Comprehensive Management of OSA-An ENT Perspective (changed)
What Is Obstructive Sleep Apnea? Getting Started with Management of OSA? Well, Obstructive Sleep Apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas, due to repetitive collapse of the upper airway during sleep. It is the COMMON sleep-related breathing disorder. OSA occurs when the muscles supporting the soft tissues in your throat, such as your tongue and soft palate, relax. This causes your airway to narrow or maybe close, momentarily severing off your breathing. Obstructive Sleep Apnea is seen most common among middle aged males, but it can affect anyone, including children. The common symptoms are- loud snoring, feeling tired sleepy in the day, choking in sleep, and morning headaches, dryness of throat. If OSA is left untreated especially in the case of those with severe OSA, it can cause serious adverse affects on health -,metabolic dysfunction, and an increased risk of cardiovascular disease , stroke, memory impairment and sudden death . About our program: The goal of our program is to train physicians to manage OSA & further enhance their knowledge in sleep medicine. This is accomplished through intensive learnings on sleep apnea & related surgical and clinical procedures. You can expect to gain on the following by end of this program: Understand sleep and differentiate common sleep disorders Differentiate OSA and types of sleep disordered breathing (OHS) PAP therapy – when and how to use? Confident in selecting the right surgery for the right patient. Learn how to do Comprehensive Management of Obstructive Sleep Apnea. Modules Covered Understand Sleep and Common Sleep Disorders Sleep Apnea: Yes or No? Defining the Severity of the Problem Treatment of OSA-Non surgical Treatment of OSA-Surgical End Points in OSA Treatment This course unlike other Sleep Medicine Courses In India not only includes know how to do OSA Treatment but also helps to improve your insights and skills to implement industry-based practice. Why to opt for our Certification Course in ENT Sleep Medicine? Sleep Medicine Institute offers a wide variety of educational opportunities. Our dedicated faculty is committed to improving the knowledge in a supportive, collaborative, and respectful environment. We aim to equip our students with the skills to integrate seamlessly into the ever-changing landscape of healthcare which helps them stay up to date in their industry. The Online ENT Sleep Medicine Course in India offered by us is unique, and covers many lectures in sleep medicine, an area (to overcome the most common roadblocks in sleep medicine practice for Comprehensive Management of OSA) that is not usually a focus in other Courses In ENT Sleep Medicine and training. Serving as the best Academy Of Sleep Medicine, and a strong backbone to our enrollees, in helping them acquire intricate knowledge and development in the ENT sleep medicine space, with our Certification Course In ENT Sleep Medicine not only gets them started on an exciting journey into treating patients with Management of OSA, but also makes them capable of prescribing oral appliances to patients.
Efficacy of CPAP Therapy for OSA
Obstructive sleep apnea (OSA) is a chronic disorder characterized by frequent breathing pauses during sleep. It is a common condition that is associated with significant morbidity and mortality. The primary risk factor for OSA is obesity, and the incidence of OSA is predicted to rise as the obese population increases. The gold standard treatment for OSA is continuous positive airway pressure (CPAP) therapy. Unfortunately, 30% of patients refuse CPAP therapy from the outset, and 25% discontinue therapy within the first year. Factors that increase the risk of this form of sleep apnea include: Excess weight. Neck circumference. A narrowed airway. Being older. Family history. Use of alcohol, sedatives or tranquilizers. Smoking. Nasal congestion. Medical conditions. Symptoms include: The clinical definition of OSA requires sleep-related symptoms (daytime sleepiness, loud snoring, witnessed breathing interruptions, or awakenings due to gasping or choking) with a formal sleep study documenting at least five obstructive respiratory events per hour of sleep. Respiratory events include apneas and hypopneas, or arousals related to respiratory efforts. Consequences of OSA: The most serious immediate complication of OSA is motor vehicle accidents due to excessive daytime sleepiness. Patients with OSA can have impaired driving ability akin to that of a person with a blood alcohol level above the legal limit. Other possible consequences of OSA include cancer, hypertension, cardiovascular and cerebrovascular diseases, reduced cognitive function, and lipid dysregulation. Patients with moderate-to-severe OSA are three times more likely to die from cancer and 2.5 times likelier to develop cancer. OSA is associated with self-reported heart failure and stroke, systolic hypertension, and increased risk of heart failure and ischemic stroke in men. Patients with OSA are 2.6 times more likely to experience sudden cardiac death. Continuous Positive Airway Pressure The mainstay for treatment of OSA is the use of PAP therapy. CPAP therapy provides continuous positive pressure to the airway, acting as a pneumatic splint and maintaining airway patency during sleep. Pressure is delivered using a CPAP machine consisting of three parts: a motor that generates the required pressure, a tube that relays the pressurized air, and a mask with straps that creates the seal between the machine and the patient. Based on polysomnography, a patient-specific CPAP pressure is determined and the CPAP mask is custom-fitted. Benefits CPAP therapy has been reported to have positive associations with neurobehavioral and cardiovascular outcomes. Randomized placebo-controlled trials have shown that optimal CPAP therapy helps relieve sleepiness and improves vigilance and productivity. A meta-analysis evaluating automobile crashes among OSA patients indicated that CPAP therapy alleviated daytime sleepiness after one night of therapy and improved simulated driving performance within 2 to 7 days of treatment. Effect on Heart Disease, BP, Blood Sugar & Sleepiness CPAP may reduce cardiovascular risk and cardiovascular outcomes (fatal and nonfatal), such as stroke mortality, type 2 diabetes mellitus, hypertension, and cardiovascular mortality in the elderly. A greater reduction in mean blood pressure and a stronger dose-response relationship between CPAP use and severity of OSA have been demonstrated. The long-term effect of CPAP therapy in non sleepy OSA patients was shown to be a small decrease in blood pressure. This finding contributes to the growing evidence that CPAP therapy improves blood pressure. Among patients with OSA and resistant hypertension, improvements in 24-hour blood pressure and nighttime blood pressure pattern were observed with 12 weeks of CPAP treatment. Similarly, a reduced daytime blood pressure was seen in patients with resistant hypertension treated with CPAP and antihypertensive medications compared to blood pressure in patients treated with medications