Don't Hold Your Breath

Thank goodness.  Thank goodness I’ve finally got a little leverage I can use to convince my patients to get tested and treated.

I’m talking about the ubiquitous problem of obstructive sleep apnea, or OSA.  This is a disorder where the affected person erupts into a chorus of snoring and breath holding as they drift off to sleep.  If you’ve ever witnessed these apneic episodes you’ll never forget them.  The patient starts with loud snoring but reaches a point where it seems as if he’s sucked something into the back of his throat and can’t get another breath in.  He lies there, struggling against the obstruction for what seems like an eternity, until he wakes up and gasps for air.  To the alarmed onlooker (most often a spouse, although night-shift nurses can regale you with stories of breath holding that would impress Filipino pearl divers) it looks for all the world like the patient has sucked in his own pillow and will give up the ghost if he’s not awakened with a restorative kick.

The problem is not with an inhaled pillow but with collapse of the patient’s own tissue in the back of the throat.  When supine and somnolent, the patient relaxes the muscles that normally hoist the excess weight off the pharynx and the airway closes.  Breathing out works just fine—it’s the breathing in part that doesn’t go so well.  During inhalation the airway collapses like a flimsy straw used to suck up a milkshake.  The first time I witnessed this I found myself desperately chanting “breathe, breathe, breathe!”   Of course the patient doesn’t realize any of this is happening.

If you were to put a pulse oximeter (a device that measures oxygen level in the blood) on the finger of an OSA sufferer and watch him sleep you’d see something remarkable.  He’ll start off the evening near 100% but drop as low as 70% during a period of breath-holding lasting as long as a minute or more.  In classic cases this can happen literally dozens of time each night, each occurring during the most restorative phase of sleep.  As the concentration of carbon dioxide rises (normally exhaled during respiration) the patient begins to suffocate to the point that the brain kicks him back into semi-consciousness and triggers normal breathing.

As you can imagine the quality of sleep with OSA is terrible.  Morning headaches are common and daytime sleepiness is a hallmark of the disorder.   The long-term effects of untreated OSA are more insidious.  The recurrent low oxygen levels in the lungs leads to a scarring and stiffening of the blood vessels exiting the right ventricle of the heart.  The normally low pressure of this chamber rises two- and three-fold over time and it subsequently fails to cycle blood effectively, especially blood from the legs, which already has a tough enough time overcoming the force of gravity to get back up to the heart.  Severe, intractable swelling ensues that no amount of diuretic medication can cure.  For complicated reasons OSA also leads to high blood pressure that is very difficult to treat.  Also more frequent in this population are arrhythmias and sudden cardiac death.

While not limited to the overweight crowd, this disorder afflicts mostly those with extra pounds and is therefore rising in prevalence in parallel with the burgeoning obesity epidemic.  It’s now estimated that at least one in ten Americans suffer from OSA.

To diagnose the problem the patient has to undergo a sleep study.  This is where they come to a strange room, have every imaginable type of electrode attached to their head and body, and are monitored during the night under the watchful eye of a camera. At this point it’s actually fortunate that OSA patients are perpetually exhausted and drowsy—it’s the only way a person could be expected to sleep under these conditions.  If their oxygen levels drop sufficiently and frequently during the night the diagnosis is secured and treatment recommended.

While sufficient weight loss and exercise can effectively cure the problem in some people, therapy comes mainly in the form of a continuous positive airway pressure (CPAP) mask that the patient straps to their face with the same gusto as a creature from the movie Alien.  The mask forces air down the trachea of the patient with a slight pressure that is just enough to keep the airway from collapsing during inspiration.  A patient once told me the first time he strapped on the mask and went to bed he felt a little like Hannibal Lecter in a Serta commercial.

I hear it takes some getting used to.

For those who can tolerate the therapy it’s a life changing experience.  All of a sudden they feel more rested, have more energy, enjoy lower blood pressure, and gradually their swelling dissipates.  Now that they are no longer living life in the haze of perpetual drowsiness some patients even find the motivation to exercise more and lose the weight responsible for the OSA in the first place.

Unfortunately it has been a bit of a hard sell for us doctors.  Between the inconvenience of the sleep study and the threat of the CPAP mask many patients don’t want to have anything to do with getting to the bottom of their symptoms.  Up until now I’ve relied on the futile application of logic and reason.  Don’t like the fatigue and swelling?  Go get tested.  Want to feel better during the day?  Get back on your CPAP therapy.

Now back to the leverage.  It turns out some clever researchers decided to look at the effect that nasal positive airway pressure (NPAP) treatment for OSA has on that most important clinical marker of physiological function: the golf game.  Apparently, being compliant with NPAP improves a golfer’s game by as many as 3 strokes (the researchers didn’t comment on whether the therapy improves a golfer’s ability to accessorize with plaid):

"As any golfer knows," stated study co-author Dr. Marc L. Benton, "when your ability to think clearly or make good decisions is compromised, the likelihood of playing your best is greatly diminished. Through treatment with NPAP, we can improve many cognitive metrics, such as attention span, memory, decision-making abilities, and frustration management, which may, in turn, positively affect a person's golf game."

No more futile application of logic and reason for me.  I can now offer my recalcitrant patients not only the guarantee of better health and more fitful sleep, but also the promise of a few more birdies if they just give therapy a chance.