Elose April 2010

E-Lose

10 MOST COMMON MISTAKES AFTER WEIGHT LOSS SURGERY - FROM THE NATIONAL ASSOCIATION FOR WEIGH TLOSS SURGERY

Newsletter of the SBSG APRIL 2010

1st Mistake: Not Taking Vitamins, Supplements, or Minerals Every WLS patient has specific nutritional needs depending on the type of surgery you have had. Not only is it

a good idea to ask your surgeon for guidelines, but also to consult with an experienced WLS nutritionist.

Understand there is not a standard practice that all surgeons and nutritionists follow in guiding WLS patients.

So, it is important to do your own research, get your lab tests done regularly, and learn how to read the results.

Some conditions and symptoms that can occur when you are deficient in vitamins, supplements, or minerals

include:

Osteoporosis; pernicious anemia; muscle spasms; high blood pressure; burning tongue; fatigue; loss of

appetite; weakness; constipation and diarrhea; numbness and tingling in the hands and feet; being tired,

lethargic, or dizzy; forgetfulness, and lowered immune functioning.

Keep in mind, too, that some conditions caused by not taking your vitamins, supplements or minerals are

irreversible.

2nd Mistake: Assuming You Have Been Cured Of Your Obesity A ―pink cloud‖ or honeymoon experience is common following WLS. When you are feeling better than you

have in years, and the weight is coming off easily, it’s hard to imagine you will ever struggle again. But

unfortunately, it is very common for WLS patients to not lose to their goal weight or to regain some of their

weight back.

A small weight regain may be normal, but huge gains usually can be avoided with support, education, effort,

and careful attention to living a healthy WLS lifestyle. For most WLSers, if you don’t change what you’ve

always done, you’re going to keep getting what you’ve always gotten — even after weight loss surgery.

3rd Mistake: Drinking with Meals Yes, it’s hard for some people to avoid drinking with meals, but the tool of not drinking with meals is a critical

key to long-term success. If you drink while you eat, your food washes out of your stomach much more

quickly, you can eat more, you get hungry sooner, and you are at more risk for snacking. Being too hungry is

much more likely to lead to poor food choices and/or overeating.

10 Common Mistakes 1

Wellness Report 3

Life Better after Surgery ? 4

Recipe 5

Activity Calendar 6

A Tale of Sleep Apnea 7

About Us 16

Inside this issue:

Monthly Support Meetings

Support Group Meetings are held on the first

Saturday of every month. Meeting are from

2:30—4:00 PM at the Wascana Rehabilitation

Centre—Hostels 2& 3 on the second floor.

Annual General Meeting

May 29th 2:00 PM

Wascana Rehab Hostels 2&3

4th Mistake: Not Eating Right Of course everyone should eat right, but in this society eating right is a challenge. You have to make it as

easy on yourself as possible. Eat all your meals — don’t skip. Don’t keep unhealthy food in sight where it

will call to you all the time. Try to feed yourself at regular intervals so that you aren’t as tempted to make a

poor choice.

And consider having a couple of absolutes: for example, avoid fried foods completely, avoid sugary foods,

always use low-fat options, or only eat in a restaurant once a week. Choose your ―absolutes‖ based on your

trigger foods and your self-knowledge about what foods and/or situations are problematic for you.

5th Mistake: Not Drinking Enough Water Most WLS patients are at risk for dehydration. Drinking a minimum of 64 oz. of water per day will help you

avoid this risk. Adequate water intake will also help you flush out your system as you lose weight and avoid

kidney stones. Drinking enough water helps with your weight loss, too.

6th Mistake: Grazing Many people who have had WLS regret that they ever started grazing, which is nibbling small amounts here

and there over the course of the day. It’s one thing to eat the three to five small meals you and your doctor

agree you need. It’s something else altogether when you start to graze, eating any number of unplanned

snacks. Grazing can easily make your weight creep up. Eating enough at meal time, and eating planned

snacks when necessary, will help you resist grazing.

Make a plan for what you will do when you crave food, but are not truly hungry. For example, take up a

hobby to keep your hands busy or call someone in your support group for encouragement.

7th Mistake: Not Exercising Regularly Exercise is one of the best weapons a WLS patient has to fight weight regain. Not only does exercise boost

your spirits, it is a great way to keep your metabolism running strong. When you exercise, you build muscle.

The more muscle you have, the more calories your body will burn, even at rest!

