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Apnea-Hypopnea Index (AHI)

Have you noted term AHI on your CPAP report and wondered what does it mean? Do you know what the normal range for AHI is? Do you know the reason why AHI may vary each night or why is it higher when you are taking a nap? If so, continue reading to get your answer.

It’s common for people using CPAP to still experience apneas while they sleep. CPAP, oral appliances and other sleep apnea treatment options are designed to reduce your AHI, but not necessarily eliminate them completely, since it’s normal for everyone to have up to four apneas an hour. The initial goal is to get AHI below 5. Keep in mind it may take a little time to reach to the target AHI if you’re new to CPAP or even trying a new mask. In some patients with severe sleep apnea a higher AHI is acceptable as long as they’re feeling more rested each morning and experiencing fewer symptoms. For example: for someone with initial AHI of 45, AHI of 8 with CPAP might be considered normal.

It’s common for AHI to vary from night to night.

It is also normal for people that take a half-hour nap to have higher AHI since Your AHI measures the number of apneas and hypopneas you experience per hour, not the total number. For example, if you nap for a half hour and have an AHI of 8, that means you only experienced four apneas which is still within the normal range.

There are three reasons that your AHI may rise. First is mask leak. If air is escaping your CPAP mask, you’re not getting all the air pressure needed to keep your airway open and as a result AHI rises. Second is consumption of alcohol, narcotics and drugs which increases obstruction and as a result AHI. Third is development of central or complex sleep apnea. In central sleep apnea, the brain is not telling your body to breathe. This is caused by a dysfunction in the central nervous system, not a physical obstruction, and requires a different type of machine and PAP therapy.

If your AHI was stable, but it is suddenly increasing over the past few weeks or months, you should book a follow up appointment at CanSleep.

By Bahareh Ezzati (BSc, CPhT, RRT)

Obesity & Sleep Apnea

Did you know obesity is an important risk factor for OSA and weight loss can reduce apnea severity and even lead to resolution in some patients?

Even though obesity usually is not the cause of sleep apnea, it makes the severity of sleep apnea greater. There are different factors that may cause sleep apnea to be more severe in the heavier population such as: increases in neck circumference and fat deposit around the upper airway, increase in upper airway collapsibility and reduction in lung volume (which leads to a loss of caudal traction on the upper airway and an increase in pharyngeal collapsibility). Obesity and OSA form a vicious cycle where each results in worsening of the other. Obstructive sleep apnea in turn could worsen obesity because of sleep deprivation, daytime somnolence, and disrupted metabolism. It also could increase appetite and caloric intake by changes in hormones such as ghrelin, leptin and orexin.

Let’s look at a few more facts:

10% change in body weight is associated with a parallel change of approximately 30% in the apnea-hypopnea index (AHI), which is the major index of sleep apnea severity.
The chance of that an obese male has sleep apnea is 2-3fold of a female because of the fat distribution in men. Male predominantly have central fat deposition pattern around the neck, trunk and abdominal viscera compare with women.
Increases in visceral fat with age may also account for an increase in sleep apnea occurrence in middle-aged and older men and in postmenopausal women.

Effective CPAP therapy may lead to weight loss by a few mechanisms such as increased physical activity and increased responsiveness to Leptin.

Talk to your clinical specialist at CanSleep to find out your AHI and if it has changed over the years with aging and gain/loss weight.

By Bahareh Ezzati (BSc, CPhT, RRT)

Sleep and Light Therapy

Did you know that 35 million Americans suffer from Seasonal affective disorder (SAD)? Did you know that light therapy could help people suffering from SAD or chronic Insomnia as well as people that have difficulties adjusting to shift work and air travel?

Researchers have discovered a new type of cell in the eye that is directly related to the brain’s “body clock”. Melanopsin photoreceptor responds to a very specific color of blue light and tells the body clock when to produce the hormones that control sleep/awake, mood and energy cycles. Therefore, exposure to bright light stimulates nighttime melatonin production, whereas ordinary room light is not sufficiently intense to be effective.

