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Counting sheep, losing sleep

MARKHAM, Ont. - Drugs and alcohol have both been longstanding health and safety threats for those behind the wheel of a vehicle, large or small. Lately, however, there is a lot of awareness being rais...

MARKHAM, Ont. –Drugs and alcohol have both been longstanding health and safety threats for those behind the wheel of a vehicle, large or small. Lately, however, there is a lot of awareness being raised around the issue of sleep apnea. Just when you thought keeping track of your hours-of-service was under control, sleep apnea is the latest accident risk factor drivers are being asked to look for.

Going beyond just “sleep deprivation,” sleep apnea, where up to 90% of sufferers go undiagnosed, is a condition that sees its sufferers actually stop breathing, sometimes more than 30 times an hour, in the most severe cases. Mild sleep apnea would see cessation of breathing occur five to 15 times an hour, while moderate sleep apnea entails 16-30 events per hour.

The actual condition is defined by the cessation of breathing for 10 seconds or more. Sleep apnea can also lead to hypopnoea, which is oxygen desaturation of 4% of more.

The reduction of oxygen causes plaque to build up in the arteries, and the blood vessels to get thinner, often leading to strokes.

Dr. Brock Rondeau, a London, Ont.-based dentist and specialist in orthodontic treatment for sleep apnea, suggested that the possibility of drivers being tested for sleep apnea when they apply for their licence could be not so far away.

Drivers who are drowsy as a result of sleep apnea cause more fatalities per accident than drunk drivers, said Rondeau, who spoke to a packed audience at the 2010 Canadian Fleet Maintenance Seminars in Markham, Ont.

There are two major indicators of sleep apnea: snoring and daytime sleepiness.

Rondeau said some 50% of patients over the age of 40 snore, and based on several studies, there seems to be a prevalence of sleep apnea among commercial truck drivers.

“It’s said that truck drivers with sleep apnea are seven times more likely to have a motor vehicle accident. If you are a mouth breather, you should get your nose checked,” noted Rondeau.

Sometimes you can’t tell if someone has sleep apnea. The person may have a physiologically narrow airway, and might not necessarily be overweight.

“Not only obese people have it. The main thing is do they snore? Do they sleep during the day? Are they gasping for breath (in their sleep)?” asked Rondeau. “When you snore, your tongue falls back and partially blocks the airway, and the tissues at the back of the throat vibrate,” he explained.

Large tonsils can cause sleep apnea in children.

Anyone with a retrognathic profile, where the jaw is set back, can be at risk for sleep apnea, so “how people are treated orthodontically can also make a huge difference,” said Rondeau.

Devices such as a pharyngometer can measure the size of the airway. A rhinometer, meanwhile, measures the nose.

“Some 50 million people in the US suffer with sleep apnea, increasing their risk of high blood pressure, strokes, heart attack and Type 2 diabetes,” he said.

Official diagnosis of sleep apnea must be done through an overnight sleep study and through a physician. The condition is treatable.

Dr. Michael Sarin, associate professor, Department of Medicine at the University of Toronto, and a panel speaker at CFMS, said the university runs a program for people with heart disease and/or diabetes.

“The risk of sleep apnea in these two populations is very high. Waking up in the morning with an extremely dry throat can be another indicator,” said Sarin.

Other factors affecting sleep apnea can include facial structure, weight, alcohol use, underactive thyroid, having a thick tongue, airway size, nasal stuffiness, allergies, medication use, and having a condition such as Down’s Syndrome.

Risk factors include having a family history of snoring, an age greater than 50, excessive weight (collar size greater than 17 inches), the presence of chest symptoms, alcohol consumption, use of sleeping medication, sedatives and muscle relaxants, noted Sarin.

There are some severe consequences to inadequate sleep, including a lack of concentration, memory loss, poor judgement, being quick to anger, getting into motor vehicle accidents, having high blood pressure, a high likelihood of heart attacks/stroke, an inability to lose weight, and in general, having a poor quality of life.

