Provent, A New Treatment for Obstructive Sleep Apnea

Written by Dr. Artal on June 2, 2012 — Leave a Comment

 

Provent is a new treatment for obstructive sleep apnea, developed in the past several years, which represents a new treatment option for patients suffering from obstructive sleep apnea.

 

Provent is technologically classified as an expiratory positive airway pressure nasal device. In plain English, Provent is basically a one time use disposable sticker (it looks a little like those small circular bandaids that you get at the doctors office after you get a shot or vaccine). The sticker has a tiny plastic valve in their center to allow you to breath through. Every night when the user goes to bed, he or she places one sticker over each nostril, and peels off and throws away the sticker in the morning on awakening.

 

The valve in each sticker is the key to how they work. They are one way valves which allow unimpeded inhalation, but create resistance when one exhales. The back pressure created by the resistance to exhalation is transmitted to the throat, creating a very subtle increase in airway pressure, and helping to prevent or mitigate airway collapse. In most users this results in a decrease in the quantity of sleep apnea and snoring.

 

There is one very important point to keep in mind. Most studies looking at Provent show that it decreases apnea frequency by around 50%. What that means, is that if you have severe sleep apnea, and are having around 50 apneas per hour, Provent would be expected to decrease your apnea frequency to around 25 events per hour – still a significant quantity. Therefore, Provent is not my recommended first line therapy for individuals with moderate or severe obstructive sleep apnea. The only treatment which offers near 100% success is CPAP. Provent is however an excellent option for individuals with mild sleep apnea, or for individuals with moderate or severe sleep apnea who are CPAP intolerant.

 

It’s not a cure all, and it’s not for everybody, but it does represent a new option for patients and their bed partners looking for relief. Discuss it with your sleep physician if you’d like more information.

 

Check out this link to a CBS News interview with me about Provent.

 

Provent – Manufacturer’s Website

 

As always, if you have any questions or concerns about your health you should speak to your physician.

 

Roy Artal, M.D., F.C.C.P.

Medical Director, Tower Sleep Medicine

Diplomate, American Board of Sleep Medicine
Los Angeles, California

 

 

**Please note that the CBS video piece above contains an error in content. It incorrectly states that Provent is the only alternative to CPAP. Provent is actually one of many alternative treatments for obstructive sleep apnea.

 

 

 

 

Posted in Obstructive Sleep Apnea | Tagged , , , ,

Dental Management of Sleep Disordered Breathing

Written by Dr. Artal on February 29, 2012 — Leave a Comment
Obstructive sleep apnea has different treatment options, with treatment selection dictated by both disease severity as well as patient choice and preference. One of the hallmark treatments of sleep apnea has been via the fabrication of a very specialized oral appliance, or mouthpiece, which is custom fashioned for the patient by a dental specialist. There are dozens of different styles and types of oral appliances in use around the country, but in general they can be divided into two broad types. The first, most commonly used is the mandible advancement type. These work by repositioning the mandible (jaw) forward just a millimeter or two, with idea being that it pulls the tongue off the back of the throat and helps to keep open the airway. The second type is known as a tongue restraining type, in which a mechanical positioner, often a bar or band, holds or presses the tongue downward- again with the idea of keeping the tongue from dropping backwards against the throat. Oral appliances are an excellent, efficacious, and well tolerated treatment option for patients with obstructive sleep apnea and snoring. For many patients with severe OSA, but who are CPAP intolerant, oral appliances may serve as an excellent “second best” solution. More information about oral appliance therapy for obstructive sleep apnea and snoring can be found at the website for the American Academy of Dental Sleep Medicine.

As always, if you have any questions or concerns about your health you should speak to your physician.

Roy Artal, M.D., F.C.C.P. Medical Director, Tower Sleep Medicine Diplomate, American Board of Sleep Medicine
Los Angeles, California

Posted in Obstructive Sleep Apnea | Tagged , , ,

Treating Obstructive Sleep Apnea with Throat Exercises

Written by Dr. Artal on February 10, 2012 — Leave a Comment

 

Obstructive sleep apnea (OSA) is essentially a plumbing problem. Apneas, or pauses in breathing, are caused by the collapse of soft tissues in the throat and behind the tongue, leading to (literally) the airway pancaking down on itself. Because obstructive sleep apnea therefore is a pure plumbing problem, there are no medications that treat it. All of the different treatments for sleep apnea involve various mechanical attempts to keep the airway open and to prevent the apneas or breathing pauses.

