Sleep and Sleep Apnea in the COVID19 Era
As a sleep technologist, you likely know COVID-19 has disrupted many people's lives, and can cause a dilemma for individuals struggling with sleep apnea. In the COVID-19 era, sleep is more important than ever for your patient’s physical and mental health and their immune systems.
Here, and through his YouTube channel, Dr. Bob Ledda, M.D., a health and wellness physician at Community Health & Wellness Center, shows there is scientific evidence pointing to the association between metabolic diseases and poor sleep. Dr, Bob, who is a partner at Cenegenics® Alaska, talks about the physiology and long-standing medical consequences of sleep apnea, what the various treatment options are, and what supplements he suggests that scientific studies have shown to improve sleep.
This is essential information, as recapped from Dr. Bob's video, for you to know about, and potentially discuss with your sleep apnea patients, more so now during the COVID-19 pandemic than perhaps any other time in our history.
Why Is Sleep So Important?
Sleep is important because it can have an impact on the following factors:
1) Attention and Memory
Human and animal research suggests the quality and quantity of sleep have an immense effect on memory and learning. Studies suggest sleep helps memory and learning in a couple of ways:
- Sleep-deprived individuals can't focus attention optimally, so they can't learn effectively.
- Sleep plays a role in memory consolidation, which is important for learning new information.
2) Daytime Sleepiness
Obstructive sleep apnea (OSA) commonly causes daytime sleepiness for millions of people in the U.S. More and more adults and children are struggling with daytime sleepiness caused by sleep apnea these days.
Because there's an interruption in breathing, there's an interruption in sleep which can lead to sleepiness during:
- Other activities
Your patients may think they’re decent sleepers since they can sleep anywhere, anytime. But, when they’re falling asleep at work or in traffic, it's obviously not ideal. Individuals with sleep apnea have far more vehicle accidents than individuals who don't have sleep apnea.
Research shows even partial sleep deprivation has a substantial impact on mood. According to researchers from the University of Pennsylvania, subjects limited to just 4.5 hours of sleep for seven days reported feeling more:
- Mentally exhausted
After resuming normal sleep, the subjects reported a drastic improvement in their mood.
4) Increased Risk of Disease
If you're not sleeping well, you don't produce enough of the healthy hormones, growth hormones, and testosterone. During sleep, the body is resetting itself, but growth hormone specifically is secreted during slow wave or deep sleep. Low levels of this hormone lead to different types of diseases.
Poor sleep can lead to increased risk of disease such as:
Adequate sleep supports the immune system, reducing the risk of infection, and improving the outcome for fighting a virus, like COVID-19. Sleep deprivation, on the other hand, weakens the body’s defense system, making people more susceptible to contracting a virus, like COVID-19. And, some of the above medical conditions, such as obesity, diabetes, and heart disease are risk factors for developing serious complications of COVID-19.
How Much Sleep Is the Right Amount?
So, how much sleep do we need? Most people have their own ideal number of hours of sleep, and with some experimentation, they can figure out what works best for them. However, looking at the bell curve, most individuals do best with about seven to seven and a half hours of sleep.
Teenagers need around 11 to 12 hours of sleep. Babies are still growing, so their sleep needs are different too.
Barriers to Sleep: Obstructive Sleep Apnea
One of the most significant barriers to sleep is obstructive sleep apnea. And, an interesting fact about OSA relates to how it affects genders. Numerous population based studies show OSA affects men more so than women.
Many pathophysiological differences show the reason why men are more prone to OSA than women. While the precise mechanisms aren't known, some factors thought to play a role are:
- Upper airway anatomy
- Breathing control
Symptoms of OSA
The primary OSA symptoms include:
- Daytime sleepiness
- Attention and memory deficits
- Bad mood
- Metabolic diseases
- Respiratory arrest during sleep (stop breathing during sleep)
Quick Check (Sleep Cycle App)
There are numerous free apps that show the phases of sleep that sleepers experience during the night. These can be loaded on smartphones, and provide data such as a sleep score.
Some lab clues are:
- Elevated inflammatory markers
- Elevated blood sugar (sign of type 2 diabetes)
- High fasting insulin levels
- High fasting blood sugar
- Low IGF 1 levels (represent growth hormone levels)
- Elevated red blood cell count (when you're chronically oxygenating poorly from things like sleep apnea or chronic obstructive pulmonary disease the body, in order to transport more oxygen, will develop more red blood cells)
Formal Check-Full Night Polysomnography (AHI)
Doctors often prescribe Continuous Positive Airway Pressure (CPAP) based on a sleep study diagnosis. The goal is to improve breathing during sleep.
But for sleep technologists to determine the severity of OSA at baseline and to see if CPAP or other relevant treatments are working sufficiently and track their effectiveness, they need to measure this through a full night sleep study to determine the patient's Apnea Hypopnea Index (AHI). They use the AHI to classify how severe sleep apnea is. They also use this same classification to evaluate how well the CPAP machine or other treatment is working.
They often present this measurement within a sleep study report context. It's the number of times each sleeping hour that the patient’s tongue or throat soft palate (upper airway) completely or partially collapses, causing apnea or hypopnea, which leads to a brief awakening or arousal from sleep and/or a drop in levels of blood oxygen.
Weight Loss Vs. Anatomy
Weight can be a predisposing factor of sleep apnea, and we have learned obesity is a risk for more severe complications related to COVID-19. But like most other things in medicine, sleep apnea is a combination of genetics and behavior. That is, some people can get pretty heavy and never develop sleep apnea, and some can have significant sleep apnea at their ideal body weight.
What Is So Bad About OSA?
