Shocking the Low Road for Central Sleep Apnea

Central sleep apnea is rarer than obstructive sleep apnea. In obstructive sleep apnea, the tissues of the airway collapse, closing the airway, preventing air from entering. CPAP and oral appliance therapy treat sleep apnea by keeping the airway open, but are of limited value for central sleep apnea. In central sleep apnea, the brain stops sending signals telling the body to breathe. CPAP is used for central sleep apnea, and it can be helpful because it ensures there is always some amount of fresh air in the lungs that can partly keep the blood oxygenated. But even for patients that tolerate the treatment, it can only improve the condition, not fully treat it.

Now researchers at Ohio State University think they may have found a good solution to the problem. Similar to the tongue shocker for obstructive sleep apnea, they have invented a pacemaker-like device targeted at the diaphragm. When this device senses that the sleeper has stopped breathing, it shocks the diaphragm, stimulating it to function.

Currently, the device is being tried on one patient, but if it works, it may be the long-sought best treatment option for central sleep apnea.

If you are looking for a successful sleep apnea treatment, talk to a local sleep dentist today to learn the full range of options available.

QUESTION ABOUT THE PILLAR PROCEDURE

Question: What do you think of the pillar procedure?

Answer: The pillar procedure is not effective for treating blockage at the base of the tongue where almost all obstructive apnea occurs. If you have sleep apnea the pillar procedure alone will almost never cure it and you will still need CPAP or an appliance. I would not suggest this procedure for patients who have sleep apnea. This may be be considered for patients with simple snoring only especially if the frequency of the snoring suggests it is specifically from the soft palate. Otherwise, it would seem to be a surgery looking for a problem it can cure. It will rarely, if ever be an apnea cure and then only in the mildest cases.

ARM AND HAND NUMBNESS AND PAIN IN SLEEP APNEA PATIENTS RELATED TO SCALENE MUSCLE NERVE ENTRAPMENT

The Russian article (see abstract below) discusses the entrapment of the neuromuscular bundle in fibruous bands in the scalene muscles. These muscles are very important in sleep apnea patients. They are normally accessory breathing muscles but are overused when patients with obstructive apnea try to breathe past an obstruction. Long term overuse can lead to taut bands and trigger points as described by Dr Janet Travell. These trigger points can lead to upper quarter pain including the entire arm and hand as well as anterior and posterior shouler regions.

In addition the nerve roots of the brachial plexus can be compressed between the anterior and medial scalene muscles. The authors call this scalenus anticus syndrome a subtype of thoracic outlet syndrome. These problems can be adressed by body work such as massage or myotherapy but correcting the underlying sleep apnea will often result in self correction of this problem. This will result in many patients utilizing CPAP or oral appliances.

In patients where the condition does not self correct a neuromuscular orthotic may give amazing relief. See http://www.ihateheadaches.org

Georgian Med News. 2005 Sep;(126):18-23.

[Fibrous-muscular and vessels anomalies revealing during surgery of the scalenus anticus syndrome]

[Article in Russian]

Tsitsuashvili G, Dzhavakhishvili G, Buddzhiashvili V, Gogeliani A, Rcheulishvili I.

National Center of Surgery, Tbilisi, Georgia.

One hundred and twenty five operations on 100 patients were performed due to the symptoms suggesting presence of the pressure on the neurovascular supraclavicular structures, although X-ray showed no evidence of cervical rib. In 15 cases of patients with so-called scalenus anticus syndrome as one of the forms of thoracic outlet syndrome (TOS) seemed to be compressing the neurovascular bundle. Scalenus mediums muscle appeared to be producing more compression of the nerve roots than did the scalenus anterior in 5 patients. Pressure from Rudimentary First Rib--in 2 cases in our series malformation of the first rib was the cause of the patient's distress. Anomalous Bands--in 4 cases anomalous bands of fibrous tissue in the supraclavicular area were the cause of compression of the neurovascular bundle Anomaleus Arteries Compressing Nerve Roots- large arteries compressed roots of trunks of the brachial plexus in four patients in our series to such an extent that it seemed these structures were the cause of the patient's symptoms. All anomalous structures were removed, good results after such surgical tactics were kept for long time in all cases. Therefore the surgeons, performing scalenotomy have to pay particular attention to the fibrous bands and anomalies in the scalene group of muscles.