 

CPAP use air pressure to literally splint open the airway. The example I give my patients is that of inflating a balloon. When you blow air into a balloon it expands as it fills with air. CPAP is doing the exact same thing to your throat- your throat and upper airway are being filled up and expanded, just like a balloon, with the air pressure generated by the CPAP machine. This positive air pressure keeps the airway inflated open. (CPAP actually stands for Continuous Positive Airway Pressure.)

 

Surgical treatments for OSA involve changing anatomy in order to move, modify, or reduce structures size in order to keep the airway from closing down.

 

Oral or dental appliances for sleep apnea work by attempting to move the jaw or tongue or both forward and off the back of the throat- again a mechanical attempt to keep the airway open.

 

These three treatment approaches, CPAP, surgery, and dental devices, represent the majority of treatments recommended in most doctors’ offices for the treatment of obstructive sleep apnea.

 

One of the most common questions I get from patients though, after running through these options is, “are there any exercises I can do to strengthen my throat muscles and to prevent sleep apnea?”

 

The answer is yes, but it’s not easy and is certainly not for everyone. On the other hand, for individuals who are determined, committed, and fitness minded there are exercise alternatives (or complements) to the traditional treatments- exercises that strengthen the muscles of throat and that effectively prevent or reduce the occurrence of obstructive sleep apnea.

 

For those of you who are more medical or scientific minded, two interesting medical journal references are located at the end of this blog. They will provide you with detailed information on the medical studies that examined the question of treating obstructive sleep apnea with exercise.

 

In the first article cited below, “Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome”, the authors took a group of individuals with moderate obstructive sleep apnea, and divided them into two groups. One was assigned to perform 30 minutes of daily sham (or placebo) exercise, and the other was assigned to perform 30 minutes of exercises actually designed to strengthen the muscles of the throat wall. The results were quite impressive. The group performing the sham exercises had no improvement in any of the study variables. The throat exercise group had significant improvements in neck size, snoring, daytime sleepiness, and, most importantly, in the Apnea-Hypopnea Index (the unit of measure of sleep apnea severity). The authors concluded that throat exercise could significantly improve sleep apnea severity in individuals suffering from moderate obstructive sleep apnea.

 

In addition to traditional exercises, there’s also been quite a bit written about the didgeridoo, a traditional wind instrument developed by Indigenous Australians over 1500 years ago. The second article below examines the use of playing the didgeridoo as a tool to strengthen the muscles of the throat. In addition, entering the terms “didgeridoo and sleep apnea” into your favorite search engine will pull up plenty of information on the subject.

 

There is no question that individuals with moderate or severe obstructive sleep apnea should pursue aggressive treatment of this condition in order to treat their symptoms and to prevent medical complications. Nevertheless, there is no reason why those traditional medical treatments cannot be supplemented with these types of throat exercises. For folks with mild sleep apnea, or those with more significant disease who can’t tolerate CPAP or the other treatments, throat exercise remain a viable treatment option.

 

Throat exercises to treat sleep apnea definitely isn’t for everyone, but for those looked for an out-of-the-box approach it shouldn’t be overlooked.

 

Guimaraes KC, Drager LF, et al. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009;179:962-966.

 

Puhan MA, Suarez A, et al. Didgeridoo playing as alternative treatment for obstructive sleep apnea syndrome: randomized controlled trial. BMJ 2005;332:266-270.

 

http://en.wikipedia.org/wiki/Didgeridoo

 

As always, if you have any questions or concerns about your health you should speak to your physician.

 

Roy Artal, M.D., F.C.C.P.

Medical Director, Tower Sleep Medicine

Diplomate, American Board of Sleep Medicine
Los Angeles, California

Posted in Obstructive Sleep Apnea | Tagged , , ,

Sleep Articles for Qualityhealth.com

Written by Dr. Artal on February 20, 2011 — Leave a Comment

 

Earlier this year I was asked to write several sleep health related articles for qualityhealth.com.

They deal with pretty common issues and problems that have affected virtually all of us. Check them out.

