← Chasing Life with Dr. Sanjay Gupta
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- [00:04]
A
Hey there. Welcome to Chasing life. Snoring, it can be good for a chuckle or two, right? I mean, you see it depicted in all sorts of television shows. Many times, snoring may just be harmless, may not mean anything, but sometimes it can be an indication that there's a more serious health condition underlying all that, something known as sleep apnea. And it can lead to you not getting enough sleep, disrupting your natural sleep cycle. But it can also lead to other problems that maybe you hadn't considered. It could have an impact on your heart, could have an impact on your brain, could have an impact on your ability to stay awake when you're behind the wheel, leading to accidents and even deaths. Again, yeah, sleep apnea can do all that sort of stuff. So when we're talking about this, we're talking about a problem that affects maybe up to 80 million people in the United States. Think about that. A quarter or roughly a fifth of the adult population, and 80% of them don't even know that they have it. They're undiagnosed or at least under diagnosed. So this is a significant problem. It's been a growing problem in the United States for a long time. There's all sorts of strategies to try and deal with sleep apnea. We're going to talk about this today. I want to talk About it with Dr. Paul Hoff. He is an ENT doctor, ears, nose and throat doctor, who focuses on sleep. Should also point out that Paul is a dear friend of mine. We've known each other for a long time. We went to medical school together. We knew each other before we got married. His wife, Donna, my wife Rebecca are close friends as well. He's got two daughters. I have three daughters. And his dad, Dr. Julian Hoff, actually trained me to be a neurosurgeon. Very, very important person in my life. He was Paul's father, but in many ways, he was a father to all of us. So today we're going to talk about sleep apnea, how to diagnose it, when does it become dangerous, and I think, most importantly, what you can do about it. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and this is Chasing Life. Hey. Yeah.
- [02:08]
B
Hey.
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A
How you doing?
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B
Good. Great to see you.
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A
You too. You too. It's been a while.
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B
It has been. I feel like I see you all the time, but I'm sure you haven't seen me in a little while.
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A
So you decided to go into ent? I decided to go into neurosurgery. What was it that interested you? About sleep.
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B
So sleep surgery, really, you know, it started in the Detroit area. There was a Dr. Fujita that worked down at Henry Ford Hospital, big, big, famous hospital in. In metro Detroit. He kind of started sleep surgery with what a famous procedure, People call it a U, triple P. Basically, it's. You're removing the tonsils and working on the palate. And that was the only surgery from about 1980 to about the time we finished training. And that's pretty much all I saw during training. But I knew that there was more. And one of the faculty at Michigan, you know, sort of introduced me to sleep surgery. And so then I just started picked up on. I just kept following the sort of the evolution of sleep surgery over the years, and it was just became more and more my practice.
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A
So when. When does. I mean, a lot of people have sleep problems, difficulty with sleep. At what point does it become something that would warrant a visit to someone like you?
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B
So, yeah, you know, most people with sleep apnea, and there are many people with sleep apnea. And in the US it's probably. Let's talk about 80 million people with sleep apnea. With.
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A
Is that right?
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B
Yeah, 80 million. Most of them.
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A
I mean, so you're talking, you know, a quarter, you know, fifth of the population.
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B
Yeah, yeah. It may not. May not be severe sleep apnea where it's, you know, causing, you know.
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A
Sorry to interrupt, but, like, what percentage of that. That 80 million know that they have sleep apnea?
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B
About 20%. So they're really. 80% of people are undiagnosed. So it's a huge population that's, you know, undiagnosed, which is.
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A
That's a striking number. I knew that. You know, there's probably a lot of people out there who haven't been officially diagnosed, may worry about it, but 80%, that. That's a gigantic number.
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B
Yeah. And many of them come to the surface when they present to the, you know, to the. Their cardiologist with atrial fibrillation, or they present. Present to the neurologist with, you know, cognitive decline, dementia, you know, even Alzheimer's. All these different things that can. Or they, you know, get in a car accident, they drive off the freeway, you know, single car accident. They weren't. Alcohol content was zero. But they crashed because they were, you know, they fell asleep at the wheel. So then they get a sleep study. So that's the entry point to understanding if you have obstructed sleep apnea.
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A
So just let's define a few terms then. So what exactly is sleep apnea?
