Living With Sleep-Disordered Breathing: Expert Q&A
Education and Advocacy Most people don’t recognize how common sleep apnea is but it is a disorder that can have devastating effects. Dr. R. John Kimoff, Dr. Manisha Witmans and Dr. John Fleetham make sure you recognize the symptoms and are up-to-date with the latest innovations in treatment and technology.
- Dr. R. John Kimoff
- Dr. Manisha Witmans
- Dr. John Fleetham
Dr. R. John Kimoff
Mediaplanet: What are some of the misconceptions surrounding sleep-disordered breathing (SDB) and sleep apnea?
Dr. R. John Kimoff:One common misconception is that one has to be overweight to have obstructive sleep apnea (“OSA”). While OSA is linked to obesity, and weight loss is important in OSA management, there are genetic and other factors which can predispose normal weight, fit individuals. Another misconception is that because there may be long waiting times for sleep studies, it is “not worthwhile” making appointments to be tested. OSA can have insidious, but ultimately devastating effects on quality of life, mental functioning, productivity, and cardiovascular health. Individuals with symptoms of OSA should definitely pursue testing.
MP: What are some of the latest innovations and advancements in sleep treatment and technology?
JK: The main treatment for moderate and severe OSA is positive pressure (“PAP”) therapy delivered through a mask, which prevents the airway from blocking during sleep. There have been recent technical improvements in PAP blower units and masks which make treatment easier to adapt to and benefit from. Dental appliances have been developed to move the lower jaw forward during sleep. Sleep testing should be performed to assess eligibility, and the device should be made by a dental health professional with specific OSA expertise. There is promising preliminary work with pacemaker-like stimulators for the tongue which may come into mainstream treatment.
MP: When should someone consider seeing a professional surrounding sleep and sleep-disordered breathing issues?
JK:While not all snorers have sleep apnea, most (but not all) OSA patients are, or have in the past, been snorers. Other symptoms of OSA include breathing pauses witnessed by a bed partner during sleep, having to get up to void at night, restless, non-restorative sleep, morning headache, and excessive daytime sleepiness, defined as falling asleep in unwanted or dangerous situations despite adequate nocturnal sleep time. In that there is growing evidence linking OSA and cardiovascular conditions, cardiac patients with OSA symptoms should give particular consideration to being evaluated.
Dr. Manisha Witmans
Mediaplanet: What are some of the misconceptions surrounding sleep-disordered breathing (SDB) and sleep apnea?
Dr. Manisha Witmans:Some misconceptions are that snoring is normal for children. The spectrum of sleep-disordered breathing can include anything from snoring to complete airflow obstruction of the airway. As many as three in 100 children have sleep apnea, but as many as 20 in 100 children may snore. Snoring signifies that there is some flow limitation in the airway, from the nose to the lower airway. Exposure to tobacco smoke can cause children to snore. Snoring with increased work of breathing suggests sleep apnea in children. Sleep apnea is associated with significant effects on behaviour, academic performance, as well as physical and mental health. Vulnerable children who have developmental delays can also have more problems with sleep apnea. Diagnosis in children is not as easy as it is in adults because the technology used for diagnosis in children is cumbersome and not always accessible, with lengthy waitlists. Families report children snoring should be asked about their sleep, physical health and daytime function.
MP: What are some of the latest innovations and advancements in sleep treatment and technology?
MW:A study in the NEJM in 2013 showed that adenotonsillectomy is associated with improved quality of life and sleep in children who have sleep apnea. Although adenotonsillectomy is the first line for treatment for children with sleep apnea, there may be a role for other therapies that address the craniofacial form and function, such as interdisciplinary teams that address SDB in children more broadly (IARC at University of Alberta). Poor sleep quality, whether it is from sleep apnea or not, can be linked to daytime problems with functioning. There is an interest in developing more portable, easily accessible means of diagnosing sleep apnea in children. An overnight polysomnogram (formally attended sleep study) is difficult to get and often only available at tertiary care pediatric centres. Research teams are working towards being able to diagnose sleep apnea using urine, much like diagnosing infections. This would allow children to be diagnosed and treated efficiently.
MP: When should someone consider seeing a professional surrounding sleep and sleep-disordered breathing issues?
MW:If the sleep problem is medical, with symptoms of sleep apnea, and there are health related consequences or functional consequences such as obesity or developmental delays, parents should seek out health professionals to discuss the possibility of SDB. Every province has some local resources of sleep professionals that can direct care or point patients in the right direction. The Canadian Sleep Society website and the lung associations will likely have listings of professionals in the area that treat children and/or adults. Other reasons to seek out professional help is if the sleep problem is resulting in family disruption.
Dr. John Fleetham
Mediaplanet: What are some of the misconceptions surrounding sleep-disordered breathing (SDB) and sleep apnea?
Dr. John Fleetham: There are three major misconceptions. The first is the general recognition- most people don’t recognize how common sleep apnea is. It’s as common as diabetes or hypertension and it occurs in about 8 percent of men and 4 percent of women. The next misconception is that it’s not a serious condition. Sleep apnea can give rise to quite serious symptoms especially daytime sleepiness, which can often be a devastating effect, and it can also give rise to a wide range of consequences including high blood pressure, diabetes, heart disease, stroke, increases the risk of motor vehicle accidents, increases risk of surgery, causes complications with the eye, and more recently it is has been linked as a contributing cause in terms of developing cancer. The third misconception is that sleep apnea is simply just one thing and all you have to do is use a continuous positive airway pressure (CPAP) device. However, there are 5 different types of sleep apnea and they each need to be diagnosed correctly and treated in different ways. Those are the three biggest misconceptions: that it’s uncommon, it’s not serious, and it’s all the same thing.
MP: What are some of the latest innovations and advancements in sleep treatment and technology?
JF: The major advancements are with the standard treatments. There are three standard treatments for sleep apnea, which have been established over the past several years and still remain today. These treatments are CPAP, oral or dental appliances, and weight loss, which includes bariatric surgery. There are a lot of other treatments but they should all be considered experimental. What is new in the field is that there are now advanced forms of CPAP. Everybody thinks that CPAP is one specific type of treatment, when in fact there are 4-5 different types of CPAP therapy. But also, the CPAP machines now are very sophisticated in that they can provide doctors with information about the patient including whether the patients are using the machine, whether they had a leak in terms of their mask and how effective the machine is. Beyond this, there are now mobile phone programs which can be integrated so that patients can be reminded on a daily basis to use their treatment and doctors can reinforce patient compliance through mobile devices as well. There also now with oral appliances we have the ability to monitor and record whether a patient is using their treatment.
MP: When should someone consider seeing a professional surrounding sleep and sleep-disordered breathing issues?
JF:If any patient thinks they have anything wrong with them they should always start off with their family physician, this is no different from if they think they have high blood pressure or anything else. The point I would make strongly is that you should see someone that is completely independent and has no conflict of interest, such as an employee of a CPAP vendor, who’s then motivated to sell them a machine, which is a conflict of interest. The people that require high priority in terms of assessment are, the same things as any disease, anyone who has multiple health conditions, such as diabetes, or hypertension etc., and if they’re in critical safety occupation. The biggest risk for this condition is falling asleep, so if you are a cab or bus driver, if you fly a plane or drive a train, this should be a high priority. There’s a lot of concern recently in terms of people with sleep apnea having increased risk in terms of morbidity and mortality after surgery. So, anybody going for surgery should be assessed in terms of SDB.
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