 

How to Handle Middle of the Night Awakenings

 

Creating the Ideal Bedroom Environment

 

Overcoming Environmental Sleep Disruptions

 

 

As always, if you have any questions or concerns about your health you should speak to your physician.

 

Roy Artal, M.D., F.C.C.P.
Diplomate, American Board of Sleep Medicine
Los Angeles, California

Posted in Insomnia, Sleep Health | Tagged ,

An Unusual Complication of CPAP Therapy…

Written by Dr. Artal on February 12, 2011 — Leave a Comment

Over the years I’ve heard back from countless patients about their CPAP experiences- both good and bad. Certainly for most individuals with moderate or severe obstructive sleep apnea CPAP/BiPAP therapy is the most reliable and effective treatment available, and even many of my patients with mild sleep find it helpful and effective.

 

The problem with CPAP therapy though is that many patients are intolerant of it as a treatment. Whether it be general discomfort from having to wear a mask while sleeping, to dislike of the sensation if having air “blown” into their airway, many patients find long term CPAP use a challenge.

 

Fortunately though many if not most of my patients are able to quite successfully use CPAP as a long term treatment. From time to time though patients will report back to me about some difficulty or problem that’s crept up with their CPAP use. A patient recently forwarded to me this link to a non- medical blog that describes (without a doubt) the most unusual CPAP related complication I’ve ever heard of. Check it out- I think you’ll get a good chuckle.

 

http://www.treppenwitz.com/2010/12/having-to-rethink-the-logistcs.html

 

 

As always, if you have any questions or concerns about your health you should speak to your physician.

 

Roy Artal, M.D., F.C.C.P.
Diplomate, American Board of Sleep Medicine
Los Angeles, California

Posted in CPAP, Obstructive Sleep Apnea | Tagged , ,

Home Testing for Obstructive Sleep Apnea

Written by Dr. Artal on January 12, 2011 — Leave a Comment

On January 10, 2010 CBS2 News in Los Angeles broadcasted this interview with me on home testing for obstructive sleep apnea.

 

Click this link for the CBS News Website.

 

 

Home testing for sleep apnea has been around in rudimentary forms for years, however there is no doubt that significant technological advancements in the past several years have led to a profound rethinking of this tool for diagnosing obstructive sleep apnea. Whereas previous home based technologies would perhaps allow for only basic recording of oxygen levels, heart rate, and breathing pauses, new systems record multiple variables, almost approaching the level of sophistication of formal laboratory sleep studies. Home studies are suitable for diagnosing sleep apnea in medically healthy individuals, in which other types of sleep disorders are not suspected. In general, individuals with significant heart or lung disease, or individuals with suspected severe sleep apnea are poor candidates for home sleep studies. Home studies are also not suitable for diagnosing nocturnal movement disorders, nocturnal behavior disorders, seizures, or in evaluation of hypersomnia conditions such as narcolepsy. On the other hand home sleep studies are excellent tools for evaluating individuals with suspected mild or moderate sleep apnea or people with significant snoring. It also is an excellent alternative for individuals who may be phobic of sleeping in a sleep center, or for individuals who are looking for more economical alternatives to a full sleep laboratory polysomnogram.

 

As always, if you have any questions or concerns about your health you should speak to your physician.

 

Roy Artal, M.D., F.C.C.P.
Diplomate, American Board of Sleep Medicine
Los Angeles, California

Posted in Obstructive Sleep Apnea

The Link Between Insomnia and Depression Part 1

Written by Dr. Artal on August 22, 2010 — Leave a Comment

Most any physician who commonly treats either insomnia or depression will tell you that the two conditions are often linked. In yet another recent study examining this connection, researchers looked at a group of patients diagnosed with both a Major Depressive Episode and insomnia. This particular study examined Health Related Quality of Life (HRQOL) indicators as well as objective measures of sleep.

Patients were started on treatment with the anti-depressant fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI) . Patient’s still complaining of insomnia symptoms after one week were randomly assigned to receive either the insomnia medication eszopiclone (Lunesta) or a placebo. Measures of depression, quality of life and sleep indicators were recorded over subsequent weeks. The sleep measures included maintaining a sleep diary, in which participants recorded their bedtimes, sleep latency (time it takes to fall asleep), perceived number of awakenings, and total sleep time. Participants also completed regular standardized insomnia questionnaires.