8th Mistake: Eating the Wrong Carbs (or Eating Too Much) Let’s face it, revined carbohydrates are addictive. If you eat refined carbohydrates they will make you crave

more refined carbohydrates. There are plenty of complex carbohydrates to choose from, which have benefi-

cial vitamins. For example, if you can handle pastas, try whole grain Kamut pasta — in moderation, of

course. Try using your complex carbohydrates as ―condiments,‖ rather than as the center point of your meal.

Try sprinkling a tablespoon of brown rice on your stir-fried meat and veggies.

9th Mistake: Going Back to Drinking Soda Drinking soda is controversial in WLS circles. Some people claim soda stretches your stomach or pouch.

What we know it does keep you from getting the hydration your body requires after WLS–because when

you’re drinking soda, you’re not drinking water! In addition, diet soda has been connected to weight gain in

the general population. The best thing you can do is find other, healthier drinks to fall in love with. They are

out there.

10 MOST COMMON MISTAKES AFTER WEIGHT LOSS SURGERY—CON’T

Spring has finally sprung and it is the season for spring cleaning, yard work and getting out-side. In the spirit of spring, this month’s wellness activity is a walk in the park…with a twist! If you want to know what the twist is you will have to show up and participate! We will meet in the Wascana Lake Marina parking lot, just off Broad Street, at 2:30 PM, Sunday, April 18, 2010. Details of the event will also be posted on the SBSG Facebook page. Please let me know if you will be attending by email, at [email protected] or through the posted Face-book event.

Due to the low number of people who attended last month’s wellness activity, which was bowling and had a set pre-paid fee, we will not be going to Laser Quest this month. Perhaps, in the future, when we have more people regularly attending we can consider choosing pre-paid events such as Laser Quest and bowling. In the meantime, we will continue to choose activities that are free or have a small per person fee. The monthly wellness activity program was developed to provide SBSG members, non-members and their families an opportunity to get together, to get moving, to meet others indi-viduals and families dealing with the obesity. I encourage you to join us, bring your whole family, and get moving with us. If you have any suggestions for upcoming wellness activities please email Tanya, Provincial Wellness Coordinator, at [email protected].

10th Mistake: Drinking Alcohol If you drank alcohol before surgery, you are likely to want to resume drinking alcohol following surgery.

Most surgeons recommend waiting a year after surgery. And it is in your best interest to understand the con-

sequences of drinking alcohol before you do it.

Alcohol is connected with weight regain, because alcohol has 7 calories per gram, while protein and vegeta-

bles have 4 calories per gram. Also, some people develop an addiction to alcohol after WLS, so be very

cautious. Depending on your type of WLS, you may get drunker, quicker after surgery, which can cause

health problems and put you in dangerous situations.

If you think you have a drinking problem, get help right away. Putting off stopping drinking doesn’t make it

any easier, and could make you a lot sicker.

THE WELLNESS REPORT - TANYA STROM

mailto:[email protected]

mailto:[email protected]

Study Summary

Obesity is a growing problem in today's world, and

thankfully, is finally on the world’s health policy agenda.

Surgical weight loss intervention (SWLI) is expanding

exponentially to meet the global epidemic of morbid

obesity. A National Institutes of Health consensus

statement reports a 600% increase in the number of weight

loss operations between 1993 and 2003, exceeding the

120,000 surgical procedures performed in 2003.

The primary objective of a SWLI is to reduce the patient's

body mass and to minimize or eliminate the numerous

physiologic consequences of obesity. Indeed, it is often

uncontrolled hypertension, diabetes mellitus, or severe

arthritis that precipitates the patient's decision to pursue

SWLI. A SWLI is not just radical surgery; it is surgery that

influences multiple dimensions of the individual's life

including nonmedical components such as mobility,

nutrition, and socialization. It is, therefore, important to

learn about the impact of a SWLI on the patient's well-

being.

Morbid obesity has been found to have a greater impact on

physical functioning than on mental functioning. Obesity is

related to an increase in comorbidities including, but not

limited to, hypertension, osteoarthritis, lower back pain,

type II diabetes mellitus, and other conditions that increase

morbidity and mortality. Morbid obesity also has

psychosocial consequences including depression, low self-

esteem, prejudice, and social bias. Nurses are concerned

with the well-being of the whole person; therefore,

understanding the patient's perspective of the impact of a

SWLI on both the physical and emotional dimensions of life

is essential.