There are a number of reasons why OSA can spell bad news, including:
1) Cardiovascular and Metabolic Problems
There's a direct association between undiagnosed sleep apnea and cardiovascular and metabolic health. Various studies have shown a link between sleep apnea and issues like:
- Type 2 diabetes
- Heart attacks
- A shortened lifespan
Obesity, for one thing, is common in patients with sleep apnea, and it increases the risk of stroke, diabetes and heart attack. Often obesity is the primary culprit of these conditions.
But, not all individuals who have sleep apnea are obese. And, evidence shows an independent link between diabetes and sleep apnea.
2) High Blood Pressure
If you're already suffering from high blood pressure, sleep apnea can cause it to become worse. When waking up frequently in the nighttime, the body becomes stressed. This can cause the hormone systems to go into overdrive, boosting blood pressure levels. Also, the blood oxygen level drops when you're having issues with breathing, which can contribute to the issue.
3) Adult Asthma
While science hasn't shown a direct link to OSA, individuals who receive treatment for sleep apnea are finding they experience fewer asthma attacks.
And, as you've learned, individuals with a weakened immune system have a greater risk of becoming severely ill from COVID-19. They might also stay infectious longer than other people with the virus.
Treatment for Obstructive Sleep Apnea
Some OSA treatments include:
Sometimes sleep apnea can improve simply by sleeping on your side.
For individuals suffering from mild to moderate OSA, oral mandibular advancement devices, appliances that advance the lower jaw forward, or dental appliances, that can keep the tongue from obstructing the throat are available. Devices and appliances like these keep the airway open while you're sleeping.
The most effective OSA treatment is CPAP, which provides continuous air pressure to the upper airway during the night, keeping the airway open while you're sleeping. A CPAP machine is used for this treatment and consists of several primary parts:
- A mask worn during sleep that you fit over the mouth and nose or just the nose, held in place with straps
- Tubing connected to the CPAP machine
- A motor that blows room air
CPAP devices are lightweight, small, and relatively quiet. Patients can take them with them when traveling.
There are various types of sleep apnea surgery. Surgery might involve a multi-step process combining more than one procedure. CPAP might still be required even if surgery successfully decreases sleep apnea severity.
Surgical options include:
- Uvulopalatopharyngoplasty (UPPP)
- Radiofrequency Volumetric Tissue Reduction (RFVTR)
- Septoplasty and Turbinate Reduction
- Genioglossus Advancement
- Hyoid Suspension
- Midline glossectomy and lingualplasty
- Maxillomandibular osteotomy (MMO) and advancement (MMA)
- Weight loss surgery
Stress can affect life in various ways, including having a negative effect on the quality of sleep. Think about it — you're lying in bed, feeling anxious and worried, making it near impossible to quiet the mind and relax enough to fall asleep.
Reduction or Elimination of Stimulants and Alcohol
While alcohol can make you feel sleepy and might help some fall asleep at bedtime, it can actually disrupt sleep later on during the night. During the second half of the night, after someone has drunk alcohol, their sleep can be disrupted with more frequent awakenings.
Improved Sleep Hygiene
The impact of poor sleep hygiene can be experienced in various ways during day-to-day life and is just as harmful as other sleep conditions. This could include:
- Low energy
- Lack of motivation
- Overall tiredness
- Lack of drive
- Poor decisions
- Mood changes
- Trouble concentrating
- Memory problems
What are Simple Sleep Remedies?
Some simple sleep remedies include:
- A dark room: Darkness and light are strong cues that inform the body it's time for rest or time to be productive. Therefore, it's no surprise that when you have light seeping in from the window or some other type of light in the bedroom, it can affect sleep quality. By being a little creative, individuals can use their body's natural sensitivity to light to their advantage. Suggestions are to try incandescent, low-wattage lamps in the bedroom that can help one to start winding down several hours before it's time to sleep.
- Avoid caffeine before bed: It’s recommended to limit caffeine intake at least four hours before bedtime. This is because caffeine could make it harder to fall asleep and lead to lighter sleep.
- Brief napping: Naps are effective, but make sure they're brief. Long naps seem to be associated with increased mortality.
- Exercise: Exercise is fine, but not before bed. Exercising is great for the mind and body and can help you obtain quality sleep at night. But, for some individuals, working out too late in the day can disrupt their ability to rest at night.
- Supplements: You may want to try a "supplements and sleep" remedy. You can try supplements such as: Magnesium 500mg, Melatonin 3mg, L-Tryptophan 1gm, Gaba 1gm, Relora patented blend of plant extracts, or L-Theanine 50mg.
With the unprecedented changes going on these days so quickly, it's not surprising sleep's importance is flying under the radar. However, as people are adjusting to stay-at-home orders and trying to stay healthy during these times with the spread of COVID-19, staying focused on sleeping well can provide your patients with tremendous benefits.
Remember, sleep is crucial to physical health as well as immune system functioning. Whether your patients were experiencing sleep issues before COVID-19 or they’re beginning to experience them now during this outbreak, there are solid steps they can take, like those above, to improve their sleep apnea, enhance their sleep, and potentially strengthen their immune systems during this global pandemic and beyond.
Additional COVID-19 Resources
About Robert Ledda, MD
Dr. Bob Ledda, President of All Alaska Outdoors will be offering wellness weeks throughout the Summer. After graduating from University of Texas Southwestern Medical School with honors, he completed a residency in Emergency Medicine. He has become a true expert in disease and has practiced for over 26 years and seen over 60,000 patients. Six years ago he did a fellowship in Wellness and Precision Medicine. Now, Dr. Ledda is a Cenegenics Partner operating his own clinic on the lodge grounds.