CSSC July Edition By Nalaka de silva
Sleep is a complex physiologic status of the body. Approximately an average of eight hours of sleep with good sleep architecture is needed for both the brain and body to rejuvenate fully. Anything that affects this regularly will lead to poor sleep and as a result poor health consequences.
Sleep architecture consists of lignt, slow wave sleep and REM sleep. Slow wave sleep and REM sleep should account for about half of the sleep cycle.
Stage 1 sleep is light sleep and non-restorative. Stage 2 is the longest phase of sleep and not as restorative slow-wave sleep. Slow wave sleep is considered to be the deepest stage of sleep and the most restorative. During this stage, the heart rate and blood pressure are generally at its lowest. Then there is REM sleep which more commonly occurs during early hours of the morning. In REM body is paralysed, apart from the muscles of respiration. The loss of muscle tone is a natural state that occurs to avoid acting out our dreams. During the REM phase of sleep, the airway muscles also lose tone except for the diaphragm. The shallowness of breath, along with the lack of muscle tone leads to obstruction of breathing or apnoeas.
The aim of the above discussion is not for me to dwell too much on sleep physiology, but to explain how complex the sleep architecture is and why it has to be good for both the brain and body to rejuvenate. Obstructive sleep apnoea is only one type of sleep-disordered breathing. There are many other conditions that affect sleep. At times patients are affected by more than one type of sleep disorder. For example, one may have sleep apnoea and narcolepsy together. Both these conditions lead to sleepiness but treatment for each condition is entirely different.
The most knowledgeable in the field of sleep physiology are Respiratory Physicians. They undergo the most training on sleep physiology and related disorders. Dr Juan Mulder, who is a Respiratory Physician has trained further in this field with a particular interest in sleep disorders, especially complex disorders such as insomnia, parasomnia, narcolepsy, restless legs syndrome and sleep apnoea. Given their knowledge sleep physicians are also the best at evaluating sleep architecture and identifying sleep disorders. This can be done through various methods; however, the gold standard is a sleep study. A sleep study can measure up to ten parameters including nasal airflow, chest movement, brain waves, cardiac rhythm, sleep position and many more. It can be done at home or in a lab. Once the sleep study has been performed; one needs to look at all aspects of the sleep, types of dysfunction that occur and to see if there is a clear explanation to the presenting symptoms of the patient.
Once diagnosed with sleep apnoea with a sleep study, the ENT surgeon is the best trained in anatomy to identify the site of obstruction. Airway obstruction doesn’t just occur at the oral cavity but can occur in multiple locations along the airway. This can be assessed in several ways. One method is doing endoscopic examination of the airway by an ENT surgeon from the nose through to the voice box with sedation in the operating room. This is called Drug InducedSleep Endoscopy (DISE). Another method is doing this evaluation with local anaesthesia and get the patents gently to exhale in order to identify where the main collapse occurs. ENT surgeon can then determine how likely the degree of destruction can be improved through surgery. Once assessed correctly They also have the technical ability to achieve success with minimally invasive procedures.
When evaluated by both Ear , Nose & Throat specialists & Respiratory Physicians together, it is possible to put all the information together during one clinic visit. First, we evaluate & understand precisely what’s happening with ones sleep through a sleep test done before the clinic. Second, ENT specialist & physician will make a joint endoscopic evaluation to determine what structural anomalies are causing the apnoea. By combining the skills and knowledge of both specialists an unbiased opinion on what is happening and what could be done to assist the patient is made. Some options are non-surgical and some are very modern evolving surgical options with proven success rates. The joint effort will enable the patient to know the exact reason for their condition. Once the evaluations are made, the two specialists along with the patient carefully consider & look at the treatment options available. Through this method of combining specialist clinic, a greater majority of patients are more likely achieve a successful outcome through a single modality or a combined treatment modality when necessary.
Finally, once a patient is treated, it is paramount that they use their new found energy and remain well long term. There is sufficient data to show that the majority of the patients can gain weight after successful treatment as they spend fewer calories tossing and turning during sleep. We have recently added to our team of specialist, a health coach. The health coach is experienced in being able to provide a post treatment patient of sleep apnoea with practical, tailored exercise programme, insight into the diet and assist with mindful living for long term benefit. The patient and health coach will be able to meet at intervals for assessments and fine tuning. We hope to have Gamu join us, a national level ex-basketball player, who now is now a qualified physiotherapist and pilates teacher. She also has a wealth of knowledge on diet and mindful living and will be able to guide those who are at a high risk of weight gain and relapse with a programme to enhance the effects of the sleep apnea treatment provided at the clinic.
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