Best Diet for Sleep Apnea

The Sleep Apnea Exercise Program

Here Is a Tiny Sample of What Youll Get When You Register for the Sleep Apnea Exercises Program: 18 step-by-step videos that show you exactly how to do the sleep apnea exercises. A 52-page manual that includes a description of each exercise; illustrations to show you how to do each exercise; an explanation of what each exercise does for your body. The manual includes these sections: Causes of sleep apnea; Relationship between sleep apnea and snoring. Scientific studies backing up sleep apnea exercises. How to test your sleep apnea at home. Daily tasks to keep your sleep apnea at a low level. Names and website addresses of speech language pathologists in the U.S. and U.K. who specialize in sleep apnea, and have agreed to list their contact details in my manual. Names and contact details for obstructive sleep apnea support groups. MP3 (audio) recordings of the exercises that you can download and listen to on your iPod, iPhone, or MP3 device. (This is especially useful for the exercises that youll want to do in front of the mirror) Access to an online Members Area, where youll be able to download the manual, watch the videos, and get the bonuses! Continue reading...

The Sleep Apnea Exercise Program Overview

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Contents: 52 Pages EBook, 18 Videos
Author: Marc MacDonald
Official Website: www.sleepapneaexercise.com
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My The Sleep Apnea Exercise Program Review

Highly Recommended

It is pricier than all the other books out there, but it is produced by a true expert and is full of proven practical tips.

Overall my first impression of this ebook is good. I think it was sincerely written and looks to be very helpful.

Didgeridoo for Sleep Apnea

This complete package includes the following to help you learn to play the didgeridoo as quickly as possible: a) A no-fluff 21-page guide with all you need to know to start playing the didgeridoo including tips on buying the didgeridoo that is right for you, along with advice on how to play the instrument to get maximum benefit (in plain English!) b) 6 instructional videos by noted didgeridoo teacher Tyler Sussman. These videos have been created specifically for sleep apnea sufferers, and provide step-by-step instruction on these topics: History and health benefits of the didgeridoo. How to buy or make your own didgeridoo. Preparing to play. How to make the basic drone sound on the didgeridoo. How to make advanced sounds on the didgeridoo. How to do circular breathing on the didgeridoo. c) Bonus ebooks on overcoming insomnia and proven sleep hygiene techniques Continue reading...

Didgeridoo for Sleep Apnea Overview

Contents: 21 Page EBook, 6 Videos, Bonus EBooks
Author: Marc MacDonald
Official Website: www.didgeridooforsleepapnea.org
Price: $47.00

Obstructive sleep apnea

The most effective non-pharmacological therapy currently available is (nasal) continuous positive airway pressure (nCPAP), but even so this therapy may be unacceptable or be used irregularly in over 50 of patients prescribed nCPAP 14 . Tracheostomy is an effective surgical treatment for OSA but not currently recommended except in the most extreme circumstances. Other surgical procedures have included uvu-lopalatopharyngoplasty but substantial evidence for benefit is lacking 15 . Facial reconstructive surgery has a limited role in individuals with OSA secondary to facial dysmorphia. Oral appliances including mandibular advancement splints (MAS) may have a role in treating mild or moderate degrees of OSA, but long-term compliance is uncertain, and occasionally dental malocclusion and tempero-mandibular joint dysfunction may eventuate with use of MAS 16, 17 . These non-pharmacological therapies of OSA share a number of features, such as variable efficacy, significant side-effect profile,...

Controversies in Surgical Management of Sleep Apnea

This chapter compares clinical assessment and patient counseling regarding continuous positive airway pressure (CPAP) with the results achieved with palatal surgery or dental appliances. Office-based palatal reduction and tongue base reduction remain either unproven for true sleep apnea patients or somewhat experimental.1 The initial controversy faced by many of us is the value of CPAP and its effectiveness in the long-term management of sleep apnea. The trend of managed care has been to require patients to use CPAP as first-line therapy before considering surgery. CPAP has proved the most effective and safest form of therapy, but compliance and patient acceptance are usually dismal, with the patient often remaining untreated with the machine at the bedside.1'2 Patients I do not consider candidates for CPAP, and who I do not feel obliged to have fail this modality before surgery, are those with nasal obstruction3 or significant tonsil hypertrophy. These patients have obstruction that...