This study used a cross-sectional, nonexperimental survey

design to describe the individual’s self-perceived health-

related quality of life following a SWLI. A convenience

sample of 87 participants in a post-SWLI support group

associated with a hospital bariatric program completed

global quality of life and demographic surveys.

After statistical analysis, findings indicated that overall

quality of life was rated excellent or very good. However,

self-reports of health-related quality on social functioning,

vitality, and mental health were less positive, although

these findings appear not to be statistically significant. The

results of this study were compared with those of a

previous study of the general US population. The physical

dimensions measured by the scale for the sample

population were rated more positively than those of the

general public, possibly because the study patients

experienced a tremendous improvement in their physical

functioning as a result of surgery. However, when

compared with the general population, the mental function

subscale for the research sample was not as positive.

The investigators conclude that the findings of this pilot

study indicate the need for research about the meaning of

psychosocial and physiologic well-being in patients who

undergo SWLIs. They also remind nurses that to be holistic

in their care, a broader focus of support that includes

psychosocial strategies is necessary.

Viewpoint

I must admit that I was a little surprised by these findings. I

assumed that patients who had undergone a surgical

weight loss procedure that produced rapid and startling

losses in weight, and which alleviated many of their

physical symptoms, would find that social function, vitality,

and mental health would significantly improve as well. I

suspect I am not the only nurse who would make such an

assumption.

Although we are committed, as nurses, to the wholeness of

individuals, we may not always know how to practice in

holistic ways. This pilot study suggests that it is critical for

nurses to make sure that we evaluate the social and

emotional needs of patients who pursue SWLIs, but it is a

good take-home message for all types of patient situations.

Sometimes just identifying that patients are lonely, find it

difficult to mix with others, or lack the emotional energy to

leave the house and engage in activities can help the nurse

plan and implement simple educational strategies to

address these problems. The lessons of this study can be

extended well beyond the patient who has a SWLI.

IS LIFE BETTER AFTER SURGICAL WEIGHT LOSS ? - Marilyn W. Edmunds, PhD, CRNP

Recipe

Hot Boneless Buffalo Wings

Per serving (5 wings) 175 calories, 1.5g fat, 1,153 sodium, 14g carbs, 4g fibre, <1g sugars, 27g protein

Ingredients

8 ounces raw boneless skinless chicken breast, cut into 10 nuggets

¼ cup Fiber one bran cereal

1 ounce (about 14) Pringles light Fat Free BBQ potato chips

3 tablespoons Frank’s Redhot Original Cayenne Pepper Sauce

Dash onion powder

Dash garlic powder

Dash cayenne pepper

Dash black pepper and dash salt

Directions:

Preheat oven to 375 degrees

In a blender or food processor, grind Fiber one to a breadcrumb like consistency. Crush potato chips completely. In a

small dish, mix crushed chips with cereal crumbs. Add onion powder, garlic powder, cayenne, black pepper and salt. Mix

well.

Place chicken pieces in a separate dish. Cover with Frank’s hotsauce and toss to coat. Spray a baking sheet with non-stick

spray. Give each chicken piece a shake so it’s not dripping with sauce, and then coat evenly with crumb mixture. Lay

crumb covered nuggets on the baking sheet. Bake in the oven for 10 minutes. Flip nuggets over and bake for 10 more

minutes, or until outsides are crispy and chicken is cooked throughout.

Makes two servings.

ACTIVITY CALENDAR

2010 Monthly Activity Schedule*: (*The start time is 2:30 pm unless otherwise posted in the Facebook event notice.

Each event notice will be posted 7-10 days prior to the event date.)

Jan 17 Apr 18 July 18 Oct 17

Feb 21 May 16 Aug 15 Nov 21

March 21 June 20 Sept 19 Dec 19

Activities booked for the next couple months are:

April 18: Walk in the Park 2:30 – 4:30 PM Meet in the Wascana Lake Marina parking lot

NCE UPON A TIME, 48-year-old Stan Richards—affectionately known as “Tree” because of his large neck—found himself waking up with a head-ache every morning. Already tired before the day got started, he’d nod off while driving to work and doze at meetings. He started taking an over-the-counter sleep aid, but he still felt like he never got any sleep. It was starting to affect his concentration…not to mention making him grumpy! So he told his wife, Jennifer, his tale of woe, and she said, “You snore so loudly when you sleep on your back that you wake me up, and you’re always tossing and turning. Sometimes it sounds like you stop breathing for a few seconds. Do you think that has something to do with it?” Tree pondered his wife’s words. He thought she might be on to something, but what? Determined to uncover the origin of his plight, Tree began readying himself for an impor-tant journey—a quest, if you will.

