Today's #Sleeptember FACT --- Snoring as a result of allergies

#SLEEPTEMBER

If you've been sneezing a lot lately and you're certain you don't have a head cold, you probably have allergies or sensitivities to particulate matter in the air. Pollens and grasses are problematic all the way to the end of the fall, but people who live in areas where wildfires are a problem will also suffer from rhinitis caused by the added smog caused by them.

At SHC we often talk about snoring in the context of obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS), but allergies can also commonly lead to snoring. After all, the mucous membranes are swollen or inflamed as they do their work battling histamine responses and filtering external pollutants and allergens. When you have a swollen upper airway, and your nasal passages are congested, you naturally have an increased chance of snoring while you sleep.

"20 Minute Fix for Nasal Allergies."
Turbinate coblation procedure on video (snip).

Aside from treating the allergies so that you don't have strong reactions to particulates that lead to airway restrictions, you can also treat  chronic snoring related to allergies by a procedure known as turbinate coblation. This outpatient treatment shrinks the swollen turbinate tissues within the nasal passages to achieve better air circulation in the upper airway, which can lead to fewer problems with snoring. Patients receive the procedure and then immediately return to a normal day of work or family; there is no downtime associated with turbinate coblation.

See the video about how this procedure is performed here. 

Note: the procedure, which lasts between 10 and 20 minutes and can be done during one's lunch hour, can cost up to $1500 and may or may not be covered by insurance. However, patients who've received this treatment say it does work immediately and the results are positive and noticeable.

If you are interested in learning more about turbinate coblation, please consult your general practitioner to determine if you are a good candidate for this procedure.

SLEEP STUFF: Anti-snoring nasal products

For some people, the worst thing about their sleeping life truly is their snoring. It's loud enough to keep their sleeping partner awake, and it leads to discomfort in the nasal tissues and airway, dry mouth and sore throat. 

For those who snore but do not have sleep apnea*, the options for treatment are a bit different. It may be that they have other issues causing their airway resistance, such as a deviated septum, chronic allergies, narrow passageways or other physiological problems, such as overlarge tonsils or swollen turbinates.

Many of these people qualify for surgical approaches to repair their physiological challenges, but these can be expensive procedures, difficult for adults to recover from and may still not completely eradicate the problem.

Treatment of allergies is generally limited to nasal steroid sprays and medications, yet chronic post-nasal drip associated with allergies--even when treated--can still contribute to snoring.

There are small companies out there manufacturing various kinds of mechanical devices which promise to help physically open up the nasal passages via the nostrils in order to facilitate better breathing.

Some users swear by these products, while others try them and find no relief. Fortunately, most of them are inexpensive and promise to be a one-time purchase, so if they do work, the promise of a simple inexpensive solution delivers.

Listed below are four products out on the market that have been created to assist those people with sleep breathing problems that are not related to apnea or upper airway resistance that can be linked to a clinically identified respiratory system condition.

NASAL DILATORS
These products use plastic or medical grade stainless steel with silicone to physically widen, or dilate, the nostrils in order to increase airflow while sleeping. The applications vary, but all of them require inserting a portion of the dilator into the nostrils. The user adjusts the device following instructions provided by the manufacturer to achieve a widening of the nasal passages. Some of these devices are meant to be cleaned and reused repeatedly, while others are disposable and recommended for up to three uses in a row before disposing. These products are generally marketed toward people who struggle with nasal congestion, allergies, deviated septum or sinusitis, all of which can interfere with breathing during sleep. Price ranges are all across the map; cheaper dilators tend to be all-plastic and disposable, while more expensive ones that incorporate stainless steel wire run closer to $30. Some brands available include Airmax, Brez, ClipAir, Nozovent, Respitec, Rhyno and SleepRight. FDA approval depends upon the product.

NOSE CONES
These are a different variety of device which are shaped exactly as they sound, like tiny conical shaped cage-like inserts for the nostrils. They also purport to prevent nasal collapse while sleeping and can be found in both disposable and reusable options. Some brands available include Max-Air, SinusCones and Snorepin. FDA approval depends upon the product.

NASAL STRIPS
You're probably most familiar with these products, BreatheRight being the most popular brand. These external nasal passage wideners are applied across the bridge of the nose, and usually incorporate tension from the adhesive with or without a wire insert to stretch open the upper passage of the nose. They come in a wide variety of options, including some with fragrances, color choices, variations in strength and special adhesive for sensitive skin.

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*The only way to know whether a snoring condition is related to sleep apnea is to undergo a sleep evaluation from a sleep health professional. Not all snorers have sleep apnea and not all people with sleep apnea snore. SHC encourages its readers to seek the advice of a medical professional and resist the urge to diagnose themselves. 

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A friendly reminder that links to websites offering products does not imply endorsement by SleepyHeadCENTRAL.com.

SleepyHeadCENTRAL strongly encourages people with ongoing sleep health problems to approach a medical professional to determine appropriate differential diagnoses and treatment. This post, like all other posts on SHC, is not intended to substitute for medical advice.  

The Wisdom of Sleep || Anthony Burgess

"Snore" (2007) by blogger Sue Ling.

LAUGH and the world laughs with you; 

SNORE and you sleep ALONE. 

—Anthony Burgess, author (1917-1993)

WOMEN & SLEEP || Adventures in Sleep for the Pregnant Woman, Part Three: The Third Trimester

Congratulations! You've made it to the final third! Now what?

