Obstructive Sleep Apnea

Podcast Transcript

Raed Dweik:

Hello and welcome to the Respiratory Inspirations podcast. I'm Raed Dweik, chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Hello, everyone, and welcome to this episode of Respiratory Inspirations. I'm your host for today, Raed Dweik, the chairman of the Respiratory Institute at the Cleveland Clinic. And my guests today are Dr. Reena Mehra, who is the director of sleep disorder research at the Clinic, and Dr. Loutfi Aboussouan, who is the director of the neuromuscular program here. And the topic today is something familiar to both of them: obstructive sleep apnea. Welcome.

Dr. Loutfi Aboussouan:

Thank you.

Dr. Reena Mehra:

Thank you so much.

Raed Dweik:

Loutfi and Reena let's start with the very basics. You know, for our audience, what obstructive sleep apnea is?

Dr. Reena Mehra:

Obstructive sleep apnea involves the collapse of the upper airway. So, the airway closes off, and apnea means that there's then stopping of breathing for 10 seconds or longer as a result of that collapse or closure of the upper airway. And then as a consequence, what happens is the oxygen levels can go down, blood pressure can rise, and carbon dioxide levels can rise.

Raed Dweik:

Yeah, so that seems very dangerous, you know. But it doesn't happen for very long, right? But it happens frequently at night, right?

Dr. Reena Mehra:

That's right. So, the definition of an apnea is that it must occur for 10 seconds or longer, the equivalent of the average adult missing two breaths. And the duration of these events can vary from person to person. So sometimes they can be shorter. Sometimes they can be up to 30 seconds, a minute long, for instance, and it depends upon the kind of mechanisms, the arousal mechanisms, and when those kick in, in terms of the duration of these events.

Raed Dweik:

And usually, the way I understand it, the individual may not be aware of it. But if you have a sleeping partner, that's how they notice. And that can be scary sometimes to notice that somebody next to you has stopped breathing.

Dr. Reena Mehra:

Oftentimes, it is the bed partner that prompts the patient to come for an evaluation. And yes, there can be absence of these witnessed apneas and still be obstructive sleep apnea. So sometimes, people will have other symptoms. And in the witnessed apneas aspect of things, it depends upon if the bed partner is awake enough to be able to observe these events.

Raed Dweik:

Yeah so, the other thing that probably people are more familiar with is snoring, right? And how is snoring related to sleep apnea? Is that the same, or are they two different things or are they related? Loutfi.

Dr. Loutfi Aboussouan:

Yeah, that's wonderful. So actually, most of the patients who have sleep apnea have snoring, but not everyone who has snoring has obstructive sleep apnea. So, I think I would consider snoring as part of the continuum of the disease.

One way I explain it to patients, so it's really vibration of the upper airway because of this collapse of the airway. And one way I discuss this with my patients is the concept of nodding off. You know, I'm talking to you right now. My head is upright because the muscles in the back of my neck are holding my head up. But I'm not aware of that until I sleep, and my head falls off. So, it's the same with the muscles that hold the airway open. You're not aware that they're held open until you fall asleep and then it starts narrowing. And that could start the snoring process. And along that spectrum, as it gets worse, if the narrowing gets worse, the narrowing could lead to actually obstruction and drops in oxygen and so on. So that's how I tend to explain it to my patients.

Raed Dweik:

Yeah, that's a great explanation. But now, let's say you are the bed partner or the spouse of someone and you hear them snoring. Does that mean, automatically mean you have to kind of take them to the emergency room and say like, there is something wrong with them? Or what's your approach to that?

Dr. Reena Mehra:

That's taking it into context. So, if there's snoring, there's other symptoms of obstructive sleep apnea such as daytime sleepiness, fatigue, restlessness of sleep is not specific, but it is a very common symptom of obstructive sleep apnea, and there are a variety of other symptoms as well. So, snoring onto itself? Perhaps not. But if it's in the context of some of these other symptoms, then that's what really raises the suspicion for obstructive sleep apnea.

