Sleep-Disordered Breathing: An Under-recognized Cause of Chronic Disease – Part 2
David Nortman, ND
Part 1 of this article covered the pathophysiology and clinical presentation of obstructive sleep-apnea syndrome (OSAS). Below, we continue with a description of the sleep study and an overview of treatment methods.
The primary tool for studying all sleep disorders is the Level 1 sleep study, or polysomnography (PSG), during which cerebral, respiratory, cardiovascular, positional, and other measures of sleep quality and behavior are recorded and interpreted during the subsequent scoring of the raw data. PSG reliably detects apneas, hypopneas, respiratory effort-related arousals (RERAs), and a wealth of other information relevant to OSAS and other sleep disorders. Like all tests, PSG is subject to inter-test variability, so a single night of testing can occasionally miss OSAS and may need to be repeated.1* If a continuous positive airway pressure (CPAP) machine is prescribed, a follow-up titration PSG is often performed in order to establish the baseline flow-pressure that eliminates arousals; however, since the advent of automated CPAP machines, this step is sometimes omitted.
The severity of OSAS is commonly graded by the apnea-hypopnea index (AHI) – a score that reflects the night’s average hourly number of apneas and hypopneas; <5 is considered normal, 5-15 mild, 15-30 moderate, and >30 severe. The respiratory disturbance index (RDI), introduced once upper-airway resistance syndrome (UARS) was recognized, incorporates (on the same severity scale) the impact of not only apneas and hypopneas, but also RERAs (ie, RDI = AHI + RERA). Although both AHI and RDI are in current use, the more standardized AHI remains popular with physicians (for guiding treatment) and insurance providers (for determining eligibility for treatment). Yet, just because detecting RERAs with sufficient sensitivity is technologically challenging, their impact should not be ignored, lest “non-OSA” OSAS be left untreated.**
The arousal index (AI) is a measure of sleep fragmentation as reflected in arousals from any cause, so it is up to the clinician to interpret the meaning of spontaneous arousals that are not secondary to respiratory or other detectable reasons. Some degree of sleep fragmentation is normal and is likely aggravated by the polysomnography setup, but it may also be reflective of chronic pain or other neurological or psychological causes. The AI is known to increase with age in normal subjects, but definitive normal values have not been established. In general, sleep data should be interpreted holistically, as the severity of sleep disturbance depends also on the clinical presentation and other factors such as severity of hypoxemia, length of arousal events, time spent in slow-wave sleep (SWS) and rapid-eye movement (REM) sleep, and frequency of arousals during these deeper stages of sleep.1***
A home-based (typically Level 3) sleep study is sometimes ordered in place of PSG for the sake of cost-savings and convenience. It can detect obvious apneas and hypopneas but may miss subtler airflow restrictions such as RERAs. Its main drawback is the lack of brainwave monitoring, which means that none of the findings can be correlated with the sleep stages, and sleep length (critical for calculating both AHI and RDI) can only be estimated. Thus, it is a suitable screening tool for those likely to have moderate-to-severe apnea, but it cannot be used to rule out OSAS, due to its limited accuracy and sensitivity.
Another test sometimes used in evaluating OSAS is the multiple sleep latency test (MSLT), which quantifies the degree of daytime sleepiness.
OSAS is readily treatable through a variety of methods; however, there is no universal solution for all patients, and the most common therapies involve an adjustment period that limits compliance. CPAP therapy is the most popular approach and is usually the first and only one offered to patients. But it need not be the last one, nor does it or any other treatment need to be used on its own. A successful approach to OSAS may require multiple solutions, and, as naturopathic physicians, we are perfectly positioned to encourage patients to seek further treatment when the prescribed one has proven inadequate.
CPAP was introduced in the early 1980s, revolutionizing the treatment of OSAS. Yet despite its unrivaled efficacy among non-surgical solutions, CPAP is poorly tolerated by many patients. Concerns include claustrophobia, airway dryness or congestion, increased risk of respiratory infection, mask leakage or pressure points, restriction of movement during sleep, tooth movement from mask pressure, noise, aerophagia, and, last but not least, interruption to the sleeping partner. The required equipment maintenance further decreases long-term compliance. Ultimately, most patients require weeks of acclimatization, and many never learn to tolerate the treatment.
CPAP comfort has improved over the years, thanks to better mask design, automatic pressure settings, built-in humidification and heating, and virtually silent operation. In recent years, automatic-pressure (Auto-CPAP/APAP) machines and bi-level (BiPAP/VPAP) machines, with independent exhalation and inhalation pressures, have become available. These have further improved patient comfort, but access is still limited by knowledge on the part of sleep specialists and by insurance considerations. Given its high efficacy when tolerated, CPAP users should be encouraged to receive proper training and follow-up, proactively seeking optimal settings, masks, and machine types until compliance is achieved.
