sleep disordered breathing

Sleep Disordered Breathing (SDB) is very complex breathing condition that destroys your slumber and endangers your health by two very prominent physiological processes:

• Sleep Fragmentation:  SDB is so disruptive because it constantly interferes with your brain waves as you attempt to sleep.  Instead of remaining in deeper, restorative stages of sleep for much of the night, SDB forces you into lighter sleep stages and in the most cases, it triggers hundreds of little awakenings during the night that literally rob you of sleep.  In fact, if you sleep 8 hours and suffer from moderate to severe SDB, chances are high you are only getting 4 to 6 hours of solid sleep.
• Oxygen Fluctuations:  SDB dramatically alters stabily of the oxygen your body receiveds into the body and transfers into your bloodstream.  In a normal sleeper, oxygen levels are maintained in a surprisingly stable pattern.  For, if the level were 94% (90 to 100% being the standard normal range), then this value could be maintained for minutes on end with minor or no fluctuations whatsoever.  In most SDB cases, oxygen fluctuates all night long, often within a time span as short as a few seconds.  In a 30 second interval (the standard interval we use in sleep studies), oxygen could start at 94%, drop to 91 in 10 seconds, go back up to 93$ in another 5 seconds, and then drop again to 89% in another 15 seconds.  In more severe cases, these fluctuations deteriorate into what are known as desaturations, where the oxygen level drops frequently below 90% for 10, 20, 30 seconds or longer, before returning to the normal level above 90%.  Sometimes oxygen drops even lower, particularly in REM sleep or when you sleep on your back.

These two components--sleep fragmentation and oxygen fluctuations/desaturations are the key to understanding the nature of SDB.  Most importantly, it will help you understand why the term "obstuctive sleep apnea" (OSA) is a misleading term.  Sleep apnea literally refers to the process in which you stop breathing for anywhere from 10 seconds or longer, amazingly up to 60 seconds in unusually severe cases.  As you would expect, sleep disruption and oxygen desaturations are quite severe following an apnea.

SDB can produce a response this severe when the airway closes down and all breathing stops, but to continue the analogy, how do you think you would react when you "choke a little?"  I'm sure you guessed that it would still be very uncomfortable, and that's why SDB is often misunderstood and why the term sleep apnea is misleading.  As you will learn, SDB can include a whole range of sleep breathing events in which you don't stop breathing, but your effort to bring in a full breath is compromised.  Two events described below are usually more common than apneas in most patients with SDB:

• Hypopneas:  In this event instead of a complete cessation of breathing, you lose about 50% of your normal breath, which unsurprisingly is more than sufficient to trigger sleep fragmentation and to cause your oxygen to fluctuate or desaturate.
• Flow Limitation:  In this event, the airway experiences resistance, which is diffiucult to quantity, but it might be reasonable to consider these events as a 10% reduction.  Yet even this small reduction of breathing (a wee bit of choking) can still cause sleep fragmentation and oxygen fluctuations.

So, to reiterate, you will understand this condition much better and make better decisions about your healtcare choices by recognizing that when you suffer from SDB, it might be only apneas (sleep apnea), only hypopneas or only flow limitations or as in most cases, some combination of all three event types.  But even if you only suffer flow limitation events, they can cause severe sleep fragmentation and constant oxygen fluctuations that damage your sleep along with your mental and physical health.

More sleep apnea resources

Getting help to successfully treat Sleep-Disordered Breathing usually defines a few different groups of patients, depending upon how they approached the gold standard treatment of Positive Airway Pressure Therapy (PAP):

• Those currently using PAP with less than optimal responses
• Those who tried PAP who have since stopped using it at all
• Those who never attempted PAP Therapy

Current PAP Therapy Users

Current users must recognize that the secret to optimal PAP Therapy is constant fine-tuning. Ultimately, this usually comes down to only 5 minutes per day, but those 5 minutes are priceless in terms of what you can tweak to insure a great night of sleep night after night.

Start with our PAP Therapy Checklist and you'll quickly discern which areas are causing most of your problems. Things like mask fit, comfort with pressure, mask leaks, mouth breathing, and anxiety responses to mask or pressure are critical factors that affect nearly all PAP Therapy users at one time or another.

In your fine tuning efforts, you will reap great dividends through constant vigilance over how to most effectively apply your breathing mask treatment. However, we find that many SDB patients, no matter how hard they try, will not get results commensurate with their efforts.