Essentially, not getting enough sleep equates to a “disturbance of hormonal harmony,” said Sarin.

Not yet convinced?

The Exxon Valdez oil spill, the Chernobyl nuclear reactor meltdown, the Challenger space shuttle disaster and the Three Mile Island accident have all been linked to the people in charge being sleep-deprived.

“Obstructive sleep apnea is a life-threatening disorder, that dentists are not medically qualified nor legally permitted to diagnose,” said Rondeau.

But he noted that there needs to be more interaction between medical and dental professionals on some of the issues that could be leading to the problem.

“A lot of the medical and dental profession doesn’t learn about this,” he noted.

Rondeau offers an at-home version of a sleep study but this cannot be used as an official diagnosis, and is more of a tool to assist in getting the right fit for patients in terms of oral devices.

Perhaps the most common device used to address sleep apnea is the CPAP (Continuous Positive Airway Pressure) machine.

The “hose over the nose” device is 100% effective, if it’s working well for a particular patient, said Rondeau, but many people refuse to wear it.

While CPAP devices have become much quieter and more comfortable than ever before, some sufferers find they lead to soreness or sinus issues. Others just find them claustrophobic.

In 2006, said Rondeau, “the world changed” with the Academy of Sleep Apnea recommending oral appliances as the first line treatment option for patients with mild to moderate sleep apnea.

“Some patients need both an oral appliance and a CPAP to lower the pressure,” said Rondeau.

“Oral appliances can stop some of the grinding and clenching that leads to headaches. Sometimes the grinding is as a result of trying to move the jaw forward to increase breathing,” he said.

Products such as a mandibular advancement appliance can bring the jaw forward and make breathing easier for those whose jaw formation is leading to obstructed breathing.

The mandibular advancement appliances are also effective in reducing hypertension, he said.

There are also “snore shirts” available with three inflatable bumpers.

“If you stay off your back, this can eliminate a lot of the snoring. Many cases can get better as a result of wearing this,” said Rondeau.

Dentists cannot legally put an oral appliance in unless you’ve tried the CPAP, cautioned Rondeau.

“My patients are tested with a home study. I put an appliance in and test it, and then I send you to hospital for an official sleep study,” he said.

The Epworth Sleepiness Scale questionnaire, which Rondeau offers through his practice, can also help you get an early indication of whether sleep apnea is something you may be suffering from.

If you’re suffering from sleep deprivation, you had a bad night’s sleep or you had jet lag, for example, you can always get back to normal, but with sleep apnea you cannot easily get back to normal.

Getting hooked up to undergo a hospital or sleep clinic study isn’t particularly attractive -you’re attached to various wires that measure brainwaves, eye movements, etc.

The goal of the treatment, said Sarin, is to improve sleep quality and quantity, and improve daytime functioning.

Exercise, which improves endurance and muscle tone, gives you more energy, and helps with weight control, can be effective against sleep apnea as well, but may not be a cure-all.

There is also surgery for sleep apnea, where palatal pillars are put in the soft palate, lifting it upwards.

Drivers who may be suffering from sleep apnea should be aware of certain fatigue indicators, said Sarin.

They may have little recollection of
driving the last few kilometres, they may be drifting out of the lane, they may be yawning constantly, or having trouble keeping their eyes open or focused.

While a 20-to 30-minute power nap can be amazingly restorative, ideally, avoiding driving when sleepiness is likely to occur is the best and safest tactic.

“Be aware that you cannot stop yourself from falling asleep,” said Sarin.

“The average human sleeps about eight hours every day, equal to one-third of your life. Some people say sleep is a waste of precious time, but sleep is a necessity, sleep restores the body’s energy and allows the body to repair tissue,” he said.

In other words, effective sleep is well worth pursuing.

“Don’t get medication, get oxygen, it’s a really good drug,” said Rondeau.

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