Many sleep problems return as your body and baby both grow more rapidly as you near the end of pregnancy. You may find you cannot sleep at all at night, thanks to the kicking baby and other pregnancy-related sleep disturbances. Knowing what you can expect and preparing for it can be helpful in getting through these last 13-15 weeks.

The main problems pregnant women experience with sleep during the third trimester relate to the following challenges: 

1. Bladder issues
2. Fatigue 
3. General discomfort
4. Heartburn 
5. Obesity
6. Snoring

Let's take a closer look. 

Bladder pressure returns in the last third of pregnancy because, you guessed it, there's little room left for all your different parts in the presence of your growing baby. You may even feel as if you are being kicked or pushed on by the baby as they float about in the womb. It will make you want to use the bathroom a lot, but don't limit your consumption of fluids if this is the case. Solutions? Time your water drinking so you get most of your fluids during the day, if that helps keep you in bed more at night. Try to lean forward when on the toilet to fully empty the bladder, as well. 

Some people find the new-fangled device, the Squatty Potty, a great tool for helping to void urine as it allows you to tilt your pelvis in a way that makes urination and defecation easier to complete. Fully voiding the bladder may help give you more uninterrupted sleep at night or during naps.

Fatigue comes back again, maybe worse than ever. It's all for the same reasons before: either your body is working in overdrive and you need to rest and recharge your batteries, or you may have some hidden sleep breathing issue or restless legs concern interrupting your ability to sleep soundly.

Solutions? Nap whenever possible, and look into advice from your doctor for any nighttime sleeping issues which might be disrupting your sleep pattern if they relate to discomfort in the legs or breathing.

See Also:
Adventures in Sleep
for the Pregnant Woman, Part One:
The First Trimester
---
Adventures in Sleep
for the Pregnant Woman, Part Two:
The Second Trimester
---
Adventures in Sleep
for the Pregnant Woman, 
Postpartum Edition

General discomfort with your pregnant body is a common problem at bedtime; it's hard to find a comfortable position for sleeping. Your baby maybe be very active, it seems, at night (which is not necessarily true; you might just notice their activity more when you are at rest). Finally, you may suffer from back pain (especially sciatica) from carrying out your load, and that can interfere at night when trying to get comfortable for sleep. 

Solutions? Enjoy the feelings that come from your kicking baby! It's a good sign that all is going well from the inside. Using pillows to prop you up and/or support your back while sleeping is a popular solution when the belly becomes too big to move about easily. Sometimes a recliner makes for the perfect solution, and don't forget to consider propping up the head of your bed by 3 inches. Easy lower-back stretches, massages, and warm baths can help with back pain before bedtime, as well.

Heartburn, gas and reflux come back with a vengeance, too; your digestive system is cramped and overtaxed with processing your meals. It may even make you less hungry; the thought of discomfort after meals can be a real motivation for not eating at a time when your baby needs you to be eating well. 

Solutions? Propping up the head of your bed by 3 inches uses gravity in your favor to keep food moving downward through your digestive tract. This may also be a good time to use a recliner. Eat smaller meals made of complex carbohydrates and lean proteins more frequently to keep a steady supply of nutrients without sending your system into turmoil. Avoid high-fat foods or foods you know will make you gassy. Drink your water, too, as it is essential for good digestion. There are some calcium products that are safe to use for heartburn during pregnancy; ask your doctor if you can't seem to surmount these challenges at night. There's no need to suffer unnecessarily.

Aside from obstructive sleep apnea, obesity during pregnancy
can bring on a host of other unwanted problems. 

Obesity can become a problem at the end of pregnancy. You are supposed to gain some weight, but sometimes the weight gain becomes very hard to control, and yet you still need to eat to support the baby. It is concerning not just from a general standpoint, but because it can become a major risk factor for sleep apnea during late-stage pregnancy; the extra tissue in your neck and throat can threaten to block your airway at night, which puts both you and baby at risk for hypertension, insulin resistance and other problems.

Solutions? Try to exercise however much you are able in order to maintain good metabolism. Choose foods that are nutrient dense but not calorie dense. Avoid empty calories and high-fat foods, especially take-out, fast food and junk food. It's of questionable value to you and your baby. Ask your doctor for help if you wake up with headaches, see a rise in blood pressure, start retaining water unnecessarily, or have sore throats or dry mouth upon awakening as each of these may signal the presence of upper airway resistance or apnea. 

Snoring will likely return in the third trimester. It may be harmless but it could also indicate upper airway resistance or apnea. You don't have to be overweight to snore. You could have allergy issues, or problems with nasal or sinus congestion that mean you have extra mucus or swollen membranes getting in the way of your ability to breathe while asleep. 

Solutions? It never hurts to use saline nasal spray to keep passages moist and to relieve elevated levels of mucus. Ask your doctor to check out your options for safely treating concerns about nighttime congestion.

WOMEN & SLEEP || Adventures in Sleep for the Pregnant Woman, Part Two: The Second Trimester

See Also:
Adventures in Sleep
for the Pregnant Woman, Part One:
The First Trimester
---
Adventures in Sleep
for the Pregnant Woman, Part Three:
The ThirdTrimester
---
Adventures in Sleep
for the Pregnant Woman, 
Postpartum Edition

So you've made it through the first 13-14 weeks, congratulations! You may find the second trimester much easier to cope with in regard to sleep issues. Less nausea and more energy are common improvements women enjoy as they move into the middle of their pregnancy. But sleep may still be disrupted, at least compared with how you slept before pregnancy. 

