Rise and Shine - Sleep Apnea Killing Productivity

“I hate waking up feeling rested and refreshed”, said no one, ever!! 

I have never met a soul who has confided in me that they hate a good sleep. On the contrary, when someone sleeps well, it shows in every aspect of their disposition. Why, because there is nothing quite as satisfying as a good, recuperative night’s rest. Who hasn’t lamented that intrusive sound of a blaring, beeping alarm clock, signaling the premature end of a slumber that didn’t quite cut the mustard? Who hasn’t thought to themselves in that moment, “If only I could get a few more hours in before I have to get up..?”

We love sleep because it makes us feel good when we get good quality sleep! Sleep is one of our most complex functions. I like to compare sleep to an airplane being set on autopilot. When all of the systems are working, autopilot can do 99% of the work over an 8- hour journey or more. Sleep is like this in many ways. The body takes a journey through time, and its various systems autopilot it safely on a nighttime journey towards recovery, health, and repair from the previous wear and tear of the previous 16-18 hours of being awake. 

Sleep is highly regulated by certain genes, and these genes geolocate us on the planet. In a 2017 Nobel prize press release honoring the 3-way Nobel prize winners Hall, Rosbash and Young we are reminded that “Life on Earth is adapted to the rotation of our planet”, and that we “have an internal, biological clock that helps [us] anticipate and adapt to the regular rhythm of the day (and night). With exquisite precision, our inner clock adapts our physiology to the dramatically different phases of the day. The clock regulates critical functions such as behavior, hormone levels, sleep, body temperature and metabolism.” https://www.nobelprize.org/prizes/medicine/2017/press-release/

Breathing Disturbed Sleep

Another autopilot function of the body is breathing, and it can’t be overrated, and it should not be overlooked in your health… because when we stop doing it, we die. Thankfully, we don’t have to consciously think about breathing to breathe—it is just something that our body does naturally. So, it is no surprise to find that good uninterrupted breathing is a key part of “good, uninterrupted sleep”. Research has shown that when our breathing is disturbed, so is our sleep, and when our sleep is chronically disturbed, it can affect our brains in both the short and long term, our mental health, our productivity, and our relationships.  

There are several types of disturbed sleep associated with events where the body stops breathing. These episodes are called apneic events. There are two main types of apnea, “central” and “obstructive”. Obstructive is where a part of the upper airway (soft palate, tongue or throat muscles lose tone, and collapse in on the airway closing it off partially or completely.) Central apnea is more complicated in that the brain shuts off and restarts breathing at intervals. A third type of apnea combines the two. Recent research suggests that some people with obstructive sleep apnea develop central sleep apnea as a result of using CPAP machines. --Mayo Clinic, Jun 25, 2019 

The long-term effects of sleep apnea can be far reaching and touch every aspect of our lives.  Aside from affecting our state of alertness and functioning during the waking hours after a restless night sleep, it can affect our personal relationships and work life.  If left untreated, sleep apnea can increase our risk of health problems, including; headaches, worsening ADHD, depression, diabetes, high blood pressure, stroke, and heart failure.  It has also been linked to obesity and loss of brain matter.  It is not a problem to be taken lightly.

The most common treatment of choice for sleep apnea is a continuous positive airway device (CPAP).  CPAP is a mask that fits over the nose and/or mouth and gently blows air into the airway to help keep it open during sleep.  The problem with CPAP is that it only treats sleep apnea as a symptom and does nothing to treat the cause of the sleep apnea.  It is a lifelong treatment plan.

A quick Google search of “sleep apnea” and you will find ten common CPAP alternatives for the apneic patient, 8 of them are surgical. Below I review those 10 options and point out important UPSIDES and DOWNSIDES to those procedures which are mostly surgical.   Ultimately though, none of the discussed treatments address the cause of the problem and can be a bit extreme and invasive in their treatment. 

But before I do, I want to tell you about a very important part of your brainstem that governs your upper airway and share with you a nonsurgical, noninvasive option that not only works but carries no adverse risks.  It also gets right to the root of the problem and allows the body to perform the way it’s designed to allow us to get the restful rejuvenating sleep that we need to be healthy, high functioning and happy.

NTS

The NTS is an area of the brainstem that is involved with breathing and swallowing. The NTS is an acronym for Nucleus Tractus Solitarius, and it is a hub of brainstem circuitry that controls the size and function of the upper airway, among other things. It participates and coordinates movements and function of the tongue, the soft palate, chewing and swallowing muscles, the diaphragm, the epiglottis, the heart and lungs.  When it is not functioning properly, it can reduce size and interfere with the function of the throat. That means is can affect breathing (even while your awake) and sleep breathing as well. When the NTS is not working properly, it can interfere with the autopilot systems of the body.  The NTS lives inside the upper cervical region of the spine or directly inside the atlas (C1) and the C2 vertebra.  This often overlooked region of the head and neck are essential to sleep, breathing and body function.  The upper cervical area needs to allow a high degree of mobility, but at the same time stabilize the head and neck.  The head is balanced nicely on top of the spine and held in place by muscles and tendons.  A small misalignment of the C1 and C2 vertebra can result in pinching off the functional space that the brain stem and NTS reside.  This can cause a cascade of problems that the body must make adjustments to accommodate.  First and foremost is a lack of function of the muscles that control the expansion and collapse of the upper airway.  We have seen in many patients that experience sleep apnea, that they are trying to breathe and function through roughly the equivalent of two drinking straws.  

