of weight. CPAP users require careful long-term follow-up for the process to be successful. Once a patient is dialed-in to the right settings and routine, CPAP use can be a very positive and life changing experience.

It really depends on the severity of your sleep apnea. Mild to moderate sleep apnea can be investigated for contributing factors based on the dominant physiologic mechanisms at issue. CT of the throat or Drug Induced Sleep Endoscopy (DISE) can evaluate the anatomy, looking for enlargement of the soft palate, collapse of the tongue into the airway or the presence of enlarged tonsils and/or adenoids. Tongue related airway collapse can benefit from tongue and oral exercises (myofunctional therapy), tongue stabilizing devices or the elimination of tongue ties that can cause a low resting tongue position and can promote tongue related obstruction. Furthermore, mouth opening at night can encourage Sleep Apnea by leading to that same problematic low resting tongue position. Treating nasal congestion is therefore of benefit (including sprays, breathing strips, nasal cones and procedures such as VivAer, nasal septum deviation correction, that can streamline nasal airflow and eliminate nighttime mouth opening). There are even mouth taping solutions that can provide benefit. Hypoglossal nerve stimulator devices such as the Inspire device works by keeping the tongue muscles firm so that the tongue remains in-place using electrical stimulation. Other tongue focused interventions include surgical expansion of the jaw or upper palate which allow for the tongue to have more room forward in the mouth instead of falling back into the airway. The most common dental devices for sleep apnea are Mandibular Advancement Devices (MADs) that attempt to push the lower jaw forward enough to similarly keep it from falling backwards at night. If the dominant issue is enlargement of the soft palate, there is a procedure called Uvulopalatoplasty that can utilize a laser to help shrink the soft palate down or even surgical reduction of the soft palate. There is a procedure called the Pillar procedure where tiny rigid rods are inserted into the soft palate to give it additional structural integrity, thereby minimizing its collapse. Weight loss, sleeping on the side and/or chest, avoiding nighttime medications or other substances that reduce muscle tone should provide general benefit to these mild to moderate cases, but most of these strategies outlined in this post cannot 'cure' Severe Sleep Apnea. From my personal experience, CPAP or APAP are the most effective ways to combat substantial disease and its associated damage to the body. If someone absolutely cannot tolerate CPAP, Sleep Doc LA helps determine a multimodal approach to improving sleep that may combine a variety of strategies, with the understanding that complete resolution is difficult to achieve without a CPAP device. For that reason, we treat CPAP seriously, including acquiring the best machines and masks as well as customizing the right settings for each individual. In addition, we work hard on solving issues that may keep someone from getting comfortable with the device.

If you are obese, losing weight has all sorts of great benefits from improving cholesterol, blood sugar and stress on knees and lower back. However, a big misconception is that sleep apnea is exclusively a disorder of "fat" people. Often, people think that diet or weight loss medication is the cure for OSA. Naturally, accumulation of fat around the neck area and chest can restrict the movement of air at night. Through testing, we know that weight loss has some measure of objective improvement in respiratory events at night. However, for many people, the chief mechanism for these respiratory problems is the tongue, soft palate and mouth anatomy and how they interact during sleep. Anecdotally, the extremes in obesity certainly suggest significant sleep apnea, however in the mild to moderate obesity range, there are unpredictably severe sleep apnea patients among them and Sleep Doctors see their fair share of severe sleep apnea cases among lean and even athletic individuals.

One of the reasons that treating sleep apnea with CPAP is so fulfilling is that unlike medications or quick fix solutions that may make things 'feel' better initially, CPAP is actually attempting to restore the 'natural' function of your upper airway. There's nothing natural about having your breathing intermittently blocked several times an hour and there are virtually no other medical conditions that are so routinely traumatic to the body as severe sleep apnea. When CPAP is done right, patients tell me that they feel like themselves again as the device has restored their natural breathing and normal sleep quality that many of us take for granted. Sleep Doc LA will work with each patient and discuss various options, but we also want to help dispel the idea that CPAP devices are so strange as returning normalcy is one of the most essential things good healthcare can do.

Acronyms can get confusing, especially ones with similar letters and sounds. Even doctors get this confused. OSA is "Obstructive Sleep Apnea" and OHS is "Obesity Hypoventilation Syndrome." OSA is when the upper airway gets mechanically blocked several times an hour. OHS is when those people who carry a lot of fat around their chest and abdomen area have difficulty moving air all day because of this mechanical restriction. OHS sufferers typically carry higher CO2 levels in their bodies because of this issue. What do they have in common? Almost all OHS sufferers have significant Obstructive Sleep Apnea. Treating it will not only improve their breathing at night but help OHS patients carry around less CO2 during the day. High CO2 levels can cause fatigue, confusion and predispose those with OHS to "decompensation" which is a potentially life threatening, rapid decline in breathing usually requiring hospitalization.