Potential sleep disruptions during the second trimester include: 

1. Sleep breathing problems
2. Charleyhorses and restless legs
3. Vivid dreams 

Let's take a closer look.

Sleep breathing issues can become more apparent during the second trimester. At this point, the pregnant woman has gained some necessary weight, and swelling and fluid retention have likely become the new "norm." 

Sleep breathing issues that can emerge include snoring, nasal congestion, upper airway resistance and obstructive sleep apnea. 

Body tissues during pregnancy soften due to hormone changes and retain more fluid, making the airway a target for airflow resistance. Mucus membranes may in fact be generating even more mucus than normal, which contributes to that resistance. Snoring reflects the vibrations and sounds that come from the friction inside the airway as the person breathes in and out. Nasal and sinus congestion can also be blamed on these hormonal shifts. Blood vessels will also expand, crowding your airway passages as well. 

Upper airway resistance syndrome is a sleep disorder in which the pattern of snoring and friction through the nasal passages and upper airway in general leads to micro-arousals, mini waking sessions which disrupt the architecture of sleep and can lead to sleep fragmentation, a cause of excessive daytime sleepiness. 

Finally, if the airway becomes blocked, either partially or completely, by enlarged or swollen tissues or due to fluid retention in the neck, obstructive sleep apnea can occur. OSA is especially concerning for pregnant women because it leads to lower blood oxygen saturation during the night which can have negative impacts on both mother and baby.

Solutions? Speak to your doctor about nighttime congestion, excessive daytime sleepiness or any reports from your sleep partner about gasping, loud snoring or choking sounds you might be experiencing during sleep. Other signs you might have a sleep breathing issue include waking up with dry mouth in the morning, headaches upon waking, and elevated blood pressure that can't be explained by anything else. 

Snoring and congestion can usually be corrected by simple treatments or behaviors like positional therapy or saline nasal spray. Try elevating the head of your bed by three inches to help with postnasal drainage, and learn how to sleep on your side, if you haven't already.

If your doctor suspects UARS and/or OSA, they may have you participate in a home sleep study and/or an overnight sleep study to identify what's going on so they can give you appropriate treatment.  This can include a trial on PAP (positive airway pressure) therapy or an oral device to reposition your jaw so that your airway remains clear throughout the night.

Nighttime leg cramps, sometimes called "charleyhorses," are a common complaint among women who are pregnant. You're sleeping just fine, then WHAM! your toe or calf muscle seizes up, sending you out of your bed to massage the rock-hard spasm or walk it off. The experience is painful and highly disruptive to sleep.
Similar to these leg cramps are restless legs. They occur just as you are going to bed; your legs begin to feel restless and you are compelled to walk to calm them down. Some people describe the feeling as crawling, tingling or burning sensations or an undeniable need to move the legs. As many as 16 percent of all pregnant women experience restless legs. Restless legs can happen during the day as well, especially after long periods of sitting. At night, however, they become a nuisance because they can force a delay in sleep onset and pregnant women need to get as much sleep as possible.

In either case, leg cramping may indicate a dietary imbalance in minerals like potassium, calcium, magnesium or iron. It could be that your enlarged blood vessels in your legs experience more pressure than usual, leading to these kinds of discomfort. Surges in estrogen and progesterone can lead to the experience of restless legs. Finally, restless or cramping legs may present in a way that is similar to "growing pains" in children. Many pregnant women literally feel their body growing while pregnant and these sensations in the legs might reflect that phenomenon. 

Solutions? Some simple habit changes can go a long way to help you prevent leg cramps at night, such as standing for long periods or sitting in a way that prevents good blood flow. You would be better off moving your body from sitting to standing to walking to elevating your feet throughout the day to improve circulation in your legs. Stretching your calves and moving your feet in circles in both directions also offers some relief; so does massage. Left side sleeping improves blood circulation while you sleep. 

Don't forget to drink you water as dehydration can be a direct cause of leg cramps. If you drink a lot of tea or coffee during the day, you may rethink this habit; both have a diuretic effect on the body and can lead to unintentional dehydration. If you don't want to exclude these beverages from you diet, at least consider chasing each glass or cup of tea or coffee with an equal amount of water to replace your fluids. Remember, dehydration can also lead to ongoing fatigue.

How to fix a charleyhorse: Stand upright and straighten your affected leg, flexing your heel so that your toes are pointed back toward your shins. Breathe through the pain this might cause at first; it will subside as the spasm lets go of the affected calf muscle. Walking a few minutes to improve mobility of the muscle, or using a hot pad or heating ointment on the muscle can also help.

Be wary of any swelling or tenderness in your leg that may accompany the cramping. With the larger volume of blood circulating in your blood vessels, the odds naturally increase for blood clots. Though these are rare, they still require immediate identification and treatment. 

For people with restless legs, a massage or warm shower at bedtime can be extremely helpful for calming those uncomfortable sensations. Taking a short, slow walk can also help. It may be that an increase in light exercise during the day can counteract some of the restlessness that some feel in their legs at night.

