Sleep Apnea – Medical Insight: My Chat with Dr. David M. Rapoport by Robin Gorman Newman

In an effort to continue to educate myself about sleep apnea, to further my desire to treat my case and to share with others who may benefit, I’ve been speaking with medical practitioners who are not treating me at present but are experts in the arena.

dr david rapoport3I had the pleasure to chat with the kind, wise and highly informative Dr. David M. Rapoport, MD, Professor of Medicine at Mount Sinai in NYC, a true pioneer in the sleep medicine field.

Below is our Q&A.

How does someone know what type of CPAP mask is best for them?  I have always been a very strong advocate of the nose rather than the mouth.  It’s more comfortable and interestingly enough, it works better.  Despite that, almost everybody in the field was, until quite recently, heading toward face masks because they thought logically you should cover up the mouth.  Turns out that’s not necessary, and in fact, interferes with things, except in the rare patient who has a very large leak out the mouth.  Most of us who breathe through the mouth when we’re awake stop doing so when we’re asleep.

If someone is sinusy, can a nasal mask be effective?  For some people that is a problem. For others, it is easily accommodated by increasing the pressure a tiny bit.  Despite patients telling us they don’t breathe through their nose, they almost always switch to doing so when they’re asleep.  There is a group of people with totally blocked noses, so they would not put a nasal mask on.  We use a lot of nasal steroids which reduce inflammation and introduce humidity through the CPAP machine.

How essential is it to treat sleep apnea?  Sleep apnea has huge consequences and is something which we believe should be treated.  When we do treat it, people often feel so dramatically better that they become “CPAP addicts.”  A small number of patients are adamant it’s the best thing that happened to them, and that’s what keeps us continuing to work at trying to make it better for others.  Many people hate their CPAP.  About a third to half of the people we start on it just give it up completely. It’s an uphill battle to convince people to use it, which is why there is a lot of research going on in other treatments.  We have yet to find anything that works anywhere near as well as CPAP.  It’s probably the most effective treatment, when used, of any condition in all of medicine. Things like the dental device, a stimulator implanted pacemaker that pushes the tongue, surgery…almost all of these are more acceptable to patients, but they only work on a third to half of the patients.  If we knew ahead of time who would succeed with CPAP alternatives, we would only then offer it to those types of patients.

Does it take the body a while to recover after being sleep deprived for a good period of time prior to treating sleep apnea?  In some people, when we treat them, they readily feel better.  But, in many people, we don’t get a complete improvement.  In those circumstances, there are several hypotheses.  One is that the body has accumulated such a deficit that it takes time to go away or may never completely go away.  Another explanation is that people aren’t using the CPAP enough in terms of the number of hours/night they wear the mask. There are two approaches as well that may include taking a subtle stimulant during the day which keeps you awake during the day and all the more tired at night so you sleep through the CPAP.  And, the other is to take a gentle sleeping pill which is sometimes done.  But, these are approaches taken when we feel desperate, and they should be discussed with a doctor.

Is it helpful/important to sleep more upright when you have sleep apnea, even if using a CPAP? Sleeping upright reduces the tendency for obstruction. If you are not using CPAP, this will possibly help. If you are on the right CPAP, it is of no real benefit for most people, although it might make it possible to lower the air pressure a little from your machine.

Is it advantageous to lose weight?  There is lots of evidence that people who are overweight and lose weight improve dramatically in some cases not needing any treatment at all and in other cases getting better and needing lower pressure or can succeed with the dental device.  However, not everyone with sleep apnea is overweight.  Lots of thin people have very severe apnea.

Should you sleep on your side?  There are those with mild or moderate sleep apnea who can potentially be dramatically cured by sleeping on their side.  Or, patients might do better with CPAP treatment and need less pressure when not sleeping on their back.

Is it important to keep to the same sleep schedule/time frame nightly?  Keeping to the same schedule ensures the body’s “circadien rhythm” stays lined up. It is an important part of treating insomnia, but if you are sleeping well and having no daytime symptoms, it is no worse than “jet lag” to try to change your sleep times. It affects some people more than others. That is why some people just cannot adapt to shift work, and others have no problem.

If someone skips a night here and there without using their CPAP, is that highly detrimental?  What about if on a two week vacation without it? It has been shown that after even one night without CPAP, sleepiness returns nearly to untreated levels. Many people do  however skip a night here and there. We don’t know much about the long term costs of doing this (other than for the symptom of sleepiness). Taking a two week vacation without CPAP is definitely a bad idea. If nothing else, it will make you feel as miserable as you did before treatment, and may predispose you to many of the long term effects of sleep apnea – for example, high blood pressure, heart attack and stroke risk, etc. Sometimes it is possible to use partial treatment during travel (eg an oral appliance, even if it does not work completely, but provided it is shown to work for you at least partially). However, many of the modern CPAP’s are relatively easy to travel with, and that is what we recommend.

Is sleep apnea becoming more common? Every day we keep discovering that mild forms of sleep apnea are affecting around 20 to 30% of the population.  It’s that common.  I think the biggest factor is we are looking for it. I’ve seen this in many communities when they open the first sleep lab, they think it’s rare, and suddenly they are like the rest of the world seeing it all over the place.  Part of it is recognition and technology for doing the studies.  Part of it is driven by the obesity epidemic.  In the last 20 years, there is an extraordinary explosion of weight…the worldwide population is much heavier than it used to be.  We don’t know why, but one of the results can be sleep apnea.

Do hormones play a role for women developing sleep apnea as they approach menopause?  Yes.  It’s been studied very carefully.  It’s less common in women until menopause, and then the women rapidly catch up.  We don’t know if it’s the hormones by themselves or some other manifestation of the anatomy that may change because women’s voices also change.  There are many changes that are not just hormonal.  We know that testosterone makes sleep apnea worse.  Estrogen doesn’t seem to help.  Though progesterone does have an effect on breathing, it doesn’t seem to cure sleep apnea when you give it to people.

Have you heard of the instrument the Didgeridoo?  A friend of mine published a paper that showed it worked.  We started a study group on it, but were never able to get people to learn how to play the Didgeridoo.  I’ve taken it up myself out of interest (I don’t have sleep apnea.) and was interested in seeing why it might work.  I believe it has a logic to it.  There is a whole group of people doing this, if you look on the web.  It probably trains the right muscles in  just the right way in the back of the throat.  My own hypothesis is that it’s not playing the Digeridoo that matters, it’s learning the circular breathing. If you try and do it, you become sore and become aware of exercising the muscles in exactly the place where the obstruction occurs.  There’s a group of Brazilians and others throughout the world who have actually developed exercises for the palate and throat which are very similar, and they have shown some benefit for sleep apnea.  Practitioners offering this training are usually in dental offices.  It takes a fair amount of effort and needs to be kept up.

Thank you for all that you do in this arena. Any comments in conclusion?  It’s been a long interesting run for me in my medical career and a pleasure to be part of something where we have done something good.  Recognizing sleep apnea and putting it in the research forefront as well as developing CPAPs and other treatments has been a very exciting period for me.


David M. Rapoport, MD, is Professor of Medicine in the Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai and Research Director of the Mount Sinai Health System Integrative Sleep Center. He has been involved in clinical care in sleep medicine, training of sleep physicians and research in sleep and sleep apnea. Dr. Rapoport’s research interests center around pulmonary physiology, control of breathing and of the upper airway, the epidemiology, causes, consequences and treatments of sleep disordered breathing and ways to improve nasal CPAP, the main treatment for sleep apnea. He has been part of many research studies funded by the NIH and industry.


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