How Dangerous Is Sleep Apnea | Why Is Sleep Apnea So Underdiagnosed
What Is the Role of a Sleep Lab for Diagnosing Sleep Apnea 
What Is the Role of the WatchPAT for Diagnosing Sleep Apnea 
What Treatments Are Available | Ask the Experts

Sleep Apnea Roundtable 

The Panelists: 

David P. White, M.D., Professor of Sleep Medicine at Harvard Medical School, is the former Chairman for the Research Committee of the American Academy of Sleep Medicine and Editor-in-Chief of the journal Sleep. He is a renowned sleep expert who has lectured internationally on sleep-related topics.

H. Kenneth Fisher, M.D., a noted sleep expert who has been diagnosing and treating sleep apnea for more than 30 years, is currently the Consultant in Pulmonary Diseases and Sleep Medicine at the Wyoming Cardiopulmonary Services and Wyoming Medical Center in Casper, Wyoming.

Steven Lamm, M.D., the long-time medical correspondent for The View (ABC-TV) who is noted for his ability to talk to women about their important health issues, and the health issues of the men they love, is a practicing Manhattan internist who has performed hundreds of ambulatory tests for sleep apnea.

Barry Glassman, D.D.S., is on staff at the Lehigh Valley Hospital (Pennsylvania) where he serves as a resident instructor of Dental Sleep Medicine. A Diplomate of the Academy of Dental Sleep Medicine, he lectures regularly on sleep disorders and the diagnosis and treatment of sleep apnea.

Koby Sheffy, PhD., the former Director of the Sleep Medicine Center at Technion-Israel Institute of Technology, Haifa, also acted as the manager of one of its sleep labs. Dr. Sheffy is currently the Chief Scientific Officer for Itamar Medical.

Introduction

Sleep apnea, a serious medical condition characterized by brief, frequent breathing interruptions during sleep, is a problem that affects an estimated 45 million Americans. These numbers are probably on the low end, however. According to the American Academy of Sleep Medicine, upwards of 90% of people with sleep apnea go undiagnosed.

The consequences of undiagnosed and untreated sleep apnea can be dire: Severe apnea can lead to a heart attack or stroke.

Obstructive sleep apnea (OSA) is the most common form of sleep apnea. The condition is caused by the collapse of soft tissue at the back of the throat during sleep. When this tissue collapses, the movement of air through the airways is impeded, which reduces—and oftentimes stops—airflow to the lungs.

The primary symptom of sleep apnea is snoring, although not everyone who snores has sleep apnea. This snoring is typically followed by a pause in breathing called an apnea. Apneas can temporarily prevent air from reaching the lungs from 10 seconds to as long as a few minutes. When the brain realizes this acute oxygen shortage, the sleeping person briefly awakens, gasps for air, and then quickly goes back to sleep. In severe cases, this unnatural sleep/wake cycle can occur 30 to 100 times an hour.

Oxygen deprivation caused by sleep apnea extracts a toll on a person’s health. Memory problems are not uncommon with the ailment. A recent study in the journal Sleep reported that men with sleep apnea showed substantial reductions in gray matter in the cerebral cortex region of the brain. This is the brain area responsible for cognition, judgment, and memory.

Hypertension (high blood pressure) is also not uncommon with people who have the sleep disorder. More worrisome, however, is the fact that people with sleep apnea are about three times more likely to suffer a heart attack or stroke thansomeone without this sleep disorder.

Itamar Medical recently hosted a roundtable discussion featuring top sleep experts who addressed the growing sleep apnea health crisis and provided clarity about WatchPAT, which is the best available home ambulatory tool for diagnosing sleep apnea. The panel also noted who should be tested, and what patients and their physicians should know about using and interpreting ambulatory sleep study results.

Q. How dangerous is sleep apnea?

Dr. White: Sleep apnea is a common disorder with important adverse medical consequences. The primary hallmarks are snoring, gasping, increased neck size (17 inches in men, 16 inches in women), and hypertension.

Dr. Fisher: The association between sleep apnea and heart attack is real. It’s estimated that the risk of suffering a heart attack is six times higher for those with untreated sleep apnea.

Dr. Glassman: The reality is that sleep apnea is associated with heart attack, stroke, diabetes, and depression and the dentist can play an important role in screening, diagnosing, and treating this common disorder.

Dr. Lamm: Sleep apnea is not just a nuisance condition having to do with loud snoring, but it’s a serious medical condition withquite serious consequences if not diagnosed and effectively treated.

Q. You mention neck size as a tipoff for sleep apnea. What about a person’s weight?

Dr. Lamm: The sad truth is that 50% of the American population is overweight and obese. If I have a patient who is 30 pounds overweight, I will immediately suspect sleep apnea.

Dr. Fisher: Weight is definitely a sleep apnea marker and people with sleep apnea are certainly tilted to the high end of the weight scale. The good news is that in some cases, people who lose 25 to 30 pounds might lose their sleep apnea. However, weight loss less than that will probably not make a difference.

