Sleep Dynamic Therapy

Archive for the ‘Snoring’ Category

This report from the European Respiratory Society highlights two important problems in the way the media and bariatric researchers are framing the discussion about post-operative sleep breathing changes following significant weight loss. First and foremost, they only report the AHI, the apnea-hypopnea index, and not the RDI, the Respiratory Disturbance Index. Thus, it is safe to assume that the researchers did not use advanced respiratory technology to measure UARS events (a.k.a. flow limitation events), the subtle breathing patterns that also provoke sleep fragmentation and subsequent daytime impairment in ways quite similar to classic sleep apnea. The second issue is the comment that the surgical intervention reduced or eliminated snoring in some patients, as if to suggest that snoring is a reliable marker of sleep breathing problems.

In sum, we are faced with the dilemma that both the media and the bariatric researchers are accepting outdated metrics for assessing sleep-disordered breathing (SDB). In the first instance, the assumption is that the AHI tells the whole story. It’s wonderful news to hear that AHI drops post-weight loss, but by not defining and measuring the RDI, it is safe to assume that many of these patients still suffer from SDB that likely needs treatment. The commentary on snoring represents another outdated metric in that we know many patients don’t snore and have SDB, and there are some who do snore and don’t have SDB. Bottom line is that snoring doesn’t tell us a lot about someone’s SDB condition. Again, it’s wonderful news that snoring decreases or disappears with post-op weight loss, and it likely signals that SDB severity has decreased, but it doesn’t tell us whether or not the patient still suffers from SDB, and that is the most important issue in question about the patient’s sleep health.

Imagine if the heart surgeon told a patient, “Looks like we’ve cut down your coronary blockages by 50%.” No intelligent heart patient would be satisfied with such a claim. “Okay, but how much coronary blockage do I still have left?” Same goes for SDB, “how much SDB do these patients still suffer from?” is the question at hand.

In this short video on WebMD, the explicit discussion revolves around one man’s desire for a better night’s sleep, which will somehow be achieved by eliminating his snoring. The treatment he receives is polyester implants into the soft palate for the expressed purpose of stopping the vibrations of these tissues to reduce snoring. What’s the problem here? Actually a very serious one. At no point in the video do we learn whether the patient has been tested with an overnight sleep study (polysomnography) before the surgery or after to evaluate its effects. What would the sleep study show? In all likelihood, the patient has something far more medically significant than snoring; namely, sleep-disordered breathing (SDB), for example, obstructive sleep apnea or upper airway resistance syndrome. The standard of care in the field of sleep medicine requires the patient to undergo a sleep test before and after such treatments to determine to what extent the procedure has improved his condition. Many of these site-specific snoring surgeries provide scant relief of SDB. Some actually worsen SDB. We do not know the patient involved in this video and cannot comment on what he may or may not be suffering from. However, we can state categorically that patients who share some of his features, apparently a long history of snoring, a thick neck, dark circles under his eyes, and most importantly a recessed chin (often covered up by a beard or goatee) frequently test positive on a polysomnogram for obstructive sleep apnea or upper airway resistance syndrome. Was this patient informed of the need for testing before and after surgery? Did the patient receive a full explanation of the risks snoring carries for an SDB diagnosis. Was the patient evaluated by a sleep specialist for a possible SDB diagnosis? If not, then the standard of care established by the field of sleep disorders medicine was not met prior to the surgical intervention.