Raed Dweik:

Yeah, that's make a lot of sense. Like, not just snoring alone, but other things that, you know, are like, not having a good night's sleep, I hear that often when you wake up in the morning, you are not refreshed. Is that a good indicator that there's something going on?

Dr. Reena Mehra:

Yeah, so unrefreshing sleep is quite common in obstructive sleep apnea. Again, not specific, but in the context of other symptoms. So, if there's snoring, unrefreshing sleep, daytime fatigue, sleepiness, morning headaches, dry mouth in the morning, awakening to urinate at night. A lot of people are not aware that that is a symptom of untreated obstructive sleep apnea.

Raed Dweik:

That's a very good tip. Anything to add to that, Loutfi?

Dr. Loutfi Aboussouan:

This is a great point. Many urologists refer patients to us because they recognize nocturia. And patients won't tell us, but one of the things they say after they start CPAP is I didn't tell you, but I don't wake up anymore to go to the bathroom. I don't wet the bed anymore accidentally. These are the things they notice and report.

Dr. Reena Mehra:

I agree with Dr. Aboussouan. The awakening to urinate sometimes is not picked up on. And those are some of our most grateful patients, are the ones where they're no longer awakening to urinate and then have better continuity of their sleep as a result.

Raed Dweik:

So, let's say as a patient or as a partner you recognize, well, I may have sleep apnea. What are the next steps? What should you do next?

Dr. Reena Mehra:

So if we're suspecting that there's sleep apnea, then having a formal evaluation by a medical provider that can then do a formal assessment of the symptoms that the individual's having and also doing a physical examination to look for factors that put people at risk for sleep apnea, and then taking all that information together to understand how likely it is for somebody to have sleep apnea and then potentially the need for diagnostic testing.

Raed Dweik:

So let me ask the next question, too, is say you see your physician and they don't think you have sleep apnea. So, I guess is that it, or you have to require, you know, you insist on seeing a sleep specialist? Or maybe if the physician agrees that you have sleep apnea, what do you do next? You know?

Dr. Loutfi Aboussouan:

Once sleep apnea is suspected, I think it's important to pursue that. One important thing to ask is actually the opinion of the bed partner or the spouse because in my experience, the spouse is actually more in tune with what's going on than the patient himself or herself. They are more aware of things that may be going on in sleep or daytime functioning that the patient himself may be suppressing or not aware of. So, I think making sure that the physician who wasn't convinced this is sleep apnea should talk to the spouse. And I like to have a partner in the room when I do an interview. I think that's important. So that's where I would push. I would push for; you know confirming the diagnosis.

Raed Dweik:

Especially if you have the symptoms we talked about earlier, like dry throat, daytime sleepiness, not refreshing sleep. You know, you should really continue to push for that, right? You should not take no for an answer if you have significant symptoms. If it's just snoring, you can move on. But if it's beyond snoring, I think what I'm getting from you is you should pursue it.

Dr. Loutfi Aboussouan:

You should pursue it and definitely ask your partner. I think they're helpful. We sometimes call them on the phone when they're not in the clinic. I end up calling them.

Raed Dweik:

Yeah?

Dr. Loutfi Aboussouan:

You know, what does your wife think? I want to talk to her.

Raed Dweik:

Oh okay. Well, we don't get into domestic disturbances here. Okay, so what's next? Let's say, you know, we agree this sounds like sleep apnea. What are the next steps for me as a patient, let's say I'm a patient or a family member. What do I expect next?

Dr. Reena Mehra:

So, for suspecting obstructive sleep apnea, then the next steps would be really to undergo testing to figure out whether there really is sleep apnea. We know that unfortunately, clinical symptoms, characteristics of the, on physical exam are not sufficient in of itself to really make the diagnosis of obstructive sleep apnea. So, the different ways we can approach it include home sleep apnea testing and polysomnography.

Dr. Loutfi Aboussouan:

With the home sleep apnea tests, it's very simple. And I've done that on myself as we were sampling the equipment. We were sampling the equipment to decide which ones to settle on. I got a feel for it.

