Combination Therapy More Effective Than CPAP Alone

According to research presented last week at the American Academy of Dental Sleep Medicine (AADSM), combination therapy is more effective in treating obstructive sleep apnea than CPAP alone. The study also showed that people tended to be more tolerant of CPAP therapy when it was combined with oral appliance therapy.

The small study looked at 10 women and 10 men who were being treated for severe obstructive sleep apnea. The patients experienced a mean of 66 apneic events or breathing pauses prior to treatment. When treated with CPAP, the number of events decreased to only 4.4 per hour, and 2.6 with combined therapy. Although the vast majority of breathing interruptions were corrected with CPAP alone, patients experienced considerable benefit from MAS when measured by the Epworth Sleepiness Scale (ESS). ESS scores decreased from a mean of 10.1 before treatment to 7.9 with CPAP treatment to 4.9 with combination treatment, showing that even if the changes in breathing interruptions may not seem to be as significant, the contribution to a person's quality of life may be dramatic.

Researchers also note that patients who did not comply with CPAP therapy alone were comfortable with combination therapy, but did not release clear data to support this assertion.

If you are struggling with CPAP therapy and are looking for a more comfortable alternative, oral appliance or combination therapy may be a better option for you. To learn more, please contact a local sleep dentist today.

Why CPAP is not effective in treating resistant hypertension. Does CPAP fail to reduce stroke risk and myocardial risk?

I have reviewed several article recently on why CPAP doesn't seem overly helpful in treating hypertension. A new article in Sleep Medicine Review "A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions." clearly explains why CPAP is ineffective intreatment of hypertension. IT ISN'T USED or it isn't used enough. The article clearly states "Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients", in simple English, CPAP does not work because CPAP is not used!

Numerous studies have shown low CPAP compliance with only 23-42% of patients utilizing CPAP and a recent study showed 60% quit CPAP completely.

CPAP SUCCESS IS DESCRIBED AS USING CPAP 4-5 NIGHTS FOR 4-5 HOURS A NIGHT, THIS TYPE OF SUCCESS CAN KILL YOU OR LEAD TO CARDIOVASCULAR ACCIDENTS AND STROKES. More importantly this horrendous description of success lulls cardiologists into a false sense of security with treatment.

Studies have shown that most heart attacks and strokes occur between 3-5 AM. The typical patient only wears their CPAP for 4-5 hours/ night. Patients who go to sleep with their CPAP at 10 PM and wear it 4-5 hours will be untreated during the critical hours of 3-5 AM.

It is time for the sleep community to recognize that part-time CPAP use can result in deadly outcomes. An article in the Journal of Human Hypertension "Resistant hypertension, obstructive sleep apnoea and aldosterone." state that "CPAP studies do, however, indicate a wide variation in the BP effects of CPAP, with some patients manifesting a large antihypertensive benefit such that a meaningful BP effect can be anticipated in some individuals. OSA is particularly common in patients with resistant hypertension (RHTN)" The wide variation is likely based on CPAP use. CPAP used 4 hours a night is at best 50% effective, and totally ineffective during times of highest risk.

Treatment of Obstructive Sleep Apnea is essential for many reasons. A recent study showed that oral appliances and CPAP are equivlant when objectively titrated. Oral appliances show much higher compliance than CPAP in both time of use and frequency of use. This could correct hormonal changes that occur due to sleep disruption.

"Diagnosis and treatment of primary aldosteronism" is an article published in
Endocrinology Metabolism Clinics of North America (2011 Jun;40(2):313-32) states that "A few simple rules can allow physicians to successfully identify many patients with arterial hypertension caused by PA among the so-called essential hypertensive patients. The hyperaldosteronism and the hypokalemia can be cured with adrenalectomy in practically all of these patients.

The removal of the adrenal gland may cure the hypertension but the cause of adrenal excess is obstructive sleep apnea that is not effectively treated due to short time use of CPAP.

IF PATIENTS ARE NOT RESOLVING HYPERTENSION PROBLEMS AN ORAL APPLIANCE TRIAL SHOULD PRECEDE ADRENALECTOMY.

Many sleep physicians are "married" to CPAP and their blinders make them declare 70-90% success rates in their patients even though objective studies show that their success is due not to high patient compliance but rather success described as 4-5 hours of use.