alone. Prehypertensive patients may also benefit from CPAP therapy by reductions in both daytime and nighttime blood pressure.1 In patients with congestive heart failure (CHF), CPAP therapy may improve ejection fraction, nocturnal oxygenation, 6-minute walk distance, New York Heart Association functional class, blood pressure, and sleepiness, but it has not shown a survival benefit. Patients with CHF treated with 2 weeks of daily CPAP experienced better pulmonary function and greater tolerance for physical activities, suggesting that CPAP may be an effective adjunct therapy in CHF. Similarly, patients with asthma crises have clinically improved pulmonary function with CPAP therapy, and patients with stable asthma have reduced airway reactivity after 7 days of CPAP. Patients with chronic obstructive pulmonary disease (COPD) who are adherent to their CPAP regimen are reported to have increased inspiratory capacity. The benefits of CPAP on blood glucose control have been less clearly delineated. Studies have shown mixed results for improved nighttime blood glucose control in patients with type 2 diabetes mellitus and OSA. Recently, CPAP therapy combined with weight-loss intervention for 24 weeks produced greater reductions in insulin resistance and serum triglyceride levels than CPAP treatment alone. Overcoming Challenges Adherence, the primary obstacle associated with CPAP therapy, involves patient-specific characteristics, healthcare conditions, and social factors. Challenges to CPAP therapy include mask-related problems (air leakage, skin abrasion, mask discomfort), treatment-related side effects (nasal congestion, dry throat, frequent awakenings), patient attitudes, knowledge, and perceived benefits and risks. Poor adherence has been observed in patients who are black, have lower socioeconomic status, or are claustrophobic. Smoking, nocturia, and benign prostatic hyperplasia may also complicate adherence to CPAP. Role of the Sleep Specialist As front-line healthcare professionals, can increase OSA awareness and improve adherence with CPAP use. In addition, sleep specialist can also promote wellness through education about smoking cessation, exercise maintenance, proper diet and nutrition, effective sleep habits, and compliance with medications and CPAP therapy. Optimizing CPAP therapy outcomes may be improved using a patient-centered approach. Patients new to CPAP have longer-lasting success if they achieve adherence early. Patients who communicate to healthcare providers any difficulty with autotitrating CPAP use are more likely to remain adherent than those patients who do not report problems. Thus, doctor who is aware that a patient is initiating CPAP therapy can inquire about the patient’s experiences. For patients who report discomfort with the CPAP device, the sleep specialist can help identify the source of discomfort, discuss the importance of a custom fit. Patients’ perceived benefit and other psychological variables have stronger associations with CPAP adherence than disease-related factors. This suggests that support is integral to successful treatment. Explanations
Sleep Apnoea – YES OR NO?
As we have been breaking down many myths and beliefs by the valuable advancement in science, we should learn better about the basic necessity of our body – SLEEP- the first thing people compromise on for the daytime work. Worst case scenario, they take it as a waste of time and want to sleep the least to function for extra hours. The importance of good quality and quantity of sleep needs to be understood better. There are many myths about sleep but what we are discussing here is the one that can impact health severely. Myth: Snoring is a sign of deep and sound sleep. Fact: Snoring isn’t good for anyone as it is caused by an obstruction in the airway during sleep as the muscles relax that keeps vibrating the soft tissues in your mouth, nose, and throat causing loud noises and even disruption of sleep. Definition: Snoring can be often associated with a sleep-related disorder that is SLEEP APNEA which is defined as repeated cessation of breathing for 10 or more seconds with or without significant de-saturation during sleep. Sleep apnea can be obstructive or central or mixed, obstructive sleep apnea (OSA) being the most common one About 80 percent to 90 percent of adults with OSA remain undiagnosed. What is OSA?: Repeated blockage of the upper airway by the collapse of the soft tissue of throat and tongue, causing complete or partial cessation of breathing for 10 or more seconds (even for a minute or more at a time) with or without de-saturation is called obstructive sleep apnea. If this occurs more than 15 to 30 times per hour it is severe and needs to be paid attention to. HOW DO WE RECOGNISE OBSTRUCTIVE SLEEP APNEA? : Often OSA is recognized by those at home who observe you sleeping. OSA can have night and day time symptoms: Nighttime symptoms: Loud snoring, choking/gasping during sleep, sudden breath pauses related arousals, dry mouth, and headache. Daytime symptoms: waking up with headaches, excessive daytime sleepiness, irritability, mood swings, memory loss, short temper, anxiety, and eventually depression. WHY DO WE NEED TO TREAT IT?: In addition to short term effects of OSA like excessive daytime sleepiness, headaches, mood swings, anxiety, irritation, etc. other long term consequences of OSA are: High blood pressure Heart disease Stroke Pre-diabetes and diabetes Depression ARE YOU AT RISK OF HAVING OSA? : Risk factors that contribute to high chances of OSA: Overweight (Body Mass Index of 25 to 29.9) and obese (Body Mass Index of 30 and above) Neck circumference 17 inches (40cm) or more for men, 16 inches (35cm) or more for women. Habits like alcohol and smoking. Middle-aged and older men and post-menopausal women People with abnormalities of the bony and soft tissue structure of the head and neck Adults and children with Down Syndrome Children with large tonsils and adenoids Anyone who has a family member with OSA People with endocrine disorders such as Acromegaly and Hypothyroidism A person suffering from nocturnal nasal congestion due to abnormal morphology, rhinitis, or both. DIAGNOSTIC TESTS OF OSA?: People who snore and have excessive daytime somnolence should undergo the diagnostic tests of OSA. Level 1 In-laboratory, technologists attended polysomnography. (Gold-standard). It records brain waves (EEG), the oxygen level in your blood, heart rate, and breathing, as well as eye and leg movements during the study. It can also be used to diagnose periodic limb movement disorder, narcolepsy, chronic insomnia, and REM sleep behavior disorder. Level 2 Full polysomnography is done at the comfort of your home. Level 3 Portable monitoring with three or more channels, including pulse oximetry, heart rate, asses airflow, and thoracoabdominal movements. Used for screening in patients at high risk of OSA. The AHI is the number of times you have apnea or hypopnea during one night, divided by the hours of sleep. Normal sleep: An AHI of fewer than 5 events, on average, per hour Mild sleep apnea: An AHI of 5 to 14 events per hour Moderate sleep apnea: An