Raed Dweik:

It's nice. You got a free test. You got a free test.

Dr. Loutfi Aboussouan:

Yeah. So, you put the belt over the abdomen, a belt over the chest, a little sensor over the nose and the mouth. So, the belts over the belly and chest are picking up whether the patient is breathing or not, and then the flow over the nose and mouth is picking up whether, is there a follow-up flow getting in and out of the lungs? And that's really the key part of how we diagnose sleep apnea. Is the breathing of the chest and belly effort, is it translating into a flow through the nose and the mouth? And then the other characteristic that we measure is the oxygen level. We want to see if there's a correlation between the stoppage of flow or narrowing of the flow pattern and a drop in the oxygen level. And that's what a home sleep study will tell us.

Raed Dweik:

Yeah. The drop in the oxygen level sounds serious. And I know maybe we didn't talk about this. This seems like maybe there's serious consequences for that, so what are some of the health effects of really having sleep apnea and not treating it?

Dr. Reena Mehra:

Yeah, so the oxygen lowering, the intermittent rises in blood pressure and heart rate and CO2, carbon dioxide levels, over time when we have these repetitive nighttime stresses, this really then increases the risk for a variety of cardiovascular outcomes.

Raed Dweik:

Heart disease, basically.

Dr. Reena Mehra:

Heart disease.

Raed Dweik:

Yeah.

Dr. Reena Mehra:

Exactly. And the strongest heart outcome related to sleep apnea is really high blood pressure. And there are many studies that have shown that treatment of sleep apnea will actually help reduce blood pressure oftentimes not enough for people to come off of their medications, but it improves the profile of the blood pressure. In addition to negative heart outcomes, there can also be relationships with negative neurologic outcomes as well, even, ability to focus, concentrate and stroke outcomes as well.

Raed Dweik:

So how do we treat this then? It looks like it's important to treat since this has negative consequences. How do we treat sleep apnea?

Dr. Loutfi Aboussouan:

So particularly when it comes to patients with these cardiovascular problems, such as heart problems or hypertension problems, I think the most important application of the treatment would be CPAP, I think. That's continuous positive airway pressure. So, because the airway is narrowing during sleep, we try to open it up. At this point, we don't have drugs, at least on the market, that would open up the airway. Just simply taking a pill that would help open the airway and keep it open. So, we depend on pushing air into the airway.

Just like when you pump air into a bicycle tire, you just pump a little bit of air under pressure. We don't add oxygen. The machine doesn't add oxygen. It's just pressure. And it splits the airway open. It just pumps it open and allows the air to go through. Even though the muscles that hold the airway open are too relaxed, the pressure inside the airway will keep it open, just like pumping a bicycle tire. And that usually improves the condition. It builds up the oxygen level over time. It may improve blood pressure in the long-term. It may reduce a serious consequence down the line. And in the short-term, it may improve the quality of sleep or reduce the risk of car accidents.

Raed Dweik:

The way you describe it, I wonder if a patient is listening, they think, that sounds uncomfortable. How comfortable or uncomfortable is this to kind of blow air into your mouth to keep it open?

Dr. Reena Mehra:

You know, it does take some getting used to, and that is why the initial exposure to CPAP, or continuous positive airway pressure, is really important to make sure that, you know, if it's in the sleep lab interacting with the technologists or with the durable medical equipment company that supplies the device and the respiratory therapist from there that the patient gets some TLC, some tender loving care, and attention in terms of figuring out okay, you know, how are you doing with the mask? How are you doing with the pressure? You know, we have various tricks up our sleeve for most of the issues that are encountered with CPAP.

And most patients actually tend to do quite well. I mean, I recently saw a patient who actually told me yesterday that he looks forward to using his CPAP. He finds it comfortable and soothing and, in some ways, reassuring knowing that his sleep apnea is being effectively treated.

Raed Dweik:

Yeah, that's wonderful to hear. We've all had these patients who get on CPAP, and they just swear by it. You know, it makes them feel better in the morning. They sleep better, and, you know, even take it with them, you know, on their travels. The equipment is easy to carry around and take with you, so that's really good to hear.