At this point, and actually much sooner at our sleep center, we encourage patients to return for a full night PAP therapy titration, allowing us to professionally evaluate and adjust everything on the PAP Therapy Checklist.

The well-trained sleep technologist may discover that:

• The mask you thought was not leaking is actually cracked
• You really are mouth breathing, and a chinstrap or partial mouth taping is the solution
• The pressures you thought were just right from the last titration turn out to be too high or too low
• The leg jerks you said you've never noticed turn out to be occurring at a rate of more than 15 movements per minute
• And the list goes on.

And, for a majority of Sleep-Disordered Breathing patients, the largest problem is that fixed CPAP pressures will never provide the best treatment results.

No surprise, most of us with SDB respond to different pressures when we sleep on our backs compared to our sides, in REM vs. NREM sleep, and during the latter half of the night compared to the first part of the night. Yet, for reasons I've never been able to sort out (except maybe through the limitations of cost and technological advances), most sleep centers continue to prescribe fixed CPAP pressures for the vast majority of their patients.

See why we rarely prescribe CPAP...

Our Model is Different

We rarely prescribe CPAP because it is an old technology. In fact, less than 2% of our patients of the last 3 years have received prescriptions for fixed CPAP. Instead, greater than 90% of our patients are now titrated with bilevel therapy, which supplies a higher pressure on inspiration and a lower pressure on expiration.

We believe that bilevel treatments as well as some of the newer technologies that provide auto-titrating technologies or "breathing assessment" devices are the clear wave of the future, and we expect that fixed CPAP will be soon recognized as a primitive treatment option that does not yield optimal results in the vast majority of SDB patients.

Thus, the Pearl that we leave you with here is to appreciate the possibility that you might never attain an optimal response while using fixed CPAP pressure. If you have addressed all the factors you think might be causing your lack of great results, you certainly should discuss how to proceed with your sleep doctor, and we recommend that you broach the topic of a bilevel titration or explore the use of the newer technological devices.

What if you're a former PAP user?...

Former PAP Therapy Users

Sadly, there are probably as many users of PAP Therapy as there are those who have tried and failed to use it. In fact, the number of SDB patients who once used a PAP device may outnumber those who are still using it.

There are many reasons for this lack of success, and I personally had to travel down many of these paths before I could find success with my current bilevel therapy. My struggles occurred during the early phase of the writing of Sound Sleep, Sound Mind; and, these barriers served as a major motivating influence to push me to find solutions for myself and others who were frustrated in their efforts.

While my book goes into more depth on this problem, the following list reflects the biggest issues I have found that prevent SDB patients from succeeding with PAP Therapy:

• Wrong mask or poorly fitting mask
• Wrong pressures or wrong pressure delivery system
• Inadequate problem-solving or coaching from the supplier of the PAP Therapy device or prescribing sleep facility
• Failure of the sleep facility to schedule PAP retitration tests to fine tune pressure settings and facilitate compliance
• Anxiety or fear about PAP Therapy
• Pain or discomfort with any aspect of the treatment
• Embarrassment, shame or guilt triggered internally by your sensitive personality or by a non-supportive family environment
• Co-occurring psychiatric conditions such as depression, anxiety, and PTSD that trigger frequent episodes of insomnia
• Co-occurring medical conditions such as chronic pain syndromes, diabetes, asthma, and heart disease that compromise functioning in general, which then limits the SDB patients ability to fine tune and follow through with all the necessary adjustments that must be made on a daily basis.

These barriers are sometimes quite large, but virtually all of them can be overcome. When you work with the right mix of sleep professionals, from the sleep staff to the sleep technologists to the sleep physician to providers of the PAP equipment, then your chances of achieving success skyrocket. These professionals will help you directly or motivate you to "help yourself" seek and apply solutions to the various barriers in your way.

In the past, you may have used CPAP to treat a sleep breathing disorder, discovered that the treatment worked somewhat well, but not well enough to put up with the general hassle. We can expect that you would remain highly motivated if your benefits were obvious, even while the breathing mask is difficult to use.

More commonly, we see patients who tried CPAP, but did not receive any benefit and found it a huge hassle. If you fall into this category, your motivation is of course much lower. Even though you may initially have been eager to gain something from treatment, your negative experience may have triggered a belief that future treatment efforts will also be negative, a hassle, or simply not worthwhile.

If you have stopped using PAP Therapy and still have a machine to use, we recommend starting with our PAP Therapy Checklist. The items on that list can help you organize your thinking to pinpoint where you need to focus for starting up again.