AHI of 15 to 29 events per hour Severe sleep apnea: An AHI of 30 or more events per hour HOW DO WE MANAGE OSA? Mild OSA can be managed with weight management, diet control, avoiding supine position, avoiding personal habits like smoking and alcohol, and some oropharyngeal exercises. Moderate and severe OSA can be managed with PAP THERAPY which is the positive airway pressure that is given by a device and delivered to the patient using a nasal or oro-nasal mask. This air pressure keeps the airway open during sleep thus improving sleep quality, and normalizing the apnea-hypopnea index (AHI) and oxyhemoglobin saturation levels. Along with PAP therapy, diet control, weight management, and lifestyle changes are also recommended. CONCLUSION: To conclude we can say that sleep is as essential as food and exercise to our body. If we get the proper quantity and quality of sleep, we can work efficiently even during the day and enhance productivity. The most prevalent, and majorly unrecognized, the underdiagnosed sleep-related disorder is Obstructive sleep apnea which often occurs with repetitive snoring, choking, or gasping during the night followed by morning headaches, excessive daytime sleepiness, and severe mood swings like irritation, memory problems, and anxiety. Obesity and male gender are at high risk of having OSA. If left untreated, OSA can lead to heart diseases, high blood pressure, diabetes, stroke, and depression. To diagnose it level 1 to level 3 of overnight sleep study can be done at our center. PAP therapy is the gold standard therapy that is recommended along with behavioral and lifestyle changes to manage the signs and symptoms of OSA. To seek help or know more about your sleep apnea, you can visit the Neurology and Sleep Centre, the 1st sleep centre in the country accredited by the Indian Board of Sleep Medicine at L-23, Hauz Khas Enclave, New Delhi, Delhi-110016 (INDIA) Or give a call on +91-11-46070321, +91-9643500270 Book your sleep study today.
Role of Myofunctional Therapy in OSA
Obstructive Sleep Apnoea(OSA) is a sleep disorder in which a person experiences difficulty in breathing while sleeping. It is characterised by repetitive cessation of breathing at night due to complete or partial upper airway collapse. It is a chronic disorder that affects mostly middle aged men. Tracing a single cause of OSA is extremely difficult as there are complex interplay of anatomical and neuromuscular factors that cause upper airway collapsibility. When one is unable to breathe, the heart rate drops due to decrease in the body’s oxygen levels. That is when our involuntary reflexes come into action and we startle and wake up at the end period of not breathing. Frequent recurrence of apnoea affects our body adversely. It causes a rise in blood pressure and thickening of the heart walls due to increased workload, leading to an overall change in the heart structure. Sleep apnoea has serious effects on our body as well as our regular life. It causes daytime fatigue, increases the risk of hypertension, diabetes, heart diseases and liver problems. The chances of complications post surgery is also higher. Keeping these in mind, it is important that OSA is managed and treated well at the right time. A few treatment options have been listed below. Treatment of OSA: Adenotonsillectomy – This is the first line of treatment during childhood. It involves the removal of adenoids and tonsils, thereby providing an open airway to enhance breathing. Continuous positive airway pressure (CPAP) – In this method, a constant air pressure higher than the atmospheric pressure is applied to the upper respiratory tract. This constant positive pressure prevents collapse of the upper airway. Mandibular advancement device – It is effective in case of mild to moderate apnoea. It is a non continuous method of providing positive pressure to the upper respiratory pathway. Irrespective of these options, there is a need for alternative methods to treat OSA because these are of very little help to some people. They are unable to respond well to these methods. Myofunctional therapy is at the focal point of complementary treatment methods for OSA. What is Myofunctional therapy? Myofunctional therapy(MT) is a set of specific exercises that target the facial muscles involved in chewing and swallowing. These exercises strengthen the tongue. It is composed of isotonic and isometric exercises that target oral (lip, tongue) and oropharyngeal structures (soft palate, lateral pharyngeal wall). It works for almost everyone. It is generally performed in kids above 4 years and does work very well for adults. There are dilator muscles in the upper airway which are crucial for keeping it open during sleep. Targeting these muscles along with the oral cavity and the orofacial structures with the help of exercises and airway training (such as singing, playing an instrument) can alleviate OSA. Myofunctional therapy has been suggested for the same since 1918. MT exercises involve the soft palate, tongue, and facial muscles and address stomatognathic functions. Orofacial myofunctional disorders are abnormal patterns of the oral and orofacial muscles that interfere with the normal growth, development and function of these muscles. It includes sucking of thumb and other fingers, tongue thrust, resting always with the lips apart etc. These are accompanied with other comorbidities like blocked airway and obstructive sleep apnoea. Consulting an oral myofunctional therapist to deal with this is a good help for the patient concerned. Breathing is adversely affected in OSA. Therefore, pairing myofunctional therapy with breath retraining can be of great help. The objective of this is to have normal breath while awake and sleeping. How does Myofunctional therapy work? Myofunctional therapy focuses on the following: Strengthening the facial muscles. The exercises are designed such that continuous breathing becomes possible. Correct swallowing Sealed lips Correct tongue position and oral rest posture. There are exercises that strengthen the muscles around the upper airway and in the orofacial region. Some of them are: Tongue exercises – The tip of the tongue is placed on the hard palate and is pressed against it for 5 seconds. It is made to touch the tip of the nose and the bottom of the chin and is held for 10 seconds. It is also moved along the superior and lateral surfaces of the teeth. Tongue rolling is also included. Facial exercises – These include exercises that target various facial muscles e.g. contraction and relaxation of the orbicularis oris, which are muscles around the lips, suction movements and application of intraoral finger pressure against the buccinator muscles present under the cheek and lateral jaw movements to strengthen the jaw muscles. For soft palate exercises, patients pronounce oral vowel sounds either continuously or intermittently. Stomatognathic exercises– First, the patients are instructed to inhale nasally and exhale orally without a balloon. This process is again repeated with a balloon. Specific swallowing and chewing exercises, for example, swallowing with the teeth clenched together, tongue