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The Dose Transcript for February 8, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. If you're a regular listener to The Dose and our sister podcast, White Coat Black Art, you may have heard me talk about my lifelong battle with insomnia. My sleep issues revolve around a restless mind that can't be still. But there's this other condition that disturbs the sleep of millions of Canadians, a condition whose origins are physical. I'm talking about sleep apnea, and many Canadians don't know they have it. So this week, we're asking, what do I need to know about sleep apnea? Hi, Sachin. Welcome to The Dose.

SACHIN PENDHARKAR: Hi, Brian.

BRIAN GOLDMAN: So what surprises you most about sleep apnea?

SACHIN PENDHARKAR: What surprises me most is how many people have somebody with sleep apnea in their family. And when we talk about it, how many people, you know, the lights go on. Oh, of course, I have a family member that has this. And probably the related thing is how many people can tell me a story of somebody that got way better when we've discovered and treated it.

BRIAN GOLDMAN: Well, now, everybody who's going to listen to this conversation knows why we've turned to you for your expertise. But before we begin, can you give us a hi, my name is? Tell us what you do and where you do it. Just adlib.

SACHIN PENDHARKAR: Hi, my name is Sachin Pendharkar. I am a sleep and respiratory physician scientist and the medical director of the Foothills Sleep Centre in Calgary, Alberta. I'm also an associate professor of medicine and community health sciences at the University of Calgary.

BRIAN GOLDMAN: First of all, what do we mean by sleep apnea?

SACHIN PENDHARKAR: What it is is as the name suggests, a sleep disorder that is characterized by recurrent interruptions in breathing. To take it a step further, what it really comes down to is a problem that's primarily in the airway. So in our throats, in the back of our neck. And what we have is a problem where the muscles relax when we go to sleep. And what is normally a nice open airway, like a pipe that we can breathe through, starts to narrow progressively as those muscles relax, and in the case of obstructive sleep apnea, can collapse completely, leading to a whole host of other consequences.

BRIAN GOLDMAN: I think a lot of people who have heard of obstructive sleep apnea, which is what we're going to talk about mostly, know that people snore loudly, loud enough to wake the dead. That's a description that I've certainly heard. But that's not the only symptom, is it?

SACHIN PENDHARKAR: No, not at all. If we think about sort of the mechanism I described earlier where the airway is collapsing, if you have partial collapse, that air doesn't flow smoothly. Tissues start to vibrate. That's what we think of when we think of snoring. That's what we're hearing. But the more extreme on that spectrum is when you start to actually have obstruction. And so snoring is often a feature, but usually, people with obstructive sleep apnea will have other symptoms. It sort of carries over into the day. They’re sleepy during the day. They might have difficulty with concentration or alertness. Another common one is, you know, they have a bed partner that says, hey, you stopped breathing at night. It's kind of scary when it happens. Sometimes, a little elbow or a nudge and you start breathing again. So those are sort of common things that might be symptoms. The other sort of place where we might see it in a physician's office or in a medical setting is if somebody has high blood pressure that's really poorly controlled, and in people that are overweight or obese, where we know that sleep apnea is much more common. We won't talk a lot about kids, I don't think. That's not really my area of expertise, but I will say that sometimes, things like poor school performance or even ADHD can be associated with obstructive sleep apnea in children. Looks a little different in adults.

BRIAN GOLDMAN: You mentioned off the top that one of the surprising things is how many people have those symptoms and don't know about it. I'm guessing that one of the reasons why would be somebody who sleeps alone, who doesn't have a partner.

SACHIN PENDHARKAR: Absolutely. That's not an uncommon scenario. One of the risk factors for sleep apnea, obstructive sleep apnea is actually age. So if somebody is older and doesn't have a bed partner, they may not have anyone to tell them. And sometimes, in those scenarios, what you'll have is someone goes away for a weekend or has a family member come to visit. They're sharing a living space, not necessarily a bedroom with somebody, and they get told, did you know you snore? Did you know you stopped breathing? The rest of us in the place can't sleep. And then, you know, that sort of leads people to think about sleep apnea.