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B
When you fall asleep, your body relaxes, you get into sort of deep sleep. You're, you know, you're, you're laying flat. So all these things that kind of contribute to relaxation of the airway. And sleep apnea is basically your tongue falling back or your palate, you know, the area at the back of the throat where the uvula sits, all that collapses down and stops your airway. And there's, there are certain criteria for, you know, my mild, moderate, severe, and the duration of the obstructions, but it's basically your airflow has been stopped for 10 seconds or more or at least partially obstructed, and that, that leads to disrupted sleep, fragmentation of your sleep, which leads to fatigue in the morning, and all these other side effects that we're talking about.
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A
If you snore, does that mean you have sleep apnea?
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B
No, it doesn't. That's an important thing to mention because many people snore. And snoring can be horrific. Snoring, and you still might not have sleep apnea, but snoring is a partial obstruction. So airflow is limited to some degree, maybe just because you have some nasal congestion at night, but it's not necessarily obstructive sleep apnea. Obstructive sleep apnea is when the airflow actually stops for a certain amount of time.
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A
So you're describing an anatomical blockage of your airway.
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B
Yes.
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A
Is that the only cause of sleep apnea or are there other causes that's
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B
called obstructive sleep apnea. There are definitely other types of sleep apnea, but obstructive is by far and away the most common, like 95%.
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A
Okay, so you have an anatomical problem, obstructive sleep apnea. And you said for a long time what they sounds like, what they would do is try and address that anatomical problem by removing tonsils and addressing the palate. What was it called? The UPPP you said?
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B
Yeah, upp.
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A
What does that stand for?
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B
It's a long one. It's a uvula palatal pharyngoplasty.
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A
So, okay, so your uvula, your palate, your pharynx, you're basically modifying all that.
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B
Exactly.
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A
Sounds like a big operation. You go in through the mouth and just recreate that opening.
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B
Yeah, it's a big operation. People spend the night in the hospital afterwards. The recovery is long. It's two to three weeks to recover. And unfortunately, you know, you can have some short term success, but the long term success is not that great. And it didn't address a real key component. So just A step back. Obstructive sleep apnea is a small area, the back of the tongue to the top of the palate, you know, where the uvula is. That's where the sleep apnea obstruction comes from. So it's a small area we're dealing with. But that tongue base is a big problem.
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A
If you were to just look in someone's mouth, could you predict that they would have sleep apnea?
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B
Yeah, yeah. It is pretty predictive. People with a big tongue, if you look in their. Have them open real wide and you can't see the little dangly uvula back there, that can help predict that. The other bigger predictor is body mass index. So pick people who are heavier. Yeah.
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A
Just before we get to the association with being overweight or obese, you mentioned that if someone even had a cardiac problem, like atrial. I think you said atrial fibrillation. Or if they were developing cognitive difficulties or drove their car off the road. As a sleep surgeon, which you are, you'd be thinking about sleep apnea. How is sleep apnea connected to atrial fibrillation?
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B
Well, yeah. So sleep apnea, when you don't breathe, when your airway is blocked, that may go on for 10 seconds. It may go on for, you know, multiple minutes at a time. Yeah. And they look at the percentage of time while you're asleep at night that your oxygen levels are below, like, 88%. So there's something called hypoxic burden. Basically, you know, your oxygen levels are low throughout the night, which creates stress on all the systems, including your heart. And that can lead to arrhythmias as
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A
well as cognitive dysfunction, I guess. Just from lower oxygenation levels.
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B
Yeah, exactly. And then the sleep fragmentation is also important. So when you drop your oxygen levels, then you suddenly wake up, partly wake up. You might not wake up all the way and remember it, but some people have an obstruction every 60 times an hour. So every minute they're waking up, that would be considered severe. So they're waking up and they're just not getting good sleep. So all the healing of the brain that occurs during restorative sleep doesn't happen. And those are the things that lead to cognitive decline and other more serious things. Alzheimer's, dementia, things like that. There are more studies coming out looking at that.
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A
Are we going to have a hopeful discussion today, Paul, about sleep apnea? Because this sounds pretty frightening and you're talking about 80 million people out there.
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B
It's hopeful because we have good treatments for it. I think the part that's Frustrating is that we talked about 80% of the patients are not diagnosed. So we need to do a better job, and that's probably in diagnosing people. And that's where things like consumer sleep technology comes in, like the Apple Watch and things like that, that, you know, it's much more widely available, at least as a screening device. Not necessarily diagnostic, but at least it gets people aware. It's like, oh, I have a problem, I need to go in and talk to a sleep physician about this. So that's the hopeful thing and we do have good treatments for it.
