[Dr. Julie Kinn] This is A Better Night's Sleep, a podcast about sleep, sleep disorders,
and evidence-based treatments.
From Military Health Sleep Experts, I'm Dr. Julie Kinn, with the Defense Health Agency.
[Dr. Jon Olin] And I'm Dr. Jonathan Olin, sleep physician and medical director of the
Evans Army Community Hospital Sleep Lab.
[Dr. Julie Kinn] Jon, in our last episode, you taught us about sleep apneas and how you
diagnose them with in-lab studies and studies at home.
Today, we're going to talk about treatment.
But before we get into that, can you please remind us about the different kinds of sleep
apneas?
[Dr. Jon Olin] Sure.
So obstructive is more common.
And think of it as frankly an obstruction, kind of like a cork blocking a bottle.
So there's actually a problem with a blockage leading to the person-- obstructive sleep
apnea, when the person is asleep, they're obstructed and they're not able to move air.
Generally, their tongue, their soft palate, their upper airway is collapsing and then
blocking and interfering with air flow.
So again, we earlier described that we don't demand perfection in the field.
They don't have to be open 100% of the time throughout all sleep time when studied.
But if that's occurring 15 or 30 times an hour, we'd call that, for more 15 to 30, moderate
obstructive sleep apnea.
If it's more than 30, we call it severe obstructive sleep apnea by frequency of events.
[Dr. Jon Olin] Central sleep apnea is again asleep, not moving air, but not an effort
to breathe.
And that's the brain not giving input to go ahead and breathe.
That's common in some conditions.
The conditions that are associated with central sleep apnea are broad.
Like obstructive sleep apnea is generally a blockage or is a blockage.
Central sleep apnea, all of us here in the Northwest, I'm in Colorado.
If you take me to the top of Mount Rainier or I take you to the top of Pikes Peak, both
of us are going to have central sleep apneas, where we're going to hyperventilate because
of the altitude and elevation.
We're going to hyperventilate and then our brains are going to go, "Oh good, I got a
good oxygen level."
And as we drift off to sleep, we're not going to breathe.
And then our brains are going to, "Oh, there's a problem."
[Dr. Jon Olin] So, that can be seen, for example, with elevation.
It can be seen with medications, including for example narcotics or respiratory depressants.
Medications that decrease brain input to sleep.
It can be seen with cardiac conditions, like congestive heart failure.
It can be seen with pulmonary conditions.
It could be seen with neuromuscular conditions, for example polio.
I know that's relatively rare in the US now.
So the causes for why someone is not breathing can be more complex than usually the causes
with an obstructive sleep apnea, which generally is an obstruction of the upper airway.
[Dr. Julie Kinn] And it sounds like you might not even know that you're prone to this until
you're deployed or having a permanent change of station to a place with a different elevation.
[Dr. Jon Olin] I mean realistically, I think a substantial portion of us are going to have
these central apneas at over 10,000 feet elevation.
Certainly, more people have them at Fort Carson, which is ballpark 6,000 feet, than say, Tacoma
area, basically sea level.
Is 6,000 feet absolutely where everyone has them?
No.
But they're way more common here.
And there is a sleep lab at the Air Force Academy here in Colorado Springs that's another
1,000 feet and they're more common just additional 1,000 feet.
So we're kind of teeter-tottering here at this elevation, at 6,000 feet, with more common,
but not way, way common.
And then think, at 14,000 feet, basically, everyone's going to have them.
[Dr. Julie Kinn] I'm assuming the treatments differ for obstructive sleep apnea and central
sleep apnea?
[Dr. Jon Olin] Sure.
So central sleep apnea, you figure out what the cause is and then address that.
[Dr. Julie Kinn] Okay.
[Dr. Jon Olin] If it's elevation, then they may need time to adjust.
We try to avoid studying someone that just got off a plane and just arrived here 12 hours
ago.
So we're going to give them time to adjust.
If they're on narcotics or medications, just had surgery, had a procedure, we're going
to try to study them off of the narcotics or respiratory-depressant medications.
And then if they have ongoing central events, we can look at PAP, which is positive airway
pressure, which can be useful.
Sometimes for people, [bleeding?] in oxygen can be useful, where they're getting some
extra oxygen.
And then there are special PAP-type machines that are useful for treating central apneas
called ASV, for example, is one type.
They're specific treatments for central apnea, but in general, looking at why they're having
the central apneas and trying to address that is useful and appropriate.
[Dr. Jon Olin] But we should really talk about the more common condition which is obstructive
sleep apnea.
So in general, you're going to try to somehow hold the airway open that's collapsing.
So one way to do that is weight loss or weight control, if that's relevant and appropriate.