A TALE OF SLEEP APNEA MARY DUGAN, APRN,BC, MSN Assistant Professor • Graceland University • Independence, Mo.

Published in Nursing Made Incredibly Easy May/June 2007

Sleep apnea affects about 18 million adults in the United States, but as many as 90% of

them are undiagnosed—how’s that for a wake-up call? At the least, this common disorder

can disturb your patients’ sleep; at its worse, it can lead to serious health problems.

Learning about sleep apnea will help you assist your patients in catching those much

needed ZZZs and reduce their risk of suffering long-term effects. Think of it as a bedtime

story with a message…

NCE UPON A TIME, 48-year-old Stan Richards—affectionately known as “Tree” because of his large neck—found himself waking up with a head-ache every morning. Already tired before the day got started, he’d nod off while driving to work and doze at meetings. He started taking an over-the-counter sleep aid, but he still felt like he never got any sleep. It was starting to affect his concentration…not to mention making him grumpy! So he told his wife, Jennifer, his tale of woe, and she said, “You snore so loudly when you sleep on your back that you wake me up, and you’re always tossing and turning. Sometimes it sounds like you stop breathing for a few seconds. Do you think that has something to do with it?” Tree pondered his wife’s words. He thought she might be on to something, but what? Determined to uncover the origin of his plight, Tree began readying himself for an impor-tant journey—a quest, if you will.

So what do you think is happening with Tree? If you guessed sleep apnea, you’re probably right. Let’s take a closer look.

An endless cycle Apnea literally means without breath. Sleep apnea is defined in adults as the cessation of breathing during

sleep that lasts for at least 10 seconds. Each apneic event sends a signal to the brain that arouses the

person from sleep so he’ll resume breathing. This cycle of arousal, sleeping, cessation of breathing, then

arousal again prevents the rapid eye movement (REM) phase of sleep—the deep sleep needed for ade-

quate rest. But the person with sleep apnea may not even realize his sleep is being disrupted.

In this article, I’ll take a look at why sleep apnea occurs, who’s at risk, and what to look for in your pa-

tients. Then I’ll discuss diagnostic testing and treatment options, and let you know what to teach your pa-

tients so they can sleep more soundly. All with a little help from Tree, of course.

A TALE OF SLEEP APNEA— CON’T

I’ll huff and I’ll puff… There are three different types of sleep apnea—obstructive sleep apnea (OSA), central sleep apnea (CSA), and mixed-complex sleep apnea—and they can be classified as mild (5 to 15 apneic events per hour), moderate (15 to 30 apneic events per hour), or severe (more than 30 apneic events per hour), depending on the number of times per hour that breathing stops (commonly called the apnea-hypopnea index or the respiratory disturbance index). Mild apnea is called hypopnea, or a 50% decrease in respiratory volume for more than 10 seconds.

OSA is the most common type of sleep apnea. Normally, the loss of muscle tone that occurs when a person sleeps may cause occasional mild snoring, but it doesn’t dis- rupt air flow. In patients with OSA, the relaxation of the soft tissues that surround the pharyngeal airway, including the soft palate, tongue, tonsils, mucosa, muscles, epiglottis, fat, and blood vessels of the neck, becomes severe enough to cause complete collapse of the airway, totally obstructing air flow (see Understanding obstructive sleep apnea). Respiratory effort is observed, but air flow is restricted in this type of apnea.

The patient with OSA may have an abnormally large amount of soft tissue surrounding the bony structures of the pharyngeal airway, which include the mandible, nasal turbinates, hard palate, hyoid, and cervical vertebrae. This may be caused by increased centrally located fat in the upper body and neck, so a patient with central obesity is more likely to develop OSA. He may also have an abnormality in the bone structure itself, which could shift the soft

tissues toward the posterior. For example, a patient who has hypoplasia (incomplete development) or

posterior displacement of the maxilla and mandible will experience space reduction in the oropharyngeal cavity if the soft tissues are displaced to the posterior, which decreases pharyngeal diameter. Displacement of the hyoid bone can also contribute to lumen narrowing in the OSA patient, and hypertrophy or edema of the soft tissues surrounding the area may add to the narrowing. An abnormally large uvula, large tonsils, or large adenoids may also obstruct the airway.