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A
Let's talk about the thing you've alluded to. So, body mass index. How would you best characterize the relationship between being overweight or obese and sleep apnea?
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B
Well, it's interesting. So a thin person can have sleep apnea, but as the BMI goes up, the incidence and the prevalence goes up significantly. So if your BMI is 35, 40, the incidence of sleep apnea is going to be much greater.
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A
If you are someone who has a very high BMI like that, how can you, can you say how likely you are to have sleep apnea?
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B
Oh, greater than, greater than 50% chance.
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C
Really?
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B
Sleep apnea if your BMI is over 35? Yeah.
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A
I guess some of this maybe intuitively makes sense to people who are listening, but what exactly is happening?
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B
Yeah, it's pretty interesting. As you gain weight, your tongue actually gets bigger. So when you fall asleep at night, you relax and especially if you're on your back, it just falls back and blocks the airway.
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A
I actually didn't know that. You've taught me something. Are there certain demographics obviously obese, but like I read this one study, I think Asian Americans have a higher rate of obstructive sleep apnea, despite the fact that they're often not as likely to be obese.
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B
Yeah, it has. So you think about sort of the soft tissue filling the back of the throat, that would be fat, but also the skeletal framework. So the box that everything is contained in. And so, so Asian American or Asians have a. Just a small. The box is smaller in a front to back dimension. So that contributes to more crowding of the airway as well. You also might think about patients like with a recessed jaw. That's another population of patients who have bad sleep apnea.
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A
Is it being screened? Well, at the primary care level, it is screened.
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B
I know that primary care doctors will look in your mouth, see if your tongue is big, and they'll ask some basic questions. But I think, as we mentioned, Again, it's definitely under reported and underdiagnosed.
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A
Many people snore that don't have sleep apnea. You've established that. But does everyone who has sleep apnea snore?
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B
You know, you could say, for the most part, they do. The one caveat is a lot of women are at significant risk for sleep apnea, just like men, but they often go undiagnosed a lot more than men because men snore really loud. It's really kind of obvious. A lot of times women will have, you know, they won't snore so much. They have more partial obstruction, so they might breathe heavy, but it's not recognized as obstructive sleep apnea. And their symptoms might be different. They might have more symptoms of, you know, depression and brain fog and things like that. This especially happens as they get into perimenopausal and postmenopausal time. So, yeah, it's different in women.
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A
We'll have much more on snoring and sleep apnea with Dr. Paul Hoth after this short break.
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C
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A
So let's say I'm worried about this. What do I actually do? Is there an app to, to, to try and do a home sort of screening test?
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B
Yeah, I mean, with the Apple Watch and you can upload to your, your phone and it'll kind of keep track of the data. And it's nice because it's night by night, you know, minute by minute. And then, you know, you can show that to your primary care doctor, you know, your sleep medicine doctor. They're interested to see that. And if they, if it looks, you know, suspicious, then they'll order a diagnostic study, usually like a home sleep study to start with.
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A
And what does that entail the home
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B
sleep studies are variable. They're a lot nicer because you do them at home. So you're sleeping in your own bed, there's not somebody watching you. An in lab study. The big difference is they, they put wires that are looking at brain waves, EEGs. They put cardiac monitors on you. They put monitors on your leg, but look to see if your legs are kicking around. Monitor on your chest just to see if you're breathing or not. You know, central apnea, you don't take a breath. So lots of monitors and there's somebody watching you, monitoring you at night. So it's very accurate. But it's, you know, you're sleeping in a different room. So people don't like them, but they're very good. Study, home sleep study. It might just be something on your finger and your wrist.
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A
So I guess the thing on your finger probably is measuring your oxygenation or something. You said there is mild and moderate and severe sleep apnea. What constitutes mild versus moderate or severe?
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B
They just measure the number of times per hour that you stop breathing. It's like a 10 second pause in general is kind of considered an event. It can be a lot longer, but that's kind of the cutoff. And so up to five events per hour is normal. Five to 15.
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A
That's normal. Okay, so everybody would have that, that wouldn't constitute sleep apnea.