The researchers found that patients treated with the combination of fluoxetine (Prozac) and eszopiclone (Lunesta) had significant improvements in measures of depression, depression severity and sleep quality.

The complete study may be found online and in print. The reference is:

McCall WV, et al. Treatment of Insomnia in Depressed Insomniacs: Effects on Health Related Quality of Life, Objective and Self Reported Sleep, and Depression. Journal of Clinical Sleep Medicine, Vol. 6, No. 4, 2010.

As always, if you have any questions or concerns about your health you should speak to your physician.

Roy Artal, M.D., F.C.C.P.
Diplomate, American Board of Sleep Medicine
Los Angeles, California

Posted in Depression, Insomnia

Obstructive Sleep Apnea and Risk of Stroke

Written by Dr. Artal on August 8, 2010 — Leave a Comment

Numerous small studies over the past several years have suggested increased rates of strokes in persons with obstructive sleep apnea (OSA). In persons with severe OSA these studies suggested that the risk of stroke increased anywhere from 2 to 4 fold. Stroke is the second leading cause of death globally. It is known that stroke risk factors include hypertension, coronary artery disease, diabetes mellitus and atrial fibrillation.

The Sleep Heart Health Study (SHHS) is a multi-center prospective study implemented by the National Heart Lung and Blood Institute to determine the medical consequences of OSA and sleep disordered breathing. From 1995 to 1998, the SHHS researchers conducted baseline sleep and general medical health assessments, including overnight polysomnography, on study participants. Since that original baseline assessment, the SHHS researchers have been following the study population and tracking the occurrence of various medical events, including that of stroke.

Updated findings from this study have just been published. 5422 participants without a history of stroke and untreated for obstructive sleep apnea were followed for approximately nine years. 193 episodes of ischemic strokes were observed in the group over that time frame. The occurrence of stroke was associated with increasing age and systolic blood pressure, atrial fibrillation, and marginally with diabetes. Stroke was not associated with BMI, smoking status, or alcohol use. At baseline, moderate or severe obstructive sleep apnea defined as an Apnea-Hypopnea Index (AHI) > 15 was approximately 30% more common in men and women who subsequently had an ischemic stroke (compared to those who remained stroke free). Even after adjusting for age, race, systolic blood pressure, blood pressure medication use, and diabetes, men who had an AHI greater then 19 per hour had an almost 3-fold increased risk of ischemic stroke compared to men without OSA.

This large study provides compelling evidence that OSA increases the risk of ischemic stroke in both men and women, and lends yet further evidence to the involvement of obstructive sleep apnea in cardiovascular and stroke morbidity and mortality.

The complete study may be found online and in print. The reference is:

Obstructive Sleep Apnea Hypopnea and Incident Stroke: The Sleep Heart Health Study. Susan Redline, MD, MPH, et al. AJRCCM Articles in Press. Published on March 25, 2010 as doi:10.1164/rccm.200911-1746OC.

As always, if you have any questions or concerns about your health you should speak to your physician.

Roy Artal, M.D., F.C.C.P.
Diplomate, American Board of Sleep Medicine
Los Angeles, California

 

Posted in Cardiovascular Health, Obstructive Sleep Apnea

Welcome to Tower Sleep Medicine

Written by Dr. Artal on March 11, 2010 — Leave a Comment
Welcome to the online home of Tower Sleep Medicine. This News and Blogs section has been created as a way of communicating new sleep health related advances and scientific research, as well as to discuss sleep medicine topics in the news and media.

Like all of medicine, the study of sleep disorders is progressing at a break neck pace. This continual flow of knowledge represents an ongoing challenge to physicians who need to maintain their fund of knowledge and stay cutting edge. This represents an even bigger challenge to patients, who have neither the access to medical information resources nor the scientific and medical background to make sense of it all.

This blog will attempt to highlight a selection of sleep health related advances and scientific publications. It is not meant to be a comprehensive overview of sleep disorders, and, most importantly, it is not meant to replace or substitute conversations with a health care providor. It will hopefully, however, educate, stimulate curiosity, and bring a greater awareness to the importance of sleep health.

Roy Artal, M.D.
Medical Director, Tower Sleep Medicine
Diplomate in Sleep Medicine, American Board of Internal Medicine
Posted in Welcome