PMID: 16234586 [PubMed - indexed for MEDLINE]

I HATE CPAP FAN

Hey very nice blog!!….I’m an instant fan, I have bookmarked you and I’ll be checking back on a regular….See ya

Sleep Apnea, TMD, Myofascial Pain and Headaches

The American Equilibration Society hed its 2010 meeting and Sleep apnea and sleep disordered breathing were continually reference as comorbidities for headaches, TMD (TMJ), fibromyalgia and muscle and joint disorders. Patients who visit this site and suffer from headaches, myofascial pain, fibromyalgia or TMJ disorders should go to http://www.ihateheadaches.org and read my blog http://www.ihateheadaches.org/blogs/illinois/2010/02/myofascial-trigger-points-are-explained.html covering muscle pain and how the newest research agrees with neuromuscular dental concepts.

Nap 'boosts' brain learning power according to article on BBC news.

"Sleep not only rights the wrong of prolonged wakefulness, but, at a neurocognitive level, it moves you beyond where you were before you took a nap" according to Dr Matthew Walker,at UC Berkeley.

I found this post on BBC news " The latest study, from the University of California at Berkeley, suggests that the brain may need sleep to process short-term memories, creating "space" for new facts to be learned. " http://news.bbc.co.uk/2/hi/health/8524549.stm

The quality of sleep at night as well as during naps determine how successfully are brains function cognitively and in terms of short term memory.

According to the BBC news "Dr Matthew Walker, who led the study, reported at the AAAS conference in San Diego, said: "Sleep not only rights the wrong of prolonged wakefulness, but, at a neurocognitive level, it moves you beyond where you were before you took a nap.
"It's as though the e-mail inbox in your hippocampus is full, and, until you sleep and clear out all those fact e-mails, you're not going to receive any more mail.
"It's just going to bounce until you sleep and move it into another folder."
However, Professor Derk-Jan Dijk, the director of the Surrey Sleep Research Centre, said that there was no clear evidence that daytime napping offered a distinct advantage over sleeping just once over 24 hours.
"The sleep-wake cycle is not as rigid as we might think - we have the capability to sleep in different ways."
He said that while the brain effect reported in the study might be spotted in a laboratory setting, the picture became more clouded in the "real world".
"The size of these effects are much more difficult to assess - if I have to learn something, for example, it's easier to do this when I'm feeling awake and alert than when I'm sleepy.""

I will try to read original studies and post again.

Dr Shapira

SWEDISH EPIDEMIOLOGY: OBSTRUCTIVE SLEEP APNEA INCREASE CARDIOVASCULAR MORBIDITY AND MORTALITY

Obstructive sleep apnea increases cardiovascular morbidity and mortality according to Swedish article. This increase suggests that OSA is an increased (additive) risk above and beyond established risk factors of obesity, hypertension, smoking and hyperlipidemia. (see PubMed Abstract below).

A second article (see PubMed abstract below) published in the Journal of Cardiology 2010 Jan;55(1):92-98 concluded that Sleep Apnea Syndrom increased nocturnal blood pressure even in patients without hypertension. Patients with severe apnea demomstrated more sever elevations in nocturnal blood pressure.

A Japanese study (Heart Vessels. 2010 Jan;25(1):63-9) showed effectiveness of CPAP in treating arrythmias. Sleep apnea treatment with oral appliances and dental sleep medicine should show identical results based on other studies comparing treatment outcomes. This study showed " The results of this study demonstrate a significant relationship between OSA and several cardiac disorders, and also demonstrate the efficacy of CPAP in preventing OSA-associated arrhythmias in a large population of Japanese patients." Again I expect that apnea treated with oral appliances would have similar outcomes to CPAP use. This study again relates cardiac disorders to obstructive sleep apnea.