BRIAN GOLDMAN: What are some of the most important risk factors for sleep apnea?

SACHIN PENDHARKAR: A big one that we see now very commonly in our population is when people are overweight or obese. You can imagine there's more tissue everywhere, but more tissue in the neck that can sort of add an additional load on the throat and can lead to more weight to collapse the airway. There's also probably some changes in the airway itself in people that are overweight that might contribute to that collapse. And that's sort of one big category and probably the most prominent risk factor that we think about. But the other one that's probably a little less well-recognized is when people have jaw structural abnormalities. So if you have a really small jaw or a jaw that sits really far back, kind of your lower jaw, I mean, it's really far back on your face. Again, back to this idea that we're starting with an airway that's open like a pipe. If that airway is narrowed because of the way the jaw sits, then it's more likely to collapse when those muscles relax. That's another big factor that even in people that aren't overweight, for example, we might see pretty severe sleep apnea. A couple of other things to think about. I mentioned age earlier. We know that sleep apnea is more common as people get older. Historically and traditionally, we've thought of male sex as a risk factor, although we're learning more about sex differences and sleep apnea between males and females. So those are sort of the main risk factors that we know about.

BRIAN GOLDMAN: Can we still say that the incidence is higher in men than in women or is there new science about that?

SACHIN PENDHARKAR: I mean, we still are working with the information that we've had now for many years that it is more common in men than in women. There's some science or research that suggests that reproductive hormones in earlier life may be protective. And so postmenopausally, then we may see more sleep apnea occurring in women when some of those protective effects are no longer present. But yeah, for the most part, we still think of male sex as being a risk factor for sleep apnea.

BRIAN GOLDMAN: What is it about the collapse of the airway that triggers apnea? Because my first thought is that would make people choke and want to wake up and start breathing. But you're saying that they develop apnea. What's the connection?

SACHIN PENDHARKAR: As I was saying, you start off with you're awake with an open airway. And as you fall asleep and go into deeper sleep, those muscles relax progressively. And when we get into the deepest stages of sleep, we can get more of that relaxation and more of that narrowing. And so for some people who snore, it's just a little bit, and the air can still flow relatively uninterrupted. But if that collapse is more pronounced, then you get a significant reduction in the amount of air that's going in. And again, if there's complete collapse, you get essentially a complete blockage of air going in. And so that's the phenomenon that occurs. Now, it gets a little more complicated than that in what we've understood about sleep apnea more recently where there are a number of other factors. So how well does the brain respond to interruptions in breathing? How well do the nerves and the muscles in the throat respond to interruptions in breathing? So there are these feedback loops that can sometimes influence the response. And of course, how deeply is somebody actually sleeping? Or how likely are they to wake up when there's an obstruction? And so when you put all these things together, you can sort of think about, well, if someone is a pretty deep sleeper, they may not wake up when they have obstruction. And so it might take a little more of a longer event or a more pronounced episode of interruption to actually lead them to wake up or to relieve that obstruction.

BRIAN GOLDMAN: As you mentioned, there are some people who have mild sleep apnea and others who have much more severe disease. What are the factors to account for the difference?

SACHIN PENDHARKAR: Back to those risk factors. You know, if you have a higher weight, we know that as people gain weight, sleep apnea tends to get worse. As people lose weight, it tends to become less severe. Again, back to the jaw structure. That can certainly play a role for people that have more pronounced jaw structural issues. Those are sort of the main things that determine severity. And then again, back, you know, some of these other things that I talked about, how much the brain responds to some of these interruptions and disruptions in normal breathing physiology can contribute to severity. I think we're learning a lot still. There's still quite a bit of variability between one person and the next, all other things being equal. And I mean, that's what makes this a really kind of exciting area in medicine and in science more generally.

BRIAN GOLDMAN: I've certainly seen patients with serious heart disease whose main risk factor is sleep apnea. What's the connection?