Cardiologists, endocrinologists and vascular surgeons need to demand higher levels of success from the sleep community. Unfortunately CPAP is the fiscal engine that drives much of sleep medicine. The elimination of stage 4 sleep from sleep reports was due to the inability of CPAP to return a normal Delta Sleep percentage. Research at University of Chicago showed that Growth Hormone is produced during the first period of Delta Sleep as a quick example. Dumbing down of sleep medicine is inexcusable. Currently Sleep Labs Accredited by the AASM are not even allowed to break Slow Wave sleep into stage 3 and 4.


Sleep Med Rev. 2011 Jun 6. [Epub ahead of print]
A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions.
Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE.
Source

University of Pennsylvania School of Nursing, Biobehavioral Health Sciences Division, USA; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.
Abstract

Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.

Copyright © 2011 Elsevier Ltd. All rights reserved.

J Hum Hypertens. 2011 Jun 9. doi: 10.1038/jhh.2011.47. [Epub ahead of print]
Resistant hypertension, obstructive sleep apnoea and aldosterone.
Dudenbostel T, Calhoun DA.
Source

Vascular Biology and Hypertension Program, Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
Abstract

Obstructive sleep apnoea (OSA) and hypertension commonly coexist. Observational studies indicate that untreated OSA is strongly associated with an increased risk of prevalent hypertension, whereas prospective studies of normotensive cohorts suggest that OSA may increase the risk of incident hypertension. Randomized evaluations of continuous positive airway pressure (CPAP) indicate an overall modest effect on blood pressure (BP). Determining why OSA is so strongly linked to having hypertension in cross-sectional studies, but yet CPAP therapy has limited BP benefit needs further exploration. The CPAP studies do, however, indicate a wide variation in the BP effects of CPAP, with some patients manifesting a large antihypertensive benefit such that a meaningful BP effect can be anticipated in some individuals. OSA is particularly common in patients with resistant hypertension (RHTN). The reason for this high prevalence of OSA is not fully explained, but data suggest that it may be related to the high occurrence of hyperaldosteronism in patients with RHTN. In patients with RHTN, it has been shown that aldosterone levels correlate with severity of OSA and that blockade of aldosterone reduces the severity of OSA. Overall, these findings are consistent with aldosterone excess contributing to worsening of underlying OSA. We hypothesize that aldosterone excess worsens OSA by promoting accumulation of fluid within the neck, which then contributes to increased upper airway resistance.Journal of Human Hypertension advance online publication, 9 June 2011; doi:10.1038/jhh.2011.47.

PMID:
21654850
[PubMed - as supplied by publisher]

Prog Cardiovasc Dis. 2009 Mar-Apr;51(5):371-80.
Sleep apnea, aldosterone, and resistant hypertension.
Pimenta E, Calhoun DA, Oparil S.
Source

Department of Hypertension and Nephrology, Dante Pazzanese Institute of Cardiology, Sao Paulo, SP, Brazil. espimenta@hotmail.com
Abstract

Obstructive sleep apnea, aldosterone excess, and resistant hypertension are common comorbidities in obese patients. The mechanisms that link these conditions are not fully elucidated, but sympathetic nervous system activation, sodium retention, renin-angiotensin-aldosterone system stimulation, endothelial dysfunction, and increased production of reactive oxidative species may be contributing factors. Patients diagnosed with this triad should be treated with low-salt diet, weight-loss counseling, and continuous positive airway pressure, as well as aggressive antihypertensive therapy, usually with multiple agents, including a mineralocorticoid receptor antagonist. Patients with aldosterone-producing adenoma may require adrenalectomy.

PMID:
19249443
[PubMed - indexed for MEDLINE]

Endocrinol Metab Clin North Am. 2011 Jun;40(2):313-32.
Diagnosis and treatment of primary aldosteronism.
Rossi GP.
Source

Molecular Hypertension Laboratory, Dipartimento di Medicina Clinica e Sperimentale (DMCS) 'G. Patrassi' - Internal Medicine 4, University of Padua, University Hospital Padua, Via Giustiniani, 2, 35126 Padua, Italy.
Abstract

Moreover, in a substantial proportion of them, the blood pressure can be normalized or markedly lowered if a unilateral cause of PA is discovered. Hence, the screening for PA can be rewarding both for the patient and for the clinician, particularly in those cases where hypertension is severe and/or resistant to treatment, in which the removal of an APA can allow blood pressure to be brought under control despite withdrawal of, or a prominent reduction in, the number and doses of antihypertensive medications.