And Sleep Apnea

The risk of palatal insufficiency following uvulopalatopharyngoplasty, with resultant hypernasal speech or regurgitation of liquids or foods into the nasopharynx, is often used to discourage the surgery. This author has found this to be completely without merit Although the response rate is less than ideal, UPPP remains the first line surgical therapy for patients with OSA who fail to tolerate nasal CPAP.

Central sleep apnea

CSA is defined by an absence of at least 10 s duration of both airflow and respiratory effort in sleep, and central hypopnea indicates a reduction of these parameters causing reduced tidal volume. CSA comprises a heterogeneous group of congenital and acquired disorders, and in the latter grouping neurological conditions affecting the brainstem include the stroke syndromes of cerebrovascular disease. CSA is also seen in a striking proportion of males with left ventricular cardiac failure (33-40 ) 137,138 , and OSA may coexist in some of these patients 139 . CSA is also seen in high-altitude exposure and uncommonly in miscellaneous other medical conditions. In the CSA of cardiac failure, recumbent pulmonary venous congestion stimulates vagal pulmonary afferents causing hyperventilation and hypocarbia, and arousals further stimulate ventilation and drive hypocarbia below the apnea threshold. The apneas and hypoxia of CSA promote sympathetic nervous system activation and negative...

Medical Implications of OSA

Severe cardiovascular disease is also common in patients with OSA. Hypertension, cardiac arrhythmia, left ventricular dysfunction, myocardial infarction, pulmonary hypertension, stroke, and sudden death are all more common in patients with this condition.10 Systemic hypertension has been reported in up to 50 of patients with OSA, and one report implicated undiagnosed OSA in as many as 40 of patients with essential systemic hypertension.11 In an often quoted study by He et al.12 in 1988, a large cohort of patients with OSA were evaluated at the Henry Ford Hospital Sleep Disorders Center and followed for up to 9 years. Untreated subjects with an AHI of > 20 had significantly increased mortality compared with those with less severe AHI scores. Aggressive treatment with nasal continuous positive airway pressure (CPAP) appeared to reverse this trend, clearly implicating OSA for the increased mortality.

Nonsurgical Treatment Options

Nasal CPAP was first introduced in 1981 as a nonsurgical treatment for OSA and has since become widely used for this condition.16 Nasal CPAP delivers positive airway pressure through a tightly sealed nasal mask, which, when titrated appropriately, produces a constant pneumatic splint to prevent upper airway collapse during nocturnal respiration. Excessive daytime somnolence and other neuropsychological symptoms associated with OSA are quickly reversed by means of this device. The cardiovascular sequelae and mortality associated with this disorder can also be dramatically reduced. The impressive clinical effectiveness of nasal CPAP is often overshadowed by poor patient acceptance and low compliance. Early studies designed to quantify self-reported patient compliance reported rates ranging from 47 to 91 however, these studies relied on patient reporting and contained built-in bias toward higher reported compliance rates. Several subsequent studies have looked more objectively at this...

Primary Nursing Diagnosis

Incentive spirometry, chest percussion, and postural drainage may be prescribed by the physician to increase gas exchange and to decrease the risk of atelectasis. Oxygen may be delivered with humidification to improve clearance of mucus. If atelectasis persists, the physician may prescribe a mask with continuous positive airway pressure (CPAP). With the use of a CPAP mask, positive airway pressure is maintained throughout the respiratory cycle. In addition, CPAP prevents and reverses airway closure, thus expanding the lung volumes and reestablishing the functional residual capacity (FRC). If atelectasis persists and hypoxemia becomes life-threatening, endotracheal intubation and mechanical ventilation with positive-pressure ventilation and positive end-expiratory pressure (PEEP) may be necessary, but these aggressive therapies are usually not needed.

Floppy Eyelid Syndrome

Floppy Eyelid Syndrome

The cause of the disease remains unknown and histological examination of the softened and redundant tarsal plate has not suggested any conclusive etiology. A mild chronic inflammatory infiltrate has been reported in some cases, but it is not clear if this was a primary cause or a secondary effect. The tarsal plate and skin show a decreased amount of elastin fibers. The syndrome and its clinical spectrum results from loss of physical integrity of the tarsus, perhaps in part related to habitual sleeping on the involved sides in patients with excessive weight. The condition is also associated with obstructive sleep apnea.