Finally, many women will swear on supplements for minerals like magnesium, calcium, potassium or iron; you are best advised to discuss these possibilities with your doctor. For most pregnant women taking an iron-fortified prenatal vitamin, the amounts dosed in this daily supplement should be enough to supplement their needs. However, eating foods high in these minerals is still a better way to improve their levels in your bloodstream, since eating mineral-rich foods makes many minerals and vitamins more bio-available, which is better for both mother and baby. 

A vivid dream life may continue into your second trimester (see our comments on what this means in Part One). Again, go with the flow and try not to let this bother you. Dreams are a great release for anxiety and you shouldn't worry about them too much.

IN CASE YOU MISSED IT: Our most popular posts in April

As determined by Blogger, Twitter, StatCounter and Google Analytics:

THANK YOU FOR VISITING! TELL YOUR FRIENDS! --The Curator

Posts

• April 15 || JUST BREATHE: Upper airway resistance. It's a thing. And it matters
• April 8 || JUST BREATHE: What happens if I don't treat my sleep apnea?
• April 30 || JUST BREATHE: "Heard About Sleep?" APNEA... If not, listen in here
• April 10 || JUST BREATHE: How to find out if you have a sleep breathing disorder 
• April 23 || JUST BREATHE: Hope2Sleep's "Dangers of Untreated Sleep Apnoea" infographic
• April 23 || JUST BREATHE: Go to the dentist to fix your apnea?
• April 21 || JUST BREATHE: CPAP basics--how to get through the adjustment, how to improve long-term outcomes
• March 24 || INSOMNIA: Why is it linked to depression?
• April 20 || JUST BREATHE: Twelve of our best previous posts on sleep breathing disorders
• April 6 || Today is Drowsy Driving Awareness Day in California: How sleep apnea fits into this concern, and why we should ALL be observing this day
• April 30 || JUST BREATHE: What happens if I don't want or like PAP therapy? You have options
• April 29 || JUST BREATHE: No, there are no magic pills for sleep apnea, and some magic pills just make it worse
• November 29 2014 || SHED SOME LIGHT || Ask the Expert: Misconceptions about Circadian Rhythm Disorders

Pages

• WHY SLEEP MATTERS
• MEDIA
• SLEEP DISORDERS
  

WOMEN & SLEEP: 14 of our best previous posts relevant to women and sleep

SHC has been publishing some great content on the subject of women's sleep health going back as far as last June.

Please scroll through this custom archive of 14 previous posts to find links relative to sleep health which are of special interest to women.


June 6, 2014
INSOMNIA CENTRAL || Can Insomnia Lead to High Blood Pressure?

July 5, 2014
SLEEP DISORDERS 101 || What is jet lag disorder?

September 14, 2014
SLEEP Rx || Mother's Little Helper: Things you should know

October 18, 2014
CPAP Central || A Season for Masks: Smaller Might Be Better

October 29, 2014
MONSTERS OF SLEEP || Research shows that women have the scariest nightmares... Why?

January 5, 2015
Sleep Hygiene Tip of the Week || Foods that can help you sleep better

January 12, 2015
ALTERNATIVES || Aromatherapy

January 26, 2015
ALTERNATIVES || How meditation can help

February 17, 2015
ALTERNATIVES || Valerian, aka "Nature's Valium" -- safe to use, effective? You be the judge

February 25, 2015
ALTERNATIVES || The calming powers of magnesium

February 28, 2015
ALTERNATIVES || Guest Post: Using yoga to achieve relaxation, sleep and stress management [David Schaar]

March 16, 2015
INSOMNIA || Drugs and Sleep: If you have been taking Ambien (zolpidem) long-term (since before 2013), please read this

March 24, 2015
INSOMNIA || Why is it linked to depression?

April 15, 2015
JUST BREATHE || Upper airway resistance. It's a thing. And it matters.

Introducing May's theme at SHC: Women & Sleep

Women have specific sleep issues which are related to their physiology. While any woman may experience (just like any man) any of the typical disorders of sleep as outlined by the International Classification of Sleep Disorders reference, they can also have sleep problems that are directly related to menstrual cycles, pregnancy, postpartum motherhood, menopause and those disorders related specifically to female reproduction.

For May, SHC focuses on sleep problems specific to women throughout the lifespan, as well as common sleep disorders that women may be surprised to learn are not limited to their male counterparts. SHC will also discuss how lifestyle choices and demands may impact sleep quality and quantity and why this reality for women may be different than for men.

To get a jump on the topic, you can visit SHC's comprehensive page on Women's Health here.

JUST BREATHE: No, there are no magic pills for sleep apnea, and some magic pills just make it worse

Sorry, I cannot provide you a link to purchase these for your sleep apnea because they don't exist.
 

It would be so nice to just pop a pill and be done with sleep apnea, right? Except that because sleep apnea (the obstructive variety, anyway) is an issue of physiological mechanics, no pill can fix that.

(Not sure what sleep apnea is? Check out this great 3-minute video to learn how to differentiate snoring from sleep apnea.)

So there aren't any magic pills for OSA. Fine, you say. But wait! There are still plenty of drugs that can actually aggravate OSA (whether you have been diagnosed or not). This goes for all kinds of sleep disordered breathing, not just apnea.

