Could You Have Sleep Apnea? Symptoms, Risks and CPAP Alternatives

Sleep apnea can cause you to stop breathing repeatedly during the night — sometimes dozens or even hundreds of times — without you realizing it. And while loud snoring is a common warning sign, it is not the only one.

In this episode of Baptist HealthTalk, host Dr. Anthony Gonzalez talks with sleep specialist Dr. Edward Mezerhane about how sleep apnea affects the body, the symptoms people often miss, and what can happen when the condition goes untreated.

They also break down how sleep apnea is diagnosed, why weight and airway anatomy matter, what to do if CPAP is difficult to tolerate, and the other treatment options available.

•  What sleep apnea is and how common it may be 
•  Why people can stop breathing without realizing it 
•  Common and overlooked symptoms of sleep apnea 
•  The connection between sleep apnea, weight gain and heart health 
•  Whether losing weight can improve sleep apnea 
•  How sleep studies confirm a diagnosis 
•  Ways to make CPAP easier to tolerate 
•  Alternatives to CPAP, including oral appliances and surgical options 

Sleep apnea is highly treatable. If you regularly wake up exhausted, snore loudly, or a bed partner notices pauses in your breathing, getting evaluated may help improve both your sleep and your long-term health.

For more health and wellness information, visit BaptistHealth.net/News.

Host:
Anthony Gonzalez, M.D.
Chief of Surgery, Baptist Health Baptist Hospital
Medical Director of Bariatric Surgery, Baptist Health

Guest:
Edward Mezerhane, M.D.
Sleep Medicine Physician

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Transcript

SPEAKER_01 0:00

But you can absolutely snore and not have sleep apnea. You can be a silent sleep apnea where you have sleep apnea and you don't snore. But far and you know, far and wide, so to speak, the most common symptom of sleep apnea is snoring.

SPEAKER_00 0:15

Welcome to Baptist Health Talk, a podcast on all things healthcare powered by Baptist Health South Florida, your trusted source for healthcare prevention and wellness.

SPEAKER_02 0:25

Hello, I'm your host, Dr. Anthony Gonzales. Welcome back to a new episode of Baptist Health Talk, where we answer your most searched questions on trending health topics. Today we're talking about a condition that can cause you to stop breathing hundreds of times a night. And many people have no idea it's happening. Sleep apnea is far more than just loud snoring. It can affect your memory, your heart health, even your risk of accidents during the day. So, how do you know if you have it? What's most at risk? And what if you can't tolerate a CPAP machine? Today we're answering all of these questions and more. We are joined by Dr. Edward Messerhane, sleep specialist. Welcome, Ed.

SPEAKER_01 1:14

Tony, always happy to be here with you. Thank you for having me.

SPEAKER_02 1:17

All right. So what exactly is sleep apnea and how common is it?

SPEAKER_01 1:22

Absolutely. So apnea, the word apnea means to stop breathing, right? Sleep apnea means we do it when we sleep. And there's many different types of sleep apnea, but the most common uh by far is obstructive sleep apnea, which is a mechanical collapse of the upper airway. So why does this happen, right? Apnea happens when we sleep because we fall asleep. We enter in a subconscious state. And the deeper we go into sleep, the more paralysis of our body. When we dream, we're fully paralyzed, right? And so when we're in that state, the muscles of our body are paralyzed, so are the muscles of our airway. And the windpipe muscles and the airway muscles can relax to the point where they actually collapse and you end up choking and you stop breathing, right? And so that not only happens one night, that not only happens one or two times per night, it happens repetitively, not intermittently, but repetitively. And it can be dozens, hundreds of times per night. And this triggers a cascade in your body of low oxygen and sleep disruption, right? And so this disease is far more common than people expect. The latest estimates is that about 80 million US adults have sleep apnea, right? So staggering numbers, right? We think at least 15 to 20% of the population. And some of the estimates think that up to almost 30% of the adult US population has sleep apnea.

SPEAKER_02 2:41

And so, but explain to us in detail. I mean, what happens when you stop breathing? Are you actually people describe it as you're gasping and coming up for air? So you're like waking up a hundred times in the middle of the night subconsciously.