positioned in the palate and without contraction of perioral muscles; alternating chewing sides are also included. Most of these myofunctional therapy exercises are also effective for management of mouth breathing. Does myofunctional therapy work? Extensive research has been conducted to check the effectiveness of this therapy. It has been observed that: MT provides a reduction in AHI. According to a study by Suzuki et al.,(Journal of prosthodontic research, 2013) oral myofunctional therapy has the potential to improve respiration during sleep. They concluded that this therapy had the potential to increase labial closure force, improve the SpO2 levels and AHI scores. These results were observed after two months of training. MT decreases snoring. Guimaraes et al.,(American journal of respiratory and critical care medicine, 2009) conducted a study in which patients with moderate OSA were made to perform oropharyngeal exercises for a period of 3 months. These patients had a significant decrease in snoring intensity, excessive daytime sleepiness and had an improved sleep quality score as compared to the control group. A meta analysis conducted in 2015 by Camacho et al., published in Sleep, reported that myofunctional therapy could reduce the apnea –
Kickstart your knowledge about the Science of Sleep and Sleep Medicine
Kickstart your knowledge about the science of Sleep and Sleep Medicine This blog will encompass Basic Course in Sleep Medicine, Advance modules & comprehensive courses to help you grow your knowledge in the field of sleep medicine. As you know the sleep medicine field has grown rapidly in the last few years. Patients with sleep issues present to physicians of all specialties. It is important to know the sleep disorders in order to diagnose them and provide appropriate improvement. Active diagnosis and management is possible after gaining knowledge about the specialty . Keeping this in our vision, a first of its kind , an online platform to enable one to learn about Sleep and common sleep disorders was launched in 2020 by Dr. Manvir Bhatia for physicians, technicians, technologists, patients and to all those who wish to improve their awareness of sleep related problems and sleep disorders. Sleep medicine institute deals a wide range of educational choices. Our well recognized and learned faculty who are stalwarts in this field form an integral part of the family. We aim to prepare our students with the skills to assimilate this knowledge into the ever-changing landscape of healthcare which helps them stay up to date in their industry. Sleep Medicine Institute, is a division of Neurology & Sleep Centre( is a one stop solution for treatment, training, teaching & community awareness for sleep related issues & neurological disorders.) The courses are of 2 categories—those with multiple modules eg ( Comprehensive Management of OSA:An ENT Persepctive,Pediatric Sleep Medicine:A Clinical Approach,Dental Sleep Medicine Course) and other being single modules . The response has been very encouraging, the institute has trained more than 150 Doctors/Therapists and Technicians, majority of them rating the quality of the course as 5 star. Basic course in sleep medicine is intended to offer a complete state-of-the-art method to the diagnosis of sleep disorders.. This 3 month online course, covers all structures of sleep medicine and technology. Starting with base knowledge about normal respiratory and sleep physiology, it will also cover all sleep disorders and their treatment, including applied application of sleep disorders assessment and management. You will be trained about existing practice in sleep science, as well as introduced to new and sensational developments for the future. This course is a concentrated introduction to the ground of sleep medicine. It is significant for all those new to the field and mentioned for those who would like to revive their information base. Contributors will be able to review thoughts, obtain up-to-date systematic data and applied tips, to proficiently and truthfully analyze sleep disorders. Knowledge & Skills you stand to gain: Recognize the essentials of sleep functioning Assess a sleep patient Classify the main corresponding tests in sleep medicine Recognize the specific necessities for execution of sleep lab Be able to make a patient to complete a sleep study Gain involvement with polysomnography scoring Cover the basic applied skills required including wiring up, troubleshooting and report explanation – develop and improve these core practical skills Interaction with new research and developing knowledge in sleep medicine Define standard developing sleep changes across the lifespan. Clarify ordinary sleep patterns, common sleep disorders and co-morbid sleep disorders. Discuss possibly opposing health products associated with sleep disorders. Apply information of sleep into a health valuation, patient’s health care plan, and patient teaching. Observe risk factors of sleep disorders and label interferences to promote necessary sleep. Appraise and enlighten sleep problems associated with co-morbid and chronic conditions and appropriate involvements to promote sleep. Investigate evidence-based methods to evaluate sleep related data and findings of sleep research articles An MCQ pattern will be conducted at the end of the arrangement and the trainee is predictable to clear to receive a completion certification. Doctors with post graduate qualification in Internal Medicine, Chest Medicine, Psychiatry, Neurology and ENT, Physicians, Medical trainees with special interest in sleep medicine and Sleep technologists should consider taking up this course. We have various Advance modules & courses from eminent national and international faculties. These are online pre-recorded which will give you complete array of knowledge on sleep medicine. They are as following- 1.Snoring can be your practice builder Faculty-Dr. Deepak Shrivastava Learning objectives Physiologic mechanisms and prevalence of snoring How snoring causes a major health care burden? What is the association of snoring to cardiovascular disease? How snoring can be effectively managed before it causes further damage? Review of the available current clinical evidence regarding impact of snoring 2.Insomnia overview (causes & management) Faculty-Dr. Manvir Bhatia and Dr. Ravi Gupta Learning objectives Classifications of Insomnia Understand the Pathophysiology of Insomnia Evaluation of Patients with Insomnia Offer best possible treatment options to patients with Insomnia 3. Multiple Sleep Latency Test & Maintenance Of Wakefulness Test Faculty-Dr. Manvir Bhatia Learning Objectives What Is Mslt, Mwt? When to perform MSLT, MWT? How are these tests performed? What are normal and what are abnormal results? 4.Circadian Rhythm – Basic Concept Building Faculty- Dr. Karuna Datta Learning Objectives Enumerate the basic principles of Circadian Rhythm. Illustrate various ways in which these principles can be used for therapy 5.Neurobiology of Sleep Faculty-Dr. P.N Ravindra / Dr. Bindu Kutty Learning Objectives Overview of neural substrates of sleep (NREM, REM & DREAM) Interaction to maintain sleep and wake states Physiology of sleep Importance of sleep in health 6.Advances In Narcolepsy And Hypersomnia Faculty-Dr. Preeti Devnani Learning Objectives Recognize the key clinical symptoms of hypersomnia Emphasize evidence based management strategies Discuss newer treatment approaches 7.Cbt For Insomnia Faculty-Ravi Gupta Learning Objectives Initiate and conduct multi-component CBT to patients with chronic insomnia Identify use of individual modules based on patient’s clinical features Identify reasons for non-compliance and address them 8.Efficacy Of Cpap Therapy For Osa Faculty-Dr. Deepak Shrivastava Learning Objectives Review the effects of CPAP on daytime sleepiness and quality of life Review of CPAP efficacy in multiple comorbid medical conditions Review of cardiovascular functional improvement by use of CPAP Review controversy in CPAP literature and its benefit to the patient compliance Review of the available current clinical evidence to support use of CPAP 9.Build