Alcohol--Can't share this one enough. Alcohol may help you fall asleep, but you will always have a withdrawal effect a couple of hours later, after you metabolize your nightcap, which disrupts the remainder of your sleep all night. On top of that, it relaxes the airway structures in a way that encourages them to collapse.

Muscle relaxants--Makes sense, right? You have soft tissues in your airway but you also have muscles there, too. The muscles help keep the soft tissues from collapsing. Relax those muscles and you have more chances to develop an obstructed airway when you're asleep.

Sedatives--Sleep medications play a lot of tricks on your brain to get it to fall into a sleep-like state. One of the problems with sedatives is that they interfere with the neurochemical messages that your brain processes with relation to your blood's oxygen/carbon dioxide balance. Your brain normally startles you awake so that you take a breath when that imbalance hits a certain threshold. If you are taking sedatives, it will take longer for your brain and lungs to work together to avoid this depression of the respiratory system. The result will be more apneas; if you already have OSA, the result will be more severe apneas.

Cigarettes--So maybe a smoke relaxes you at bedtime. What's the harm? It also introduces irritants into the airway which cause the tissues there to swell in response, creating obstruction.

JUST BREATHE: Go to the dentist to fix your apnea?

Many of us have an underbite that could be the culprit
behind our sleep breathing issues.

While Positive Airway Pressure (PAP) therapy maintains its position as the gold standard among sleep professionals for the treatment of obstructive sleep apnea (OSA), it may be getting some serious competition from dentists who have a different mechanical approach to treating sleep apnea.

Oral Appliance Therapy (OAT) can be used to treat mild to moderate cases of OSA (as determined by an overnight sleep study to measure severity and to confirm diagnosis of your sleep breathing disorder). However, rather than using PAP therapy, which forces air pressure into the airway to open it up, an oral appliance is used to reposition part of the mouth (tongue or jaw) by way of a specific mouthpiece which allows for a larger opening at the back of the throat where tissue may otherwise collapse during sleep. Sometimes OAT can even be combined with PAP, as well, to combat stubborn cases of OSA.

There are a host of OAT devices to choose from; the American Sleep Apnea Association lists as many as 80! The TAP and Herbst devices are currently the most commonly used. There are two main categories of OAT: Some use a suction device to manage tongue position and prevent it from blocking the airway (tongue retention). Others force the jaw slightly forward to open up space for breathing (mandibular positioning).

The TAP Device

The Herbst Device

The SUAD Device

Generally speaking, most OAT devices are comfortable and simple to wear. Most patients acclimate to them within a couple of weeks. They are great for people who travel a lot; they require very basic cleaning and, with good maintenance, should last several years. Though not all devices are covered by insurance, the nightly use of them over a period of years makes them cost effective for patients who are adherent.

(Curator's note: I use an OAT; mine--an SUAD--is five years old and still works great! I paid $1000 out of pocket, which over five years' usage is not expensive, and I still have years to go. This is just my story, but I know others who use OAT who have found it to be a worthwhile, cost-effective treatment as well.)

Patients who qualify for this kind of therapy to treat their sleep breathing problems include:

• those who have mild to moderate sleep apnea or UARS or primary snoring
• those who do not/did not respond well to PAP
• those who are not overweight
• those who do not qualify for surgical procedures like tonsillectomy to treat OSA
• those for whom positional therapy is not an option

These devices resemble common mouthguards, but they are actually much more complex, as they include specific parts which help to move the lower jaw forward. They require special fitting and construction via a dentist specially trained and board certified in the field of sleep dentistry.

Make no mistake: these are handmade devices that are built to fit an individual and are not something you can pick up at the local drugstore, boil in some water and be done with. The Ohio Sleep Medicine Institute says it most clearly: "Prior to electing any form of treatment, patients should undergo an initial evaluation with a board certified sleep specialist practicing in an accredited sleep disorders center." These devices require professional fitting and testing even after they have been trialed by the patient to ensure they work.

There is no LEGAL over-the-counter option for oral devices to treat OSA at this time. OAT requires a doctor's prescription and a clinical diagnosis. 

Once you received your custom-fitted device, you will have follow ups to ensure it is treating your sleep apnea effectively, to make sure it is still in working condition, and to check for both comfort and fit issues. Your primary care physician, your sleep specialist and your dentist should all be on board together to handle these follow ups.

As with any medical therapy, there are risks and disadvantages. Some patients who try OAT discover problems with TMJ, too much saliva, dry mouth or mouth discomfort. Long-term problems may include tooth misalignment or changes in bite (though some devices offer a realigning mouthpiece for the morning after to help reposition the jaw).

People interested in locating a dentist who can assist with creating, fitting and follow up on oral appliance therapy can click this link.



Sources

American Academy of Dental Sleep Medicine || Oral Appliances
American Sleep Apnea Association || Oral Appliances
Ohio Sleep Medicine Institute || Are you a candidate for dental sleep apnea treatment?

JUST BREATHE: Twelve of our best previous posts on sleep breathing disorders

SHC has been publishing some great content on the subject of sleep breathing disorders going back as far as last August. 

Please scroll down to this custom archive of 12 previous posts to find links related to apneas, snoring and upper airway resistance issues of special interest to you and your loved ones.


August 31, 2014
Guest Post || CPAP Care and Maintenance with Rui de Sousa, RPSGT, RST, B.Sc

September 3, 2014
CPAP Central || Is CPAP therapy covered by insurance?