SPEAKER_01 2:53

Correct. And that's that's exactly what's happening. Many people will not report that. In fact, when I see a patient, very few will come in and tell me, Doctor, I'm choking. I'm gasping. I recognize it at night, right? So when we talk about apnea, there's actually two types of events that happen in apnea. There's the full apnea, the full gasping and choking. And even in those, you may recognize a few here and there, but for the most part, you're not going to recognize it. The majority of events are not full apneas or full closures of the airwear. They're partial closures. They're called hypopneas or partial apneas. Those you'll never feel, right? So while this is happening 50, 100, 200 times in a night, patients may have one or two interruptions. And these interruptions that they'll have may be because of the noise of the snoring, maybe because of a body movement. But behind that, they're not recognizing that it's the apnea causing them to disrupt their sleep. So, no, you're not going to come in and tell me I woke up a hundred times last night. What I'm going to sit around and tell you, sit, sit, sit in there and tell you is the fact that you probably did. You didn't recognize it. And that's maybe how and why you feel the way you feel today, Turnaday.

SPEAKER_02 4:04

All right. So obviously, for those patients that are not gasping, how does somebody know that something is wrong?

SPEAKER_01 4:10

Yeah. So what I tell my patients is the best way to know is actually a bed partner or a family member, right? Now, that's a tricky subject because many people sleep alone, right? 25, maybe 30% of married adults are sleep divorced, right? So sleeping in two separate bedrooms because I like a different temperature, because I can't take your snoring, because you're moving too much, because you keep the TV on, because you keep the white noise machine on, because you get up at three o'clock in the morning and turn on your iPad and disrupts my sleep. So many people are actually sleeping alone, right? So if you sleep alone, it's harder to know this, right? Of course, if you have a bed partner, they will complain of disruptive snoring, habitual snoring. They will see you gasp, they will see you choke, they'll begin to be concerned for your breathing, and that's very easy. For the patient itself, it's probably gonna be a fragmented sleep, a disrupted sleep. I wake up multiple times a night, I wake up in the morning, I don't feel recharged. I slept seven hours. I should feel great or I should feel good. Why do I feel this bad? And then, of course, during the day, tired, sleepy, fatigued, run down, irritable, cranky. These are some of the symptoms that a patient will come in and tell us. Many don't come in and saying, it's my snoring, it's my gasping and choking, right? That's what the bed partner will see. They don't necessarily see that.

SPEAKER_02 5:24

And so you mentioned the snoring. Um, are there other signs that uh people may miss, obviously, uh, and not know that they have sleep apnea?

SPEAKER_01 5:33

Yeah, absolutely. So the classic is obviously the snoring, the gasping, the choking, right? And that may come from them, but typically the bed partner. The next most common thing that we see is the daytime tiredness, sleepiness, fatigue. This is very common in these patients, right? But sleep apnea has an array of symptoms, not only at nighttime, but also during the day, right? So, so that unexplained arousals in the middle of the night, frequent urination, waking up three, four times a night and I saw my urologist and they say, nothing's wrong with me, right? So we see that often. Waking up with morning headaches, waking up with headaches in the middle of the night. They'll describe that headache kind of as a mild, typically less than five out of 10 headache, typically in the nuclear or the back of the head, just kind of there, just kind of bothersome. I don't do anything for it. It's two or three hours in the morning, then it kind of just goes away, right? Or brush my teeth, take a shower, have some breakfast. By the time I get to work, it's gone, right? But I keep waking up with this headache, nobody knows what's wrong with me. Uh, and then during the day, tired, fatigued, run down, cranky, irritable, anxious, depressed, uh, can't focus, can't concentrate. I used to be able to do 20 reports a day. Now I'm only doing 15. I'm falling behind. I'm getting reprimanded because my work performance, my physical performance is not the same. I used to be able to go to the gym and do this amount of repetitions or this amount of cardiovascular work. Now I can't do it. I'm always tired, I'm always run down, right? And so these are signs and symptoms of sleep apnea.

SPEAKER_02 6:49

And what about the snoring? Is it absolutely always snoring? Or if you don't snore, you definitely don't have sleep apnea?

SPEAKER_01 6:55

Yeah, no. So so they're not sort of mutually inclusive and exclusive, right? So what I tell my patients is about 50 to 60% of the population will actually snore. Okay. At any given point in time, they'll actually snore. So it's that common. When we talk about a habitual disruptive more nights than not snoring, that's about probably 25% of the population. Of those, the majority, 60, 70% of them will have sleep apnea. But you can absolutely snore and not have sleep apnea. You can be a silent sleep apnea where you have sleep apnea and you don't snore. But far and, you know, far and wide, so to speak, the most common symptom of sleep apnea is snoring, and and they typically go hand in hand. Kind of go in hand. Yeah.