Another review article (Curr Opin Pulm Med. 2009 Aug 2) "Heart failure and sleep-disordered breathing: mechanisms, consequences and treatment." reviews recent articles on Sleep disordered breathing and Heart Failure. The article's summary (see PubMed abstract below) say "The relationship between CHF (congestive heart failure) and SDB (sleep disordered breathing) is likely to be bidirectional, CHF impacting on SDB severity and vice versa. Identification of SDB in the CHF population appears to be important as it is probably associated with greater mortality, but whether SDB intervention significantly influences CHF survival still remains to be determined. The effects of each conition worsens the other. Treatment that eliminates sleep disordered breathing should result in positive effects on cardiac symptoms. The article also discusses patients with central sleep apnea associated with Cheyne-Stokes breathing. Unfortunately CPAP and Oral appliances are not effective for central sleep apnea but adaptive servo-ventilation shows encouraging results. "Small, short-term studies are discussed, however long-term randomized trials with objective cardiac outcomes are still lacking" in regards to aaptive servo-ventilation.

A key point from all of these studies is that sleep apnea is a dangerous condition with multiple associated morbidities and with treatment improvement in morbidities and mortality is seen. While CPAP is extremely effective studies show it is rejected by the majority of patients. Dental Sleep Medicine and oral appliances provide needed alternatives to CPAP. Oral appliances are a first line treatment for mild to moderate sleep apnea. Patients with severe apnea who do not tolerate CPAP will benefit from an oral appliances. Patients with central sleep apnea may want to consider sero-ventilation.


Anadolu Kardiyol Derg. 2010 Feb;10(1):75-80.
Cardiovascular consequences of sleep apnea: I -Epidemiology.
Turgut Celen Y, Peker Y.

Sleep Medicine Unit, Department of Neurology and Rehabilitation Medicine, Skaraborg Hospital, Skövde, Sweden. yuksel.peker@lungall.gu.se.
Obstructive sleep apnea (OSA) is common in general population. There is an accumulating research evidence for an independent relationship between OSA and cardiovascular morbidity and mortality. This relationship is stronger in clinical cohorts compared with the general population, which suggests that concomitant OSA in subjects with traditionally recognized risk factors such as obesity, hypertension, smoking, and hyperlipidemia may provide an additive risk factor for the cardiovascular consequences. In the current article, the clinic-and population-based epidemiologic data will be reviewed in this context.

PMID: 20150011 [PubMed - in process]

J Cardiol. 2010 Jan;55(1):92-98. Epub 2009 Nov 22.
Relationship between sleep apnea syndrome and sleep blood pressure in patients without hypertension.
Sekizuka H, Kida K, Akashi YJ, Yoneyama K, Osada N, Omiya K, Miyake F.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao Miyamae-ku, Kawasaki-city, Kanagawa-prefecture 216-8511, Japan.
BACKGROUND AND PURPOSE: Ambulatory blood pressure monitoring (ABPM) provides an accurate assessment of blood pressure (BP) and shows non-dipper BP pattern in many sleep apnea syndrome (SAS) patients with hypertension (HTN); however, little information is available on the relationship between the severity of SAS and circadian BP changes in SAS patients without HTN. This study investigated whether SAS patients without HTN would have different BP courses in the severity of SAS. METHODS AND SUBJECTS: Seventy-four consecutive outpatients without HTN [systolic BP (BPs) at clinic <140mmHg and/or diastolic BP (BPd) at clinic <90mmHg], who received no antihypertensives, underwent overnight polysomnography (PSG) and ABPM. The apnea-hypopnea index (AHI) was calculated from the PSG results; patients were stratified into the following 4 groups based on their AHI: non-SAS, mild-, moderate-, or severe-SAS. RESULTS: The diurnal BPs and BPd showed no differences in the severity of SAS; however, the sleep BPs, lowest BPs, and pre-awake BPs were significantly higher in the severe-SAS group than the non-SAS group (p=0.02, p=0.04, and p=0.006, respectively). The sleep BPd and pre-awake BPd were significantly higher in the severe-SAS than the non-SAS (p=0.01 and p=0.0003, respectively) and mild-SAS (p=0.01 and p=0.008, respectively) groups. CONCLUSIONS: The results of this study suggested that SAS affected nocturnal BP elevation even in SAS patients without HTN. The diurnal BP showed no difference in the severity of SAS; however, the severe-SAS group revealed significant nocturnal BP elevation. Copyright © 2009 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

PMID: 20122554 [PubMed - as supplied by publisher]

Heart Vessels. 2010 Jan;25(1):63-9. Epub 2010 Jan 21.
Efficacy of continuous positive airway pressure on arrhythmias in obstructive sleep apnea patients.
Abe H, Takahashi M, Yaegashi H, Eda S, Tsunemoto H, Kamikozawa M, Koyama J, Yamazaki K, Ikeda U.