September 17, 2014
INSOMNIA CENTRAL|| Do you have insomnia... or do you have sleep apnea?

September 20, 2014
Guest Post || Edward Grandi on Sleep Apnea: What is it and what can I do about it?

September 26, 2014
ABCs of Sleep || A is for Apnea

September 30, 2014
New Technologies || Inspire to stimulate your airway

October 16, 2014
Sleep in the Media: Video || Suspect your snoring sleep partner might have apnea? Check these five signs

October 18, 2014
CPAP Central || A Season for Masks: Smaller Might Be Better

December 28, 2014
ABCs of Sleep || C is for CPAP

February 7, 2015
ABCs of Sleep || D is for DME

February 13, 2015
Alternatives || Therapies for Sleep Apnea that don't involve a mask

March 18, 2015
Insomnia || Be on the lookout for insomnia's secret cousin: untreated OSA

JUST BREATHE: Upper airway resistance. It's a thing. And it matters.

Graphic courtesy Dallas Center for Sleep Disorders

Upper airway resistance is a problem for people who don't have full-blown sleep apnea. It's essentially a form of obstructive breathing during sleep which only yields a partial blockage of the airway.

This is essentially snoring, right?

Well... it includes snoring. But it may also happen in the absence of the log cutting you might be lucky enough not to hear all night long from your sleep partner.

What's the problem with silent snoring? With upper airway resistance, the airway narrows so much that the muscles of breathing along the ribcage and the diaphragm work double duty to inhale. These create what the Ohio Sleep Medicine Institute refers to as "snore arousals."

In technical terms, these are called RERAs (Respiratory Event Related Arousals); they differentiate from apneas primarily in that they do not result in the reduction in blood oxygen that makes Obstructive Sleep Apnea (OSA) so dangerous.

However, when many of these arousals take place over the course of the night, snoring is no longer the root cause of the patient's problem.

People with UARS (Upper Airway Resistance Syndrome) have frequent RERAs all night long which interfere with their ability to sleep deeply; they suffer the dreaded "fragmented sleep" that is the same demon behind insomnia, sleep apnea and other sleep disorders. Fragmented sleep is dangerous; it leads to health and relationship problems and can be the cause behind traffic and work accidents.

UARS is a 'thing'

Unfortunately, people with UARS can be left undiagnosed because, well, if it's not sleep apnea, then a Positive Airway Pressure (PAP) device or other treatment to alleviate UARS may not happen: traditionally, insurance companies have been unwilling to acknowledge UARS as a legitimate sleep breathing disorder. This, despite its prevalence, weighing in at about 1 in 7. Match that with the growing numbers of people being diagnosed with OSA, and it's not hard to imagine a relationship between the two. Clinical studies continue to bear this out empirically as well.

The discovery of UARS as a certifiable sleep breathing issue took place in 1993 at Stanford, but diagnosing and treating it has been inconsistent at best. The initial identification of the syndrome came as a result of sleep lab patients having disruptions in their breathing that didn't quite fall into the apnea category. They were still tired, still suffering physically and mentally even if they didn't "qualify" for PAP therapy. But they don't always get therapy for this problem.

Why not?

It turns out that UARS is a sleep breathing disorder that sleep medicine may not more actively identify as a legitimate problem due to the lack of doctors who recognize it, and the insurance companies who fail to acknowledge it is "a thing."

The Ohio Sleep Medicine Institute refers to UARS as "the orphan child of sleep medicine" because, let's face it, there's money in OSA, with PAP therapy leading the pack in treatment options; insurance acknowledges the existence of OSA. For UARS, the treatments are similar: PAP or oral devices are the common approaches, and other options like surgery can help. But doctors may fail to recognize UARS as a legitimate problem first. Even if they do recognize and diagnose it, it may not even matter. Only very recently have insurance companies accommodated UARS as a real diagnosis and reimbursed patients and doctors for its treatment.

Bottom line: If insurance doesn't believe it exists, then there is no money to pay for therapy.

Ultimately, UARS is "a thing" even if insurance payers aren't on board. In terms defined by the American Academy of Sleep Medicine (AASM), it has most certainly been a "thing" since 2005, as it is included in the ruling sleep research body's most recent updates on practice parameters, right alongside its popular sleep breathing disorder bedfellow, OSA.

Here's the kicker

Untreated UARS can evolve from its "harmless" position in the hierarchy of sleep breathing disorders--between snoring and apnea--into full blown Obstructive Sleep Apnea (OSA). We've already talked about what untreated OSA can do to the human body. (It's not pretty.)

UARS is also often misdiagnosed as Chronic Fatigue Syndrome (CFS), Fibromyalgia, depression, mood disorder, Attention Deficit Hyperactivity Disorder (ADHD) or migraine by primary care physicians who do not think to have their patients undergo a sleep study, where the imprint of UARS on respiratory recordings as RERAs is hardly a mystery. Whether a lab tech or a doctor counts RERAs or not in their diagnostic tests actually makes a difference in the final diagnosis; yet, even then, insurance companies may still not be satisfied and refuse to reimburse for treatments.

So... it would make sense to identify and treat UARS in order to prevent full-blown OSA (and all of these other problems), wouldn't it? As a form of preventive medicine?