SPEAKER_02 7:44

All right. So we're gonna try something a little new. So we pulled up the most searched questions online, and we're gonna go rapid fire through these questions. All right. So will sl will sleep apnea kill you?

SPEAKER_01 7:55

So the answer is yes, right. However, it is not common that that's the case, right? So I don't want anybody to panic or freak out, right? Uh sleep apnea can cause many complications. There have been some deaths related to sleep apnea. And so for that, this is what I tell my patients. What we're trying to do here is treat you to prevent complications in the future.

SPEAKER_02 8:13

All right. Does it actually cause you to stop breathing? Is it intermittent or forever?

SPEAKER_01 8:18

Yeah. So it does cause you to stop breathing. Now, let's take a step back there and explain that a little bit further. We breathe because our brain tells us to breathe, right? That process still happens. In obstructive sleep apnea, the problem is the airway collapses. So we're still sending the signal to breathe. It's just not getting there because the mechanical collapse of the upper airway. Okay. It's intermittent, right? So these episodes last at least 10 seconds, you know, and sometimes up to 20 or 25 seconds or even longer. And then oxygen levels drop, adrenaline kicks in, and that disrupts your sleep. You wake up and you gasp and breathe again and reestablish your breathing pattern. So it's intermittent and recurrent. All right. Does sleep apnea cause weight gain? Absolutely, right? So sleep apnea is an inflammatory condition, sleep apnea is a hypometabolic condition, and it is a counter-regulatory condition. So it goes against the hormones to help you lose weight, right? And so absolutely, and then it's a self-fulfilling prophecy or a vicious cycle. You gain more weight, you have more sleep apnea because you gain more weight, right? So all the uh excess adipose tissue or fat tissue accumulates in our neck, in our tongue, and that worsens the sleep apnea. More sleep apnea, more inflammation, more hypometabolism, more weight gain, more weight gain, more sleep apnea, and then it's hard to break the cycle. So if I lose weight, my sleep apnea will go away. That's the only chance you have, right? So the way I explain to my patients is if I diagnose you with sleep apnea and you're overweight, right? More weight, more sleep apnea, less weight, less sleep apnea. I can treat you, I'll treat you forever, right? If you want to have a chance to get better, it's weight loss. And many studies show from the bariatric surgery journals, from the sleep journals, that at least a 10% body weight loss can make or gain, one way or another, but hopefully loss, will make a significant impact to your sleep apnea. And about a 20% body weight loss will lead to about a 50 to 60% reduction on average of the sleep apnea index.

SPEAKER_02 10:18

All right. With the exception of weight gain, uh I'm sorry, with the exception of weight loss, will SAP sleep apnea go away by itself?

SPEAKER_01 10:24

No, naturally it is a disease that is chronic. It's a disease that is forever. And as we age, it will increase and it will progress, right? Meaning it will increase slightly. Where people get into trouble, uh, and touching back upon that, is the weight, right? Weight makes you exponentially worse in your index. H will make you linearly worse in your index.

SPEAKER_02 10:45

Will sleep apnea cause high blood pressure or other heart conditions?

SPEAKER_01 10:48

Absolutely, right? So we know that's been well studied, well linked, right? One of the factors for what we call secondary hypertension or malignant hypertension can be sleep apnea. What I tell my patients is that treating the sleep apnea will help your other treatments for your blood pressure work better, right? So it's not to say I treat your sleep apnea. Now you're not going to need your blood pressure meds. That's not the case. You're going to need less of them, you're going to need less dose of them. They will work better, absolutely. And besides sleep apnea, this has been linked to coronary artery disease. It's been linked, well linked to arrhythmia, specifically atrial fibrillation, heart failure, valvular disease of the heart, and on a neurovascular or from a brain perspective, stroke and dementia and Alzheimer's. Wow.

SPEAKER_02 11:32

Bad, bad. Okay, what about alternative approaches? We know that the CPAP machine is frequently used, but what about mouth tape wedge pillows?

SPEAKER_01 11:40

Yeah, absolutely. So when we look at a patient that has sleep apnea, a lot of the factors that we kind of forget to think about is what about some of these conservative strategies, right? Things like position, right? Things like weight, things like um different alternative therapies to CPAP. So a wedge pillow may be a good option if you have a positional sleep apnea. What does that mean? Well, you have sleep apnea only in a certain position on your back, for example. So having a wedge pillow may help you side sleep or a side sleep pillow that may help treat your sleep apnea, right? That on its own. Uh things like mouth tape, that's a controversial topic, right? The problem with mouth tape is it works well to increase nasal flow of air if you don't have an impediment or a resistance or an interference to nasal breathing. Problem that that's hard to know who has that, right? And so you have nasal obstruction, mouth tape is not recommended because you need the mouth as an escape valve. If I tape it shut, I don't have an escape valve, it could worsen your apnea. Well, if you don't have nasal resistance or nasal obstruction, mouth tape will increase nasal flow and decrease dry mouth and improve breathing. But it's hard to know on any clinical signs and symptoms without having an ENT evaluation if you have nasal resistance or not.