Oral Appliance Therapy
Oral appliance therapy, typically in the form of a mandibular advancement device (MAD), can be used to reposition the mandible anteriorly in order to expand the airway. Compact and convenient, it is compatible with drinking and speaking, is unobtrusive and much simpler to use than a CPAP machine, and can be implemented even without a sleep study. It is most effective in milder forms of OSAS and in patients with low body mass index (BMI). Although typically less effective than CPAP in reducing arousals, the higher compliance rate makes it a serious contender to CPAP. Oral appliance therapy can be a standalone treatment or a useful adjunct to CPAP therapy, as expanding the airway allows for lower CPAP pressure settings and a reduction in pressure-related side-effects such as mask leakage and airway dryness.
A MAD is custom-fitted by a dentist trained in sleep medicine. The adjustment period, during which the jaw is gradually protruded to the treatment position, may involve temporary temporomandibular joint (TMJ) discomfort. Tooth movement resulting in bite alteration commonly occurs in the long term, but this can usually be managed successfully, and in some cases may even be a desirable outcome. Do-it-yourself devices marketed for snoring or sleep apnea should be avoided, as they are usually ineffective and may cause harm in the long term.
Surgical options for OSAS may be resorted to when other approaches have failed or not been complied with. [For a detailed overview of surgical options, you might check the book by Fairbanks et al.2] A popular soft-tissue surgery is uvulopalatopharyngoplasty (UPPP), although it has a high recurrence rate and is ultimately not very effective. Maxillomandibular advancement (MMA) is a radical but highly effective surgery that can be considered when all other options have been exhausted. A growing array of surgeries is available depending on the precise location of airway restriction, including septoplasty (deviated-septum correction), tonsillectomy, superficial implants to stabilize the soft palate, radiofrequency ablation of the base of the tongue, and bariatric surgery to address morbid obesity.
The simplest thing a patient can do to improve OSAS symptoms is to manage one’s sleep position. Moderate neck hyperextension in the supine position, using a “contour” or “anti-snore” pillow or a suitable neck brace may offer relief. Encouraging the patient to side-sleep may be a partly effective solution to mitigate the effects of gravity on the airway, and various worn devices that discourage sleep in the supine position are available for this purpose. The effectiveness of side-sleeping should ideally be evaluated through PSG, especially if it is relied on exclusively. As an adjunct to CPAP treatment, positional therapy often allows for lower pressure settings and greater comfort.
Various behavioral therapies may be effective for addressing OSAS. First and foremost is weight loss. In overweight patients this is a reliable method of improving or resolving OSAS, although in some cases addressing OSAS first might be necessary.
Myofunctional therapy (retraining of oral and facial muscles), sometimes combined with a tongue-tie release, is a promising and still-evolving approach that is highly compatible with naturopathic principles.3 On the do-it-yourself front, nocturnal mouth breathing in adults and older children can be both diagnosed and addressed by taping the mouth with medical tape, ensuring first that the nasal passages are clear.
No age is immune from sleep-disordered breathing (SDB). OSAS is more common than supposed in children, and along with snoring and mouth breathing, should always be addressed promptly because of their considerable long-term impact on development and behavior.4 In infants, sudden infant death syndrome (SIDS) may be a consequence of undiagnosed SDB. Suffice it to say that infants with unreasonable sleep dysregulation or perplexing ailments should undergo a sleep study as part of their overall evaluation.
The following may be indicative of OSAS in children:
- Unusually restless sleep
- Behavioral issues (including ADD/ADHD and autism spectrum disorders)
- Decline in school performance
- Cardiovascular problems
Mouth breathing in childhood may affect craniofacial development and alter the shape of the airway at any point up to early adulthood, such that even a previously well-formed jaw may fail to complete its proper development if it goes unchecked for a long enough time. When enlarged tonsils or adenoids are to blame, their removal should be considered unless the issue can promptly be addressed by other means, as the negative immunological consequences of removal are far less significant than those of mouth breathing. Allergies should likewise be promptly addressed for the same reason. Habitual mouth breathing that arises after a cold, or persists after addressing some other underlying cause, can be addressed through behavioral retraining or specialized dental appliances.