New Research Areas

In sleep apnea syndromes, e.g., OSAHS, upper airway restriction leads to deteriorated sleep, ultimately resulting in daytime sleepiness and impaired cognition. Treatments with classical stimulants like amphetamine are limited due to the side effect profile and potential for abuse. Modafinil has been evaluated as adjunctive therapy to CPAP treatment in OSAHS. In a randomized double blind placebo controlled study, modafinil in conjunction with CPAP therapy significantly improved both the subjective and objective measures of daytime sleepiness compared to CPAP alone as assessed on the ESS testing findings supported in a larger study.97 Advances in the treatment of circadian rhythm disorders are still at an early stage as the basic mechanisms and potential drug targets are better understood. Behavioral interventions and light therapy are still the mainstays of circadian disorder therapy.

Primary Sleep Disorders Dyssomnias

Obstructive sleep apnea is characterized by daytime somnolence with frequent dozing, nocturnal respiratory pauses, and loud snoring. Impaired concentration, decreased performance, and headaches are also common. Extrinsic sleep disorders. Sleep may be disturbed by external factors such as noise, light, mental stress, and medication use. Disturbance of the circadian rhythm. Sleep may be disturbed by shift work at night or by intercontinental travel (jet lag). Parasomnias. These disorders include confusion on awakening (sleep drunkenness), sleepwalking (somnambulism), nightmares, sleep myo-clonus, bedwetting (enuresis), and nocturnal grinding of the teeth (bruxism).

How to Get a Good Nights Sleep

Healthy may find that they simply don't need as much sleep as they did when they were younger. Overweight men may have problems getting a good night's sleep. Snoring also may contribute to a loss of sleep. Sleep apnea (a condition characterized by brief episodes of interrupted breathing during sleep) is another common reason for losing sleep. Many people who have sleep apnea find it difficult to stay awake during the day. However, the most common reason for an occasional night of lost sleep is worry or anxiety.

Syndromes Table 18 p 370

Pathological breathing patterns may be due to metabolic, toxic, or mechanical factors (obstructive sleep apnea) or to a lesion of the nervous system (p. 118). Morning headaches, fatigue, daytime somnolence, and impaired concentration may reflect a (nocturnal) breathing disorder. Neurogenic or myogenic breathing disorders often come to medical attention because of coughing attacks or food going down the wrong pipe. Neurological diseases are often complicated by respiratory dysfunction. The respiratory parameters (respiratory drive, coughing force, blood gases, vital capacity) should be carefully monitored over time so that intubation and or tracheostomy for artificial ventilation can be performed as necessary.

Treatment of insomnia

The effective management of insomnia begins with recognition and adequate assessment. Family doctors and other health care providers should routinely enquire about sleep habits as a component of overall health assessment. Identification and treatment of primary psychiatric disorders, medical conditions, circadian disorders, or specific physiological sleep disorders, such as sleep apnea and periodic limb movement disorder, are essential steps in the management of insomnia 8 .

In Search and Discovery of Potential New Therapeutic Indications

The search for additional indications for modafinil naturally focused on diseases associated with wake deficits and somnolence. The effects of the drug in an animal model of sleep-disordered breathing suggested that modafinil might be effective in reducing sleepiness associated with sleep apnea,50 and this was subsequently demonstrated in the clinic.51-53 Other disorders where somnolence or sedation was concomitant with the disease, e.g., Parkinson's disease,54-56 myotonic dystrophy,57-60 fibromyalgia,61 amyotrophic lateral sclerosis,62 multiple sclerosis,63 cerebral lymphoma,64 or resulting from the side-effects of other medications such as antidepressants,65 antipsychotics,66 dopaminergic D2 agonists,67,68 opioids,69 or valproic acid,70 have also proven to be amenable to treatment with modafinil.