Circadian Rhythm
‘Early to bed and early to rise makes a person healthy, wealthy and wise.’ This is a very old saying that all of us have heard from our elders. The true essence of it can be understood only when one knows about the natural clocks, also called the circadian clocks present in our body. The circadian clock is a controller of all sorts of biological processes which follow a 24 hour cycle. These processes include brain-wave activity, sleep-wake cycles, body temperature, hormone secretion, blood pressure, cell regeneration, metabolism and behaviour. The circadian clock of mammals and humans have a central clock and numerous peripheral clocks in the tissues. The central one is the master clock, also called the circadian pacemaker, which is present in the suprachiasmatic nucleus(SCN) located in the hypothalamus of the brain. This master clock is influenced by environmental cues, especially light. This master clock synchronises the functions of the other peripheral clocks. Among the various circadian rhythms, the sleep wake cycle is a very important one. Significance of circadian rhythm: ●This rhythm is important for maintenance of good, restorative sleep. A good sleep helps us to be safe while performing various activities, like driving, cooking etc. ● It regulates release of hormones that are responsible for various vital functions in the body. ● It is significant for metabolic activities of the body, especially lipid metabolism. It also plays a role in thermogenesis and energy homeostasis. ● It is also essential for neurodevelopmental processes. Factors regulating the circadian rhythm: The human clock is generally longer than 24 hours. There are regular cycling environmental cues that entrain it to be 24 hours. These factors called zeitgebers, are external time giving cues which include: Light – For the circadian rhythm, light is the strongest entraining agent. Information about the light-dark cycle is relayed from the retina to the SCN. This is done primarily via the retinohypothalamic tract which is a neural pathway distinct from the visual system. The timing of light exposure is extremely crucial. It determines its ability to bring about changes in the timing of circadian rhythms. In humans, exposure to bright light in the early morning induces phase advances, whereas light exposure in the evening delays the phase of circadian rhythms. Temperature – There is a close relation between the circadian cycles of sleep and temperature. Sleep is majorly initiated in the evening when the core body temperature(CBT) declines. By the next morning, this temperature reaches its minimum and then starts rising again. This is when our major sleep period ends. Our CBT is lower when we are asleep as compared to when we are awake. Body temperature nadir is reached around one and half to two hours before sleep timing. If this is somehow altered, it affects the onset of sleep as well as awakening from sleep. Hormones: ● Melatonin – It is less effective as compared to bright light, but it has circadian phase shifting properties. The SCN regulates the timing of melatonin release from the pineal gland. Its secretion is suppressed by exposure to bright light. The levels of endogenous melatonin begin to rise approximately 2 hours before sleep onset. It remains elevated during the habitual sleep hours and is responsible for the circadian expression of various clock genes. ● Cortisol – This hormone keeps us alert and active and is released more during the day. Exposure to light in the night can also trigger its release instead of melatonin. There are genetic factors that regulate circadian rhythm : At the molecular level, the circadian rhythm is regulated by a transcriptional feedback loop. This loop consists of two components: Positive limb – These include the genes Clock and Bmal1 Negative limb – It consists of Per (Per1 and, Per2) and Cry (Cry1 and Cry2) genes. The CLOCK:BMAL1 heterodimer initiates the transcription by binding to specific DNA elements, E-boxes (5′-CACGTG-3′) and E′-boxes (5′-CACGTT-3′) in the promoters of target genes. This activates the Per (Per1 and, Per2) and Cry (Cry1 and Cry2) genes. These produce the proteins PER and CRY respectively. These proteins bind to the CLOCK:BMAL1 heterodimer bound to the E-boxes and inhibit them from further activation of Per and Cry genes. Once the PER and CRY proteins are degraded, the CLOCK:BMAL1 heterodimer can once again promote the production of Per and Cry genes. Conditions that can disrupt the Circadian Rhythm: Jet lag – This condition generally arises when a person travels to different time zones. It is generally experienced by people who take intercontinental flights. The effect continues until a person is able to adjust with the day-night timings of the new place. Shift Work Disorder – A number of jobs these days are such that it requires people to work through the night or up till late night. This severely disrupts their sleep wake cycle as they sleep during the daylight hours. Light from electronic devices at night – White light is made up of seven colours. Out of these, blue light is the most detrimental to sleep. Exposure to blue light emitted from fluorescent and LED lights, screens of tablets, computers, mobiles, etc. during the sensitive periods trigger the photoreceptors in the retina to send signals capable of suppressing the release of melatonin. This causes a major shift in circadian rhythm. Delayed sleep phase disorders(DSPD) – This is associated with people who tend to stay awake late in the night(night owls) and sleep till late in the morning. It generally affects 0.1 or 0.2% of the population but impacts upto 16% of teens. It presents itself as sleep onset insomnia and sleep sets in between 2 to 6 AM and one is not able to wake up on time for work, school, etc. Genetic mechanisms may also play a role. For example, the DSPD phenotype has been associated with polymorphisms of the circadian genes, Clock and Per3. Non 24 hour sleep wake disorder – Blind people are mostly affected by it as they do not receive the light cues in their
Online Sleep Medicine Course: Why to Enroll? Who should Enroll?