So someone who is overweight by 10 or 20 pounds, or 10 or 15 percent, if they lose weight, that may
be helpful, especially lose some weight around their neck.
There's obviously no way to specifically only lose weight around their neck or in their
oral area.
But avoiding gaining weight is going to be important.
So weight loss, weight control is relevant for some, for some, not relevant.
They're normal weight or underweight and they still have severe apnea.
[Dr. Jon Olin] PAP, positive airway pressure, where you're holding open a collapsing airway
with air pressure.
So if I break my finger-- I know Julie we're doing this podcast not nearby, but if you
were nearby, you could grab a pencil or pen and some duct tape or something and splint
it up.
And we could go over to the ER and they'd look at it, but we could somehow splint or
control it so it's not flopping around my broken finger.
So airway, obviously, much trickier area to splint.
We can't tell people, "Hey, reach in the back of your mouth, pull your tongue forward, push
your tonsils out of the way, now fall asleep."
They're going to say, "I'm going to throw up, never mind try to fall asleep."
So one way to splint it, to hold it open, is actually with air and air pressure.
So these are machines that pump air and they'll get many different types of masks.
And they're connected with a tube, from the machine through the tube, to the mask.
And some of the masks go over just nose and some of them just barely touch or kind of
touch the nostrils, the opening and will push in air.
So holding open this airway that was collapsing.
[Dr. Julie Kinn] So is it pushing oxygen in to replace oxygen from breathing less?
[Dr. Jon Olin] It's actually room air.
So we're not pumping in that, oxygen only, it's room air that's being pumped in or--
that's using the room air pressure to hold open the airway.
That's actually a common thought is like, "Well, why can't I just put in a little oxygen?"
Like the nasal cannulas, you see those in medical movies or TV shows of like, "I could
just have some oxygen.
That'll help my obstructive apnea."
And it may help it very, very slightly, in the sense that your oxygen levels are slightly
higher, but it's not doing anything to open the obstruction.
It's just waving around a higher concentration of air in front of the obstruction, not going
to do anything to open the obstruction.
So we need to do something to open the obstruction.
[Dr. Jon Olin] So PAP sure can and that's considered the gold standard.
And for severe, that's going to be generally the treatment that's recommended.
There will be some people in a sleep study, either home or in lab, that have documented,
say, severe or moderate sleep apnea when they're on their back, supine, and none or good breathing
when they're on their side, lateral.
If there's significant data for that, then positional therapy could be considered.
And this is a person doing something in an organized way, not just saying, "Oh, my sleep
study said I'm severe on my back," but they're going to do something in an organized way
to make sure that they're not sleeping on their back.
So, that's going to be like body pillows, could be tennis balls sewn.
This will sound a little weird, but tennis balls, pockets for tennis balls sewn in the
back of their pajama top and you put those in an X or a T and you can sleep.
[Dr. Julie Kinn] So that if you roll onto it, it's uncomfortable?
[Dr. Jon Olin] Exactly.
So you train yourself to sleep on your side.
Exactly.
So why are people worse on their back?
Because their tongue is generally flopping back and then blocking or closing the airway.
So they do something in an organized way to make sure that they're not on their back.
Surgery can be considered.
There are multiple surgeries.
The most common one is removing tonsils and some of the soft palate and the adenoids,
the little dangly thing back there called the uvula.
The statistics for that are not very, very encouraging and that under 50% of people get
50% improvement is what I've seen and so it's generally not a first-line treatment.
It could be something that is considered for people in the mild range for severe obstructive
sleep apnea.
Some of these surgeries are not first-line treatments.
There are other surgeries that are more aggressive, but people need to be thoughtful and discuss
those on my opinion with an experienced eye, ear, nose, and throat surgeon before they
do that.
[Dr. Jon Olin] Generally, PAP is as I said the mainstay gold standard of treatment for
severe.
There are also, for mild obstructive sleep apnea, things called oral appliances or mandibular
advancement devices.
So it'll sound a little weird, but tongue, believe it or not, is attached to jaw and
if you do something with like a double retainer to advance jaw even millimeters, you're pulling
tongue forward millimeters and opening airway possibly millimeters.
So again, for someone very severe and not a first-line treatment, but for someone with
mild, the millimeters may be enough to then have effective treatment.
I like getting follow-up sleep studies to prove that treatments are effective.
If they had an in-lab study and we know they're good in various stages, including REM on their
side, then that's your data, but I like getting follow-up study with an oral appliance to
show that it's effective and achieving good results.
[Dr. Julie Kinn] Now what about nose strips and devices for the nose?
[Dr. Jon Olin] Nose strips can be useful for snoring.
There's not really good data that they're useful for obstructive sleep apnea.
So it can improve airflow through the nose, so then there's less fluttering or less snoring
as it's going by the soft palate.
