Proper CPAP intervention requires:

• Patient education regarding obstructive sleep apnea (OSA) as well as an understanding of medical complications related to an untreated condition. The patient needs to understand how and why CPAP therapy works.
• Proper fitting of the mask and headgear is crucial. Accurate fitting of the proper mask is similar to fitting a dress shoe. If it doesn’t fit correctly, the patient will never wear it. Once the proper mask is chosen and fitted correctly, CPAP adaptation becomes much easier.
• Appropriate CPAP titration: One of the more common flaws is to prescribe less pressure, thinking that this would improve compliance. However, under-titration of the CPAP will make the intrusion of the CPAP worse on the patient, as the patient’s sleep is even more severely interrupted with an improperly titrated CPAP.
• Keeping the nose open: CPAP works by applying air pressure through the nose. This also applies to full-face mask. By treating nasal congestion and allergies appropriately the patient can fully benefit from CPAP therapy. The proper level of heated humidity is also crucial in keeping the nose open. Sometimes there may be anatomical anomaly that will require an ENT evaluation.

CPAP Desensitization Technique

• Gradual initiation of CPAP therapy is one accepted desensitization technique. Rather than immediately implementing CPAP therapy at the prescribed pressure, first become familiar with the mask and machine.
• Try using CPAP during the daytime for short periods of time, such as 10–15 minutes to start. While sitting upright on a comfortable chair, hold the unstrapped mask loosely against your face for brief periods until you can breathe while holding the mask in place for one minute or more.
• After you are comfortable with the mask in place, strap the mask on and make sure it is comfortable (not so tight that it hurts and not so loose that leaks irritate the eyes).
• Once you can breathe with the mask strapped on, start adding a low level of CPAP by utilizing “ramp” and gradually increase to the prescribed setting.

This may feel uncomfortable but realize this is a normal reaction for everyone. It is natural for all patients to need time to adjust to sleeping with a CPAP mask on his or her face. It will take time before you can get adjusted to positive pressure in the airway.

• If you feel acute discomfort at any time, feel free to back off and start again.
• Always try to relax and feel loose during initial phase of CPAP and remember frustration is normal for many beginning CPAP users.
• Once you feel comfortable, start using CPAP regularly during sleep.
• Always try to relax and feel “loose” during the initial phase of CPAP and remember some frustration is normal for many beginning CPAP users.
• Once you feel comfortable, start using CPAP regularly during sleep.
• Always remember that the purpose of the CPAP is to help you. The more you try using it, the sooner you will be successful.
• Feel free to call our Sleep Lab with any questions or issues you may have.

We at Pacific Sleep Lab are dedicated to the highest level of patient care. We spend a considerable amount of time on patient education and CPAP adjustment. Patient satisfaction and successful outcomes have been the reward for our hard work. Do not hesitate to contact us if we may be of any further assistance.

A silly question? You probably answered “yes”.
You may be interested to know that many people experience difficulty sleeping and breathing simultaneously. Sleep related breathing disorder, commonly known as Obstructive Sleep Apnea (OSA), affects over 12 million Americans.

Do any of these signs and symptoms apply to you or someone you know: Difficulty falling asleep? Loud snoring? Choking or gasping? Kicking legs during sleep? Waking up with a headache? Feeling sleepy during the day? Memory or learning problems? Feeling irritable or lacking energy?

If you observe a person who is lying down with his eyes closed, he looks about the same whether he is sleeping or quietly awake, resting, with his eyes closed. But, if you pay particular attention to the person’s breathing pattern and facial muscle tone, you will notice subtle differences. The face of a person who is sleeping will be relaxed while the person who is awake with his eyes closed exhibits subtle facial muscle tension. Also, a careful observer will notice that the breathing pattern and sound is also slightly different as a person falls asleep.

The most easily discernible sign of transition to sleep is muscle relaxation. When we get tired and sleepy, we often notice our eyelids getting heavy. This is because our facial muscles are starting to relax. When someone is “nodding off,” his neck muscles begin to lose their tone, and it becomes apparent that the person is falling asleep.

Human airway begins with the nose and ends deep within the lungs. Constructed of cartilage and facial bones, the nose is semi-rigid. The windpipe, or trachea, is lined by rings of cartilage which give it shape and hold it open. Our throat, or pharynx, located just above the vocal cords is different. This part of the airway is unusual as it lacks any rigid structures. It is simply a group of thin, floppy muscles that require tension to maintain shape. Another characteristic of this area is that it is under a high level of control by the brain and it takes up an enormous amount of brain function. The reason is because we use this part of our airway for oral communication. This particular function separates us from animals. A thin and floppy airway is needed not only for communication but also for eating, swallowing, and of course for breathing. Unfortunately, when we fall asleep we lose muscle tension and this area may become partially narrowed and obstructed. As a result we are the only “mammals” that snore and have sleep related breathing disorders.