What is online education? The lives of people in the field of healthcare and medicine are very eventful and busy. Be it doctors, interns, nurses, pathologists etc. all of them have packed schedules. Their devotion to the profession is what gives them the strength to keep working hard and learn something new everyday. Online education can boost their knowledge and skills irrespective of the time constraints. Online education is the use of the internet via electronic devices such as laptops, mobile phones and other electronic devices to gain knowledge about a variety of topics. It allows mentors to reach out to a large number of learners. It allows students without access to traditional classes, working individuals and home-makers to learn new skills and topics. This mode of education has an edge over classroom learning because of its flexibility with respect to speed and time of learning, cost effectiveness and networking opportunities with people of different backgrounds. What is sleep medicine? Sleep is essential to survival. It is important for growth, normal functioning of the brain and other organs of the body and helps our tired body to re energize itself. Getting good quality sleep regularly is a priority. The duration depends mainly upon the health and age of an individual. Sleep medicine is the field of study that focuses on diagnosis and treatment of sleep disorders. Specialists in this field have special training that gives them the expertise to diagnose and treat sleep problems and disorders. They can treat a wide range of disorders related to sleep, such as breathing problems, abnormal activity during sleep, insomnia, hypersomnia, etc. Patients with sleep issues can present to all disciplines and sleep issues can occur alone or co-exist with other medical conditions. Thus it is essential for specialists, physician's surgeons in all disciplines of medicine to be familiar with the conditions. Factors responsible for sleep problems: A number of factors are responsible for sleep disorders and its disruption. This can vary depending on the type of disorder. A few of them are listed below. Gender – Females are more prone to sleep disorders( Insomnia , RLS) as compared to males. Lung disease – Both obstructive and restrictive lung diseases are associated with sleep problems. Renal diseases – About 80% of patients suffering from end stage renal disorders have reported sleep disorders. The symptoms include difficulty falling asleep, awakenings in the middle of the night, waking up too early, restless legs, jerking legs, and daytime sleepiness. Endocrine disorders – Hypothyroidism and acromegaly are associated with Obstructive Sleep Apnea(OSA). Diabetes is associated with sleep disturbance, difficulty in falling asleep and maintaining a good quality sleep. Short duration sleepers are more prone to diabetes as compared to long duration sleepers. Also, glucose tolerance is impaired in patients with OSA. According to a study published in the Journal of Family Medicine and Primary Care(Bhaskar et al; 2016), with increasing age, diabetic patients are more likely to suffer from insomnia. Infectious diseases – People with acute infection need more sleep. This may be due to the action of the immune system by the release of cytokines. People infected with influenza virus tend to sleep more during the symptomatic phase as compared to the incubation phase. Lyme disease, hepatitis B and C, brucellosis are infections in which the patient suffers from difficulty in getting a good quality sleep. Patients with HIV have reported insomnia, excessive daytime sleepiness, and multiple awakenings at night very frequently. In a longitudinal study by Choudhary et al, published in Cureus, a significant prevalence of insomnia has been reported in COVID-19 patients upto 30 days post recovery. The social confinement and financial constraints experienced by people worldwide during the pandemic is a reason for sleep problems, fatigue and excessive sleepiness that they experienced. Menopause – Most women experience a lot of sleep related problem during menopause because of hot flashes, sleep apnea, restless legs syndrome, depression, and symptoms of fibromyalgia. Cancer – Patients undergoing cancer therapy(especially lung and breast cancer) commonly report hypersomnolence, excessive fatigue, insomnia and multiple awakenings. Neurologic disorders – These include Alzheimer’s, Parkinsons, epilepsy, etc. these patients report poor night sleep, rapid eye movement (REM) sleep behaviour disorder, insomnia, restless legs syndrome, etc. Pregnancy – According to a study by Mindell et al(Sleep medicine, 2015), around 75% women experience poor quality sleep during the whole period of pregnancy. All of the subjects reported night time awakenings. This is mainly due to the frequent urinations and the difficulty in finding a comfortable sleep position. Theyalso reported insomnia, day time sleep, restless leg syndrome, etc. Hence, keeping in mind the range of factors and diseases which can affect and be affected by sleep, it becomes extremely important for all physicians and specialists to screen and treat all their patients for any sleep related problems. Online sleep medicine courses can be extremely helpful for them. Who should enroll ? Doctors who preferably should have additional training in sleep medicine include: ●Anesthesiologists (surgical care and anaesthesia) ● Cardiologists (heart) ● Family physicians ● Internal medicine doctors ● Neurologists (brain and nervous system) ● Otolaryngologists (ear, nose and throat, or ENT, specialists) ● Paediatricians ● Psychiatrists ● Pulmonologists (lungs) ● Psychologists – for special training in treating sleep related behaviours and insomnia ● Dentists – some of them create and fit dental devices used to treat sleep apnea. Sleep medicine and management is emphasised upon very less in both undergraduate and postgraduate medical education in India. As a result, awareness about sleep(even among physicians) and presence of sleep labs across the country is very less. This also leaves patients unaware about the importance of sleep. They seldom realize that a health reason might be a result of sleep deprivation. Knowing the importance and significance of sleep in our life, online comprehensive courses on sleep medicine in India should be extremely helpful for medical practitioners at all levels. It will increase sleep awareness among people in the society, improve the quality of life of the individual and
Why You Should See a Sleep Specialist and What You Expect from the Visit?