But in general, the obstructions are an upper airway and so improving some airflow from
nose does not open the airway.
[Dr. Julie Kinn] Okay.
Good to know.
Sounds like there's a lot of different treatment options and that surgery is definitely not
the first step.
[Dr. Jon Olin] Yeah, there are many treatments.
I should say also with PAP, again for moderate is generally considered the gold standard.
For PAP, the machines now, they're increasingly modern.
They're quiet, they're quieter than your household's fan in general.
They're relatively small, they are little bigger than-- they're like a small shoe box
and they have modems in them.
So they track actually hours of use that the person is using it and advance per hour.
So it's I think interesting and fun for patients to be able to look at that data so they can
track their hours of use, their advance per hour.
Is it as accurate as a full in-lab attended study?
No.
Because it was not a tech nearby, there was not all the wires, but we can look at how
they're using it.
The army, I think of the military and the field, in general, consider adequate treatment
more than four hours a night, more than 70 percent of the time.
So in other words, 21 out of 30 days for more than four hours.
[Dr. Jon Olin] And in general, we'd like to see events per hour at less than five, especially
if they're moderate or severe.
Sometimes, if they have 100 events an hour in their eight-- with the PAP, they reduce
to 6.0 events per hour and might view that as pretty darn good, they're 94% improved.
But in generally like events, at less than five per hour.
So there aren't that many treatments we can see how people are doing over a 30-day period,
over a 60-day period.
But this is one and then hopefully we get patients and service members buying it and
going, "Oh wow.
Actually, I'm starting to feel a little better.
Does takes weeks off and I'm starting to feel a little better.
My memory is a little better, my concentration is a little better.
I've noticed my blood pressure might be a teeny bit better."
People can get a lot of improvement with quality life with improved sleep.
[Dr. Julie Kinn] So can you take the PAP machine with you on deployment?
Would having this kind of diagnosis and treatment make one unable to deploy?
[Dr. Jon Olin] No.
That's a good question.
So years and years ago, yes, you could not take it with you to deploy.
Now you can.
And in fact, it's encouraged.
If someone has a knee condition and need a brace, then we're going to say, "Yes, deploy
with a knee brace."
We're not going to ask you to rock or to deploy and do significant time on your feet without
your knee brace and the same thing for sleep.
So they do need access to electricity.
They may deploy with the battery pack, which is eight-hour one-night backup.
It's not a one month supply of ongoing battery.
They'd have to recharge it.
So they do need access to electricity.
I like people to have filtered air.
What does filtered air mean?
It means a room or some kind of enclosed container with a floor, four walls, and a ceiling.
In other words, I don't like PAP just being sat down, the machine being sat down in a
pile of mud.
[Dr. Jon Olin] Even if they have a generator nearby, yeah, it's not going to do well for
them or for the machine to be doing that.
Yes, it'll keep your airway open for some of the hours, but it's going to break the
machine impact on the filter.
But [inaudible] people deploy and the machines themselves will again track their use, track
their data.
But if someone has severe obstructive sleep apnea and then deploys, and then is not with
their machine, and then is bound to falling asleep, that's dangerous.
That's a problem.
So the dangerous significance and consequences of untreated apnea are not just civilian,
they can be military obviously also when deployed.
So the army would like people to, especially the people with symptoms, meaning daytime
sleepiness, to be deploying with their PAP because we want them to be treated, want them
to have a better quality of life, better concentration, better attention, better focus.
[Dr. Julie Kinn] I'm hearing that there's a lot of treatment options and that any sleep
physician will be able to walk our listeners through them to figure out the best
place to start.
[Dr. Jon Olin] Right.
And it doesn't have to be a Board-certified sleep physician, there are many of the PCMs
are increasingly knowledgeable about sleep apnea, abstractive sleep apnea, and treatment
options.
So review this with a provider.
They may consult or the person may choose to be seen by a sleep physician.
But treatment is better than the no treatment.
And there are many primary care managers that are familiar with many of the sleep conditions
and treatment options.
Untreated sleep apnea is associated with high blood pressure, strokes, diabetes, and car
accidents.
And these, again, things tend to, again, normalize with treatment.
Is it an emergency if someone misses their PAP for one night?
No.
But ongoing no treatment or non-treatment is a significant health concern and safety
concern.
So we do encourage people to follow up and get treatment for their sleep disorders.
[Dr. Julie Kinn] That's a great reminder about the importance of this topic for our listeners
and our loved ones.
Thank you Jon.
Thank you listeners for tuning in.
You can subscribe and rate A Better Night's Sleep on iTunes or wherever you get podcasts.
A Better Night's Sleep is produced by the Defense Health Agency.
You can get In touch with us on Facebook and Twitter @MilitaryHealth.
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