Copyright © 2011 Elsevier Inc. All rights reserved.

PMID:
21565669
[PubMed - in process]

Can the Brain Learn to Overcome Sleep Apnea?

New research from the University of Toronto shows that the brain might be more plastic than previously suspected, a quality that will help it overcome the damage inflicted by sleep apnea. The study, published in the December 2010 issue of The Journal of Neuroscience, studied the body's ability to lay down an adaptive respiratory memory.

Researchers studied long-term facilitation of breathing in response to repeated apneic and hypopneic events. In response to these types of events, the body lays down a respiratory memory that that strengthens the ability of respiratory motoneurons to trigger contraction of breathing muscles. In particular, the researchers looked at the effect obstructive sleep apnea had on a number of motoneurons in test rats. In studied rats, the breathing interruptions strengthened muscle tone in the tongue and the muscle that supports it from the chin. Interestingly, this stimulation did not affect the nerves controlling the diaphragm.

This research may help find a drug treatment that can support current forms of sleep apnea treatment. However, the treatment may not be successful if it is not coupled with appropriate positioning of the lower jaw, which supports the tongue. This repositioning of the lower jaw can be accomplished with an oral appliance. With support from a new drug treatment, oral appliance therapy may become the frontline treatment for obstructive sleep apnea even for severe cases. However, since this feedback channel does not stimulate the diaphragm, it may not be a good treatment avenue for central sleep apnea.

To learn more about the sleep apnea treatment options available, please contact a local sleep dentist today.

Chemical Triggers of Memory Loss

Research published this month in The Journal of Neuroscience has revealed some of the chemical triggers that mediate memory loss related to sleep deprivation. The researchers looked at the role of the nucleoside adenosine in the hippocampus, the center of the brain that directs the function of memory.

Sleep deprivation has long been known to cause an increase in adenosine, an effect common in all animals from arthropods to vertebrates, including humans. Now there is growing evidence that this nucleoside is the source of memory deficits that result from sleep deprivation.

Researchers tested the role of adenosine using two parallel experiments on sleep-deprived mice. In one experiment they used genetically engineered mice that were altered so they could not produce adenosine. In another experiment, researchers used a chemical pump that blocked an adenosine receptor in the hippocampus. Both of these experiments were designed to test whether adenosine was the key factor in sleep deprivation-related memory defects.

In both cases, the mice did not show memory deficits following sleep deprivation. The mice were able to recognize that a box had been moved in their environment, as opposed to the mice without adenosine blocking, who were all unable to identify what part of their environment had been changed from the prior day. These mice also stood up to an electrical measurement of their memory-forming synapses, showing objectively that they were unaffected by the loss of sleep.

In the future it is possible that this research will lead to us blocking the cognitive effects of sleep deprivation, but it is unlikely that it will help prevent some of the physiologic dangers of sleep apnea, such as coronary artery disease (CAD). Avoiding these consequences will still depend on successful sleep apnea treatment.

To learn more about your sleep apnea treatment options, please contact a local sleep dentist today.

Grinding (Bruxism )appliances and Sleep Apnea: Can a grinding appliance make Sleep Apnea Worse? The answer is a definite maybe.

A recent article inthe Journal of Oral Rehabilitation examined the question as to whether a grinding appliance could make sleep apnea aworse. ( of 18 patients showed increases in AHI when their bites were opened without mandibular advancement but only 2 were significantly changed. The article considers whether the vertical opening is responsible for increasing AHI but it is also possible that grinding and/or clenching habits may be protective of the airway and the utilization of these appliances may reduce that activity that is protective against sleep apnea.

It has been previously reported that bruxism appliances can increase sleep apnea in some patients.