In CSA, the brain fails to communicate with the respiratory muscles, resulting in cessation of breathing with no observable respiratory effort. This communication breakdown is usually caused by diseases affect-ing the neurologic system and the heart. Hypoxia of the medulla oblongata may also be a factor. The use of alcohol and sedatives can contribute to CSA.

Mixed-complex sleep apnea, as the name suggests, is a combination of the two etiologies.

You leave me breathless What types of pathologic conditions occur in patients with sleep apnea? Let’s take a closer look. Sleep apnea results in decreased alveolarventilation, regardless of the type. This causes hypoxia and hypoxemia, especially in patients with chronic pulmonary disease. A patient’s oxygen desaturation level de-pends on two things: his ventilation during sleep and his oxygen saturation value before sleeping. The series of hypoxemic events creates a stress condition that results in the activation of the sympathetic nervous system and a decreased level of vasopressin (antidiuretic hormone). This causes changes in fluid volume that lead to chronic changes in the renin-angiotensin-aldosterone system. Because volume receptors are stimulated during apnea, a patient with sleep apnea will have decreased renin and aldosterone levels. This causes over-secretion of renin during the day in reaction to a decreased level at night. Hypoxemia may also cause endothelial dysfunction and increased vascular oxidative stress. This could result in the genera-tion of free radicals; higher levels of C-reactive protein and interleukin-6; and increased platelet activation. However, the exact mechanism of damage to the endothelium isn’t completely understood

a night!

The combination of sleeping in the horizontal position and the pressures of greater inspiratory effort increases venous

return to the heart. The increased preload in the right side of the heart, in turn, increases pulmonary blood flow. Be-

sides these hemodynamic changes, alveolar hypoxia causes vasoconstriction and proliferation of smooth muscle

cells, resulting in vessel wall remodeling. This combination contributes to pulmonary hypertension, which begins as

an intermittent condition and may become chronic over time.

Hypertension in patients with apnea is well documented. Normally, blood pressure falls during sleep due to de-

creased sympathetic activity, which causes decreased levels of adrenalin. Many patients with sleep apnea don’t ex-

perience this lowering of the blood pressure. In fact, they experience two periods in which blood pressure rises: once

during the apneic event and again when ventilation is restored.

Throughout a night of apneic events, the body, including the heart, experiences hypoxia, acidosis, and hypercapnia

(in creased levels of carbon dioxide). This potentially deadly trio of conditions predisposes the patient to angina and

myocardial infarction. The coronary arteries often spasm in these conditions, but even without spasm, the low arterial

oxygen content can lead to ischemia. The patient may also experience periods of bradycardia due to stimulation of

the parasympathetic nervous system brought on by apnea. This will change to rebound tachycardia during the hyper-

ventilation phase because the sympathetic nervous system has been stimulated. More research is needed to discover

the exact mechanism of heart rhythm disturbances in patients with sleep apnea, but because these patients are at in-

creased risk for sudden death, treatment for sleep apnea could liter ally be a lifesaving endeavor.

The left ventricle of the heart may also be affected; OSA can exacerbate left ventricular failure in patients who have

heart disease. Although the mechanism isn’t fully understood, it’s thought that the apneic event increases negative

thoracic pressure, which increases left ventricular afterload.


Sleep apnea and stroke also have a complex relationship. Stroke may cause paralysis, which contributes

to the development of OSA immediately after the incident. Even patients with mild sleep apnea have a

documented higher incidence of stroke.

So which patients are most at risk for sleep apnea? Does Tree fit the bill? Let’s take a look at that next.

What’s behind fewer ZZZ’s

Risk factors for sleep apnea include:

family history

obesity

large neck circumference

abnormal anatomy (recessed chin, abnormal up per airway

structures, large tonsils or adenoids, cranio facial anomalies,

or nasal obstruction)

age over 40

male gender

menopause

African-American, Pacific Islander, or Mexican ethnicity.

this just in… It’s no secret that obstructive sleep apnea (OSA) can affect children as well as adults. Results from a recent study of 156 children age 3 to 5 di-agnosed with OSA found that these children had an average of 8.1 ap-neic events per hour. They also had 40% more hospital visits and 20% more repeat visits from the first year of life to the date of OSA diagnosis. And they used more respiratory in-fection drugs. Researchers suggest that early diagnosis and intervention are key.