Q. With so many patients displaying obvious—and not so obvious symptoms for sleep apnea—why aren’t they being diagnosed?

Dr. White: Sleep apnea is acommon disorder with serious adverse medical consequences. It is not appropriate for a physician to ignore this disorder. I don’t think it’s the difficulty in getting appropriately tested that has led to poor sleep apnea diagnosis figures. I think doctors just don’t pay attention to sleep apnea symptoms or complaints from their patients. Doctors have to realize that it is an easy disorder to diagnose, that it’s not that hard to treat, and that it is a medical disorder they should be looking for in their patient population.

I would guess that only 20% of people are being diagnosed and that even though many people suspect that they have sleep apnea, they don’t go to see their doctor because they think the current treatment possibilities are not satisfactory.

Dr. Fisher: There are many reasons why sleep apnea is not being diagnosed as much as it should be. First, many patients are reluctant to tell their doctor about their loud snoring at night or about the problems they have staying awake during the day.

Secondly, many physicians were trained at a time before sleep apnea was recognized to be the major health problem that it is. Then, too, many physicians tend to be so rushed taking care of a patient’s other health complaints that they don’t get around to thinking about the fact that the patient in front of him is awfully big, has gained weight, has a very large neck, and that he just might have sleep apnea.

A doctor would be remiss if he didn’t ask his patient about sleep apnea. By ignoring the apnea, the doctor will never be successful in treating the other ailments a patient may have like diabetes, hypertension, and heart disease. That’s because the endocrine and other systems are being upset by the sleep apnea. Hypertension is more difficult to treat if sleep apnea is present and not treated. The bottom line is that the family doctor should be discussing sleep apnea with his patients, and recommend appropriate testing for it.

In any general health survey with his patients, a doctor should always ask about snoring. Do you snore? Do you snore loudly? If the answer is “yes,” then they had better probe further and find out if the patient also has excessive daytime sleepiness. Does it seem to be out of proportion to the time they spend trying to sleep in bed? Do they wake up gasping or choking? Does their bed partner say they snore and/or stop breathing?

Another basic question to ask would be has your weight changed in the last year or two? And if it has gone up by 25 or 30 pounds, then there is a high chance the patient has sleep apnea.

Dr. Glassman: Sleep apnea is woefully underdiagnosed and undertreated and I think that dentistry should be the number one portal for diagnosis and treatment of patients. It’s my firm belief that a dentist has the capability of screening their patients appropriately with a questionnaire. A questionnaire asking the right questions is as predictive of sleep apnea as anything we have.

Once the patient has been screened, the dentists then have two options: they can refer the patient to a sleep center for an official sleep apnea diagnosis, or they can—as many patients would prefer—offer the patient a WatchPAT ambulatory screening that can be done in the comfort of their own home.

Dr. Lamm: I think that the underdiagnosis of sleep apnea probably goes back to medical school education. Yes, we were taught about Pickwickian Syndrome, the sleep disorder manifested by Joe, the chubby boy in Charles Dickens’ The Pickwick Papers. In the modern era, while the medical profession has recognized sleep apnea, the medical community has not appreciated it, probably because we did not have the technology readily available to diagnose it.

Most diagnosing for sleep apnea has historically taken place at hospital-based sleep centers with an overnight polysomnography test, and many patients often balk at that.

Sleep apnea creates an unhealthy and dangerous domino effect: Sleep apnea disrupts sleep and sexual relations for a patient, who is then tired during the day, eats more, becomes less physically active, which then leads to hypertension, overweight and obesity, and heart disease. This dangerous and potentially lethal downhill direction has to be stopped.

With WatchPAT, we now have that technology that allows the doctor to easily diagnose sleep apnea. We also have the therapies to effectively treat it.

Q. What is the role of a sleep laboratory for diagnosing sleep apnea? What is the role of WatchPAT for sleep apnea diagnosis?

Dr. White: The American Academy of Sleep Medicine conducted an international study to see how long a patient would have to wait in order to get a sleep study performed at a sleep lab and they reported that in most places it tookthree weeks, on average. I don’t think that it is that long. If you wanted a routine MRI or mammography done, it could take that long as well. I really don’t think it’s a huge problem getting evaluated for sleep apnea at a sleep lab.

Dr. Fisher: There will always be a role for sleep centers because many patients have complicated sleep problems. But right now, in my experience, sleep centers are behind by typically several weeks in terms of being able to get patients in for testing. Yes, there is a long waiting list. That may not be important for some patients, but for those who are desperate for sleep it is very important. It’s better if we can get them promptly seen so we can treat them quickly. That said, WatchPAT could certainly be used for patients with suspected sleep apnea in lieu of a sleep center study.

Most patients prefer to have their sleep study performed at home. It’s easier for them, it’s generally less expensive, and it’s certainly less disruptive to their schedule. It may even provide a better result because they are sleeping in their home environment. When I offer the patient a choice between a sleep lab test and WatchPAT, most choose WatchPAT.

Dr. Glassman: Sleep medicine is a very young science, and somewhere along the way it was determined that the polysomnogram, the sleep study that was done in the lab, was the gold standard for sleep apnea diagnosis. I think that WatchPAT can provide equally important information. Frankly, I think in some instances the WatchPAT sleep report is actually more valid because the patient is in their own bed instead of the uncomfortable setting of the hospital for their sleep test. WatchPAT sleep studies have been demonstrated to be very valuable and very comparable to sleep lab studies.

