“I’m Always Tired… Do I Need More Sleep?”

HNP Communications Friar News

As part of its series on health issues, the HNP Wellness Committee offers information and guidance on obstructive sleep apnea. This piece was written by a friar who is a clinical anatomist. The last Wellness Committee article was titled “Where Did I Put My Glasses…?”

As you are packing up the Advent wreath and chasing stray pieces of crèche straw, you may also have lingering feelings of post-Christmas exhaustion. This is normal; however, some may never know anything but feeling tired, every day. “I’m a good sleeper, all night, but I still get drowsy,” you may say. In fact, there might never be full night’s slumber — ever. It is possible that you have a sleep problem and do not know it. That could explain the everyday “drowsy time”; or worse, you get an uncontrollable urge to nap driving 70 mph on the NYS Thruway.

It’s never too late to take control of your own wellness. If you’re wondering if in fact you do have a sleep problem, start simply. Make a sleep timeline list. Note when you go to sleep, wake up, and take naps. Also jot down how rested you feel in the morning or sleepy during the day. Continue your “sleep diary” and bring it with you the next time you visit your doctor who may be able to help you determine if your problem is one with sleep. You can find a sample of a sleep diary in the National Heart, Lung, and Blood Institute’s “Your Guide to Healthy Sleep.”

You and your doctor must work on this together. However, fellow friars may be the best detectives of the underlying problem. For years, they may have been more than mildly annoyed by your snoring, but have consistently “offered up” this irritation and not said anything. All along, a friar could have been a significant other person to push for a diagnosis of obstructive sleep apnea. Most people who have it don’t know it because it only happens when they are asleep. The cardinal symptoms of sleep apnea include the “Three S’s”: sleepiness, snoring and significant-other report of the episodes. In addition your doctor can’t diagnose it in the office nor is there any blood test for it. An estimated 80 percent of Americans with forms of sleep apnea are not diagnosed.

A growing number of Holy Name Province friars have been successfully caring for their diagnosed sleep apnea. This Provincial Wellness Committee article will address obstructive sleep apnea, which is only one in a spectrum of sleep disorders. It is intended to give information to those already diagnosed — and more importantly, to alert the undiagnosed to signs that may be helpful for their own detection.

What is Obstructive Sleep Apnea?
Although simple apnea is defined by the American Academy of Sleep Medicine as the cessation of airflow for at least 10 seconds, it may last for 30 seconds or even longer. There is a range of apnea, each type triggered by something different. One cause is the collapse of your upper airway during sleep. When this happens, you unconsciously increase your breathing effort.The apnea resulting from such obstruction is called OSA. Regular and normal breathing, even while asleep, assures that the blood flowing to the brain is saturated with oxygen. The brain can detect even a slight drop in blood oxygen and you automatically take more and deeper breaths. In some people, the apnea occurs hundreds of times nightly, one to two times per minute. It is often accompanied by wide swings in heart rate and gasping sounds as air rushes through the reopened airway. The person wakes up, gulping and grabbing for air.

The ‘wind pipe’ in the neck and upper chest is supported by cartilage and usually keeps the airway open. But the wall of the very top part of the airway at the back of the throat is not supported. It is subject to collapse. Even the entrance to the throat can be obstructed by shifting the soft palate or the tongue.

Everyone snores at some point during the sleep cycle. Longer periods of snoring with no pause in breathing can have some minor effects such as a dry mouth or nose bleeds. However, when upper airway resistance increases, short periods of apnea may occur. When apnea becomes longer and more frequent, you may wake up, briefly but often. Interrupted night sleep can result in chronic daytime sleepiness, one of the most potentially morbid symptoms of sleep apnea. Daytime sleepiness can progress to such varied outcomes as obesity, depression and automobile accidents. Studies have shown that patients with OSA are two to seven times more likely to have a motor vehicle crash than people who do not have OSA.

Drowsiness is the most obvious symptom of OSA. There are, however, a variety of other potentially serious health problems that can develop. The persistent nightly low blood oxygen in OSA can result in elevations in daytime blood pressure, and can bring about coronary artery and other cardiovascular diseases. It has also been linked with insulin-resistance diabetes.

How is OSA Diagnosed?
If you suspect that you may have an apnea problem, discuss your sleep diary with your doctor. She or he may want to find out if indeed you have a sleep disorder and, if so, how severe it is. The doctor may recommend a sleep study test to accurately determine how well you sleep. More importantly, you need to know how your body responds to your unique pattern of sleep and abrupt arousals. Sleep studies are the most accurate tests for diagnosing sleep apnea.