SACHIN PENDHARKAR: There's many consequences of obstructive sleep apnea when it's untreated. We're continuing to learn more about these. But the main connection to heart disease really is around, at least what we think, is around these repeated interruptions in breathing through the night. So when your air flow through into the lungs stops, then, you know, along with that, you have reduced oxygen getting into the blood. And so you can have these intermittent episodes of low oxygen. Now, the brain typically will respond and either wake you up from deeper sleep to lighter sleep or activate the muscles in a way that normalizes that breathing. But over the course of the night, you're having many, many of these episodes. And so when that happens, we call that intermittent hypoxia. That can lead to a whole cascade of changes in normal body function. So a stress response in the body, for example, might be heightened. Normally, when we're sleeping, we don't expect that stress response. There's inflammation that can be sort of triggered. So lots of things that can happen in the body in response to these dips in oxygen. And when we get, as you can imagine, a stress response is one example, well, blood pressure might be a little bit higher at night. More strain on the heart, for example. And so those sorts of things may be a little more, you know, kind of irritability of the heart to maybe pump faster or to beat irregularly. So those sorts of things, when you pull them all together, can contribute to cardiovascular disease.

BRIAN GOLDMAN: How common is it for people diagnosed with advanced heart disease to only then find out that they have obstructive sleep apnea and that that was a significant risk factor?

SACHIN PENDHARKAR: It's always a bit tricky to come up with numbers because first of all, you have under diagnosis, as we talked about before, where there's lots more people who probably have sleep apnea than have a diagnosis. But of course, depending on where you live and how it's diagnosed and where you present to first, definitely, those are factors that need to be considered. From my clinical experience, I would say it's pretty common, and especially when people don't have sleepiness associated with the sleep apnea. And I didn't mention this earlier, but we know that the relationship between how severe your sleep apnea is and how sleepy you are isn't actually that strong. And so you can have a lot of people with pretty severe disease that don't have any symptoms, and conversely, people with milder disease that have a lot of symptoms. But for that severe group that don't have symptoms, nobody really knows what's going on. They're snoring. You know, maybe they just don't think very much of it because they feel okay, and then there's, you know, stuff happening in the background.

BRIAN GOLDMAN: What's the connection between obstructive sleep apnea and mental health issues?

SACHIN PENDHARKAR: Even more broadly with sleep disorders, lots of overlap with mental health. But with sleep apnea, we think that probably the most prominent feature of sleep apnea that contributes to mental health is sleepiness. So consequences of untreated sleep apnea. I talked about the sort of dips in oxygen. But the other big category is sleepiness. And that leads to mood issues. It could lead to anxiety, poor quality of life. You can imagine, you know, you think you're getting an adequate amount of sleep, seven, eight hours, nine hours, but you wake up feeling pretty crummy every day because the quality of that sleep is so poor. That can certainly lead people to feel pretty lousy, irritable, and then again, anxious, depressed, etc.

BRIAN GOLDMAN: So let's move into talking about diagnosis. The first thing I wanted to ask you is who should be seeing somebody who can help them make a diagnosis? What are the indications for seeking some advice from a health care provider?

SACHIN PENDHARKAR: Symptoms are a really big piece of this, right? And I would say symptoms that you feel during the day, and I guess things that people are telling you about at night. So if you're waking up after what seems to be a pretty good night of sleep and feeling lousy and oh, you've been told you snore, you stopped breathing at night, I think that's a really good place to start. Sleepiness is always a bit tricky because we have lots of other things that can make us sleepy, including not sleeping enough. But assuming we're trying to do all of those things and the quality is just very poor, I think that's a good indication. If you're waking up a lot at night, not staying awake, as we might see in someone with insomnia, but waking up a lot at night and having to go back to sleep and then sort of having this repeat over and over again, I think that would be another reason to think about, well, hey, my sleep is of very poor quality, so maybe I should get checked out. One of the symptoms that's a little less common but I think, you know, we see quite a bit, less commonly reported, but we see quite a bit and often gets better with treatment is having to pee a lot at night. Nocturia, we call it, which has to do with that stress response in the body. And again, we want to sort of think about why it's occurring. But if they really don't have another good explanation and, you know, you might want to think about a sleep disorder and sleep apnea be one of the things to think about there.