Secondary Sleep Disorders

Secondary Sleep Disorders

Wakefulness normally follows a circadian rhythm (p. 112). Sleep apnea syndrome, narcolepsy, and parasomnia are disorders of arousal (dyssomnias, p. 114). Hyper-somnia is caused by bilateral paramedian thalamic infarcts, tumors in the third ventricular region, and lesions of the midbrain tegmen-tum (p. 70 ff). The level and content of consciousness may also be affected. In patients with bilateral paramedian thalamic infarction, for example, there may be a sudden onset of confusion, followed by somnolence and coma. After recovery from the acute phase, these patients are apathetic and their memory is impaired (thalamic dementia).

Sleep Switch Hypothalamus

Rem Sws Acetylcholine

Figure 2 Systems regulating sleep-wake biology. Upper panel (a) Sleep-wake states are controlled through a delicate balance of activities between the thalamus (cortical activation and EEG synchronization), the hypothalamus (sleep wake switch), the superchiasmatic nucleus (SCN or circadian clock) and the brainstem (ascending cortical activation, REM SWS switch). Lower panel (b) Multiple neurotransmitters are involved in sleep-wake regulation. The ventrolateral preoptic area (VLPO) contains sleep promoting GABA Galanin (Gal) neurons whereas wake-promoting orexin (hypocretin) neurons reside in the hypothalamus. The VLPO and orexin systems innervate key areas of the ascending arousal system locus coeruleus (LC adrenergic), dorsal raphe (DR serotonergic) and tuberomammillary nucleus (TMN histaminergic). Other key regions include the dopaminergic ventral tegmental center (VTA or A10 and A11 projections) which plays a role in alertness and may be important in cataplexy and restless leg...

Gentle Homicides and the Lethal Variant of Munchausens Syndrome by Proxy

Sids Death

The more lethal variant of Munchausen's syndrome by proxy was long unrecognized by pediatricians, though it was described in the forensic pathology literature, without resort to this terminology, by Di Maio and Bernstein in 1974.15 Rosen et al. were the first to describe two siblings with recurrent cardiorespiratory arrest caused by smothering by the mother, in which the act was documented on videotape.12 The first child was a 5-month-old girl admitted for cardiorespiratory arrest. Her 4-year-old brother had had a similar medical history. The mother gave a history of almost daily episodes of apnea, cyanosis, bradycardia, and loss of consciousness since 1 week of age. The attacks were very common, with the longest period between attacks only 72 h. These attacks occurred whether the child was asleep or awake. The child had been extensively worked up by computerized tomography, ECG, and EEG and had been given multiple anticonvulsive medications. She had had multiple apneic episodes in...

SIDS and the Munchausen Syndrome by Proxy

The second child, a male, was studied from age 5 days to 33 days. The morning following discharge, he had an alleged episode of prolonged apnea and cyanosis. A similar alleged episode occurred 15 to 20 min later. The child was hospitalized for 34 days and then discharged. He was re-admitted the following day for a period of 6 days because of apparent aspiration during feeding. He was discharged and, on the morning following, had an apneic episode, became cyanotic, and died. The two deaths reported by Steinschneider that form the basis for the contention that apneic episodes are associated with SIDS cases involved a brother and sister. In addition to these two deaths, mention is made in the article that three other children in the family had also died. The first male developed recurrent cyanotic spells and died suddenly at 102 days of age the second, a female, turned blue and died at 48 days of age. Neither of the two children was autopsied. The third cried out and died suddenly at 28...

Clinical Uses Of Electrical Stimulation

Electrical stimulation of the phrenic nerve or the diaphragmatic muscles is used to support ventilation. Candidates for breathing pacing include patients who require chronic ventilatory support because of spinal cord injury, decreased day or night ventilatory drive (e.g., sleep apnea), intractable hiccups (chronic hiccups often lead to severe weight loss and fatigue and can have fatal consequences), and damaged phrenic nerve(s). The physiological respiratory function provided by these devices is far superior to that provided by mechanical ventilators since the air inhaled is drawn into the lungs by the musculature rather than being forced into the chest under mechanical pressure.