When we fall asleep and our muscles relax, there is a collapse of this part of the airway. For the majority of people, this is not a problem because the airway remains open enough to adequately facilitate breathing during sleep. However, for millions of others, collapse of this part of the airway is beyond normal and there is very little open space in the pharynx for breathing during sleep. This causes increased turbulence which we call snoring. Further relaxation and the resulting collapse of the airway lead to apneas.

While our brain is in the sleep mode, normal breathing occurs without much effort. But severe snoring, or sleep apnea, results in an increased effort to breathe as the body struggles to get more air though the narrowed airway. This causes an amplified level of stress to the body and sometimes a drop in oxygen level. There is surge in the stress hormones called catecholamines. Soon, the brain wakes up to respond to the “breathing emergency” that it detects and our sleep is interrupted. The awakening by the brain causes a sudden increase in the upper airway tone. The airway opens as the body continues to hunger for oxygen. This leads to sudden inhalation of air which sleep mates sometimes describe as a “snort” or “gasping for air”.

The result of untreated sleep apnea is that labored breathing constantly interferes with sleep and the sleep pattern becomes fragmented. We now understand that fragmented sleep is non-restorative. Most people experiencing sleep apnea wake up without feeling refreshed and feel less awake throughout the day.

A profound cardiovascular effect often accompanies obstructive sleep apnea syndrome. With increased efforts to breathe through the narrowed upper airway, the body produces tremendous variations in chest pressure. At the same time, there is a rise in stress hormones being released into the body. There may be “heart pounding” and the development of anxiety (the “fight or flight” response) as the body and lungs continue their struggle for air. Normally, during sleep hours, our blood pressure drops to compensate for less expenditure of energy. Sleep apnea syndrome causes wide swings in blood pressure that can result in hypertension and heart disease.

Inchel C. Yeam, MD, FCCP Diplomate, American Board of Sleep Medicine,
Pulmonary & Critical Care Medicine,
American Board of Internal Medicine

How is my Sleep Hygiene?

Sleep habits, or sleep hygiene, are behaviors that we learn throughout our lives, from childhood to adulthood.

Most teenagers and young adults tend to be late sleepers and sleep into the late morning (“delayed phase”). However, our society is structured so that schools and most work places start early in the day. When these teens and young adults go to bed late and get up early to meet their school or work demands, sleep deprivation sets in. This condition is obvious, because on weekends or holidays they tend to “sleep in” trying to make up for their sleep loss. During the week however, they are required to wake up early, thus feeling tired and sleepy. This creates a significant problem for the circadian rhythm (a pattern repeated approximately every 24 hours). Our brain cannot adapt to such rapidly changing sleep patterns. Therefore although a person may be physically awake in the morning, the brain is still trying to sleep, resulting in poor performance at school or in the work place. 


Why do people go to bed late? There may be some genetic predisposition. However the biggest issue could surprisingly be artificial lighting. For thousands of years people have depended on the sunrise and sunset to help us set our biological clocks. Now, however, we have artificial lights including television and computers. When the sun goes down, instead of slowing down and sleeping, we remain active with the “help” of artificial lights. 

Another cause of poor sleep is alcohol. Many people rely on alcohol to help them fall asleep. The problem is that although alcohol may be a sedative/depressant, when the effects of the alcohol wear off there is rebound awakening. Typically, as the effects of alcohol wear off in the middle of the night, people awaken and experience difficulty falling back to sleep.

Coffee is another important issue in sleep health. The effect of caffeine takes about eight to ten hours to wear off. It is helpful to avoid caffeinated beverages anytime after lunch. Also, gourmet coffees contain a very high dose of caffeine. A regular cup of coffee contains approximately 80 to 150 milligrams of caffeine, but some of the gourmet coffees contain 300 to 500 milligrams of caffeine.

Good Sleep Hygiene Hints

Behavior

Maintain a consistent wake-up time. This will promote strong circadian rhythm. Wake up time is the only thing you can voluntarily control in your sleep cycle. This routine will force you to become sleepy earlier and eventually you will have a regular sleep-time. When you get tired and sleepy after sunset, don’t fight it. It’s time to go to bed!

Create a relaxing evening and bedtime routine. Activities like reading, listening to music, and taking a warm bath can help ease your body and mind, prompting you toward sleep. Keep lights low. Avoid stimulating activity during the evening. Any activity that promotes anxiety or emotions such as work, doing bills, or problem solving will make it difficult to fall asleep.