If it's been awhile and you no longer have a PAP Therapy device, returning to the sleep lab is the ideal way to start again, or you could contact your sleep physician to discuss your perceived barriers before returning to the lab.

Just started PAP?...

PAP Therapy Newcomers

If you've never tried PAP Therapy, you truly do not know what you're missing! Of course, that could cut both ways as you've probably guessed in reading the sections above. PAP Therapy really is a life-saver for a lot of people, but the adaptation process is quite miserable even for many who eventually obtain a great response.

At times, you would feel like the horse constantly striding after the carrot held out in front of your nose, yet never snatching even a little taste of your reward. For some, things go very smoothly very quickly, literally in a matter of days or weeks. Yet, as the complexity of your sleep disturbance increases, the likelihood of a longer adaptation period increases as well.

When I've worked with many trauma patients with insomnia, nightmares, SDB, leg jerks, claustrophobia, and who use multiple psychotropic medications for PTSD, depresssion, and anxiety, the process unfolds over a period of months and occasionally a year or longer.

Did these people believe that the effort was worth it? Virtually every patient who eventually adapts to PAP Therapy, uses it every night, and all night long will report some benefits that demonstrate to their satisfaction their sleep quality was restored in ways never previously achieved with medications, psychotherapy or any other treatment.

To conclude...

Summing Up

If you find yourself here because you have “Been There, Done That,” then we want you to know that there is still hope. While you may have “Been There” before, you most likely have not "Been Here.” Our Sleep Treatment program is based on my work with extremely complex sleep disorders patients who suffer from multiple sleep problems and often a wide range of other physical or mental health conditions.

We believe we have developed more ideas, systems, and treatments for which the vast majority of troubled sleepers can benefit. You see, we don’t believe in the “one size fits all” mentality that is seen in a lot of approaches to sleep disorders patients. Our goal is to personally tailor treatments to the individual, or to coordinate your care with your local sleep physicians, assisting them to fine tune your results by adding precise steps not previously utilized.

Our primary recommendation to you is to read Sound Sleep, Sound Mind to learn about several of these newer approaches to insomnia and sleep breathing problems. But, we also welcome the opportunity to consult with you personally, if you think we can help you get started again with PAP Therapy or fine tune your current efforts. Click here to learn about becoming a patient, or here to learn about setting up a consultation in which our sleep center works directly with your local sleep physician to assist in optimizing your care.

Sleep breathing problems are the single most common physical disturbance in someone who suffers from poor sleep quality.  Whether you suffer from insomnia, complain of nightmares, restless or jerking legs, or show signs of poor functioning on the Sleep Misery Index, remarkably, breathing problems are the most universal finding among all these types of troubled sleepers. 

Many with sleep problems have a great deal of difficulty accepting or appreciating the role of breathing when it comes to sleep.  But, let's stop for a moment and ask ourselves, "what is the single most important physiological function of the human body?"  Answer:  Breathing!  Indeed, if you stop breathing for just a few minutes, the risk of brain damage is enormous.  Think about the role of CPR; why is it so important to pump on the chest wall?  Answer:  To deliver oxygen to the brain and to the muscles of the heart.

If breathing is so important to your survival, I would ask, "how could breathing not be an important factor in your sleep? How could it not have a major influence on your slumber?" 

As you will soon discover, breathing is critical to Sound Sleep, because even the slightest disruptions in breathing can lead to major disruptions in your sleep. Yet you must  this crucial point: it is extremely difficult, if not impossible, to gain any awareness about your own sleep breathing disruptions, because you are asleep when they occur.

If you want to figure out now whether or not breathing could play an important role in your particular sleep disturbance, I invite you take the 3 survey components below.  Each component shows you a different way to predict whether or not you suffer from a relevant sleep breathing condition.  

• Unrefreshing sleep
• Poor sleep quality
• Daytime sleepiness or fatigue
• Breathing disruption episodes during sleep
• Snoring
• Difficulty with Concentration and Memory
• Morning Headaches
• Waking up at night to use the bathroom
• Waking up with a dry mouth
• Insomnia and unexplained awakenings
• Leg jerks / restless legs at night
• Abnormal behaviors at night (e.g. sleepwalking)

• Snoring
• Waking up unrefreshed
• Poor Sleep Quality
• Daytime Sleepiness or Fatigue
• Difficulty falling or staying asleep
• Waking up with headaches
• Difficulty with concentration and memory
• Waking up at night to use the bathroom to urinate
• Waking up sweating