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[Music] welcome to another medcram video we're going to talk today about obstructive sleep apnea I'm a sleep certified specialist and so this disease I know it pretty well also it is a very low
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hanging fruit for those that want to optimize their health it's very common and it's also in people that don't even know that they have it today we're going to talk very briefly about it and go over some very basic points so people
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understand what it is that we're dealing with here when we talk about obstructive sleep apnea so the problem in a lot of cases is mechanical here you see a cross-section and the first thing you can notice is that their tongue takes up
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a pretty large portion of this area the problem is is that when you go to sleep your Airway goes to sleep this is the airway here this is your nose and the airway going in to breathe this is the
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part above your tongue that goes back and you can see right about here is where the problem is and then of course oxygen needs to go down into your lung and carbon dioxide needs to come out and the problem is is that there's an actual blockage right here and so really when
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you go to sleep your Airway muscles go to sleep and when they close off you're trying to breathe air in and the air can't get down and so this transposition of oxygen going down and carbon dioxide coming up can't happen the more important of those two if there is one
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is that the oxygen isn't getting down and so what happens is that the part of your brain that stays awake the whole time and monitoring your Vital Signs detects that your oxygen levels are going down and it wakes up the rest of the brain to alert them to this
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emergency and the rest of the brain has to wake up tighten up the muscles allow the air to go in the airway opens up oxygen gets in oxygen comes back up that part of the brain that is monitoring oxygen is basically satisfied and then
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the brain goes back to sleep again this thing repeats itself over and over again you can see here that some of the risk factors for this would be having a large tongue now as it turns out typically men more than women when they gain weight tend to store fat in their tongue and so
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their tongues will swell you can see that really nicely on MRI actually because fat shows up as basically white tissue on MRI the other thing is that men's Airways are larger and so because of the law of Laplace which we don't
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have time to get into larger Airways are more collapsible and so they're easier to close off with pressure placed on the outside so that's why men are typically more at risk for obstructive sleep apnea
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but women are also at risk for sleep apnea especially after menopause how would you know that someone has sleep apnea snoring or their bed partner is witnessing that they stop breathing at night they gasp for air they wake up in
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the morning with headaches they don't feel well rested they fall asleep very easily while not really being engaged or it could be very subtle things like fibromyalgia body aches low energy what exactly is going on in sleep apnea let's
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take a closer look here this is known as a polysomnography we look at the brain waves and we can tell when they're sleeping this person is sleeping because we can see this and the brain waves you may not be able to recognize this but the brain waves are slow enough that
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they are sleeping we're looking here at different parts of the brain where looking at their eye movements we're looking at their muscles we're also looking at what their heart is doing we can see the heart rate going across here and you can see their heart rate 62 62
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pretty consistent and then the key is looking at their oxygen saturation you can see here this point right here their oxygen saturation is close to 100 but then it drops down and then it goes back up again and then it drops down why is that happening why is there this
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undulation of oxygenation well it's because we're looking at flow through the nose and then basically it stops there's no flow happening at this point here at night and when we look at their
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chest movement their chest movement starts to go down but it's not completely stopped we see their abdominal movements not completely stopped it's as if they're trying they're trying to get air in but no air is going in this is basically a very
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diagnostic pattern for obstructive sleep apnea the muscles are trying to get the air down but because the airway is closed off where we showed you you're not going to see any movement of air and air is not actually not getting in then we see the leg movements here pretty
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consistently not moving basically no airflow is happening and that causes the oxygen saturation to drop until of course it drops so low that there is an arousal in the brain and that causes the
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airway to open up we start to see the motion again with the abdomen and the chest and then of course we start to see airflow again until the oxygen level starts to come back up when it comes back up again things are already starting to shut down and we see this
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cycle over and over again until finally it gets so bad that there is a huge arousal the patient wakes up and now we are awake and that's the problem and we see this happening over and over sometimes this
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can happen up to a hundred times in an hour that means at least once a minute or more maybe even twice a minute that this is happening you can expect that people are not going to get very good sleep with this this is what it would look like the entire night compressed