SPEAKER_02 12:54

All right. So let's talk about some of the lifestyle changes. Because obviously, before we get into real medical therapy, there are some lifestyle changes like diet, exercise, avoiding alcohol, physical therapy. Talk to us about some of those.

SPEAKER_01 13:06

Absolutely. So, so uh, like I had mentioned, a lot of these conservative strategies are always foregone because, you know, us as physicians, every nail needs a hammer, right? So we're always like CPAP, CPAP, CPAP, CPAP, and we forget to take a step back and say, look, you're overweight, you have obesity, we need to address that because that's going to make your disease better. So weight loss is the number one thing that we can recommend from a conservative perspective to our patients, right? Other simple things, as you mentioned, alcohol, right? Alcohol right before bed is muscle relaxing. It's going to worsen your sleep apnea, right? So that's that's something to think about. Medications, right? Hypnotics, narcitives, sedatives, muscle relaxants. A lot of patients are on these medications and they will worsen sleep apnea. So if we can modify their treatment regimen, that that's something that's of importance. And you mentioned physical therapy. There's something called myfunctional training of the tongue, right? Which is a sort of physical therapy for the tongue. Uh, studies are back and forth on that, whether there's kind of persistent and continuous effects. That works uh in some cases for snoring and mild sleep apnea. If it's a more moderate or severe sleep apnea, the results are are kind of haphazard and not really uh consistent study after study.

SPEAKER_02 14:13

All right. So people always picture the sleep apnea patient as somebody who's overweight and snores. Is that always the stereotype? Uh I know that you can be thin and still have sleep apnea.

SPEAKER_01 14:24

You're absolutely right, right? And so I cannot express to you how many young teenagers, females that are thin, that you know, weigh less than 60 or 70 kilos, 110, 120 pounds, and they have terrible sleep apnea. What we're coming to realize is that weight exacerbates the disease, but by and far it's an anatomical problem of the airway, whether it's due to obstruction because of enlarged tissues, whether it's due to how your muscles relax, because maybe your muscles relax more than mine, and so you'll have more sleep apnea, even though you're thin. So, really, it's an airway, anatomical issue. The problem definitely gets compounded and worsened by weight.

SPEAKER_02 15:05

All right. So somebody suspects they have sleep apnea, their bed partner. Hey, you're snoring. I think you have sleep apnea. What does that diagnosis look like?

SPEAKER_01 15:14

Absolutely. And so the clinical picture definitely points us towards the diagnosis, but the diagnosis is based off of sleep study. There's two ways to get that done. One could be at at home sleep study, the other way could be at a sleep center, right? And that depends on what medical conditions you have besides the sleep apnea. So what other heart disease, what other brain disease, what other lung disease you may have, right? And and we may want somebody to do an in-lapse sleep study or at a sleep center, right? And then, of course, other sleep comorbidities, right? If you have insomnia, if you have a movement disorder, all this, I then need to bring into a sleep lab to take a little bit further look, other than just your sleep apnea, right? So the sleep study is what confirms the diagnosis. And then once you have those results, discuss it with the physician based on the severity of the sleep apnea, what are the appropriate treatment options or available treatment options for the patient?

SPEAKER_02 15:58

Obviously, one of them and the most common one is the CPAP mask, right? Absolutely. But we hear that patients, you know, some of them struggle with the CPAP and they have a lot of difficulty. And I think you've mentioned it, you know, you either hate it or you love it or you hate it, right? So what advice would you give to somebody who's struggling with that CPAP mask?