The Ohio Sleep Medicine Institute explains the importance of diagnosing and treating UARS here: "Patients simply do not go to bed normal one night, only to awaken the next morning with obstructive sleep apnea. Instead, they typically go through natural progression over time or following weight gain from 'benign snoring,' to UARS, and finally to obstructive sleep apnea. This progression may take years or decades to occur."

Other impacts from untreated UARS include:

• Acid reflux, heartburn, Gastroesophageal Reflux Disease (GERD), Laryngopharyngeal Reflux Disease (LPRD)
• Bruxism (teeth grinding and jaw clenching)
• Chronic insomnia
• Excessive daytime somnolence
• Headaches
• Hypertension
• Hypotension
• Irritable Bowel Syndrome (IBS)
• Memory problems
• Morning nasal congestion
• Night sweats
• Nocturia
• Non-refreshing sleep (or, waking up tired)



This rendering of the Mallampati Scale
is one way doctors can screen for potential
 UARS. Notice the normal airway structure
structure in figure I, and how the oral cavity
can be crowded, either by the tongue, the
hard palate, the soft palate, the uvula or the
adenoids (tonsils). The higher the Mallampati
score, the more likely a patient will suffer
Upper Airway Resistance Syndrome (UARS).
[Graphic is public domain.]

• Parasomnias like confusional arousal, sleepwalking, sleeptalking, sleep paralysis

Dr. Steven Park is a popular activist on the subject of sleep-disordered breathing; his excellent podcast here gives very clear descriptions of what can happen if you let UARS go untreated.


What causes UARS? 

Like OSA, the causes of UARS are primarily mechanical in nature. The tongue is overlarge. The upper airway passages (nasal, pharyngeal) are congenitally narrow. The adenoids or the uvula get in the way. People with UARS often have a high narrow palate or an overbite. Other problems, like allergies, and chronic respiratory infections like rhinitis, swell the mucous membranes lining the airways, thereby narrowing them. A deviated septum might be the obvious source of UARS-related obstruction. Swollen turbinates or collapsing nasal valves can also lead to UARS. And edema anywhere in the body (even in that far-off location, the ankles) can be redistributed at night while the body is horizontal, sending more fluid up into the neck, creating weight and swelling there that can close off the space you need to breathe. Pregnant women suffer a lot from UARS, perhaps without even knowing it.

What distinguishes UARS from full-blown OSA, then?

• OSA prevails in men, but women are more likely to suffer from UARS
• OSA is more common in older people, while UARS occurs in patient of all ages, even the very young
• OSA often accompanies someone with obesity, whereas UARS sufferers often have normal BMI or are even underweight
• People with UARS suffer more from frequent awakenings and difficulty resuming sleep than those with OSA
• People with UARS do not always snore, whereas snoring or gasping is a common marker of OSA
• People with UARS do not have dangerous changes in their airflow during the night; those with OSA have remarkable shifts in which no breathing happens at all
• People with UARS do not have significant drops in their oxygen saturation; in OSA, patterns of low blood oxygen confirm apnea

Try breathing like this while you are awake, then
imagine spending 6-9 hours like this, asleep.

UARS is hardly "OSA Lite." As the website for the Center for Sound Sleep describes it, "To understand the difficulty that someone with UARS has with breathing, try to imagine breathing for an extended period of time through an opening no larger than a small soda straw."

How to breathe like a boss while you sleep

Treatments for UARS mirror those for OSA. Continuous Positive Airway Pressure (CPAP) therapy combined with cognitive behavior therapy for any underlying secondary behavioral issues is advocated by some; others promote surgical reshaping of the upper airway by removing excess tissue as a solution. Orthodontics can help pediatric patients breathe more easily and correct cranial issues to support healthy breathing in their future while their bodies are still growing. Oral devices, which force the lower jaw forward to open the airway enough to improve airflow, are popular and finally finding some support via reimbursement by insurance companies. Positional therapy for mild cases can work. Weight loss is always a good option as it shrinks the fat pads which store fluids in the neck, therefore freeing up pace for better breathing while asleep.

Still, given all this information we have on hand regarding the legitimate condition of UARS, there are still challenges being made to the ways in which it is assessed and treated. Some doctors demand that all RERAs (see definition above) be counted during a study, while others don't consider them until treatment happens. This ongoing debate about how to measure upper airway resistance (and here's another link) continues at the peril of thousands of untreated sufferers of UARS. Let's hope they can arrive at a consensus soon, and that insurance companies can find wisdom in reimbursing necessary preventive medicine.

___________________

Note to sleep activists:

KEEP YOUR EYES PEELED for the May 15, 2015 release of these two highly anticipated commentaries on the subject of diagnostic measures of UARS:

• "Scoring respiratory events in sleep medicine: who is the driver--biology or medical insurance?" by Thomas, Guilleminault, Ayappa and Rapoport
  
• "Capitulation or advocacy for sleep physicians and patients?" by Morgenthaler, Thomas and Berry

____________________

Sources

"Breathing Related Arousals: Call Them What You Want, but Please Count Them." Collop, N. Journal of Clinical Sleep Medicine. 2014 Feb 15; 10(2): 125–126.

"Frequency and Accuracy of 'RERA' and 'RDI' Terms in the Journal of Clinical Sleep Medicine from 2006 through 2012." Krakow B, Krakow J, Ulibarri VA, McIver ND. Journal of Clinical Sleep Medicine. 2014 Feb 15; 10(2): 121–124.