J Oral Rehabil. 2011 Apr 5. doi: 10.1111/j.1365-2842.2011.02221.x. [Epub ahead of print]
The effect of raising the bite without mandibular protrusion on obstructive sleep apnoea.
Nikolopoulou M, Naeije M, Aarab G, Hamburger HL, Visscher CM, Lobbezoo F.
Source

Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE, University of Amsterdam and VU University Amsterdam, Amsterdam Department of Clinical Neurophysiology and Center for Sleep-Wake Disorders, Slotervaart Medical Center, Amsterdam, The Netherlands.
Abstract

Summary  It has recently been suggested that wearing a maxillary occlusal splint (i.e. a hard acrylic resin dental appliance that covers the occlusal surfaces of the maxillary dentition and that is being indicated for the treatment of, e.g. temporomandibular pain) may be associated with a risk of aggravating obstructive sleep apnoea (OSA). The present study tested the hypothesis that raising the bite without mandibular protrusion in OSA patients is associated with an increase in the apnoea-hypopnoea index (AHI). Eighteen OSA patients (13 men; 49·5 ± 8·1 years old) received a mandibular advancement device in 0% protrusion of the mandible (0%MAD). The MAD caused a bite rise of 6 mm as measured interincisally. Polysomnographic recordings were obtained at baseline and with the 0%MAD in situ. No statistically significant difference in AHI was noted between the baseline night and the 0%MAD night. However, nine patients had an aggravation in AHI during the night they used the 0%MAD. Taking into account the previously established smallest detectable difference of 12·8 in AHI, the AHI increased in only two of the patients. The outcomes of this study suggest that an increased jaw gape without mandibular protrusion might be associated with a risk of aggravation of OSA for some, but not for all OSA patients. Dental practitioners should be aware of this possible association when treating patients with oral devices that raise the bite.

© 2011 Blackwell Publishing Ltd.

PMID:
21463349
[PubMed - as supplied by publisher]

Sleep Apnea, Cancer, and Mice

If you suffer from sleep apnea, you are no doubt familiar with the dangers of this condition. The combination of disrupted sleep and lack of oxygen aggravates countless systems in the body and leads to many health problem, one of the most notable being cancer.

We don’t fully understand all the associations between sleep apnea and cancer, but a new study presented yesterday at the ATS 2011 International Conference in Denver has concluded that sleep apnea can speed the growth of cancerous tumors.

Researchers in Spain used two test groups of mice, injecting each group with melanoma cells and monitoring the growth of tumors over a period of 40 days. One group was subject to intermittent hypoxia, or periodic oxygen deprivation meant to simulate obstructive sleep apnea conditions. Since the researchers used mice instead of humans, they were able to make sure that no other conditions, such as heart disease or obesity, affected the data. Intermittent hypoxia was the only variable.

After the 40 days, researchers found that while the tumors grew in both mice groups, the tumor volume was greater in the intermittent hypoxia group, and that these tumors contained greater numbers of dead cells, indicating a more aggressive cancer. This is indeed a frightening finding for sleep apnea sufferers.

Other research on sleep deprivation finds that lack of sleep affects hormones and proteins that play a role in the development of cancer. They also find that sleep deprived people have increased levels of inflammatory indicators, which is a huge risk factor for cancer. The combination of sleep and oxygen deprivation seems to point gravely towards increased risk of cancer and quickly spreading tumors.

If you suffer from sleep apnea, seek contact a local sleep dentist to learn about effective and comfortable sleep apnea treatments.

Sleep Apnea Linked to Incontinence and Erectile Dysfunction

The American Urological Association released research this weekend linking sleep apnea to two different urological disorders: incontinence and erectile dysfunction.

The incontinence study, performed by researchers at the New England Research Institutes, followed 4145 adults--1620 men and 2535 women--for five years. They looked at the incidence of urological conditions and found that restless sleep among men and women was strongly associated with the incidence of urinary tract symptoms. Short sleep duration was also associated for men but not for women.

The other study was conducted by researchers at the Mt. Sinai Medical Center in New York City, and looked more specifically at the link between obstructive sleep apnea and erectile dysfunction. The study looked at men who were being treated for erectile dysfunction. Nearly two-thirds of the men had obstructive sleep apnea, causing researchers to conclude that a man with erectile dysfunction is twice as likely to be a sleep apnea sufferer than the general population.

These studies give additional support to the dangers of sleep apnea, but do not give us insight into new conditions associated with sleep apnea. In the future, it is hoped that further studies will reveal the relationship between successful sleep apnea treatment and alleviating many of these conditions.

To learn more about sleep apnea treatment that is both comfortable and effective, please contact a local sleep dentist today.