Sleeping Beauty–the story of undiagnosed apnea!

Sleep apnea (AP-ne-ah) is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.  All you need is this video about sleep apnea with Shaq!

Breathing pauses can last from a few seconds to minutes. They often occur 5 to 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.  Don’t try this one on your spouse–

What happens during sleep apnea

it’s very unnerving!

This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness, but that’s not all.  Sleep apnea contributes to traffic accidents from falling asleep at the wheel, and apnea is associated with more high blood pressure, heart attack, and stroke.

Sleep apnea often goes undiagnosed. Doctors usually can’t detect the condition during routine office visits unless you ask about daytime naps and be sure to ask wives what hubby sounds like when he’s fast asleep.

The most common type of sleep apnea is obstructive sleep apnea. When you try to breathe, any air that squeezes past the blockage can cause loud snoring. Obstructive sleep apnea is more common in people who are overweight, but it can affect anyone. For example, small children may have enlarged tonsil tissues in their throats, which can lead to obstructive sleep apnea. That’s why tonsillectomy is more effective in children than in adults!

The animation below shows how obstructive sleep apnea occurs. Click the “start” button at the bottom of the page to play the animation. Scroll down to the bottom of the page–it’s well worth 5 minutes of your time.

 Untreated sleep apnea can:

How does it feel to have sleep apnea?  Click on the video to find out.

Who Is at Risk for Sleep Apnea?

Millions of American adults have obstructive sleep apnea. More than half of the people who have this condition are overweight.

Sleep apnea appears to be more common in men than in women. The condition also becomes more common as you get older. At least 1 in 10 people older than 65 has sleep apnea. Women are more likely to develop sleep apnea during pregnancy and after menopause.

Is this condition genetic? Yes, if someone in your family has sleep apnea, you’re more likely to develop it.

People who have small airways in their noses, throats, or mouths also are more likely to have sleep apnea. This is where allergy comes in!  Smaller airways may be due to inflammation from allergy that cause congestion in the nose & throat.

What Are the Signs and Symptoms of Sleep Apnea?

Major Signs and Symptoms

One of the most common signs of obstructive sleep apnea is loud and chronic (ongoing) snoring. Pauses may occur in the snoring. Choking or gasping may follow the pauses.

The snoring usually is loudest when you sleep on your back; it may be less noisy when you turn on your side. Snoring may not happen every night. Over time, the snoring may happen more often and get louder.

You’re asleep when the snoring or gasping happens. You likely won’t know that you’re having problems breathing or be able to judge how severe the problem is. Your family members or bed partner often will notice these problems before you do.

Another common sign of sleep apnea is fighting sleepiness during the day, at work, or while driving. Remember when grandpa would fall asleep in his rocking chair during a conversation?  Probably sleep apnea.

Others signs and symptoms of sleep apnea may include:

  • Morning headaches
  • Memory or learning problems and not being able to concentrate
  • Feeling irritable, depressed, or having mood swings or personality changes
  • Urination at night
  • A dry throat when you wake up

How Is Sleep Apnea Diagnosed?

Doctors diagnose sleep apnea based on medical and family histories, a physical exam, and results from sleep studies.

Sleep specialists are doctors who diagnose and treat people who have sleep problems. Examples of such doctors include lung and nerve specialists and ear, nose, and throat specialists.

You can find a sample sleep diary in the National Heart, Lung, and Blood Institute’s “Your Guide to Healthy Sleep.”

Sleep Studies

A sleep study is the most accurate test for diagnosing sleep apnea. It records what happens with your breathing while you sleep.

There are different kinds of sleep studies. If your doctor suspects you have sleep apnea, he or she may recommend a polysomnogram (poly-SOM-no-gram; also called a PSG) or a home-based portable monitor.

PSGs often are done at sleep centers or sleep labs. In some cases, doctors suggest using portable sleep monitors at home.

Home-Based Portable Monitor

Your doctor may recommend a home-based sleep test with a portable monitor. The portable monitor will record some of the same information as a PSG. For example, it may record:

  • The amount of oxygen in your blood
  • How much air is moving through your nose while you breathe
  • Your heart rate
  • Chest movements that show whether you’re making an effort to breathe

A home monitor is more convenient & is a good way to “rule out” sleep apnea.

Lifestyle Changes

If you have mild sleep apnea, some changes in daily activities or habits may be all the treatment you need.

  • Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
  • Lose weight if you’re overweight or obese. Even a little weight loss can improve your symptoms.
  • Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
  • Keep your nasal passages open at night with nasal sprays or allergy medicines, if needed. Talk with your doctor about whether these treatments might help you.
  • If you smoke, quit. Talk with your doctor about programs and products that can help you quit smoking.


A mouthpiece, sometimes called an oral appliance, may help some people who have mild sleep apnea. Your doctor also may recommend a mouthpiece if you snore loudly but don’t have sleep apnea.

A dentist or orthodontist can make a custom-fit plastic mouthpiece for treating sleep apnea. (An orthodontist specializes in correcting teeth or jaw problems.) The mouthpiece will adjust your lower jaw and your tongue to help keep your airways open while you sleep.