Summary and future directions

There has been limited progress in the development of effective pharmacotherapy for sleep apnea. A range of agents has been utilized, but there has been lack of or only modest benefit in the treatment of OSA and CSA using these agents. A number of drug therapies are limited as well by significant side effects. The promise of serotonergic drug therapy is yet to be realized, and further developments await the full exploration and understanding of the complex interplay of the various and often counteractive 5-HT receptor subtypes in the CNS and PNS that in concert may affect upper airway patency in sleep and wake states. It is possible that effective OSA drug treatment may necessitate combination drug therapies, for example so that excitatory stimulation of upper airway dilator muscles in sleep is combined with pharmacological inhibitory actions on constrictor relaxant mechanisms. Given the lack of acceptance of CPAP in mild to moderate cases of OSA, better understanding of the...

Unmet Medical Needs

Androgen replacement therapy has been reported to cause water retention, polycythemia, hepatotoxicity, sleep apnea, prostate enlargement, and to reduce HDL cholesterol.3 Hepatic toxicity is associated with derivatives of testosterone rather than pure testosterone. Polycythemia is observed more commonly in males receiving injectable testosterone. Thus, hematocrit should be measured periodically to minimize the risk of polycythemia. HDL cholesterol lowering is more profound with oral methyltestosterone than transdermal or injectable testosterone, but this effect is dose dependent, with higher doses causing more profound lowering of HDL cholesterol. Although testosterone is associated with prostate enlargement and prostate cancer, testosterone replacement therapy is rarely associated with an increase in urinary tract voiding symptoms, leading to cessation of therapy. In addition, prostate cancer surveillance can be done by measurement of PSA during the first 6-month interval after...

Nursing Diagnoses Ineffective Airway Clearance

Assess respirations for rate (count for one full minute), depth and ease, presence of tachypnea (specify), dyspnea and if it occurs during sleep or quiet time note panting, nasal flaring, grunting, retracting, slowing, deep (hyperpnea) or shallow (hypopnea) breathing, stridor on inspiration, head bobbing during sleep (specify frequency).

Clinical Development of Aldurazyme

Stiffness, the airway problems with associated sleep apnea, respiratory insufficiency, the diverse cardiac problems, recurrent infections, and the eye disease. Other compound clinical problems that were studied, but with more difficulty, included the fatigue malaise, severe headaches, the enlarged tongue, and signs of cord compression. Besides clinical measures, the elevated level of GAG in the urine, which reflects excessive renal distal tubular storage, is commonly used as a screen for MPS disease as well. To establish the possible treatment effects that could be measured in the initial clinical study, the data from the preclinical studies in the MPS I dog with rhIDU, the reports of BMT in MPS I, and the first published clinical study of Ceredase in Gaucher's disease were reviewed. Based on the data from the MPS I dogs undergoing enzyme therapy, both liver storage and urinary GAG were found to be effective measures of lysosomal storage that did accurately reflected the storage in...

Phase 1 Open Label Study in Ten Mps I Patients 12711 Study Objectives and Design

The first study of Aldurazyme was designed as an open-label study of weekly intravenous infusions of rhIDU at a dose of 0.58 mg kg in 6 to 10 patients of age 5 years or greater and representing a wide range of disease severity 12 . Given the open-label design, only objectively measured clinical endpoints were proposed, and the analysis was based on comparing pretreatment with posttreatment measurements for the various endpoints. The primary endpoint variables were quantitative measures of storage, including liver or spleen size and urinary GAG excretion. Liver or spleen size is enlarged in MPS I due to storage, and a reduction in organ size was measured by MRI. Urinary GAG excretion is elevated in MPS I patients, and a reduction in urinary GAG excretion would represent a reduction in renal storage. Secondary endpoint variables included sleep apnea, shoulder, knee, and elbow maximum range of motion, cardiac evaluations (a scoring system of history, physical, echocardiography findings,...