Center for Sound Sleep || Learn More about Upper Airway Resistance Syndrome (commercial site)

"Practice Parameters for the Indications for Polysomnography and Related Procedures: An Update for 2005." Kushida CA, Littner MR, Hirshkowitz M, et al. American Academy of Sleep Medicine, accessed on the web April 15, 2015. (PDF)

Cleveland Clinic || Sleep Disordered Breathing

Stanford Center for Sleep Sciences and Medicine || Stealthy Insomnia Cause? Upper Airway Resistance Syndrome Subtly Disturbs Breathing in Sleep (blog)

Dr. Steven Park || Upper Airway Resistance Syndrome (podcast transcription)

Ohio Sleep Medicine Institute || Upper Airway Resistance Syndrome (commercial site)

"Upper Airway Resistance Syndrome-One Decade Later." Bao B, Guilleminault C. Current Opinion in Pulmonary Medicine. 2004;10(6).

"Upper airway resistance syndrome: still not recognized and not treated." Palombini L, Lopes MC, Tufik S, Guilleminault C, Bittencourt LRA. Sleep Science. 2011;4(2):72-78.

SleepyHeadCENTRAL || What happens if I don't treat my sleep apnea?

Just Breathe || Sleep Breathing Disorder basics

The most obvious form of sleep breathing dysfunction comes by way of the snore. Yep, the humble, often annoying, snore. Just about everybody snores at some time or another, but often it's an ongoing problem...not only for the bed partner of the snoring sleeper, but for the snorer, too. Not getting adequate oxygen over several hours at night is simply not conducive to good overall health and can actually lead to health problems if poor breathing at night is not identified and treated.

Sleep breathing disorders move well beyond the range of snores and other noises one might make or hear at night, and include a wide range of conditions--some common, some not--all of which are critical to treat. These include many kinds of health problems related to getting enough oxygen while asleep, such as:

• Obstructive Sleep Apnea || OSA (a mechanical disorder of the upper airway)
  
• Central Sleep Apnea || CSA (various problems with brain function related to sleep drive and maintenance)
  
• Upper Airway Resistance Syndrome || UARS (due to issues like crowded airways, allergies, deviated septum, swollen turbinates, etc.)
  
• Hypoventilation problems related to existing respiratory issues such as chronic obstructive pulmonary disease [COPD], asthma, pneumothorax, or hypoventilation caused by high altitude, etc)
  
• Neuromuscular disorders, which can impact the body's ability to breathe properly (scoliosis, or myasthenia gravis)

If you notice a loved one struggling to get adequate sleep at night, don't ignore it. Talk to them about your concerns. Encourage them to speak to a physician. Most sleep breathing disorders are treatable, and once treated, those who've suffered stand to feel much better and maybe even improve key health measures, like blood pressure, by doing so. 

Introducing April's theme at SHC: Sleep Breathing Disorders

GOOD SLEEP REQUIRES OXYGEN. 
Yet thousands of people are not getting adequate oxygen as they sleep. What's more, they don't know it. These aren't just the elderly or those with respiratory diseases like asthma; as much as 20 percent of the entire American adult population may be suffering from a sleep-breathing disorder and not even know it. 

For April, SHC focuses on sleep breathing disorders. The most common is snoring, but sleep apnea and upper airway resistance problems aren't far behind. Sleep breathing encompasses many healthcare categories, including pulmonary medicine, dentistry, ear-nose-throat health, neurology and more. Learn how breathing is essential for quality sleep this month, as well as discover the risks you take by not addressing your sleep breathing problems. 

Sleep in the Media || Video || Suspect your snoring sleep partner might have apnea? Check these five signs

Video courtesy The Alaska Sleep Clinic's Educational Web Series 
http://www.alaskasleep.com/blog/5-signs-chronic-snoring-obstructive-sleep-apnea

Events: September 8-14, 2014 is Idiopathic Hypersomnia Awareness Week

From the Hypersomnia Foundation website:

"Hypersomnia is a debilitating neurological disorder where patients lose their cognitive ability, sleep excessively, yet still crave sleep above all else. ...This means they often struggle to work, operate a vehicle or live independently. In fact, often just waking up is an ordeal in and of itself with even sonic boom alarms, the help of family and powerful stimulants not being enough. While the onset of symptoms is generally in early adulthood it routinely takes up to a decade for new patients to be formally diagnosed…"

"Sleepy" 

The founder of SHC was diagnosed with Idiopathic Hypersomnia (IH) several years ago after finding herself faceplanting into her laptop during engaging teleconferences with clients. At some point, the daytime sleepiness was so severe that she was afraid to drive more than an hour at a time without having to stop to nap. She finally realized that "being a working mother" was not a reasonable explanation for her otherwise unreasonable symptoms. She participated in both an overnight polysomnogram and a daytime multiple sleep latency test (MSLT) to uncover the source of her excesses daytime sleepiness. It turned out to be a combination of IH and Upper Airway Resistance Syndrome (UARS). Treating both conditions has made all the difference in the world. She can drive safely, manage online meetings with maximal alertness and get through the day without taking added naps, which impose on her already busy schedule.

If you feel excessively sleepy, day in and day out, and you want your energy and your hours back (!), please consult your physician about potential causes.