Conditions that can cause sleep apnea, or may be exacerbated by it, include atrial fibrillation, diabetes, hyperten-

sion, hypercoagulability, vascular inflammation, hypothyroidism, and atherosclerosis.

The use of central nervous system (CNS) depressants, such as muscle relaxants, analgesics, and sedatives, as

well as alcohol, may also cause or worsen sleep apnea by further relaxing the airway muscles and reducing the

respiratory drive. Smoking can cause inflammation, swelling, and narrowing of the upper airway. And sleeping

on the back may also be a factor because gravity increases the likelihood that the tongue will occlude the airway

or muscles and tissues will collapse.


Tossin’ and turnin’ all night

The most noticeable signs of sleep apnea are loud snoring and observed periods of apnea. Other signs and

symptoms that may indicate sleep apnea include:

tossing and turning or fitful sleep

daytime drowsiness after adequate time spent sleeping, including falling asleep at inappropriate times

(such as while driving)

headache on awakening

gastroesophageal reflux

chest pain

decreased libido

impotence

personality changes

depression

hypersomnolence (excessive need for sleep)

memory loss

concentration changes, such as limited attention span

poor judgment

weight gain.

The loss of deep sleep can also lead to poor work performance and decreased reaction time while driving,

which increases the patient’s risk of getting into an automobile accident.

The long-term consequences of sleep apnea are still being studied, but patients with sleep apnea seem to be

at increased risk for cardiovascular disease, cardiac dysrhythmias, sudden death, cerebrovascular disease,

and stroke.

Before we go any further, let’s check in with Tree. He has set off for a land not-so far away (a.k.a. his health

care provider’s office), where he speaks with a Wise Woman (a.k.a. the nurse) about his troubles. She asks him

many questions that illuminate his suffering. Tree is certain that soon, he’ll have the answer he seeks.

Love to watch you sleep

If you suspect your patient has sleep apnea, first take a health history and perform a physical exam.

Ask him the following questions from the American Sleep Apnea Association:

Are you a loud, habitual snorer?

Do you feel tired and groggy when you wake up?

Are you often sleepy during the day or do you fall asleep quickly (nod-off)?

Have you been observed choking, gasp ing, or holding your breath during sleep?

If your patient answers yes to any of these questions, he may have sleep apnea. You may also want to

use a sleep questionnaire (see The Epworth Sleepiness Scale). Also, make sure you ask someone in

the patient’s household if the patient snores and if he seems to stop breathing and restart with a jolt

while sleeping.


During the physical exam, you may note central obesity, a short obese neck, erythematous pharyngeal mucosa, a

thick soft palate, or enlarged tonsils. Chronic diseases may be present, such as hypertension, coronary artery dis-

ease, chronic fatigue syndrome, diabetes, or various neuromuscular diseases. Based on his signs and symptoms and

physical exam, your patient will be referred to a sleep specialist. He may need to undergo sleep studies to positively

diagnose sleep apnea and determine its severity. Let’s take a look at the two most common procedures. Polysomno-

graphy is an overnight procedure, usually

performed in a sleep lab, which records eye movement, muscle activity, heart rate, respiration, blood oxygen levels,

airflow, and brain activity while the patient sleeps. The patient has electrodes attached to

his scalp, chin, and the outer edge of his eyelids. A cannula is placed in his nose to measure airflow, and pulse oxi-

metry is used to measure his oxygen level. The data are then collected and evaluated. Because an overnight sleep

study is expensive, a portable home monitoring system may be used first. If the

patient’s home sleep study is abnormal, he may then be scheduled for an overnight study in a sleep lab.

A multiple sleep latency test measures the time it takes for the patient to fall asleep. During the test,

the patient is given several chances to fall asleep throughout the day when he would normally be awake. If the pa-

tient falls asleep in less than 5 minutes, he probably has a sleep disorder. This test can also measure the amount of

excessive daytime sleepiness the patient experiences, and it can be used to

rule out sleep disorders other than sleep apnea, such as narcolepsy.

After a night in the sleep lab, it turns out that Tree has moderately severe OSA, probably caused by his large neck

circumference and exacerbated by sleeping on his back and taking an over-the-counter

sedative before bed. He now has a name for his dilemma, but he still needs to know how to treat it

before he can end his quest.