There is evidence that, much like dental caries, dental malocclusion and palatal underdevelopment are diseases of civilization.5 The widespread substitution of breastfeeding with bottle feeding (whether with mother’s milk or formula), and the subsequent consumption of pureed and soft foods that do not require chewing, deprive the jaw of the mechanical forces necessary for its proper development. Although these trends are reversing somewhat, it remains important to inform parents of the benefits of maintaining a degree of continuity with ancestral child-rearing habits.
The growing skull of children offers further treatment options beyond those available to adults, namely orthodontic expansion of the palate and dental arches, with the aim of enlarging the upper airway. Orthotropics, an emerging subfield of pediatric orthodontics, aims to prevent both dental and airway issues by optimizing facial growth. On the other hand, outdated orthodontic methods that involve removing teeth in order to reduce crowding – a symptom of an underdeveloped arch – can further exacerbate an already restricted airway. Certain surgeries available to adults are not appropriate in children because of the likelihood of spontaneous resolution over time, and mandibular advancement is not usually applicable in a developing jaw.
Navigating the System
Polysomnography is a reliable and comprehensive diagnostic tool for OSAS, but due to its cost, access to PSG is tightly regulated. Family physicians and dentists continue to be poorly informed about the prevalence of OSAS and its atypical presentations, and dentists are generally not trained in detecting its telltale signs in the oral cavity. As naturopathic physicians, we should consider that untreated OSAS, even when mild, may be an unrelenting obstacle to the optimal health that we seek for our patients.
In this vein, sleep dentist Mark Burhenne has proposed that sleep ability be considered among the chief determinants of health, alongside such measures as blood pressure and BMI.6 [Burhenne’s compact book is a useful initial resource about OSAS, both as a patient guide and as a basic resource for family physicians.] Until such a cultural shift takes place, we can play a valuable role in informing our patients about OSAS and helping them to navigate the system. It is also worth developing a proficiency in interpreting sleep reports rather than relying on the interpretation of a specialist who may be less informed about the patient’s overall clinical condition.
The following obstacles are commonly encountered:
- The patient refuses to accept the possibility of having OSAS: Mobile apps that record snoring or restless sleep sounds are available and provide more persuasive evidence than the testimony of a spouse, although not all cases leave an audible trace.
- Being refused a referral to a sleep study: The patient may need to find out the relevant local regulations and educate the family physician about OSAS.†
- Being offered a home-based sleep study: This is an acceptable starting point, but PSG should still be pursued in case of a negative result. In addition, despite advances in CPAP machine automation, PSG is still considered the gold standard for calibrating treatment and ruling out more complex SDB.
- Being told that the PSG result is negative for OSAS: This is a common occurrence and should not be taken at face value, for reasons discussed above. Moreover, an AHI or RDI of < 5 is considered normal and treatment will normally not be offered; however, in the presence of symptoms related to sleep fragmentation, it may be beneficial to reduce the index to <1 through conservative treatment such as oral appliance therapy or positional therapy. Finally, when diagnostic results are inconclusive, CPAP, oral appliance, or positional therapy can be attempted on an empirical basis.
- Being offered only a limited range of CPAP machines and masks: The patient should insist on access to the most appropriate setup in order to achieve compliance.
- Not being offered combination therapy when indicated: CPAP is commonly combined with an oral appliance, and there is a growing array of minimally invasive surgical procedures and other potentially useful innovations.6
- Not having proper follow-up, and stopping effective therapy: The patient may need to be reminded on an ongoing basis of the importance of persisting with treatment. Also, patients considered to have only mild OSAS are less likely to be supported by the medical system.
Successful treatment of OSAS may precipitate its own psychological challenges, including depression due to the permanent lifestyle change, regret about not having begun therapy sooner, and even overwhelm from the newly found ability to interact with the world once sleep quality has been restored. These will require appropriate counseling support.
Vis Medicatrix Naturae
As naturopathic physicians, we tend to believe that the body possesses a deep intelligence that promotes optimal health under optimal conditions. While this is true when these conditions are met during early development, when they are not it becomes apparent that the vis medicatrix naturae operates within constraints set by evolution. Recognizing that nature’s intelligence is not omnipotent may help us to become more attuned to undiagnosed OSAS in our patient population, as well as motivate us to prevent airway abnormalities in the next generation through proper education and pediatric care.
From the preceding discussion, it should be apparent that the etiology of OSAS is complex. The patency of the upper airway can be compromised by inflammation, tissue enlargement or laxity, and inadequate development of the surrounding bony structures. When we consider that each of these is in turn caused by multiple factors, opening the airway through naturopathic means alone is often impractical. While it may be tempting to improve sleep quality through the great variety of tools available to us, the treatment of OSAS should be focused on the airway, even when its compromised condition might be construed as a symptom of some other underlying cause. Anatomical causes are generally not correctible in adults except surgically, and inflammation, excessive weight, and other soft-tissue concerns are exacerbated by the sleep disorder itself and may not be correctible unless sleep is addressed first.