When should you see a sleep specialist? Sleep is essential in order for the body to repair itself and work efficiently. According to the sleep foundation, almost 35.2% of Americans get less than seven hours of sleep every and night, and according to Wakefit. co which a Bengaluru-based sleep solutions start-up, around 67% of Indians suffer from sleep deprivation. Inadequate sleep can affect your physical and mental health, decrease productivity, cause inattentiveness, affect your memory and leave you lethargic. When do I see a sleep specialist? If you have any of the following symptoms, then you should consider visiting a sleep specialist: Persistent loud snoring Difficulty in falling asleep or unable to sleep throughout the night Gasping for breath in sleep Feeling lethargic throughout the day even after sleeping for 7-8 hours Uncontrollable urges to move your leg, discomfort in legs at bed time Who is a sleep specialist? The sleep specialist is a medical practitioner who diagnoses and treats sleep disorders, often trained in neurology, pulmonology psychiatry, pediatrics, ENT. These specialists study and train in sleep medicine. Sleep psychologists deal with behavioral aspects of sleep. Sleep specialists help you with the sleep disorders such as: Snoring or Obstructive Sleep Apnoea (OSA) may cause pausing of breath or difficulty in breathing during sleep Insomnia inability to fall asleep or remain asleep throughout the night Restless Leg Syndrome (RLS) uncontrollableurges or sensations making you restless at night Parasomnia walking or talking while asleep Narcolepsy uncontrollable desire to sleep , suddenly falling asleep during daytime What to expect on a visit to a sleep specialist? A sleep specialist will help you narrow down the cause of the disruption in sleep and treat it. They might ask you to stay overnight to undergo a sleep analysis or a polysomnogram. A polysomnogram consists of monitoring one’s sleep throughout the night and measuring the activity of different organ systems. It will include Electroencephalogram or EEG to measure your brain activity Electro-oculogram or EOG to measure the movement of your eyes Electromyogram or EMG to measure activity of your muscles Electrocardiogram or ECG to measure your heart rate and rhythm Pulse Oximetry test to keep track of changes in oxygen level of your blood Sleep specialists would help you treat your disorders in the best way based on these tests. Conclusion Sleep is the natural way of the body to revive itself. Disruption in sleep is the underlying cause of many problems such as obesity, high blood pressure, brain fog, heart problems, diabetes, etc. A sound sleep is necessary to remain healthy and hearty, which is just a visit away from a sleep specialist. To seek help or know more about Sleep Issues from a Sleep Specialist, you can visit the Neurology and Sleep Centre, the 1st sleep centre in the country accredited by the Indian Board of Sleep Medicine at L-23, Hauz Khas Enclave, New Delhi, Delhi-110016 (INDIA) Or give a call on +91-11-46070321, +91-9643500270, References: https://m.timesofindia.com/life-style/relationships/work/work-from-home-is-making-67-indian-suffer-from-sleep-deprivation-says-study/amp_articleshow/75126242.cms R. Gupta, S. Grover et.al (2020) Changes in sleep pattern and sleep quality during COVID-19 lockdown. Indian journal of Psychiatry. Volume 62 issue 4. 370-378.