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B
Right. And that's per hour. So up to 15 events per hour, it's considered mild. Then 15 to 30 is moderate. Once you get into moderate to severe, over 30 is severe. That's when it starts to have the cardiovascular impacts. Things with the atrial fibrillation and cognitive issues and all the things. Mild sleep apnea, not so worrisome unless you have some other preexisting sort of comorbid condition like congestive heart failure, for example, or some other thing like that.
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A
At what point would they potentially be recommended a CPAP machine?
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B
Well, CPAP is first line treatment. So they would, that would be the first line after if. So if they, even if they're trying to lose weight, it will them to lose weight if they're treated right away. So you get them on a CPAP machine.
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A
That's interesting.
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B
Yeah. Which is, you know, they, they get their energy back, they feel better, then they can, you know, you know, their metabolism improves. So that's always the best, best combination of things to do.
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A
So addressing the sleep can help them lose weight.
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B
Yeah, yeah. And for those people who don't tolerate, tolerate CPAP or other conservative Non surgical treatments, sometimes positional therapy. So some people have terrible sleep apnea on their back. You lay them on their side and their sleep apnea goes away. And so there are devices, like, different kind, like wedges you can sleep with, or there's some devices that actually kind of vibrate if you start to roll onto your back, sort of train you to sleep on your side. The old tennis ball technique, where you sew a tennis ball into your night shirt, that's not the greatest, but that's the concept is if it just makes it uncomfortable to roll onto your back. So that's a conservative non surgical thing. And it's very effective. More from mild to moderate sleep apnea. And you might have heard of oral appliances. It's like a mouth guard. People use bite blocks or for bite splints, you know, for grinding their teeth. But this is one that would kind of bring your jaw forward, which brings your tongue forward, opens the airway. And if you do that at night, you know, that's, that solves the problem for people with mild to moderate. And so that's a good option for people. And then after that you start talking about surgical treatments for those who really need it.
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A
And of the 80 million people out there, roughly with sleep apnea, any sense of what percentage of those people would ultimately need surgery or something invasive?
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B
Well, about 50% of those are gonna be like mild sleep apnea. So the other 50% is 30% moderate. And then they're 20% are gonna be severe sleep apnea. So it's that population that's needs, you know, significant treatment. An important thing to know about CPAP and oral appliances. It's about, you know, after a year or so, only about 50, you know, 30 to 50% of people continue to use it. So they started it, tried it, and then they've, you know, stopped using it. It's, you know, some people love it, they will not sleep without it. Others, it's like, I cannot do this. You know, they're claustrophobic or different things.
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A
I think a lot of people who are listening may be familiar with this. What is cpap?
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B
CPAP is continuous positive airway pressure. So you get air pressure coming in and it just expands. Open that little segment of the airway. I was talking about the tongue base and the palate and just opens it up.
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A
It's basically kind of keeping that, that part of your airway that we described at the top of the podcast open when someone's breathing in.
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B
Yeah.
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A
How well does it work?
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B
Oh, it's the gold standard. Yeah. The goal is always to get. We mentioned those numbers with the severity of sleep apnea. They're, you know, if you started off with 60 events per hour, they're shooting for less than five. It's very, very successful.
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A
So I guess the reason someone might need something other than a CPAP machine for moderate to severe sleep apnea is because they just don't tolerate the machine well. They just can't sleep with the mask on their face.
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B
Yeah, exactly. People rip it off in the middle of the night. You do have to use it more than four hours a night for Medicare to continue to pay for it. You can imagine you need more than four hours a night of good restorative sleep and feel better, like you get a good night's sleep. But that's. But if you're using it less than four hours a night, then you become a candidate for other options.
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A
Got it. Is this more common in older people? Yeah, you just mentioned Medicare, so I wondered about that.
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B
Yeah. The incidence of sleep apnea definitely increases pretty dramatically as people. As people get older.
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A
Who is your most common patient?
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B
By far the most common is the person probably around 60, just getting close to sort of Medicare age, you know, retirement age.
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A
Shit, that sounds often close for me. Who's the youngest patient or what age was the youngest patient you've ever diagnosed?
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B
Oh, I mean, sleep apnea is definitely a phenomenon in children. One of the most common surgeries in kids is tonsillectomy, and one of the more common reasons we do that is for sleep apnea.
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A
Interesting.
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B
Yeah. So tonsillectomy and adenoidectomy, what types of
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A
other surgeries or operations are available for people?