Division of Cardiovascular Medicine, Shinshu University Graduate School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan.
The purpose of this study was to determine the relationship between obstructive sleep apnea (OSA) and cardiovascular disorders in a large Japanese population, and to assess the efficacy of continuous positive airway pressure (CPAP) in the treatment of OSA-associated arrhythmias. The study population comprised 1394 Japanese subjects (1086 men and 308 women) who were divided into four groups on the basis of polysomnography (PSG) analysis as follows: the no sleep apnea (N-SA) group (n = 44, apnea-hypopnea index [AHI] < 5), the mild OSA (Mi-OSA) group (n = 197, 5 < AHI < 15), the moderate OSA (Mo) group (n = 368, 15 < AHI < 30), and severe OSA (SOSA) group (n = 785, AHI < 30). The following baseline characteristics were significantly associated with OSA: age (P < 0.001), gender (P < 0.001), body mass index (P < 0.001), hypertension (P < 0.001), diabetes (P = 0.009), and hyperlipidemia (P = 0.013). In the OSA group, PSG revealed the predominance of paroxysmal atrial fibrillation (PAF) (P = 0.051), premature atrial complex short run (P < 0.005), premature ventricular complex (PVC, P = 0.004), sinus bradycardia (P = 0.036), and sinus pause (arrest >2 s, P < 0.001) during the PSG recording. A total of 316 patients from the group underwent CPAP titration and were then re-evaluated. Continuous positive airway pressure therapy significantly reduced the occurrences of PAF (P < 0.001), PVC (P = 0.016), sinus bradycardia (P = 0.001), and sinus pause (P = 0.004). The results of this study demonstrate a significant relationship between OSA and several cardiac disorders, and also demonstrate the efficacy of CPAP in preventing OSA-associated arrhythmias in a large population of Japanese patients.

PMID: 20091401 [PubMed - in process]

Curr Opin Pulm Med. 2009 Aug 26. [Epub ahead of print]
Heart failure and sleep-disordered breathing: mechanisms, consequences and treatment.
Kee K, Naughton MT.

Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia.
PURPOSE OF REVIEW: This review examines the recently published articles pertaining to sleep-disordered breathing (SDB) and heart failure. RECENT FINDINGS: The recent findings can be classified into pulmonary, upper airway and treatment trials. Pulmonary complications of heart failure include loss of surfactant, increased pulmonary dry weight and reduced lung volume, which are likely to increase plant gain and thus predispose to central sleep apnea with Cheyne-Stokes respiration. Upper airway narrowing in normal individuals has been shown to occur with lower limb compression and the supine body position, thus suggesting that rostral fluid shifts may narrow the upper airway and aggravate obstructive sleep apnea. Extrapolating this to congestive heart failure (CHF), it is possible that CHF fluid status may impact upon obstructive sleep apnea severity. Following the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnoea and Heart Failure trial, further SDB intervention studies have been reported using adaptive servo-ventilation. Although encouraging, small, short-term studies are discussed, however long-term randomized trials with objective cardiac outcomes are still lacking. SUMMARY: The relationship between CHF and SDB is likely to be bidirectional, CHF impacting on SDB severity and vice versa. Identification of SDB in the CHF population appears to be important as it is probably associated with greater mortality, but whether SDB intervention significantly influences CHF survival still remains to be determined.

PMID: 19713849 [PubMed - as supplied by publisher]

Anonymous has left a new comment on your post "SWEDISH EPIDEMIOLOGY: OBSTRUCTIVE SLEEP APNEA INC...":

Nice post and this enter helped me alot in my college assignement. Say thank you you on your information.

Dr Shapira: I get dozens of thank you's from high school and college students who use my site as a research source. I take pride in supplying the highest quality information. I recently spoke at Integrate Chicago a course on integrative medicine for medical stuents and many who attended my lectures had spent a considerable amount of time doing research on treatment of sleep apnea. The general response was that it was one of the best sites on the internet if you were looking for alternative treatments for sleep apnea.

Dr Shapira