Organ system prostheses

Although the commercial applications of motor prostheses for the restoration of organ system functions have been limited at this time, there are numerous investigations ongoing into using motor prostheses for the restoration of these functions that should result in a variety of commercial systems in the future. One series of investigations is directed toward using motor prostheses for the treatment of upper airway disorders. Research at the National Institutes of Health109-111 is directed towards the development of motor prostheses that can be used to stimulate the genioglossus nerve to open the hypopharynx to correct for sleep apnea. Sleep apnea is a condition in which the tongue muscles relax during sleep, resulting in restriction and blockage of the hypopharynx. Studies are also being conducted on

Study Results in the Clinical Manifestations

Evaluation of range of motion showed that there were improvements in shoulder flexion, elbow extension, and knee extension that increased with time over 104 weeks. Sleep apnea declined 61 by 26 weeks, and the three patients with the most clinically severe sleep apnea all improved. NYHA classifications improved at least one class in all patients by 52 weeks. Visual acuity improved in the three patients with the worst vision. Height and weight growth velocity increased 85 and 131 , respectively, in the six prepubertal patients.

Phase3 Study of Aldurazyme 12721 Study Objectives and Design

The phase-3 study was designed as a randomized, double-blind, placebo-controlled study in 45 MPS I patients treated with weekly infusions of Aldurazyme over a 26-week period 13 . The patient population was restricted to patients over 5 years of age and was predominantly Hurler-Scheie in phenotype. The primary endpoints were the change between baseline and week-26 in the forced vital capacity (FVC), and the 6-min walk test. FVC is a measure of lung capacity, which is severely restricted in MPS I patients such that respiratory insufficiency is a common contributor to death. The 6-min walk test is commonly used in congestive heart failure studies as a measure of endurance. In MPS I, the 6-min walk distance can be severely restricted due to a combination of factors that includes poor respiratory function, cardiac disease, and joint stiffness and pain. In addition to these endpoints, secondary endpoints in the study were liver size, sleep apnea, shoulder flexion, and the Health Assessment...

Study Results in Other Endpoints

Sleep apnea was assessed using polysomnograms and the apnea-hypopnea index, a measure of the number of apneic or hypopneic events per h during sleep. When all patients were included, the treated patients had a decrease of about 3.6 events per h (p 0.145). When only patients with clinically significant sleep apnea at baseline were included, the treated patients with sleep apnea (n 10) had a decrease of 6.0 events per h whereas the affected placebo patients (n 9) had an increase of 0.3 events per h. The 11.4 events per h difference (adjusted by ANOVA) between the treated and placebo groups of patients with sleep apnea at baseline was statistically significant (p 0.014). For shoulder flexion, there was no significant difference in the overall group comparison, but for patients with more significant restriction of shoulder flexion at baseline (below the median of 90.5), the treated patients improved 9.6 whereas the placebo patients decreased 4.8 . The Health Assessment Questionnaire did...

Regulatory Strategies and Challenges with Surrogate Endpoints

Surrogate endpoints to the reduction of clinical disease in other tissues, but in the end, animal studies are not given significant weight in these assessments. Even with the combination of the data and information noted above, but without solid and convincing data from human clinical studies that demonstrated correlations between the surrogates and clinical parameters, the surrogates would not be considered likely to predict clinical benefit. In the end, the primary efficacy data on liver size and urine GAG excretion with the strong statistical significance was not accepted as sufficient. The clinical data from the first trial (joint range of motion, sleep apnea, etc.) were considered to be not interpretable because there was no control group and the measures could be affected by the evaluator or operator. A second study was needed. The key added features required were a doubleblind, placebo control and a multicenter design to ensure that inadvertent bias did not alter the results....

Advisory Committee Preparation and Execution

The main message of the briefing document from the sponsors was that MPS I was a heterogeneous and complex chronic disease with components of disease that were reversible and others that were not reversible. It is also stated that the treatment effects observed affected multiple systems within the same patients in many cases, and that the totality of the benefit from improved FVC, decreased sleep apnea, increased walk endurance, and improved range of motion must be appreciated as a synthesis of clinical benefits and within the context of a chronic disease without significant therapy.

Definition Classification and Diagnosis of Hypertension

In the diagnosis of hypertension it is important to determine whether hypertension is primary or secondary to another disease. Only 5-10 of hypertensive patients have secondary hypertension, but it should be suspected if onset is sudden, particularly in childhood or in patients older than 50 years of age, if it is severe, resistant to therapy, and or accompanied by unusual symptoms. Conditions that may cause secondary hypertension include aortic coarctation, eclampsia or preeclampsia, brain tumors, lead or mercury poisoning, illicit or prescribed drugs, renal disease, adrenal tumors, primary aldosteronism, Cushing's disease, and obstructive sleep apnea. Elimination or specific therapy of the cause of secondary hypertension should be attempted as the initial therapeutic approach.