Minimize time in bed of you are not sleeping. If you are not tired, then you’re not ready for bed. If you find that you are “forcing” yourself to go to sleep, it will not work. This scenario creates additional anxiety and frustration. Get out of bed and do something you find relaxing, such as reading.

Only use your bed for sleeping. Don’t read or watch television in bed as this will promote a poor sleep habit. You need to create a conditioned response where the feeling of a pillow and cuddling up with a blanket will lead you to restful sleep.

Designate a time and place for worrying. Stress and associated worrying are common obstacles to a restful night. Sometimes behaviors used to manage stress – drinking alcohol and caffeine, napping repeatedly, or working at night – can lead to sleep problems. That’s why it’s a good idea to set aside a regular time of day when you’re not trying to sleep, to work out stressful issues and problems. This will help relax your mind later when you lie down to sleep.

Environment

A simple rule for a good sleeping environment is, “Keep it dark, cool, and quiet.”

Dark Our brain is designed so that we sleep at night. Consider using blackout curtains or eye shades to block out any lights you cannot avoid.

Cool We tend to sleep better in a cool environment. A warm room can make us uncomfortable and disturb our sleep.

Quiet Any noise can potentially wake you up. If noise is unavoidable, consider earplugs or “white noise” machines.

Decorate your bedroom so that it is a relaxing place which invites sleep. Be sure it is safe to move around in the dark. Also, try to minimize allergens and dust, as sinus allergies can disturb your breathing and lead to frequent awakenings. This means keeping pets, such as cats and dogs, out of your bedroom.

Expose yourself to bright natural light in the morning. This will signal your brain that it is daytime and promotes a strong circadian rhythm which will improve sleep at night.

Diet

Caffeine Caffeine can interfere with sleep. It is found in coffee, tea, cola, cocoa, chocolate, and most “energy drinks”. Limit the number of caffeinated beverages you drink in a day, and avoid drinking them past noon. Many individuals claim that they sleep fine after drinking coffee. This is usually a misperception. Their sleep tends to be more disturbed and less refreshing. They usually wake up in the morning needing to drink more caffeine.

Alcohol Although alcohol may initially help you fall asleep, it can disrupt sleep later in the night. This is known as rebound arousal and is a common pattern among people who consume more than two drinks in the evening. Alcohol is also a potent muscle relaxant. It can make sleep related breathing disorder (such as sleep apnea) much worse. There are some individuals whose sleep apnea can be managed simply by the avoidance of alcohol.

Nicotine Nicotine is a stimulant found in cigarettes, cigars, and certain medications. Smoking before bed can make it harder to fall asleep, and nicotine withdrawal during sleep can disrupt sleep patterns.

Eating or drinking too much shortly before bed can interfere with falling asleep and staying asleep. However, a light snack can be soothing, and may help you fall asleep more easily.

Exercise

Expose yourself to bright natural light in the morning or early part of day. This will signal your brain that it is daytime. When evening comes, with the setting of the sun, keep your house dim and avoid using bright lights. This pattern will promote a strong circadian rhythm and improve sleep at night. Vigorous exercise during the daytime also helps one to sleep better at night. Exercise in the evening, however, will likely make sleep worse because of elevated body temperature which may take several hours to cool down. Our body temperature has a circadian pattern and cools down when we sleep.

In general, daytime exercise can aid falling asleep more easily and will help you sleep better throughout the night. Try to exercise in the morning or during the day. This will promote an early sleep-time and help you transition into deeper sleep within the same night.

In conclusion, healthy living and common sense are key components to good, satisfying sleep.

Inchel C. Yeam, MD, FCCP Diplomate, American Board of Sleep Medicine,
Pulmonary & Critical Care Medicine,
American Board of Internal Medicine

Sleep is much more complex than you may think. In fact it is a state of being just as important as being awake. Some people believe that sleep is a waste of time, and they try to sleep as little as possible to be more productive within more waking hours. The consequences of this mistaken thinking are detrimental. These people tend to be chronically tired and mentally unfocused. They are also liable to get sick more often and in the long run, their health suffers.

“I’m so tired!” When you hear these words you can almost bet that it’s because of improper sleep. But, what is it that we really do while we sleep?

Sleep is a complex and vital part of our daily routine. Sleep is not simply “turning down” the brain and resting. It is rather a complex set of behavior with a neurochemical basis. With the setting of the sun and changes in our environment that come with it, certain messages are sent to our brain. Within our brain, just behind our eyes, lie a set of nerve cells (suprachiasmic nucleus) that act as our internal clock. These groups of cells have intrinsic rhythm that acts as our “clock” and function as mediator of our circadian rhythm. These cells are under direct influence of light, especially the sun. After the sun sets, there are series of neurochemical changes that take place including a rise in our melatonin level which eventually leads us to sleep.