BRIAN GOLDMAN: So now, the patients come in to see a health care provider. Let's talk about diagnosis. I've referred patients for sleep studies. Explain what happens there and how it relates to diagnosing obstructive sleep apnea.

SACHIN PENDHARKAR: There's a couple of different types of tests that are available. And I think you're in Ontario. The main test that is sort of the gold standard test used everywhere but is the main test that's used in Ontario is a polysomnogram. So this is an in-laboratory overnight sleep study where, you know, the patient goes into the lab, they're hooked up to a whole bunch of different pieces of equipment. So we measure brainwaves through EEG, we measure muscle activity, we measure breathing, oxygen levels. We basically use that. And then the patient sleeps in the lab, and we are able to monitor their sleep. We're able to monitor their breathing and really any other thing that's happening during sleep, including muscle activity and leg movements and things. So that's sort of the main gold standard diagnostic test. It gives a lot of information. And in some parts of Canada and actually some other parts of the world there, there are, you know, challenges for people to actually get access to a lab because there just aren't enough lab resources. And so over the last 20 or 30 years, there's been this emergence of what we call home sleep apnea testing. So this is now a limited channel test that's really focussed on trying to identify breathing disorders. So sleep apnea and other breathing problems that can occur in sleep. It's only used in adults. It's not really a test that's available for children. But it's, you know, instead of having 20 different things attached to you, you have a probe on your finger, you have a little sort of flow sensor that's in your nose, like oxygen prongs and a microphone that's on your neck. You might have a band around your chest and abdomen that sort of measure movement of the chest and abdomen, but it's a much, much more limited test that people can actually take home and use in their own bed.

BRIAN GOLDMAN: What are the key things that you're looking for to nail the diagnosis?

SACHIN PENDHARKAR: In both cases, we're looking for similar information, which is if we're measuring airflow, we're looking for reductions in airflow, which tells us that there's not enough air getting in. We're looking for dips in oxygen that might go along with those reductions in airflow, again suggesting that we're not getting enough air in, and that's having an impact on the amount of oxygen that's in the blood. And then the microphones tell us if they're snoring. And so then you put all those things together and you can see over the course of a person's sleep that there are these repeated events that are, you know, have these key features. That's the same whether you're doing the home test or the in-laboratory test. As I say, the laboratory test gives you other information that you can use to sort of figure some other things out, but that's essentially what we're looking for.

BRIAN GOLDMAN: So assume that somebody has a diagnosis of OSA, obstructive sleep apnea, what's the best treatment?

SACHIN PENDHARKAR: I would say that this is one of the really kind of exciting new areas in sleep medicine is is sort of what is the best treatment. And back a little bit without getting too nerdy about it, back to those sort of physiologic mechanism that I said sort of interact in any individual patient. The mainstays that we know about or that we have at our disposal are something called continuous positive airway pressure or CPAP. That's the one that most people are going to be familiar with. And essentially, what that is is a little box that sits on the bedside table, connected to tubing, connected to a mask that fits either over the nose or over the mouth and nose, that essentially, that box blows pressurized air in through the mask and essentially blows air into the airway to hold it open to prevent it from collapsing. And we can adjust the pressure on that box to increase the pressure of air that's required to hold the airway open to allow air to flow normally in and out. That's the first line gold standard therapy, especially for more severe disease. But there's another therapy called mandibular advancement devices or dental appliances, essentially, that are intended to pull the lower jaw forward. So back to that other mechanism I talked about where the jaw might be sitting back. Some patients can use one of these dental devices to pull the lower jaw forward. So instead of now blowing the airway open with air, we're pulling it open with a device that's sort of connected to the teeth. There are many different types of devices, but that's the basic concept of those. Both of those are actually very good treatments for reducing not only the number of events, these respiratory events that are happening, but also improving sleepiness and quality of life.