Those with weak circadian rhythms need a very bright stimulus of light to reset their body clock each day. When they don’t receive this light signal, their body clock either speeds up (advance) or slows down (delay), which in turn causes the production of the wrong hormones at the wrong time of day and this can lead to mood and sleep disorders. Bright light (10000luxitensity) has been found to be the only effective means of shifting circadian rhythms. If you have difficulties falling asleep, your body clock is delayed, but if you fall asleep easily but wake up few hours later or too early in the morning (common in the elderly), your body clock is advanced.

Bright light exposure in the morning should advance circadian rhythms (shift then to an earlier time) and bright light exposure in the evening should delay circadian rhythms (shift them to a later time).

For jet-lag adjustment, it is much easier to reset one’s body clock before arriving in the new time zone. Wearing sunglasses for the first few days in the morning while resetting the body clock to an earlier time is also suggested. When traveling east, one should advance his one’s body clock (shifting from day to night). The number of time zones traveled corresponds to the hours needed to shift.

For people who want to adapt to shift work they could accelerate circadian shifting with melatonin. This can help move the body clock as much as four to six hours each day in either direction.

Talk to your sleep specialist to get a right instruction on how and when to use light therapy to overcome your insomnia and/or mood disorder.

By Bahareh Ezzati (BSc, CPhT, RRT)

Humidity or No Humidity!!

Should I use my CPAP’s humidifier or not? What is the purpose of the CPAP humidifier? Can the humidifier help me with my allergies? If these are some of the questions on your mind, this paper has the answers.

The CPAP humidifier is not only used in the cold and dry season but it can also be helpful in regards to allergy symptoms such as dryness caused by congestion and the inflammation of the nasal passages due to hay fever and other environmental allergies.

Your nose is responsible to warm the air so when it reaches your lungs, it is at body temperature; and to secrete fluid to help clear out allergens and other unwanted particles.

Using CPAP without humidification means your nose has to work extra hard to warm all this extra air and also produce even more fluid to maintain its moisture to clear out allergens. Sometimes the nose will keep overproducing fluid up to 3hrs after you stop using CPAP. This is known as nasal reactive syndrome.

Using a CPAP’s humidifier prevents the overworking of your nose and enough fluid remains to fight allergens, which in turn helps lowering congestion and inflammation caused by allergens.

Nasal cavities swell up during an allergic reaction, and if increasing humidity level doesn’t help and you are using a nasal pillow mask, consult with your clinician at CanSleep. Swollen nasal cavity (cavities) can push out the nasal pillow enough to create leak and discomfort, so using a nasal or a full face mask during allergy season is may be a better option.

It is recommended to use CPAP with a humidifier all year round. However, depending on the humidity level of the place you live, you might be able to bypass humidity. Some people do not get dry nose or runny nose by bypassing humidity. If you are travelling a lot and would like to bypass taking the humidifier part of your CPAP, you should try the CPAP without humidity for a while to see your body’s reaction first.

By Bahareh Ezzati (BSc, CPhT, RRT)

Deviated Septum & Sleep Apnea

Do you have deviated septum and wondering how it affects your CPAP therapy? This post helps you understand what is deviated septum and how is it affecting your sleep apnea and CPAP therapy.

Deviated septum is due to a misalignment in the nasal passage’s bone and the cartilage dividing nose that makes one nasal cavity larger than the other. Deviated septum can be hereditary or can be due to injuries, especially sports injuries.

Some of the symptoms are: Obstruction of one or both nostrils, nosebleeds, noisy breathing, and awareness of when obstructions in your nasal cavity switch from one nostril to the other. Keep in mind that these symptoms could be caused by other temporary or chronic conditions, so make sure you are diagnosed first before starting a treatment.

ENT specialist or your physician could diagnose you by either using endoscope or looking up your nose with a bright light to visually examine your septum.

Usually no treatment is required unless you are symptomatic. For instance if you are experiencing constant nosebleeds or sinus infections the suggested treatments are as follows:

An adhesive strip to keep the nasal passages open.
Medications: It only treat symptoms, not the condition itself. For example nasal steroids, decongestants and antihistamines.
Septoplasty: Comprises a surgery by making an incision in the septum that straightens the nasal bone and cartilage.

Deviated septum can cause sleep apnea by restricting the nasal passage to the upper airway (aka upper airway resistance). Also, if the patient already has an obstruction in his/her airway due to other factors such as larger tongue or uvula, the restricted nasal passage makes it worse. Apneas increase and symptoms are easier to notice.