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B
The toolbox that we have in surgery, it's very. It's been very broad. Usually when there are lots of surgeries, that means that there's not really great surgery. The surgeries involve. I mentioned the U, triple P. There were surgeries at the back of the tongue to remove tissue. There's ways to advance the jaw forward, upper and lower jaw. That's done by oral surgery. So, I mean, a lot of different surgeries that have been available. With the advent of neurostimulation, you stimulate a nerve that moves the tongue forward. That's really changed everything. I mean, it's a real game changer. I feel like I've lived through some of the rough times of surgery for sleep apnea. Now we're in this sort of golden age where we're just stimulating a nerve, just opening the airway sort of naturally without removing anything. It's just People go home the same day. So surgery.
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A
Can you just describe that a little bit? So this audience, pretty sophisticated audience. I think they understand generally what you're talking about here. But you say you stimulate the nerve, I think you're talking about the hypoglossal nerve that controls your tongue and you're essentially stimulating that.
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B
Yeah, yeah. So, yeah, this technology has been around. It was first FDA approved in 2014, but people have been researching this for a long time. And they found that stimulating the hypoglossal nerve, which just sits right under your, under your jawline right here, it moves your tongue in all the directions that you can imagine. And when you're asleep at night, when you have an apnea, it just senses your breathing, so it's synchronized with your breathing. So every time you breathe in, that's when your airway would obstruct. And so it just moves your tongue forward during that time. So it's relieves any obstruction that would occur.
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A
And we should disclose that you're on the board, I think, of one of two companies that make these FDA approved implants. Is that right?
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B
Yeah, I'm a chief medical officer for Inspire. So I started that about a year ago after, after working with the device for 10 years as a surgeon.
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A
How effective is this?
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B
It's very effective. You know, we, we, you know, we can, we don't tell people that it's, it's not superior overall to cpap, which is considered the gold standard. But we're seeing the results get better and better. I've had patients who've had multiple car accidents, and now they just come back and they're completely refreshed. They're like, this changed my life.
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A
By the way, you've mentioned this car accident thing a few times. That's really interesting. I mean, so that is a clue for you that there's something going on. So that's a question you probably ask people as a sleep doctor.
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B
Yeah, yeah. That's one of the big hazards people, many drivers, pilots, professional truck drivers, they all have to be screened for sleep apnea because of the hazard of having an accident on the road.
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A
So is the appropriate candidate for something like Inspire, is this someone who has failed cpap?
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B
Yes, definitely. That's a big, important point. So typically patients will have tried cpap and their sleep medicine doctor will recognize that they're not using it well enough.
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A
You've been doing this a long time now. What is a piece of advice or, you know, sort of a takeaway that you'd want the public to have about this problem.
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B
You know, untreated obstructive sleep apnea is a real kind of a silent killer. Kind of like, you know, high blood pressure is. You just really don't know what's happening. But it's one that doesn't happen immediately. This is something that happens like, it's like, you know, heavy use of your car over. Over years. You know, you need to maintain it. Otherwise things just start to fall apart. And that's what happens with sleep apnea. The first thing that may, you might present with atrial fibrillation or you might. We kept mentioning the car accidents, but there's so many things like cognitive decline and others that are out there that it'll just sneak up on you and something that could have been prevented. So it's a. Many of the side effects of obstructive sleep apnea, which are really tremendous, are almost entirely preventable if you can just get on top of the sleep apnea early on.
- [24:31]
A
You find very few people who say, yeah, my sleep's great. I'm sleeping fantastic. I have nothing to worry about. Either they're not being totally honest or the point is that most people have some sort of sleep problem. And a significant percentage of them, it might be sleep apnea, mild to moderate or severe sleep apnea. Well, look, best to you, to Donna, your wife, to Diane, your mom. She was all of our moms. And to your daughters. It's great to see you, Paul. Thank you for this time.
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B
Appreciate the opportunity and it's all the best of it, Rebecca.
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A
Yep.
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B
Okay.
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A
All right, well, hope to see you soon.
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B
Okay, see ya.
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A
Thank you. Bye. That was Dr. Paul Hoff, my good friend for 30 years. Now he's an ear, nose and throat doctor who focuses on sleep, talking about the latest in the treatment of obstructive sleep apnea. Hope you learned a lot. I certainly did. Thanks for listening. Sweet dreams and we'll see you next week.
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E
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