BRIAN GOLDMAN: This is a condition for which lifestyle changes can make a big difference, can't it?

SACHIN PENDHARKAR: Absolutely. We often jump to treatments, as I kind of did there as medical treatments, but there's a huge, a huge component of lifestyle changes that can help here. So I talked a few times already about weight gain and weight loss. And I would say that for all the benefits that might go along with weight loss, reducing the severity of sleep apnea and even getting rid of sleep apnea altogether is one of them. And absolutely, people are able to do that. It's tremendously helpful and valuable, and then you don't need to be on one of these treatments. Now, some people are really sleepy, and the idea of changing any of the behaviours in their daily life, whether it's exercise, diet, etc., can be really hard. So there are patients for whom we'll prescribe the therapy, but we're always talking to them about those lifestyle things that will help them to maybe get off the therapy one day. That's one big category. There are other things. So we know that alcohol can promote relaxation of the muscles in the throat. Certain sleeping pills can do the same. But to talk about alcohol, if anybody listening has, you know, had a few drinks too many and goes to sleep and they get told the next day they snored a lot last night, or if they wake up feeling pretty lousy, sometimes, that could represent sleep apnea that's occurring because of the alcohol or worse, because of the alcohol and the relaxation effect. So we generally will recommend that people avoid excessive alcohol, or at least be prepared to feel pretty lousy the next day if they are prone to sleep apnea. And then the last thing that works for some people if they have is they tend to have more snoring and especially more interruptions in breathing on their back. We know that's a risk factor. Or like a sleep position that tends to predispose people to having sleep apnea, that's where it tends to be worse. And sometimes, sleeping on your side can help. And so the elbow or the nudge that comes from the bed partner sometimes is just sort of a warning to turn over on to the side, and then people's snoring and apnea gets a little better. There actually are some foam pads and special shirts that have been designed and developed to sort of facilitate somebody sleeping on their side instead of on their back. So those are the main things that we generally recommend.

BRIAN GOLDMAN: I've heard that there are physical exercises that can strengthen throat muscles and in so doing, reduce sleep apnea. Can you tell us about those?

SACHIN PENDHARKAR: As I mentioned earlier, there's, you know, this collapse of the upper airway, and the tongue muscle is actually the biggest contributor to that. There have been some studies looking at different types of muscle training of the upper airway, of the tongue that could keep it a little more firm and active and less likely to collapse during sleep. One really interesting study that’s probably 10 or 12 years old now is related to the use of something called a didgeridoo, which is a long wind instrument that originates in Australia. Basically, what this study showed was that for people that played the didgeridoo on a regular basis, they were actually able to reduce the severity of their sleep apnea. And the proposed mechanism was training of the upper airway muscles to just keep them a little bit more firm during sleep.

BRIAN GOLDMAN: What's coming down the pipeline in terms of research that might lead to future ways of treating sleep apnea?

SACHIN PENDHARKAR: This is the really exciting thing. I talked about CPAP and mandibular devices, and you talked about sort of the challenges with tolerating these treatments. But, you know, we're actually, there's lots of treatments that are coming that I think are going to really change the way that we practice going forward. So, you know, a few of them just as examples. One is something called a nerve stimulator, a hypoglossal nerve stimulator. So this is something that's actually been around in the U.S. for a while. Some people in Canada may have started to see commercials. I know we're getting patients asking about it more often. It's not widely available in Canada, but essentially, what it is is a little pacemaker device that's implanted under the skin in the chest. And it works a lot like a cardiac pacemaker, except the wires are connected to the base of the tongue and provide little electrical pulses through the night that activate the tongue muscle and keep it open even when somebody is asleep. And so this is something that's actually been pretty well established in the U.S., but as I say, not quite available here yet but coming. For milder disease, it's a treatment that we're going to start seeing more and more. But the other thing that's really cool is back to those mechanisms about how the brain responds to interruptions in breathing, how the tongue muscles respond to interruptions in breathing, is we're learning about medications that can actually activate some of those pathways to allow instead of just blowing the airway open, which feels a bit like brute force, we're now going to use medications that might, say, stimulate the tongue a little bit, or maybe reduce the likelihood that someone's going to, you know, wake up from sleep too early and allow the normal feedback mechanisms in the body to open up that airway spontaneously. So this is like really cutting edge. We're just getting these studies kind of now out in literature, but I would say they’re really promising. In the next, you know, three to five years, I would hope that we'd have the ability to prescribe some of these. I think they'll really be a game changer for sleep apnea.