If you have a deviated septum, mention it to your therapist at CanSleep to see if you can benefit from a different mask type. For example using a full face mask instead of a nasal pillow for more comfort.

By Bahareh Ezzati (BSc, CPhT, RRT)

Sleep Apnea & Pregnancy

Did you know that not treating Sleep Apnea during pregnancy could put your infant at risk? Did you know during pregnancy the majority of women experience alterations in sleep? Do you know that you might need to alter your sleep or CPAP therapy during pregnancy?

The physiologic and biochemical change of pregnancy may place women at risk for developing specific sleep disorders such as obstructive sleep apnea and restless legs syndrome. Pregnant women’s sleep pattern and duration also changes due to hormonal changes mainly during the first trimester. Overall studies show mean increase in sleep duration of 0.7 hours is common; however, due to fatigue or nausea and vomiting, sleep is more disturbed. During the third trimester the REM (deepest stage of sleep) is shorter and the majority of women start taking mid-day naps. Other physiological changes such as edema of the nasal mucosa can lead to increased airflow resistance and airway narrowing which exacerbates sleep apnea.

Sleep apnea is a risk factor for pregnancy-induced hypertension which can increase the risk of premature delivery, feral growth retardation and maternal mortality. Studies shows apnea episodes causes fetal heart rate to decelerate.

Women may experience severe persistent insomnia which could fail to respond to sleep hygiene measures or targeted therapies. However trial of behavioral therapies is strongly recommended.

Sleeping on your side is strongly suggested to reduced severity of sleep apnea as well as it avoids uterine compression of the inferior vena cava and potential compromise of cardiac output. To get assistance in sleeping on your side you could obtain bumper belt from CanSleep services which has stuffed pockets that prevents you from sleeping on your back.

Some women diagnosed with OSA require higher therapeutic pressure (about 1-2 cmH2O higher). Talk to your therapist at CanSleep to perform overnight oximetry to check for desaturation and need of CPAP titration.

By Bahareh Ezzati (BSc, CPhT, RRT)

Insomnia Versus Sleep Apnea

Although both sleep apnea and insomnia are sleeping disorders and have common signs and symptoms such as; tiredness, lack of energy, difficulty concentrating and irritability, they are very different and require different approaches for treatment. To help you understand the differences between two check out the following chart.

	Insomnia	Sleep Apnea
Common signs and symptoms	Difficulty initiating sleep (longer than 30 minutes)Difficulties maintaining sleep. Waking up often during the night and having trouble going back to sleepEarly morning awakenings. Half an hour before your alarm goes off	Episodes of apnea (stop breathing)Gasping and/or chocking during sleepMorning headacheSnoring High blood pressure
Types	Primary insomnia: Having sleep problems that are not directly associated with any other health condition or problem. Secondary insomnia: Having sleep problems because of something else such as: depression, arthritis, pain, heartburn, medication’s side effect, alcohol intake. Insomnia also varies in how long it lasts and how often it occurs. It can be short-term (transient/acute insomnia) or can last a long time (persistent/chronic insomnia).	Obstructive Sleep Apnea: Airway collapses & prevents air from getting into the lungs. Central Sleep Apnea: Brain’s respiratory control center is imbalanced and doesn’t send respiration signals. Mixed Apnea:When OSA is severe and longstanding, episodes of central apnea sometimes develop
Causes	Significant life stressEmotional or physical discomfortEnvironmental factors like noise, light, or extreme temperaturesSome medications may interfere with sleep Interferences in normal sleep schedule eg. Jet Lag	Extra tissue in the back of the throatLarge tonsils and/or uvulaAirway muscle relaxation during sleepTongue falling back and closure of the airway Genetically having narrower airway
Treatment	Gold Standard treatment is Behavioral Therapy for Insomnia (CBT-I): Behavioral approaches help you to change behaviors that may worsen insomnia and to learn new behaviors to promote sleep. Techniques such as relaxation exercises, sleep restriction therapy, and reconditioning may be useful. Avoid using over-the-counter sleeping pills because they may have undesired side effects and tend to lose their effectiveness over time	Gold Standard treatment is PAP therapy: Gentle flow of positive-pressure air by a machine through a mask. Mandibular advancement devices: Oral appliance that holds the lower jaw and tongue forward making more space to breathe and prevents airway obstructionSurgeries such as: Uvulopalatopharyngoplasty Tonsillectomy and/or adeniodectomy Radiofrequency ablation (RFA) Nasal septoplasty/ polypectomy

If you believe you are suffering from Insomnia. You could contact Allison at [email protected] who is our cognitive behavioural therapist for insomnia (CBT-I) at Cansleep.