Surprisingly, people's recollections about what keeps them up at night and what is actually happening can differ greatly. That's why objective testing is an important first step to finding out "what is really going on." Patient's may think they aren't getting good sleep and objective testing may show excellent duration and depth of sleep. In such cases, working-up daytime fatigue and its possible causes, instead of insomnia, may be warranted. Other times, there are frequent and regular disruptions to sleep that may suggest disruptive sleep apnea or periodic limb movements that are jolting the patient awake. Actigraphy is an excellent testing modality for the initial work-up of insomnia, however it is seldom utilized in most sleep medicine practices because of the expense and poor reimbursement by medical insurances. Actigraphy is simply a wearable device that gives objective data on a patient's movements over a prolonged period of time. Many people already engage in some form of actigraphy assessments via smart watch apps that attempt to characterize people's activity levels and nighttime movements. This gives a rough estimate as to people's sleep schedules and nighttime interruptions and such objective data can be profound in alerting people to possible sleep disorders. What is so special about medical grade actigraphy? The devices used by Sleep Doc LA allow for continuous data collection over multiple weeks, including at night, using high sensitivity, multi-axis accelerometers. That generates a higher resolution picture of activity levels, which is paired with a light sensor to ascertain light exposure as well as approximate when the lights are turned off at bedtime. Finally, this data is paired with research grade data analysis to make predictions on sleep quality and daily activity patterns. What types of insomnia issues can be detected by actigraphy? I frequently encounter poor sleep discipline with erratic routines that can be detrimental to training the body for sleep. Such disruptions include radically different weekend sleep schedules, waking up at night to perform high levels of activity, taking naps during the day, or inadequate daytime energy expenditure or daytime light exposure. Sometimes we see consistently late sleep (Delayed Sleep Phase Disorder) which can be effectively managed with light exposure therapy to adjust one's circadian rhythm. Devices such as light boxes can be surprisingly effective and can often eliminate the need for the use of sedating medications at night for sleep. Ultimately, the recognized "Gold Standard" for the treatment of insomnia, even more potent in its benefits than medication, is something called "Cognitive Behavioral Therapy for Insomnia." What is Cognitive Behavioral Therapy for Insomnia (CBT-I)? It is a multisession management plan to help improve nighttime sleep efficiency and ultimately duration and quality of sleep. Many sleep therapists start with a sleep diary and use that to make adjustments to the patient's sleep schedule to help organize the chaos of an insomnia sufferers sleep. At Sleep Doc LA, we use actigraphy as an adjunct to establish objective measures of a patient's sleep behavior and derive an objective value for sleep efficiency. Sleep efficiency is the percentage of time that a person who is in bed is sleeping. Cognitive Behavioral Therapy's initial objective is the improvement of this efficiency to first reshape an insomnia sufferers relationship to their bed and bedroom. Improving our emotional relationship to going to bed is a major achievement as negative associations with sleep can be a self-perpetuating harm to quality of sleep. In the field of Sleep Medicine, there is a definite mind-body connection that cannot be ignored in the management of ALL sleep disorders. The use of sleep medications alone may assist in short-term sleep improvements, but seldom leads to meaningful improvements to sleep because it does not address the causes of insomnia. Furthermore, it exposes people to potentially harmful side-effects and the building of tolerance to sleep medications requiring escalating doses of the medications over many years. Such a dependency can be crippling and weaning off such medications can sometimes become impossible.

CBT-I is first and foremost a process built on communication and trust between the provider and the patient as adjustments to one's sleep routine can occasionally make sleep worse before things get better. The patient's current sleep routine is assessed, which often includes sleep diary collection and/or actigraphy, and estimates with regards to sleep efficiency are made. A Cognitive Behavioral Therapist will start to recognize unhelpful behaviors that can harm quality of sleep and counsel the patient appropriately. They will then create a new sleep routine, often making gradual corrections over time. Surprisingly, CBT-I can often involve the initiation of sleep restriction which can make the patient more tired the next day for the purposes of improving the sleep drive for the following evening. Sleep Doc LA uses research grade actigraphy to generate accurate assessments of sleep patterns for making precision sleep adjustments and because the process is physician driven, we can help identify medical issues that are contributing which may require the adjustment of medications or the initiation of new medications. We also order lab testing to look for possibly neglected medical issues that can mimic insomnia driven by what seems like psychosocial factors.

There are several chemicals found within marajuana that have different effects on the brain. The most studied and isolated for medicinal use are THC and CBD. THC is recognized as providing the psychoactive properties (the 'high' and perceptual disturbances) as well as increased appetite and anti-nausea effects. THC also provides some muscle spasm relief. CBD on the other hand, while not providing the characteristic 'high,' is known to reduce anxiety and depression. CBD has anti-inflammatory and anti-seizure properties. Both THC and CBD are known to reduce pain and increase sedation. Their different properties can provide unique forms of relief to insomnia sufferers. In addition to smoking, there are different pharmacologic compounds that contain a variety of THC and CBD ratios. There are several randomized-control studies looking at the efficacies of these various compounds on sleep. The results showed inconsistent benefit in treating insomnia, with the greatest response in those who struggle with pain. THC was shown to be more effective, with the effectiveness of CBD actually declining in higher doses (75 - 6000 mg) vs lower doses (15-30 mg). It must be noted however that the benefits of cannabis for sleep, based on the current literature, seem to be more subjective, whereas objective testing (those using devices to measure sleep) did not reveal conclusive results. It also should be noted that this is a growing field of study and more evidence is needed, especially with regards to new and specific formulations. When compared to the many different sleep medications available, the side effects of cannabis are typically mild, including dry eyes and mouth, slowed response times, coordination issues and short-term cognitive impairment. From my perspective as a Sleep Physician, the reliance on any substance to treat insomnia must be carefully scrutinized as there are likely concerning medical and/or psychological factors that are limiting sleep. Failure to identify the sources of these stressors and manage their underlying causes is what perpetuates substance dependence (including the need for escalating doses and the addition of stronger substances), major mental health problems and/or the development of serious medical issues as seen in uncontrolled sleep apnea. With surprising frequency, "medicating away" insomnia has cost someone their life. In contrast to using prescription and non-prescription substances as a "quick fix" to sleep issues, with the right guidance, substances can be utilized to control severe symptoms such as anxiety, neuropathy and pain in judicious ways. Cannabis based substances can help facilitate mindfulness and cognitive based therapies as well. Here at Sleep Doc LA, we take the management of insomnia extremely seriously as we have had experience seeing the horrible effects of this condition. A multidisciplined approach with close follow-up is what yields the best outcomes and we recognize the potential benefits to cannabis when used synergistically with a smart plan for meaningful improvement.