By ensuring that the upper cervical junction (CCJ) is in the correct alignment and the functional space allowed for the control centers of the brain are providing the space necessary for proper bodily function, the muscles that control the airway can function properly and increase the size of our breathing space to our genetic potential.  Here at The Lift Clinic, we perform a treatment that is called a Transdermal Atlas Positioning (TAP) procedure.  The TAP procedure non-surgically and noninvasively, realigns the body to its optimal position.  At which point the body can breathe and function as designed. 

Here are few before and after Transdermal Atlas Positioning (TAP) procedures. There are no downsides to this procedure. It is a closed, imaged guided procedure and as you can see in these two most recent examples from our patients, dramatic changes in upper airway space were immediate. The patients instantly felt better and could breath better. On their subsequent visits of one week and two weeks, they reported sleeping was much improved as was their upright posture. 

                         In the first case, the air flow capacity improved over 100%, and in the second 200%.

 Case One

 Case Two

The Lift Clinic offers a free initial consultation.  We can quickly assess using images and technology if our treatment plan is a good course of action for you.  Before you commit to a lifetime of sleeping with a mask or having risky surgery, you should schedule a free consultation and see how we have an over 85% positive outcome for our patients.

Continue reading below if you still think surgery is your first and best option.

TOP TEN THINGS ON GOOGLE SEARCH FOR SLEEP APNEA! 

1.     Side Sleeping

a.     UPSIDE: Minimally invasive. No surgery or drugs required. May reduce obstructive sleep apnea.

b.     DOWNSIDE: It can be painful on the shoulders, jaw joints and hips. The body can easily turn into a face down posture which is rough on the neck. 

2.     MAD. Mandibular Advancement Device. This is an intraoral appliance that draws the jaw forward, mechanically opening the upper airway.

a.     UPSIDE: This device works by moving the jaw forward, which increases the size of the upper airway and reduces air resistance behind the soft palate and tongue which can contribute to obstructive sleep apnea and snoring. It may be effective for some patients, especially those with mild or moderate OSA. May reduce obstructive sleep apnea.

b.     DOWNSIDE: When the jaw is held forward night after night for months, the jaw joints remodel to that advanced position and the bite changes permanently, often requiring more invasive dentistry to resolve—like total mouth restorations costing tens of thousands of dollars. It can also affect the aesthetics of the patients by giving them a “Bulldog” type of a bite. Who doesn’t love a bulldog? 

3. Tonsillectomy or Adenoidectomy Surgery. Sometimes if something is infected or inflamed, “conventional wisdom” suggests just getting rid of it. This “throw-away” mentality sells patients short in too many ways to list—but for starters, if the tonsils and adenoids are enlarged, instead of pulling them out and tossing them in the parts bin, let’s figure out what might be causing the inflammation and enlargement. Food and environmental allergies are very common. 

a.     UPSIDE: Instant functional space, and more upper airway volume. May reduce obstructive sleep apnea.

b.     DOWNSIDE: To get this space you will need to remove a key part of your craniofacial immune system which provides protection for the sinuses, throat, mouth, neck and face. Both your tonsils and adenoids help to trap pathogens, such as bacteria or viruses, that enter your mouth or nose. They contain immune cells that produce antibodies that kill these pathogens before they can spread to the rest of your body. 

4.     Uvulectomy (Removal of the Uvula) Some patients can have a long palate shortened with a procedure known as a UP3 (uvulopalatopharyngoplasty) or uvulectomy — a procedure used to remove excess tissue in the soft palate to widen the airway and allow air to move through the throat more easily. The thought here is exactly the same as removing tonsils, except the uvula does not perform any known immune function. It is, however, a mechanical structure that is key to the function of swallowing, phonation and airway protection. Not only does it “syphon” the sinuses, and help move fluid from the back of the nose into the nasopharynx, it also protects the airway in much the same way that a goalie protects the net.  

a.     UPSIDE:            This reduces snoring in roughly 60% of the cases and may be effective in mild to moderate cases of OSA. May reduce obstructive sleep apnea.

b.     DOWNSIDE: Many people report swallowing dysfunction, choking, pain in throat, nasal regurgitation, and voice change. (Who wants your hockey teams keeper sitting in the box rather than in front of the net?)