If you use a mouthpiece, tell your doctor if you have discomfort or pain while using the device. You may need periodic office visits so your doctor can adjust your mouthpiece to fit better.

Breathing Devices

CPAP (continuous positive airway pressure) is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your mouth and nose, or just over your nose. The machine gently blows air into your throat.

The air presses on the wall of your airway. The air pressure is adjusted so that it’s just enough to stop the airways from becoming narrowed or blocked during sleep.

Treating sleep apnea may help you stop snoring. But not snoring doesn’t mean that you no longer have sleep apnea or can stop using CPAP. Sleep apnea will return if CPAP is stopped or not used correctly.

Usually, a technician will come to your home to bring the CPAP equipment. The technician will set up the CPAP machine and adjust it based on your doctor’s prescription. After the initial setup, you may need to have the CPAP adjusted on occasion for the best results.

CPAP treatment may cause side effects in some people. These side effects include a dry or stuffy nose, irritated skin on your face, dry mouth, and headaches. If your CPAP isn’t adjusted properly, you may get stomach bloating and discomfort while wearing the mask.

If you’re having trouble with CPAP side effects, work with your sleep specialist, his or her nursing staff, and the CPAP technician. Together, you can take steps to reduce these side effects. These steps include adjusting the CPAP settings or the size/fit of the mask, or adding moisture to the air as it flows through the mask. A nasal spray may relieve a dry, stuffy, or runny nose.

There are many types of CPAP machines and masks.

This is a CPAP device

Tell your doctor if you’re not happy with the type you’re using. He or she may suggest switching to a different type that may work better for you.

People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP.

Some people who have sleep apnea may benefit from surgery. The type of surgery and how well it works depend on the cause of the sleep apnea.  Getting good sleep makes EVERYTHING more than just a bad dream!

#asthma, #chronic-obstructive-pulmonary-disease, #sleep-apnea-2

If it’s not Asthma, what is it?

As physicians, we have the unpleasant task of learning the differential diagnosis for the diseases we treat.  Patients don’t understand it, I have unpleasant memories of using it during rounds as an intern, but this exercise can be helpful for patient care and will keep us out of trouble!  Not everything that wheezes is asthma–what are some danger signals that I

Your job is to solve the puzzle!

might want to modify my original diagnosis of asthma?

Asthma invariably causes symptoms during exercise.  If your patient has no symptoms (pre-treatment) during exercise, rethink your asthma diagnosis.  How about wheezing at night?  Same story…no nocturnal symptoms, not likely to be asthma.  Finally, response to therapy is a good clue if co-morbidity is contributing to persistent symptoms.  For instance, I prescribe combination therapy (LABA/ICS), yet no improvement in wheezing.  Only the most severe asthma patient will not respond to this treatment & I’d start down the path of an alternative diagnosis.

So what is the list for differential diagnosis of wheezing, coughing and suspected asthma?  I’ll include links where I have some level of expertise 🙂

1.  Left ventricular failure, mitral stenosis–I love cardiology consults!  Pedal edema with dyspnea is a red flag even if they’re in your office for “asthma.”

2.  Bronchiectasis, cystic fibrosis.  Sweat chloride or genetic testing will suffice for CF, but bronchiectasis is often missed during the evaluation for asthma.  High resolution CT of chest is the study of choice….

Notice the large dilated airways of bronchiectasis

3.  Paradoxical vocal cord motion–This one I have to tell you can stump providers even if asthma is present.  The best link for this is American Academy of Allergy.

4.  GERD or recurrent aspiration

5.  Chronic obstructive pulmonary disease (COPD)–don’t forget about the use of Daliresp™ (500mcg/day)

6.  α-1 antitrypsin deficiency–Yes this is rare, but treatment is available and diagnosis is as easy as three drops of blood on a postcard! 

7.  Interstitial lung disease or hypersensitivity pneumonitis–Again, high-resolution CT of chest is very helpful in this scenario…it’s worth fighting insurance to get the study approved.

8.  Allergic Bronchopulmonary Aspergillosis (ABPA)–These are usually patients dependent on corticosteroids to breathe.  Check total IgE & with ABPA, values are usually >1,000. 

9.  Pulmonary embolism–usually shows up in the ER, but you never know.

10.  Laryngotracheomalacia–If you cough more when upset or crying with a “barky” cough, think tracheomalacia.  Usually present before one year of age.  Stridor may not always be present.  This video is quite informative.

11.  Airway neoplasm, foreign body.  Found a peanut, found a peanut…..unilateral wheezing is always a concern here.  Must keep a high index of suspicion even if there is no history of choking.

12.  Rhinosinusitis–Even if it is asthma, sinusitis is ALWAYS a trigger for asthma flares.  Don’t bother with plain sinus x-rays…false negative rate can be as high as 30-40%.

13.  Churg-Strauss vasculitis or Hyper-Eosinophilic Syndrome–I won’t say more, just go to the link.

#allergic-rhinitis, #allergy, #asthma, #chronic-obstructive-pulmonary-disease, #cystic-fibrosis, #respiratory-disorders, #wheeze