By Bahareh Ezzati (BSc, CPhT, RRT)

Reviewed by Allison Briggs (CBT-I)

Oral Appliance and Sleep Apnea

Oral

Have you used CPAP but couldn’t tolerate it? Are you looking for an alternative solution for your Obstructive Sleep Apnea? The good news is CanSleep Services could help you by fitting you with an oral appliance called the Silencer.

The Silencer is a mandibular advancement device similar to an athletic mouthguard. It is worn in the mouth during sleep to prevent the soft throat tissues from collapsing and obstructing the airway.

The Silencer works by bringing the lower jaw forward which it also known as jaw thrust. It shifts the tongue forward and stabilizes the dropping soft palate. Silencer is proven by medical researchers to provide long term, effective and comfortable treatment to patient’s suffering from snoring and/or sleep apnea.

Dr. Wayne Halstrom is the inventor of the Silencer. He invented the Silencer 20 years ago with the patented titanium Halstrom Hinge. Since then he treated thousands of patients in British Columbia.

CanSleep is proud to announce that Dr. Wayne Halstrom also sees patients at our Coquitlam office.

Speak with your CanSleep therapist to ask if the Silencer is right for you and get more information.

By Bahareh Ezzati (BSc, CPhT, RRT)

Reviewed by Dr. Wayne Halstrom

CPAP Therapy With No Power Source!!!

Worried about power outage? Do you like camping and want to take your CPAP with you? Do you travel for business and concerned about not having access to an outlet while you sleep? Do you want to use your CPAP while on the plane or simply on the road?

The good news is CanSleep could provide you with portable rechargeable CPAP backup batteries. Medistrom is lightweight and it is compatible with following CPAP machines: Philips Respironics, Devilbiss, ResMed and Z1 travel CPAP unit.

Medistrom power supply is only 1.8 pounds. It offers up to 12 hours of power, varies depending on pressure level and having humidifier attached or not. It only requires recharging for 2-3 hours. These features makes it more powerful than the popular alternative of plugging your CPAP into a car’s cigarette lighter and much lighter than lugging around an extra car or marine battery.

We strongly recommend that people with sleep apnea use CPAP whenever they sleep even when taking a short nap and obviously when traveling. True packing a CPAP machine adds to your luggage, but remember healthy and restorative sleep is the best way to get the most out of your day whether you’re on a business trip or a pleasure cruise. Being able to have a portable battery allows you to use your CPAP all the time.

By Bahareh Ezzati (BSc, CPhT, RRT)

Top 5 CPAP Issues & Solutions

Trouble getting used to wearing the CPAP device
To start, it may help to practice wearing just the CPAP mask with the pressure on for short periods of time while you’re awake, for example, while you are watching TV. Once you are comfortable, try wearing the mask at night for short intervals and gradually increase your time.
Dry, stuffy nose
Most CPAP come with a heated humidifier, which is attached to the machine, this can help with a dry nose. The humidity level is adjustable. You may also want to try a nasal saline spray at bedtime. It is also important that your mask fit well, a leaky mask can dry out your nose. If you have tried everything and your nose is still dry, speak with our doctor.
Unintentionally removing the mask during the night
It’s normal to sometimes wake up to find you’ve moved the mask in your sleep. If you move a lot in your sleep this may happen. Often people do not know why this happens. If this does happen to you, and you wake up in the middle of the night, simply place the mask back on and start the CPAP therapy.
Dry mouth
If you breathe through your mouth at night or sleep with your mouth open, a CPAP device will dry your mouth. A chin strap may help keep your mouth closed if you wear a nasal mask. If this doesn’t help you may need a full face mask.
My skin is irritated or I have marks on my face
Your mask might be on too tight and you need to adjust your straps. If you have adjusted the straps and the problem continues the mask may be the wrong size. A mask should be replaced annually for optimal fit.