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let's take a look at everything here before the purple line what we're looking at here is a lot of different things we can see oxygen saturation it's not straight it's a jagged line kind of Richter scalish type of look and that's because the oxygen is going up and down
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the heart rate is also going through a workout during the night going up and down each one of these bars right here is where the patient almost completely stops breathing and you can see that when they almost completely start breathing that's coordinating care with
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decreased oxygenation so this is a real problem when people have sleep apnea and they're not getting appropriate oxygen at night they're not getting appropriate rest at night there's other things that happen when all of these things occur and the oxygen levels go down this is
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going to excite the brain and the sympathetic nervous system and blood pressure is going to go up and all of these things that are cardiovascular endpoints that we look at in studies are going to go up the general population when do people generally die so we're
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looking at these bars right here if we were to divide the day into 25 so we have midnight to six in the morning six in the morning to noon noon to six in the evening and the evening till midnight when do people generally die
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well people generally die between six o'clock in the morning and noon and why is that well there's some theories that maybe it has to do with cortisol cortisol levels are the highest at that time blood pressures are up people are getting up from bed that's when
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typically we start to see all cause mortality at its highest although it's pretty even what about people with sleep apnea notice when we're looking here at sleep apnea we're looking at these bars here and you can see that people with
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sleep apnea the most likely time for them to die is between midnight and six o'clock in the morning and you can imagine why that would be they're going through The Gauntlet at night they are trying to breathe they're not their oxygen levels are low in the 60s or 7
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companies their blood pressure is high even during the day if we look at sympathetic nerve activity during the day when they're awake when they're not having sleep apnea in a normal person this is what their sympathetic nervous
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system activity looks like and people with sleep apnea who are having these difficulties at night this is what their sympathetic nervous system looks like during the day when they're actually not having apnea it's because it's ramped up
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and this is a problem that causes their blood pressure to not be able to relax and get that rest that it needs when you have sleep apnea this is something that is called dipping and non-dipping people who have no apnea in the blue notice
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what happens their blood pressures go down at nights here in the 3 A.M to 6 a.m goes down at night they're systolic and diastolic but the people who have apnea they don't get the benefit of that dipping they're not getting the benefit
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of rest at night it's because of sympathetic nervous system activity so you can see here that this mechanical problem can cause quite a bit of issues we we can talk about the diagnostic criteria and how to test for that these
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are things that Healthcare Providers need to know how to do your job as a Layman is to understand that you may have this condition and to present to your health care provider for further testing for those of you who are Health Care Providers and are watching this and
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want to learn more about this we actually have a course at medcram.com called Sleep Apnea certified for four units of continuing medical education it's brand new and we've just produced
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it and it's on our website so there are different options which we're going to talk about right now about how to attack and solve this issue basically it's an obstructive issue we need to get rid of this stuff that's blocking the back of
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the throat there are basically three different ways of doing this I mean there's more than that could obviously do a tracheostomy and just bypass the whole thing but what are some ways of bypassing this and one of the ways is
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probably the most popular and that is CPAP if you can imagine that this is a flat tire and we're trying to pump up the attire wearing a CPAP mask which is very very quiet these days attached to a
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hose goes over your nose into your nose could be a nasal pillows or a full face mask which covers both the mouth and the nose basically what we're doing is we're putting in a gentle amount of pressure here into the airway and it's going to
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push the tongue forward and off the back of the throat and that's what CPAP does so if you look here in this polysomnography remember we looked at this before everything before the purple line was what the patient was doing
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before and then what we see down here is we are increasing the pressure on CPAP so we're going from six centimeters to seven to eight to nine to ten essentially what we're doing here is we're covering the airway we're allowing
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the patient to breathe back and forth so it's not smothering them but we're instilling a pressure into the circuit that's going to inflate this Airway in a nice way which is not causing too much disturbing irritation on the tissue and
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notice what happens we keep titrating it up until we see these obstructions basically disappear and no notice instead of having a jaggedy line in terms of oxygen saturation we get a nice straight line and here even the patient goes into REM sleep which is amazing
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sleep so CPAP is probably one of the most studied and used treatments for obstructive sleep apnea and there's a lot of good data that this type of intervention is good with favorable cardiovascular outcomes what's another