BRIAN GOLDMAN: Finally, are these treatments generally, not the cutting edge ones, but the ones that are currently available, are they generally funded by the provinces, paid for under the publicly funded system?

SACHIN PENDHARKAR: The short answer is in three provinces in Canada, CPAP is funded in some way through government programs for everybody. Those would be Ontario, Saskatchewan and Manitoba. Everywhere else in the country, there are programs for people who have very low income. But otherwise, people are paying out of pocket or through private insurance. There's no province in the country where mandibular advancement devices are funded currently, and all these other treatments are not funded because they're still quite new. There's one other treatment that I didn't talk about, which is surgical reconstruction of the jaw. So upper airway surgery. That's another type of treatment that, you know, is pretty big surgery, but can be quite effective in appropriately selected patients. That may be funded in different provinces. It kind of depends on the procedure. Those treatments are unfortunately not funded across the board, which is too bad, because I think that really limits access.

BRIAN GOLDMAN: You have been a tremendous fund of information on the subject. Dr. Sachin Pendharkar, thank you so much for speaking with us on The Dose.

SACHIN PENDHARKAR: It's my pleasure. Thanks for the opportunity, Brian.

BRIAN GOLDMAN: Dr. Sachin Pendharkar is a sleep and respiratory physician scientist and the medical director of the Foothills Sleep Centre in Calgary. He's also an associate professor at the University of Calgary. Here's your dose of smart advice. Sleep apnea is an extremely common condition in which breathing stops and restarts many times during sleep. There are two kinds of sleep apnea. The most common by far is obstructive sleep apnea or OSA, which means your upper airway becomes periodically blocked while you sleep, which affects the flow of air. The muscles in the neck may relax to an extent greater than in people who are unaffected, and that causes the airway to close. Obesity and enlarged tonsils may also narrow the airway. Less common is central sleep apnea, in which the brain does not send regular signals that tell the body to breathe. As many as eight out of 10 people living with sleep apnea are undiagnosed. The condition affects men more than women. Common symptoms of sleep apnea include loud snoring and episodes of apnea or stopped breathing during sleep. Some people awaken frequently during the night with gasping or choking. Some have a dry mouth, sore throat or morning headaches. Many have excessive daytime sleepiness and trouble focusing during the day. Consult with your health care provider if you or a loved one notice any of these symptoms. Sleep apnea is diagnosed through a sleep study. This involves monitoring of your brainwaves as well as your breathing and other body functions while you sleep. Some health care providers might recommend sleep testing at home. These tests can measure heart rate, blood oxygen level, airflow and breathing patterns. Milder cases of sleep apnea can be helped by lifestyle changes such as losing weight, quitting smoking and drinking less alcohol. More severe symptoms are treated with a mask and a device at home that delivers continuous positive airway pressure or CPAP to the mouth and nose. CPAP is considered the most common and most reliable method of treating sleep apnea. Most people with sleep apnea adapt to CPAP, but those who don't can try dental appliances or mouthpieces that can help keep the airway open. Neuromuscular electrical stimulation devices send electrical impulses that stimulate and tone the tongue and upper airway muscles to prevent them from collapsing and blocking the airway during sleep. If those treatments don't provide relief, surgery may be an option. Untreated sleep apnea puts people at risk of high blood pressure, heart rhythm disturbances and heart failure, not to mention accidents caused by daytime sleepiness. The good news is that most people can be treated successfully. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What do I need to know about sleep apnea? - Transcript

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