One type of sleep study is done at a sleep center or lab. This is a painless test done while you sleep. It records your heart rate and its electrical activity, blood pressure, amount of oxygen in your blood, air movement through your nose, brain activity, and eye and chest movements. Depending on the findings, sometimes more advanced lab tests are required to determine the extent of obstruction.

Another type of test is done at home with a portable monitor. It measures heart rate, and electrical activity, blood pressure and chest movements. It gives the least information, yet could be enough to help your doctor determine your status and be a good start for diagnosis.

Who is Prone to OSA?
If someone in your family has OSA, chances are your suspicion of you also having it is correct. Families with a high incidence of OSA have a two- to four-fold increased risk than those that do not.

Research has shown that certain body features may predispose an individual to OSA.  Basically any anatomic feature that would reduce the size of the throat increases the likelihood of OSA, such as: large tongue or tonsils, long soft palate, high-arched hard palate or receding lower jaw.

Gravity is also a culprit (well known by those of us of a certain age). If you simply tilt your head back you can feel your soft palate and tongue slide backwards, reducing the size of your upper airway. This is why OSA worsens when sleeping on your back.

In addition, men may be predisposed to OSA because male sex hormones tend to deposit fat in the trunk and the neck area which may affect the relaxing of throat muscles during breathing.

How is OSA Treated?
Sleep apnea treatments range from things you can do at home to surgery. In mild cases of sleep apnea, you may be able to treat it by changing your behavior: losing weight, avoid alcohol and sleeping pills, changing sleep positions to improve breathing and stopping smoking.

Your dentist or a doctor who specializes in treating sleep apnea can fashion a mouthpiece or dental device that when worn while asleep to maintain an open airway. You should plan for periodic office visits to adjust your mouthpiece to maintain a good fit.

Another treatment, Continuous Positive Airway Pressure, is one in which a mask is worn over the nose and/or mouth while you sleep. The mask is hooked up to a machine that delivers a continuous flow of air into the nose. This airflow helps keep the airways open so that breathing is regular. CPAP is considered by many experts to be the most effective treatment for sleep apnea. The short-term prognosis of alleviating daytime sleepiness and snoring using CPAP ranges from good to excellent. Several studies have shown that just four to eight weeks use of CPAP improves general health and increased mental sharpness.

But the mask is big, bulky and obtrusive. Many people simply refuse to wear it or they rip it off while asleep. Studies show that about half of all people prescribed CPAP machines stop using them in one to three weeks. However, “the success of an unused CPAP machine is absolutely zero,” says Dr. Joseph Golish, the former chief of sleep medicine at the Cleveland Clinic. There are a number of friars who regularly use CPAP at home and carry a portable machine with them while traveling. An anecdotal satisfaction survey of friars using CPAP indicates good confidence in the result.

Surgery is another treatment option. There are minimally invasive office procedures, such as injections into the soft palate to stiffen it; or laser reduction of the uvula (the projection hanging from the middle of the soft palate in front of the throat). While these procedures have been effective in treating snoring, their effectiveness in treating sleep apnea in the long term isn’t known.

The most commonly performed operating room procedures will correct a deviated septum, remove a larger portion of the soft palate, or enlarge the lower jaw.

Living With Sleep Apnea
Sleep apnea can be very serious. Until your sleep apnea is properly treated, know the dangers of driving while sleepy. However, by following an effective treatment plan you can improve your quality of life. Treatment will enhance your sleep and relieve daytime sleepiness. It may also lower your risk for high blood pressure and heart disease.

To begin with, there are certain lifestyle changes that may help:
 Sleep on your side instead of your back (there are special pillows available to help).
 Avoid alcohol and medicine that make you sleepy
 Talk with your doctor about a product or program that can help you quit smoking.

Even a small weight loss can improve your symptoms.

If you use CPAP, daily use is important, even though it may take a while to adjust. If you aren’t comfortable with your CPAP device, or if it doesn’t seem to be working, let your doctor know. You may need to switch to a different device or mask. Or, you may need treatment to relieve CPAP side effects.

One word of warning: If you’re scheduled for any type of surgery that requires medicine to put you to sleep, let your surgeon and doctors know you have sleep apnea. They might have to take extra steps to make sure your airway stays open during the surgery.

Being sharp and prepared for ministry is always important. Chronic daytime sleepiness is not normal. Make sure that you are in charge of getting a good, complete and uninterrupted night’s sleep.

— Fr. Matthew, chair of the HNP Wellness Committee, says that sharing and networking friars’ experiences of wellness is one of the assumed charges of the committee. He encourages friars to email pravetz@nymc.edu to share personal experiences of sleep challenges, dealing with apnea, CPAP use and any comments about to this article. Responses will be included in future publications from the committee.