5.     GGA (genioglossus advancement) When the airway collapses behind the tongue, a GGA (genioglossus advancement) may be recommended. The surgical procedure is designed to move a portion of the chin bone forward, thereby pulling the base of the tongue muscles forward to increase airway size.

a.     UPSIDE: This procedure can pull the tongue up and out of the throat and is a relatively simple surgery. Few surgical complications are described in the literature. May reduce obstructive sleep apnea.

b.     DOWNSIDE: May affect the muscles used for swallowing and the many other muscles associated with tongue posturing. Potential for post-surgical infection and damage to canine roots injury. Permanent tooth numbness or death. Chin and lower lips numbness. Change in appearance. Structural weakening of the lower jaw. Need for additional procedures.

6.     Inspire hypoglossal nerve stimulator: Those with a backward collapse of the tongue, diagnosed via a nasal endoscopy, can also be treated using an Inspire hypoglossal nerve stimulator. This consists of a breathing sensor and a stimulation lead powered by a small battery. Implanted during a short outpatient procedure, the device continuously monitors a recipient’s breathing while he or she sleeps. It delivers mild stimulation to key airway muscles and moves the tongue and other soft tissues out of the airway to enable breathing during sleep.

a.     UPSIDE: Moves the tongue out of the airway and can be useful where one is CPAP intolerant. May reduce obstructive sleep apnea.

b.     DOWNSIDE: First, it’s expensive. I am aware of one surgery costing nearly $120,000! A hockey puck sized controller is installed on the chest just below the collar bone. Wires are installed on the chest wall in front and back. A stimulator lead is installed on one of the two genioglossus muscles forcing the tongue to protrude more to one side than the other. This is a surgically induced, off-center tongue thrust, which will over time interfere with your bite, tooth position and irritate the tongue (see below). Oh, and if your battery’s die—it stops working!

7.     MMA surgery (maxillomandibular advancement): Patients with shortened or underdeveloped upper or lower jawbones may benefit from MMA surgery (maxillomandibular advancement), in which the upper jaw (maxilla) and the lower jaw (mandible) are lengthened and moved forward. This surgery is reserved for patients with moderate to severe OSA.

a.     UPSIDE: In severe underdeveloped jaw situations, it can improve facial aesthetics. When all else fails, try this. May reduce obstructive sleep apnea.

b.     DOWNSIDE: The most common complications detailed in previous studies are atelectasis, pulmonary embolism, dysrhythmia, hypoxemia, hypotension, chest pain, myocardial infarction, loss of sensation on the face, post-operative pain syndrome and death.

8.     MME (maxillomandibular expansion): When a patient’s jawbones are narrow, or long enough but their OSA is severe, the jawbones may be widened using MME (maxillomandibular expansion). This option requires a combination of orthodontic appliances and surgery to expand the jawbones, with the goal of enlarging the airway and increasing the space available for the tongue.

a.     UPSIDE: Make room for the tongue in the mouth. May reduce obstructive sleep apnea.

b.     DOWNSIDE: Loss of sensation to the front face around the mouth, a risk of postoperative dyspnea due to pharyngeal edema, and some aesthetic dissatisfaction, gapping in the front.

9.     Bariatric Surgery: Excessive weight or obesity may be a major contributor to a person’s OSA. Weight gain can cause fat tissue to build up around the throat and at the base of the tongue. Medical weight loss or bariatric surgery may be indicated in certain cases.

a.     UPSIDE: You get skinny really, really fast! (May reduce obstructive sleep apnea.)

b.     DOWNSIDE: Excessive bleeding, Infection, Adverse reactions to anesthesia, Blood clots, Lung or breathing problems, Leaks in your gastrointestinal system, Bowel obstruction, Dumping syndrome, which leads to diarrhea, flushing, lightheadedness, nausea or vomiting, gallstones, hernias, low blood sugar (hypoglycemia), malnutrition, ulcers, vomiting, acid reflux, the need for a second, or revision, surgery or procedure, Death (rare).

10.  Tongue reduction surgery may be helpful when the tongue is abnormally enlarged. Reducing the size of a person’s tongue may cause the airway to collapse less, thus improving airflow and breathing.

a.     UPSIDE: Tongue has been reduced in size, and may reduce obstructive sleep apnea.

b.     DOWNSIDE: bleeding, hematoma of tongue base, abscess of tongue base, altered taste, tongue numbness, deviation of tongue extension movement, dysfunctions of pronunciation of wards and swallowing. Which taste buds do you want to sacrifice? 

So before we resolve ourselves to sleeping poorly, being unproductive, or even worse, having something cut out of our body, be assured there is a better way. At the very least, we should sleep on it.

Chris Chapman DC, BCAO, DCCJP

Rich Wilder III

The Lift Clinic is a Salt Lake City based healthcare clinic that can assist you or your employees that are suffering from sleep apnea and the resulting low productivity. Visit us at www.theliftclinic.com for a free consultation.