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way that we can get the tongue off of the back other than using a CPAP machine well you can do an oral Appliance and there's a lot of dentists who are actually experts in this area and essentially what you're trying to do is
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you're trying to get the tongue off the back of the throat now because the tongue is anchored to the mandible which is the lower jaw if you can move the jaw forward the tongue is going to come along with it another way of doing it
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also is to just grab the tip of that tongue and pull it forward so there's two Dental devices that you can use to affect that change one of them is called the mandibular advancement splint and this is basically a device that you put
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into your mouth and it moves your lower incisors in front of your upper incisors until you get the desired effect and your sleep apnea is improved now there's many ways of checking that sometimes you have to have a sleep study at the end of
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that to make sure that that is in fact the case but that is one of the treatments that you can do side effects since you're using the temporal mandibular joint which is this area back here where the mandible is joined if you're moving this forward you could get
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teeth movement you could get some TMJ issues those are things to just keep in mind but that is something that can be done these tongue retaining devices actually just go into the mouth and they grab onto the tongue and you just pull
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it forward so by pulling the tongue forward you can hopefully get it off the back and then you'll be able to breathe and not have sleep apnea these are typically used in mild to moderate sleep apnea they don't work so well in severe
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sleep apnea because we can't really pull the tongue as far forward as we would like to do so sleep apnea can be treated with CPAP it can also be treated with a dental device what's another way that we can treat it this is something that's relatively new that's come out in the
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last maybe five six seven years and this is something called a hypoglossal nerve stimulator so notice that the hypoglossal nerve comes out of the brain stem it's also known for those of you who are in medicine as the 12th cranial nerve and it innervates this muscle here
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specifically called the genioglossus muscle it's these muscles right here if you could contract these muscles you would be able to get the tongue to move in this direction that would be really important if you're wanting to get the tongue off the back of the throat why
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don't we have an implantable device that only comes on at night that can tell when you're about to take a breath and it's going to Signal this nerve to activate this muscle so that the tongue comes forward just when you need to have
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it that's exactly what they do with these hypoglossal nerve stimulators is that it goes here on the right side of your chest it's implanted there's a lead that goes here to your intercostal muscles that can tell when you're about to take a breath and then whenever that
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happens it sends a lead up here into the neck to stimulate that hypoglossal nerve and then what that does is it's pushing forward the tongue these hypoglossal nerve stimulators are typically indicated for people who have a BMI of
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less than 35 and generally speaking have sleep apnea that's either moderate or severe and they can't tolerate CPAP so this is another potential option so we've talked about obstructive sleep apnea and we've shown that it's pretty
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common and the concerns that we have with it it's very common and I see this quite a bit and a lot of people are in denial and they say that they're not sleepy when in fact they don't know how sleepy they are this really has an
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impact on your quality of life and also on your health optimization so I would highly consider making sure that you get tested for sleep apnea and this usually involves a sleep test that you can even do at home or go into the sleep lab
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because if you catch this early you can actually prevent a lot of cardiovascular problems later on in life so what are some red flags if I were to see this in a patient obesity although I've seen this in people who are as
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skinny as a rail it has to do with their anatomy in their mouth if they have parents who have sleep apnea this is also genetic if you're on more than three different blood pressure medications and your blood pressure is still high highly consider you may have
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sleep apnea if you've got atrial fibrillation which is an irregular heartbeat highly recommend testing for obstructive sleep apnea as well if you've recently gained a lot of weight more than 20 pounds in the last six
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months that's also another reason to check for obstructive sleep apnea if you find yourself falling asleep very easily that's a sign of excessive daytime sleepiness obstructive sleep apnea is a very common cause of that
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and for those who want to find out more about the details of obstructive sleep apnea from a healthcare provider point of view and get into the details of the diagnostic criteria and exactly the risks and benefits we have a course that
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we've recently published called Sleep Apnea explains clearly it's available for four continuing medical education credits and Moc points and also CES this is also for nurses and physician
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assistants as well and I will put a link in the description below to this course I hope this has been helpful for those of you who may have sleep apnea or may have loved ones who have sleep apnea so you can understand a little bit more clearly why this is important thanks for
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joining us
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