SPEAKER_01 16:14

Yeah. So the first thing is I always tell my patients is uh, you're absolutely right. Patients hate it and love it, right? So there's going to be a learning curve here and it's rather steep, and it could be the first month or even sometimes up to two months to get used to it. I tell you, you don't learn to ride a bike by me telling you how to ride the bike. You got to get on, you got to fall off, and you got to get back on. If you don't get back on, you'll never learn. And there's gonna be some slips and falls and bruises and scrapes along the journey, right? So the first thing is look, talk to your doctor. A lot of times adjusting the pressure, adjusting the comfort settings, adjusting to mass, changing the mass, fixing a mass leak makes the world a difference. After all that's said and done, not everybody's at a CPAP candidate long term, right? They don't get used to it, they can't tolerate it, it's uncomfortable, it's claustrophobic. These things happen, right? And so at that point in time, have the discussion about some of the other options of treatment for the sleep apnea. So let's talk about that. What are some of the other well-accepted medical options for sleep apnea besides a CPAP mask? Absolutely. So one uh option that works very well is oral appliance therapy or mandibular advancement devices, right? These are typically done by your dentist, right? And uh they are essentially a mouth guard, right, uh, for sleep apnea. And they are two pieces. So it's a top and a bottom, and the top anchors and the bottom slides your jaw forward. So what you're doing is a jaw thrust. So when you bring the jaw forward, the back of your tongue is inserted into your jaw. So you open up the space in the back of your throat, between the back of your throat and the back of your tongue, making that a bigger pipe, it collapses less. So you would wear an oral appliance at night, and you know, it's a shift of about maybe half a centimeter, maybe up to one centimeter. And you say, well, Ed, that's very small. It's like, you know, a few millimeters, yes, but if you already start with a few millimeters, a few millimeters improvement, maybe 20, 30, 50. Yeah, maybe double, right? And so, and so that's what I tell my patients. So, oral appliance therapy, great option. Other options, surgical treatment options, right? And uh, there's a few surgical treatment options for this. It's actually about four or five, right? From an ENT perspective, right? We have the traditional what we call multi-level surgery of the airway, right? This is done by the ENT doctors to take a look at what can be reconstructed in your nose. Maybe you have a debated septum, large turbinates, sinus disease, adenoids in your mouth, tonsils, palate, uvula, in your throat, back of your tongue, the um the glottis, right? The the the windpipe. How can they reconstruct the airway and make a bigger pipe, right? Uh and now there's the advent of the uh what we call hypoglossis nerve stimulators or the implants or or aka the pacemakers for the tongue that stimulate the tongue. They're nerve stimulators, they stimulate the nerve of the tongue and they force the tongue forward and prevent the collapse of the tongue back, right? Very good option for patients, right? Uh patients with moderate to severe sleep apnea and obesity. We now have GLP1, specifically trceptide, specifically Z-bound, has been FDA approved for the treatment of moderate to severe sleep apnea in patients with obesity. That's an option. And um, there's another option called an excite device, which is a tongue trainer, uh, which changes the fibers of the tongue and increases the muscle tone. That's approved in snoring and mild sleep apnea. So there's plenty of options. And lastly, going back to surgery, things that you know well with patients with morbid obesity, bariatric surgery works very well because of the weight loss. And patients with jaw malformations or jaw abnormalities, oral maxillofacial surgery can take a look and do a reconstruction procedure of the jaw to open and expand the airway as well. So we got options.

SPEAKER_02 19:45

And so obviously these options are for cure or control or maintenance.

SPEAKER_01 19:51

Yeah, absolutely. So so what I tell my patients is most of the options we have today are treatment and control of the disease, right? So when we look at oral appliance, if you don't wear it, it doesn't work. If you don't wear a CPAP, it doesn't work. Most of the ENT surgeries now are these implants. If you don't turn them on, they don't work, right? So they're lifelong therapies. Of course, if you have a jaw reconstruction, you open up the airway, that would be forever. Of course, if you have an airway reconstruction, for the most part, that can be forever. But those procedures are few and in far in between. And many patients will never undergo those procedures, right? Oh, they're more complex, they're more involved, they're better surgical procedures. Having other options, they'll resort to other options first, right? So those are reserved for few and far in between cases.

SPEAKER_02 20:37

Wow, great information. So remember, if you wake up exhausted, no matter how many hours of sleep, or someone has told you you snore loudly or stop breathing during the night, don't ignore it. Sleep apnea is highly treatable, and getting evaluated could improve not only your sleep, but your long-term health as well. Thank you for sharing all this information, Ed. Tony, thanks for having me. I appreciate it. All right, remember, viewers, be sure to hit that subscribe button on our channel here to keep up with the latest health and wellness information and tips from our experts. You can also find Baptist Health Talk on Apple Podcasts, Spotify, or wherever you listen to podcasts, so you can tune in anytime, anywhere.net slash news.

SPEAKER_00 21:30

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