Alcohol Induced Sleep Disorder

Alcohol consumed at bedtime may decrease the time required to fall asleep but typically disrupts the second half of the sleep cycle, resulting in subsequent daytime fatigue and sleepiness. Even a moderate dose of alcohol consumed within 6 hours prior to bedtime can increase wakefulness during the second half of sleep (Vitiello, 1997). Alcohol use prior to bedtime will also aggravate obstructive sleep apnea, and heavy drinkers or those with alcoholism are at increased risk for sleep apnea. Patients with severe obstructive sleep apnea are at a fivefold increased risk for fatigue-related traffic crashes if they consume two or more drinks per day compared to obstructive sleep apnea patients who consume little or no alcohol (Bassetti & Aldrich, 1996).

Pharmacological treatments of OSA risk factors and morbidities

The action of modafinil, though presently not fully understood, is thought to be mediated largely by dopamine 126 it is possible that it may also affect the his-taminergic system 127 and inhibit release of GABA in the hypothalamus 128 , influence serotonin release and, at least in rats, reduce noradrenaline reuptake 129 . In the case of persisting EDS in CPAP-treated OSA patients, modafinil has been shown to improve Epworth Sleepiness Scale (ESS) scores and multiple sleep latency test (MSLT) results compared to placebo in a short-term trial of therapy 130 . Other short-term studies have documented improvements in sleep-related functional health status and ESS scores 131 , or improved the frequency of lapses of attention during psychomotor vigilance performance testing 132 . On the other hand, another study of modafinil in this context did not show improvements in MSLT latency or ESS score, but did show a marginal improvement in the latency of the maintenance of wakefulness test (MWT)...

Sleep disorders

Research into sleep disorders (see 6.06 Sleep) has intensified over the last decade given new generations of hypnotics and the success of the novel wake-promoting agent modafinil. The sleep spectrum involves insomnia, narcolepsy, and excessive daytime sleepiness (EDS). Dyssomnias are primary sleep disorders characterized by an abnormal amount, quality, or timing of sleep, and include primary insomnia, narcolepsy, and breathing-related sleep disorder. Primary insomnia is defined as a difficulty in initiating or maintaining sleep, or an inability to obtain restorative sleep. Insomnia is a highly prevalent sleep disorder estimated to affect 35 of the population during the course of a year, with 60 of those afflicted reporting chronic insomnia lasting longer than 1 month. Chronic insomnia is often accompanied by impairments in social and occupational function. Insomnia is roughly twice as common in females as in males, is more frequently observed in patients 60 years and older, and is...

Role of UPPP

Given the currently available technology for OSA and considering the significant health implications of this disorder, I tend to use the algorithm shown in Figure 12-1 to provide a basis for managing these patients. In general, after a thorough discussion of OSA and its clinical implications, the success rate and nonsurgical nature of nasal CPAP is emphasized to the patient. I encourage all patients to seriously consider this alternative. However, many patients cannot or will not use the nasal CPAP alternative, citing that they are frequent business travelers or are claustrophobic or that they simply do not want to be bothered with a mechanical device every night. The importance of altering lifestyle factors such as alcohol or sedative drug intake and body mass index (obesity) should be reemphasized at every opportunity. Dental orthodontic appliances and UPPP should be discussed. Most patients favor the surgical approach because, if it is successful, it has the potential of a one-time...

Hemifacial Spasm

Pleomorphic Adenoma Facial Nerve Damage

Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnea. Clin Experiment Ophthalmol 2000 28 125-126. McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg 1997 13 98-114. McNab AA. Floppy eyelid syndrome. Ophthalmology 1998 105 1977-1978.