WatchPAT is used to diagnose sleep apnea. I teach our dentists that our goal is to become respectedmembers of the sleep team—and that means local sleep centers. I expect to make decisions in the patient’s best interest. At the same time, I understand that dentists don’t diagnose or treat narcolepsy, and that there are complicated circadian issues that we don’t deal with and behavior disorders that we don’t treat. These patients are all referred to the sleep lab for testing.

Dr. Sheffy: In a study published in 2008, Dr. Richard Berry, the noted sleep expert, reported that when patients with sleep apnea were randomized, with some receiving testing in a sleep lab and others in their homes with WatchPAT, there was no difference between outcomes in the two groups. We now have enough accumulated evidence to prove that the sleep tests for sleep apnea done at home are as good as testing in a sleep lab, provided that doctors are testing the right population of patients.

Dr. Lamm: For the patient with routine sleep apnea—and most cases are very routine—an experienced doctor is fairly certain of the diagnosis before he or she ever gets an official diagnosis. Testing for sleep apnea is supposed to prove or disprove a doctor’s diagnosis of apnea. But in the past when testing was complicated, when you had financial hurdles and difficulty scheduling a patient for a sleep test, it was difficult to go forward and get a diagnosis and eventual therapy for sleep apnea.

Doctors need an easy validation of sleep apnea, and that’s what WatchPAT can give. This handy testing device is incredibly reliable and simple to use and I have done hundreds of these tests this year with my patients. I don’t have to cross my fingers and hope the device works when the patient brings the WatchPAT home. It works flawlessly every time. Better yet, I don’t get false scores or false records when I download their information into my computer.

When it comes to retesting, it’s hard enough to get a person to go to a sleep lab the first time. To get them to go there twice is very difficult; they don’t want to disrupt their lives. The beauty of WatchPAT is that the testing can be easily repeated.

There is certainly a role for sleep lab testing. I want to reserve sleep lab studies for those patients with really complicated sleep issues. Whenever I’m not quite sure why a patient is having sleep issues such as Restless Leg Syndrome, insomnia, narcolepsy, or sleepwalking, I always send them to a sleep lab for testing.

Q. What treatments are available for sleep apnea?

Dr. White: CPAP, continuous positive airway pressure, was invented more than 25 years ago by Colin Sullivan, Ph.D., an Australian researcher. Dr. Sullivan believes that CPAP is improving and will soon be as easy to useas wearing glasses.

I am embarrassed for our field that we still don’t have anything better than CPAP. That said, I have spent a lot of time and energy trying to come up with new ways to treat sleep apnea, and it’s not that easy. In 20 years, if we are still using CPAP, we will really have failed in our mission to come up with an effective treatment for sleep apnea.

Dr. Lamm: For mild sleep apnea, weight loss, reduction in nighttime alcohol consumption, and changing your sleep position can all help alleviate the condition. For moderate to severe cases, however, CPAP remains the best option for most people. I know that many people don’t like the machine after using it for a while, and it’s these patients that I refer to a dentist for an oral appliance. I have also had patients with mild apnea who have had success with a Pillar procedure, a minimally invasive treatment that uses tiny braided material in the soft palate to keep the airways open.

Dr. Glassman: There are more than 40 FDA-approved oral appliances available for treating sleep apnea. For the most part, all of the appliances have the same mode of action: They all bring the jaw forward. Some may be more tongue-oriented, others more jaw-oriented, but they all are designed to treat apnea by repositioning the jaw.

Dr. Sheffy: Dentists definitely have a solution for sleep apnea with their oral appliances. This is a good answer for people with mild to moderate sleep apnea. While it can’t compare to CPAP when used for severe sleep apnea, the bottom line is that the dental appliances are much more convenient to use.

Dr. Fisher: I prepare the way for my sleep apnea patients by telling them why it is so important to treat their apnea. Cutting the risk of stroke is critical, I tell them. I then tell them that the best treatment, the one that is most effective, is the one that keeps the obstruction from happening with every breath. CPAP does that.

No one chooses to put on a CPAP mask, but when they do, many sleep so well that first night and feel so much better that they are willing to put up with the annoyance of CPAP therapy.

Research from the University of Pennsylvania reported that people who use CPAP immediately after diagnosis are the ones who tend to use it consistently. The best way we can ensure compliance is to get our patients back to the sleep clinic within a week of using CPAP, two weeks at the most, and troubleshoot any problems that they may be having. We make sure the mask fits well, that they are comfortable, and that they are seeing an improvement in their sleep apnea.

I occasionally have patients who say they don’t want to use CPAP anymore, but I remind them about a French study that reported on 100 people who needed CPAP. Fifty people used the device and 50 decided against it. Eight years later, the researchers found that of the 50 who used CPAP, one person had a stroke. Of the 50 who did nothing to treat theirsleep apnea, eight people suffered strokes. This is a pretty significant difference and one that is too big to be explained by chance alone.

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