Mr. Sandman, bring me a dream

The severity of the patient’s apnea (the number of ap neic events per hour) is used to determine which treatment

will be most effective. Treatment for mild sleep apnea is usually conservative and includes lifestyle changes and,

possibly, an oral appliance. Continuous positive airway pressure (CPAP) and surgery are treatment options for

moderate to severe sleep apnea. Supplemental oxygen or medication may be used as adjunctive treatment in some

cases. Let’s take a closer look.

Mild apnea

A change in lifestyle may be all that’s needed if your patient has mild sleep apnea. These changes include:

Weight loss. Diet and exercise (30 to 90 minutes, 5 to 6 days a week) may help decrease neck circumference

and the central fat deposits that press on the diaphragm. A weight loss of just 10 pounds can be effective in a pa-

tient with mild sleep apnea; however, it may be hard for the patient to exercise because of excessive tiredness, and

weight loss might be difficult because he may be eating to stay awake. If this is the case, other treatment options

can be utilized while the patient works toward the weight loss goal.


Positional therapy. Elevating the head of the bed 30 degrees tends to bring the tongue forward, which

will help maintain the airway, and sleeping on the side will keep the tongue from falling to the back of the

throat. The U.S. Food and Drug Administration has approved a pillow to reduce snoring and mild sleep ap-

nea, which positions the neck so the airway is more likely to stay open

Avoiding alcohol and other CNS depressants before bed. Alcohol can interfere with the REM cycle

and exacerbate airway obstruction because it depresses the CNS and relaxes the pharyngeal muscles. For

this reason, the patient should avoid drinking alcohol or taking CNS depressants within 6 hours of going to

bed.

Practicing good sleep hygiene. The patient should spend adequate time in bed— most adults need 7 to

8 hours of sleep a night. He should also create a bedtime routine by going to bed and waking up at the same

time every day. He may also want to avoid caffeine after lunchtime and excess fluids 4 hours before going

to bed to prevent nocturia.

An oral appliance can be used to keep the patient’s airway open; however, the effectiveness of oral appli-

ances is inconsistent. They’re most effective for treating mild sleep apnea in non obese patients who can’t

tolerate CPAP. The most common oral appliance is the mandible advancement device, which pushes the

lower jaw forward. A tongue retaining device can be used to prevent the tongue from falling back over the

airway. A patient who’s being considered for an oral appliance should undergo a sleep study to assess the

severity of the sleep apnea, according to the American Sleep Apnea Association. The patient’s insurance

company may not pay for an oral appliance, and it may be difficult for the patient to find a dentist who can

fit the device.

Moderate to severe apnea

CPAP is the first-line treatment for moderate to severe sleep apnea, and it’s the most effective nonsurgical

treatment for OSA. Through a mask that fits tightly over the patient’s nose while he sleeps, a CPAP

machine uses a fan to deliver positive pressure ventilation at a pressure high enough to keep the airway

open (3 to 20 cm of water); this eliminates apneic events (see Picturing CPAP ). Most patients require a

pressure of 6 to 12 cm of water to reduce apneic events to 10 per hour; however, patients with thicker necks,

like Tree, may need a higher pressure level. The optimal pressure for the patient is determined during the

sleep study.

Because CPAP isn’t a cure, it must be used whenever the patient sleeps, which can cause reduced adherence

to therapy. CPAP may be cumbersome for the patient, but most complaints can be addressed. For example,

if the patient finds the mask irritating, nasal pillows can be used instead, or the mask and nasal pillows may

be used on alternate nights. Masks of various sizes, shapes, and materials can also be tried. Some patients

complain about the rush of air pres sure during CPAP. If this is the case, bi-level positive airway pressure

(BiPAP) is an alternative. With BiPAP, inspiratory pressures are set higher than expiratory pressures. The

use of a nasal spray or a humidifier attached to the CPAP machine may increase comfort if the patient ex-

periences nasal irritation or congestion. If the patient finds the machine to be too noisy, earplugs may be

helpful.


Surgery to correct abnormalities of the soft tissue or bone structure that are obstructing the patient’s airway

may be performed if other treatments are ineffective.