Disease State

Breathing-related sleep disorder syndrome is associated with sleep disruption with excessive sleepiness being a prominent symptom. Within the context of breathing-related sleep disorder, respiratory abnormalities fall into three distinct categories apneas (breathing cessation), hypopneas (slow or shallow respiration), and hypoventilation (with abnormal oxygen and carbon dioxide levels). Breathing-related sleep disorder can also be subdivided into three types obstructive sleep apnea syndrome (OSAS), central sleep apnea (CSA), and central alveolar hypoventilation syndrome. OSAS, the most common type of this sleep disorder, is characterized by episodes of apnea and hypopnea that repeat during the sleep phase, is more common in overweight individuals, and is associated with high morbidity and mortality.30 Given the close clinical correspondence between sleep hypopnea syndrome and sleep apnea syndrome, the syndrome is generally referred to as obstructive sleep apnea-hypopnea syndrome...

Chylous Fistula

A suspected leak should be confirmed by placing the patient in the Trendelenburg position and asking the anaes-thesiologist to apply continuous positive airway pressure (i.e., Valsalva). This increases the flow of chyle by raising the venous and lymphatic pressures. Ligation of the thinned walled thoracic duct in isolation is not recommended, and it is better to include the surrounding tissue with the duct using a nonabsorbable suture. The scalene muscle can be included with this suture ligature. Many leaks are not treated adequately when noticed intraoperatively attention at this stage will reduce the incidence of fistula formation. Surgical glues and sclerosing agents such as tetracycline have been used with some reported success.12

Other drug therapies

There are no studies that show convincingly that hormone replacement therapy reduces sleep apnea severity in postmenopausal women with OSA 73-76 . The cholinesterase inhibitor physostigmine has been investigated in a small blinded, placebo-controlled study of moderate to severe OSA patients, and via steady-state intravenous infusion been shown to modestly decrease the overall AHI and severity of oxygen desaturation, predominantly in REM compared with NREM sleep 81 . The exact mechanism of the beneficial action of physostigmine in sleep apnea is not clear.

Etiology of SIDS

The second theory is that of hereditary idiopathic apnea. In 1972, Steinschneider described five infants suffering from multiple cyanotic and apneic episodes of unknown etiology during sleep.12 Two of these children, siblings, subsequently died. Steinschneider hypothesized that prolonged sleep apnea was a cause of SIDS. There then arose an extensive literature on this subject. Brought into prominence were near-miss SIDS cases. These were characterized by infants who were successfully resuscitated after being brought into the emergency room with episodes of apnea and cyanosis. In some children, there was repeated admission for this entity. In most, however, nothing subsequently developed. It must be realized that the initial observation of the apnea and cyanosis was often at home by nonmedical observers and the validity of their observations is open to question. In other instances, there is absolutely no doubt that these near-miss episodes represented multiple episodes of assault on...

Clinical features

An MSLT performed alone has the same drawbacks as does pupillography -it measures sleepiness regardless of its cause, which may simply be sleep deprivation. The MSLT also ignores repetitive microsleeps that can lead, in borderline cases, to daytime impairment not scored by conventional analysis. To be clinically relevant, the test must be conducted under specific conditions. Subjects must have abstained from medication for a sufficient period (usually 15 days) so that drug interaction is avoided. On the basis of sleep diaries, their sleep-wake schedules are stabilized. On the night preceding the MSLT, the subjects undergo a standard nocturnal polysomnogram. Throughout the total nocturnal sleep period, any sleep-related biological abnormalities responsible for sleep fragmentation and sleep deprivation are recorded. A nocturnal polysomnogram is useful for eliminating other possible causes of excessive daytime sleepiness such as periodic leg movements and obstructive sleep apnea. The...

Eve Bluestein

Another method that has been described for airway management is the use of an adapted bed that employs a forehead rest and occipital splint. The patient is placed in the prone position with a headrest maintaining the head. Patients have been sent home with this arrangement understanding that failure may necessitate surgical intervention. Continuous positive airway pressure (CPAP) may be necessary in some of these patients. Caouette-Laberg et al.6 use a subperiosteal release of the floor of mouth musculature on the mandible when the adapted bed previously described does not work. Although they are unable to offer an explanation regarding the success of the procedure, the operation involves removal of the genioglossus insertion from its mandibular attachment. This results in decreased glossoptosis with improved laryngeal position and, subsequently, less airway obstruction. Otolaryngology at Children's Hospital Medical Center, Cincinnati, Ohio, found no unanimity among respondents in the...

Sleep Apnea

Sleep Apnea

Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?

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