Mind, Body, and Spirit
In reflecting on the deeper meaning of sleep apnea and breathing difficulties, broadly speaking we may say that it reflects a throat-chakra issue; however, the fascinating book Messages From The Body7 offers more specific clues. Here is a sampling of rubrics:
- Sleep apnea: “Maternal deprivation.” They are intensely sensitive, fearful and longing for mother love… they dare not express or even acknowledge these feelings out of fear of total rejection and abandonment… they are so self-suppressing that they are suffocating themselves. [Note that inadequate breastfeeding is a potential contributor to OSAS.]
- Inflammation of the palate: “Life sucks!” They have intense resentment of their lot in life. They do not find what has been dealt them at all to their taste…
- Suffocation: “Self-revulsion.” They are “choking to death” on their own guilt and shame. They feel that they should be thoroughly punished or even destroyed for their “sins”…
Such patterns are vital determinants of psychic health and well-being. As we hold space for them, let us make room for sleep quality and airway integrity as crucial factors in the optimal health of the entire human organism.
* Factors such as insufficient REM sleep due to sleep disturbance associated with the test setting, insufficient sleep in the supine position, variations in neck tilt and head position, avoidance of medications or alcohol normally taken at home, and variability of the condition from night to night, may all conspire to produce a falsely normal score.
** In fact, in cases where arousals are detected with no corresponding respiratory disruptions (such that not only AHI, but even RDI, is normal), it may be worth retesting using more sensitive means. Intraesophageal-pressure monitoring is the gold standard, as it measures respiratory effort directly; however, because it requires a specialized esophageal catheter, it is not performed routinely. Most commonly, airflow limitation is measured using a pressure-sensitive nasal cannula, where increased respiratory effort is implied by a “flattening” of the roughly sinusoidal normal curve of the nasal-pressure channel. An older technology based on a temperature-based flow sensor is still in use, but it is not sensitive enough for detecting subtle airflow limitations.A “normal” AHI or RDI may at times mask an abnormally high frequency of arousals during REM sleep; this information is available from a full sleep report.
*** In order to perform an independent assessment of the sleep data, it is worthwhile obtaining access not only to the sleep report but also to the graphs that summarize the arousal patterns and related metrics. For example, a normal AHI or RDI may mask an abnormally high frequency of arousals during REM sleep, or – conversely – the absence of SWS or REM sleep during the unfavorable sleep-study conditions may mask respiratory events that would otherwise have occurred during these stages.
† Along with Mark Burhenne’s aforementioned book, an excellent introduction for both patients and physicians is: Park S. Sleep, Interrupted. New York, NY: Jodev Press; 2008.
- Chervin RD, ed. Common Pitfalls in Sleep Medicine: Case-Based Learning. Cambridge, England: University Press; 2014: p.79-83.
- Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and Obstructive Sleep Apnea. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.
- Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: A Systematic review and meta-analysis. Sleep. 2015;38(5):669-675.
- Bonuck K, Freeman K, Chervin RD, Xu L. Sleep disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857-e865.
- Boyd K. Darwinian Dentistry Part 2: early childhood nutrition, dentofacial development and chronic disease. J Am Orthod Soc. Mar/Apr 2012:28-32.
- Roy S. 10 Sleep Apnea Treatments to Consider for Patients Who Fail or Refuse CPAP. August 30, 2017. Sleep Review Web site. http://www.sleepreviewmag.com/2017/08/sleep-apnea-treatments-fail-cpap. Accessed December 15, 2017.
- Lincoln MJ. Messages from the Body: Their Psychological Meanings. Spring Creek, NV: Talking Hearts LLC; 2016.
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David Nortman, ND, studied at the University of Toronto before graduating from CCNM in 2004. More recently he completed a master’s degree in Philosophy of Science from Tel-Aviv University. Dr Nortman has completed extensive training in classical homeopathy, utilizing it to address the full spectrum of chronic conditions. He practices locally in Toronto and worldwide on a long-distance basis, and serves as a homeopathic consultant and mentor to naturopathic colleagues. Dr Nortman has published numerous articles in homeopathic journals and has lectured to both lay and academic audiences. Currently, he is writing a book on homeopathy and its interaction with modern science and philosophy. Website: www.homeopathyzone.com.