But we all have had those patients also. So, what you're recommending, what I'm hearing is give it some time and try to work with your physician and therapist to make sure you get the right equipment. But let's say all of that doesn't work. We've all had patients who still, despite all that, don't tolerate the CPAP. Are there any other options for them?

Dr. Loutfi Aboussouan:

You have to strike a little bit of a balance. You can't impose CPAP on a patient if it's obviously not a solution for them because you're going to lose them. And on the other hand, it's still the most important option. So, I want to make sure we exhaust all possibilities before we give up on CPAP, especially if it's a more serious sleep apnea, because other options are not going to be as effective.

For patients, I often tell them, this is a little bit like learning to ride a bike or drive a car. Neither of those are natural, nor using CPAP is natural either. But you use a bicycle. You drive your car. And actually, it improves your life because it gets you where you want to go. And the same with CPAP. Give it some time to get familiar with it. I think that's what's important.

And let's say it's not an option at all. You've tried for a year and it's not an option for the patient. I think we have other options. We have oral appliances. These are little devices that you know, they anchor at the top of the teeth and the bottom of the teeth, and they move the jaw forward. So that opens the back of the windpipe and actually helps control. So that's also an option.

And their other option they may hear a lot on television is the Inspire therapy, which is an electrical, it's a pacemaker, essentially, that's placed inside the body. And that sends a little impulse to the tongue to move it forward every time they breathe to keep the airway open. So that's an option for some people who are unable to use CPAP and need treatment.

Raed Dweik:

That's great. And anything to add about these treatment options?

Dr. Reena Mehra:

No. I think, you know, patient preference is really important to take into consideration and the notion that this is really a partnership between the patient and the provider.

Raed Dweik:

Okay. Thank you. The other thing is, you know, we hear about always weight loss. Can I just forget all these things? Can I just lose weight and be better? You know, what do you think?

Dr. Loutfi Aboussouan:

I'm glad you asked that. This is always a good thing to do. So, these conservative options that include weight loss, you know, sleeping on the side, avoiding alcohol, are all very important. I think this type of lifestyle change is important. Weight loss, it works very well. You know, a 10 percent weight loss can improve your sleep apnea about 30 percent, 25-30 percent. That’s worthwhile.

So definitely, weight loss is part of the treatment. It may not be the only treatment, so we may need to continue CPAP in the meantime. And if somebody feels like they lost enough weight, that sleep apnea is gone, I think it's important to double-check by repeating a sleep study if that's the case.

Raed Dweik:

That's wonderful. Any other thoughts?

Dr. Reena Mehra:

No, I think that's absolutely right. I think weight loss sometimes isn't the entire solution, but certainly lifestyle modification, discussing, you know, diet, exercise and even partnering with our endocrinology team, bariatric surgery program in some instances as well if there's morbid obesity to try to mitigate that risk in the effort to try to address their obstructive sleep apnea and other aspects of their health as well.

Raed Dweik:

Yeah. Yeah, you mention bariatric surgery. Is that a solution? You know, for people who qualify, does that cure sleep apnea?

Dr. Reena Mehra:

The data are differing on that front, actually. There are some data to show that it actually effectively resolves sleep apnea. And in other trials, it actually has not. And the reason probably for the differences in results is because while obesity is a risk for obstructive sleep apnea, it's not the entire picture in many cases. For instance, if there's differences in how our soft tissue of the upper airway is set up or our bony structure of the airway is set up, then the risk of sleep apnea may persist even if there is weight loss. So, in those trials that maybe didn't see as much of an improvement in sleep apnea with weight loss, perhaps there were some more of those underlying risk, other non-obesity risk factors that were present in that population.

Raed Dweik:

Yeah. And one other point I'd like you both to clarify, maybe, you know, we have this phenotype in our mind that sleep apnea patients are overweight, but not every sleep apnea patient is overweight. There are some people who are normal weight and still have sleep apnea. Can you maybe comment on that so that, you know, people who have normal weight, don't have a Get Out of Jail free card for sleep apnea. They may still have it. Is that true?