There are also temperature changes in our body that follow circadian pattern. Our body temperature is lowest during the deepest part of sleep. As our body starts to “warm up”, we awaken in the morning. Body temperature continues to rise during the day with a slight dip in the mid-afternoon (“afternoon dip”). When our body temperature falls we generally tend to feel sleepy. This is why we feel sleepy after lunch, not necessarily because of a heavy meal. Our level of alertness seems to follow our temperature curve. Our body temperature peeks after dinner, and then starts to cool down. This is when we get sleepy. It is interesting to know that our internal clock, the suprachiasmic nucleus, sits just above the hypothalamus, the master controller of our metabolism.

At the onset of sleep, an interesting phenomenon occurs. We all recognize that our muscles relax as we fall asleep. If you see someone become sleepy, their facial muscles begin to relax even before there are fully asleep. The eyes get “heavy” as the person has difficulty keeping them open. The head starts to nod if they happen to be sitting up. If you observe carefully as one falls asleep there is sudden relaxation of the whole body as he/she enters sleep. The upper airway also relaxes along with chest wall muscles. This results in a change in the breathing pattern and a slight under-breath during sleep. Some of us start to snore with relaxation of the airways, and in individuals with sleep apnea their upper airway collapses as they start having apneic episodes.

Sleep is organized into non-REM and REM sleep. These two sleep states appear to be as distinctly different as awake is to sleep. Non-REM is divided into stages one through four. Stage 3 and 4 is known as delta sleep or slow wave sleep. Non-REM is thought to be more of “brain resting” as there is decrease in energy consumption by the brain. We generally start our sleep with light sleep entering into slow wave sleep. Most young kids have an increased amount of slow wave sleep compared to adults. In kids it is during the first stage of slow wave sleep that growth hormone is released by the brain. Increased level of exercise has shown increased slow wave sleep, and it is thought that this stage of sleep has some kind of restorative function. During the night, the brain cycles between non-REM and REM sleep at approximately 90-minute cycles. As night progresses, REM phase becomes longer. About 25% of our sleep is spent in REM sleep.

As you may know, REM stands for rapid eye movement. REM is also referred to as active sleep or paradoxical sleep. Interestingly, in REM our brain is highly active and utilizes more energy than when we are awake. REM is thought to be a primitive type of sleep and it is the first sleep seen in the developing brain. Because the brain is highly “turned on”, other interesting phenomenon occurs. Our brain literally paralyzes our body to prevent it from moving. There are series of changes that occur in the brain stem resulting in near complete paralysis that occur at the level of the spinal cord. In fact, our spinal reflexes such as knee jerk reflex is absent during REM. If you have ever awakened and were paralyzed for a few seconds, literally could not move even though you’re awake, this is when your brain delayed turning off part of the REM mechanism. Most people have experienced this feeling and occasional episodes are thought to be normal. REM is also associated with the dream state and when people are awakened during REM they usually will have a vivid dream recall.

The question was what happens when we sleep. Honestly, we are not sure. But we know what happens when sleep is partially deprived. The most obvious changes we notice are that the person is tired and lacks energy. There is also a noticeable lack of concentration. Even if the sleep-deprived person is not tired studies have shown that with a minimal decrease in sleep-time, day time performance suffers. There is strong evidence that your metabolism will be disturbed. Chronic sleep deprivation has been shown to slow your metabolism leading to weight gain as well as fatigue. Various hormones that are released by the brain to control being awake and being asleep also appear to control hunger and satiety, and vice versa. Your immune function also appears to be directly related to sleep pattern. Lack of proper sleep will compromise the overall immune system leading to illness. Severe sleep deprivation studies done in animals often result in the animal dying, with overwhelming infections. In fact, the most efficient way to improve your immune function is to optimize sleep.

There are strong psychological affects from lack of sleep. Other than being tired, sleepy people tend to be cranky and short tempered. Chronic sleep loss is associated with fatigue and depressed mood. Divorce rate among couples with sleep problems is much higher than average. In fact, the most treatable cause of attention deficit disorder is sleep deprivation, the most common form being sleep apnea.

We know sleep has various important functions, but we still try to get by on less sleep and more caffeine. There is really no substitute for sleep, especially for growing kids and young adults. Setting a regular sleep pattern is the basis of good sleep hygiene.

Inchel C. Yeam, MD, FCCP Diplomate, American Board of Sleep Medicine,
Pulmonary & Critical Care Medicine,
American Board of Internal Medicine