Surgical options include:

Uvulopalatopharyngoplasty. During this procedure, which can be done conventionally or as a laser-

assisted procedure, part of the uvula and excess soft tissue on the palate and posterior pharyngeal wall are

removed. Although it’s the most common surgery used to treat apnea, it’s only effective in about 25% of

patients. This has led to alternatives, such as the uvulopalatal flap procedure (suspension of the uvula toward

the hard-soft palate junction after limited resection of the uvula and soft tissues) and pharyngoplasty (removal

of the soft tissues with the uvula intact).

Nasal surgery. This procedure is used to remove obstructions, such as polyps, or correct abnormalities,

such as a deviated septum, in three nasal regions: the nasal valve, the septum, and the turbinates. Nasal

surgery can improve airway patency and reduce the need for CPAP.

Maxillomandibular advancement. The most successful surgery used to treat sleep apnea, this procedure

enlarges the entire upper airway by expanding the bones that surround the airway. The maxilla and mandible

are stabilized with titanium plates and displaced up to 10 to 12 mm. A less invasive procedure, maxilloman-

dibular expansion (widening the maxilla and mandible with distractors over several months) may be used as

an alternative.

Genioglossus and hyoid advancement. The result of the genioglossus advancement procedure is to

place tension on the tongue muscles, which limits posterior displacement during sleep. The result of the hyoid

advancement procedure is to reposition the hyoid bone, which expands the airway. These procedures are

usually performed together and may be used in conjunction with uvulopalatopharyngoplasty

Tracheostomy. This last-resort procedure may be performed in severe cases. It’s usually a temporary

measure, but a permanent tracheostomy may be used in patients who are morbidly obese or those who have

significant craniofacial abnormalities. The tracheostomy tube can be plugged during the day and opened at

night.

Rarely used as a primary treatment, supplemental oxygen may reduce the number of apneic events in some

patients when other treatments are unacceptable. Patients should be evaluated for retention of carbon dioxide

if they suffer from a chronic lung condition because supplemental oxygen may decrease their respiratory

drive.

Some medications may be used in addition to other treatment.

These include:

protriptyline (Vivactil), a tricyclic antidepressant that decreases the amount of REM cycles. Apnea

usually occurs during the REM cycle, so decreasing the amount of cycles reduces the number of apneic

events. This drug can also treat possible depression associated with sleep deprivation.

modafinil (Provigil), an approved treatment for narcolepsy and hypopnea that may improve daytime

sleepiness. Its mechanism of action isn’t clearly understood, but it’s thought to stimulate the CNS in much the

same way as amphetamines.

respiratory drive stimulants, such as medroxyprogesterone, acetazolamide (Diamox), clomipramine, and

theophylline, can be used to treat CSA.


Sweet dreams are made of these

Sleep apnea contributes to a vast number of problems, ranging in severity from a patient who’s feeling a little

grumpy to the patient who falls asleep for microseconds and runs a red light. It predisposes, co-creates, and

exacerbates a number of medical conditions that we see in the hospital every day. So how can we help these

patients?

The most effective thing you can do is recognize the overt symptoms of sleep apnea. When you hear a patient

complain of fatigue, especially after supposedly sleeping all night, explore the possibility that he has sleep

apnea. Some of us might think thyroid problems or anemia when we hear fatigue. These problems are easily

explored with lab tests; if the results are normal and the patient has central obesity or other risk factors for

sleep apnea, be sure to get more history and check to see whether he’s already suffering from the cardiovascu-

lar, cerebrovascular, or endocrine changes associated with sleep apnea.

Teach your patient with sleep apnea about lifestyle changes, good sleep hygiene, and available treatment op-

tions and encourage him to stick with a treatment program. With proper treatment, he can stop the cycle of

poor rest and too much caffeine and too many carbohydrates to stay awake before it spirals out of control.

What about Tree?

Based on his sleep study results, his health care provider decided that Tree would ben efit most from lifestyle

changes, including weight management, and a CPAP machine. Tree was told to stop taking the over-the-

counter sleep aid and to avoid alcohol use before bed. He was also encouraged to sleep on his side and to de-

velop a bedtime routine. He was given instructions on how to use the CPAP machine and was told adjust-

ments could be made during periodic reevaluations if the machine was uncomfortable.

Armed with information and with his new friend—the trusty CPAP machine—in tow, Tree’s odyssey was

almost at an end.

He returned to his humble home and after a few weeks, he was sleeping soundly through the night. Sleep ap-

nea was successfully vanquished, and he and Jennifer lived happily ever after.

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Elose April 2010

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