Dr. Loutfi Aboussouan:

That's very true. About 20 percent of patients with sleep apnea are not overweight, and it has to do with other anatomic features: a larger tongue, a smaller jaw, a jaw that is retracted posteriorly to the back. Anything that narrow, as Dr. Mehra mentioned, the level of obstruction of the airway could be, could be in different places. It could be in different places on the airway. And any problem at any of these anatomic sites could cause sleep apnea without weight being a factor.

Raed Dweik:

That's funny. Thank you for clarifying that.

Dr. Reena Mehra:

This is an important point, and I'm glad you're raising it because a lot of people have in their mind this kind of phenotype of risk. And we have non-obese patients that come to our clinics who have a lot of symptoms. And they are maybe a little reticent to come in because they say, well, I'm not overweight or obese. So, it's really important to remember we have thin, maybe overweight patients who are not obese.

And I think there are also, as we're thinking about the phenotype that we conjure up in our mind with sleep apnea, many people also think about an older male individual. You know, in women, sleep apnea also can start to increase in prevalence in the post-menopausal stage. Although sleep apnea is two to five times more common in men compared to women, in women again in that post-menopausal stage, sleep apnea can kind of rear its head. And the symptoms that women have can be different. Just like with heart symptoms, that those can be different in women versus men, also sleep apnea symptoms may be more fatigue than sleepiness, more changes to mood, more insomnia and different sort of symptom profiles that are present in men, in women versus men who have sleep apnea.

Raed Dweik:

Yeah, wonderful. Thank you for clarifying that. As we close, any other final comments from either one of you about something you'd like to share with the audience that we did not cover?

Dr. Loutfi Aboussouan:

I think the most important thing is that this is a common disorder that has consequences. When I was studying this disorder, the pendulum was swinging back and forth, oh, this is just snoring. Don't worry about it, too this is a very serious disease. I think we're more towards the end that this is a serious disease that we need to be aware of, not miss it and treat it.

Raed Dweik:

Let me just add to those. So, I appreciate your time. I think the tips that you provided, and the information are gonna be very helpful to our audience.

What you just mentioned, Loutfi, is that it's a common disease. It has serious consequences, mainly for the heart but also, you know, especially blood pressure and others. It's very important to treat.

And also, you know, it's important to recognize, even, in the first place. And we talked about snoring and how snoring, you know, is common in sleep apnea, but not everybody who snores has sleep apnea. But it's probably something to think about if you're snoring. Do I have any other symptoms? You know, am I sleepy in the daytime? Am I not getting refreshing sleep? Do I have a dry throat in the morning? These are the kind of things to think about and make you more worried about having, you or a family member having sleep apnea. This is when you need to be evaluated. And that usually involves home sleep study, but it also, depending on what your physician recommends, you may end up having to go to the lab in the hospital and get a more formal sleep study.

And the main treatment is CPAP. It's something that most patients tolerate, and it's important not to give up on it too soon because sometimes it takes some adjustments to make sure that you tolerate it. There are other options, like oral devices, but they are not as effective, maybe, especially for more serious sleep apnea. I don't think we talked about something more recently in the news, which is the Inspire devices, I think. Did we talk about it?

Dr. Loutfi Aboussouan:

We did cover that a little bit. Electrical stimulation of the tongue to move it forward during sleep. And it's timed to when the breath is taken. But that helps. It's a surgical option for some patients, not everyone. Definitely, CPAP should be tried first because it's a surgery and because it's more invasive. But it is very effective and may be a solution for some.

Raed Dweik:

Thank you both. It was a very informative episode. Again, this is Raed Dweik, chairman of the Respiratory Institute. I was your host today, and my guests were Dr. Reena Mehra, who is the director of sleep disorder research at the Clinic, and Dr. Loutfi Aboussouan, who is the director of the neuromuscular clinic. And thank you both for joining me today and thank you to our audience for listening. And have a great day.

Thank you for listening to this episode of the Respiratory Inspirations podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at @RaedDweikMD.