Why You Should Keep Your Late-Night and Midnight Snacking Under Control
Why not to eat at Night? Some people have a habit of eating very late at night, eating just before going to bed, or even waking up in the middle of the night to snack on something. These habits though may not seem to be harmful, can be the reason for many metabolic and sleep issues. Nocturnal Eating and Weight Gain Most often, eating late at night is not a result of hunger, but because of habit. Due to the pandemic, many people have started going to sleep late and waking up late in the morning. Staying up until later, makes people want to eat, and very often, they do not choose to eat healthy food, but calorie-rich foods such as chocolates, chips, pizza, etc. When you snack on food during the day, your body gets the chance to burn off the consumed calories, but this does not happen at night. As a result, there is weight gain, since the calories consumed are far more than the number required. Nocturnal Eating and Sleep Delayed Sleep and multiple awakenings: Foods and drinks such as chocolates, coffee, tea, are rich in sugar and caffeine, may not only delay your already delayed bed time but also cause you to wake up several times at night. Acid Reflux and ingestion: People who snack at night tend to snack in large quantities. This can lead to indigestion and acid reflux Acid Reflux tends to get worse at night and may wake you in the middle of the night and cause difficulty falling back to sleep. Heartburn: Excessive eating can cause heartburn and the effects of heartburn exaggerate at night and cause uncomfortable sleep. Nocturnal Eating and Future Health Risks Nocturnal eating habits increase your risk of suffering from Obesity, Diabetes, and Heart Disease. Obesity: Having a calorie intake higher than what is required, leads to weight gain. Eating regularly late at night puts you at a risk of becoming obese which in turn leads to a number of health problems in itself. Diabetes: Nocturnal eating habits also puts you at a risk of developing diabetes later on in life, which will then restrict your food intake and put you at risk of developing secondary infections. Heart Risk: Snacking regularly at night can increase your cholesterol level and build up in your arteries that puts you at risk of developing cardiac risk, high blood pressure, and other heart-related conditions later in life. Avoid Going to Bed Hungry Some people who are on weight-loss diets may think that they must avoid consuming all kinds of food after a certain time in the day, but one must definitely not go to bed on an empty stomach. This is because: Your body may not be able to get enough nutrients to carry out repair and regenerative functions during sleep due to lack of nutrients. Going to bed on an empty stomach can wake you up in the middle of the night, as you may feel hungry, which will then affect your sleep at night and consequently your day time functioning. Certain foods that are rich in tryptophan and melatonin are also recommended to be consumed before going to sleep, as they help to induce sleep and regulate the sleep-wake cycle. Conclusion: In conclusion, one must not eat at night to avoid excessive weight gain, to reduce the risk of being obese, or to develop diabetes and heart disease later on in life. The gap between the last consumed food and bedtime should be sufficient enough to allow digestion and negate any effect of the food consumed on your sleep. To seek help or know more about the ill effects of midnight snacking, you can visit the Neurology and Sleep Centre, the 1st sleep centre in the country accredited by the Indian Board of Sleep Medicine at L-23, Hauz Khas Enclave, New Delhi, Delhi-110016 (INDIA) Or give a call on +91-11-46070321, +91-9643500270
Lack of Enough Sleep at Night Can Cause Incessant Headaches During the Day
Do you often wake up with a headache even if you have slept for enough hours? Do you get a headache in the evening that is only resolved if you go to sleep? Or do you wake up in the middle of the night with a headache? Sleep and headaches are intricately linked with each other. A good night’s sleep is essential for healthy living. During sleep, the body repairs itself so that it can function optimally. Disturbances in the regular sleep patterns can cause inattentiveness during the day and increase incessant headaches. It has been reported that 16 to 20 % of the Indian population has experienced a migraine headache. Link between sleep and headaches Multiple studies have linked the lack of sleep with headaches. A study published in 2011, in The Journal of Pain suggested that the disruption in REM (Rapid Eye Movement) sleep caused excruciatingly painful headaches that did not resolve easily and lasted for a while. REM sleep is essential for regulating mood and memory consolidation. The researchers found that not getting enough sleep causes the body to produce a protein that reduces the body’s threshold of perceiving pain and hence caused the painful headaches. The Hypothalamus controls sleep also plays an important role in the mechanism of headaches. A study published in 2017 in Therapeutic advances in Neurological Disorders also linked the lack of sleep with tension headaches. Moreover, the intricate link between headaches and sleep is further emphasised by the fact that the medication often prescribed for headaches regulates serotonin levels that are a chemical messenger that deals with the pain and control pathways and mood regulation. Types of headaches: There are different kinds of headaches that are linked with a lack of or disturbance in sleep. Tension headache and Migraine headache are often tiggered due to a lack of sleep. Wake up headache is experienced when you don’t get enough sleep and wake up experiencing a dull ache in the temple region of the forehead. Hypnic headaches that account for 0.07 to 0.35% of types of headaches and cluster headaches are other types of headaches that one can experience during sleep. However, more evidence is required to directly link it to the lack of sleep. OSA and Headaches People suffering from Obstructive Sleep Apnea often complain about throbbing headaches after they wake up in the morning. This has been attributed to a lack of oxygen and excess carbon dioxide in the bloodstream due to difficulty in breathing while sleeping. How can you know if your headache is sleep related? Not all headaches are caused due to disturbance or lack of sleep, and hence all headaches cannot be treated in the same manner. To know whether your headaches have been caused due a sleep issue, your sleep specialist would suggest you to keep a sleep and headache diary, where you record the onset of headache and number of hours of sleep to allow them to diagnose your condition. Do’s and Don’ts for healthy sleep to prevent headaches. If you suffer from sleep related headaches, undergoing some simple behavioural changes in your sleep pattern will help you attain restful sleep and consequently reduce headaches. These changes include: Establishing a sleep wake routine Getting between 7 to 8 hours of sleep each night Avoiding caffeine, nicotine, alcohol and other substances that impair sleep Reducing screen time close to bed time Conclusion Enough evidence indicated that sleep and headaches are linked to each other, and hence one must take utmost effort to achieve good quality, restful and enough sleep, in order to avoid sleep related headaches. To seek help or know more about sleep and headaches, you can visit the Neurology and Sleep Centre, the 1st sleep centre in the country accredited by Indian Board of Sleep Medicine at L-23, Hauz Khas Enclave, New Delhi, Delhi-110016 (INDIA) Or give a call on +91-11-46070321, +91-9643500270 References: Durham, P., Garrrett, F., Hawkins, J., Hayden, J., & Campos, J. (2011). REM sleep deprivation promotes sustained levels of proteins implicated in peripheral and central sensitization of trigeminal nerves: role in pain chronification. The Journal of Pain, 12, 31. Fernández-de-Las-Peñas, C., Fernández-Muñoz, J. J., Palacios-Ceña, M., Parás-Bravo, P., Cigarán-Méndez, M., & Navarro-Pardo, E. (2017). Sleep disturbances in tension-type headache and migraine. Therapeutic advances in neurological disorders, 11, 1756285617745444. Dodick, D.W., Eross, E.J. and Parish, J.M. (2003), Clinical, Anatomical, and Physiologic Relationship Between Sleep and Headache. Headache: The Journal of Head and Face Pain, 43: 282-292. Holle, D., Naegel, S., & Obermann, M. (2014). Pathophysiology of hypnic headache. Cephalalgia : an international journal of headache, 34(10), 806–812.