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Risks associated with Snoring

May 30 | 2:30 PM

Snoring is a common symptom of obstructive sleep apnea, a disorder that increases the risk of diabetes, obesity, hypertension, stroke, heart attack, and other cardiovascular issues. The number of people with obstructive sleep apnea is increasing as people age, develop hypertension, diabetes, or metabolic syndrome (pre-diabetes), which is particularly alarming to healthcare practitioners. Dr. Rahul Sharma, Critical Care and Sleep Medicine Consultant at Yatharth Hospital in Noida, will discuss how to tackle the hazards of snoring and how to control it.

[Music] good evening everyone this is dr vishali from matlix and i welcome you for this session risks associated with snoring today we have with us dr rahul sharma he is a senior consultant and head pulmonology sleep and critical care medicine super specialty hospital noida extension after finishing in his mbbs and md he went on to do his dnb and then dm pulmo he is also gold medal winner in critical care and sleep medicine his interest specialty interests include obstructive heart diseases severe asthma management interventional pulmonology interstitial lung disease sleep medicine and polysomnography so with this i welcome you sir on behalf of netflix and our audience with this sir i'll hand it over to you thank you very much i think this is a very very pertinent topic good evening everyone i am dr rahul sharma and i am practicing this sleep medicine for the last 12 years and recently there is a you know new curiosity regarding this snoring because we lost one of our celebrity because of sleep apnea so people are very very you know curious or they are rather stressed if they are having some kind of snoring so we must know that when snoring is problematic so this is the topic of today risk associated with snoring what is normal and what is not right so this these are some of the points that i thought when when somebody is snoring they have these questions in their mind why snoring happens is is the snoring normal is snoring means deep and sounding sleep most of us believe that snoring causes very if you are snoring then you are in a deep sleep or very sound sleep does snoring harms anyone how dangerous it can be and when to seek medical advice for snoring what are the risk factor in which you need to consider that snoring can be a problematic thing for you how to evaluate your snoring or sleep apnea which is associated with snoring and what are the managements so these are the point i am going to highlight in my talk and probably this will be a fruitful talk for everyone so the first question is what is snoring and why these snows so snoring is basically nothing but it is a loud sound which produces because of obstruction in our airway while we sleep so what happens when we sleep our muscles tone goes down the pharyngeal muscles or the muscles which are there in our throat they they tone down and if we are overweight or there are some anatomical problems in our airway it narrows down and it creates echo which is horse harsh and that is what is snoring uh you called it so snoring is nothing but it is a loud sound because of the partial obstruction in our airways so people who snores you have observed or you have must have experienced this with other people that there is a break sometimes in between people start snoring there's a block and they again start snoring so when there is a complete blockage it is called apnea or no breathing then there is no snoring snoring is always there when you have partial obstruction of the airways and nearly every one of us has experienced this snoring ourself or to our loved ones so we must understand that not every snoring is problematic as as far as the disease is concerned but yes it is always problematic to the bed partner or the person who is you know sleeping or staying uh behind you when you are snoring so problem arises when you have these symptoms persistently recurrently probably every day or whenever you are sleeping so if you have loud persistent snoring which is almost always happening to you when you are sleeping and it is associated with pause in between means that there is no sound in between which which correlates or suggests that you are having apneas or pause in the breathing in between and the most important thing is when you are snoring you must have some kind of daytime or nighttime symptoms so by that we define snoring into two parts primary snorers or people who have this habit of snoring or habitual snorers versus people who have sleep apnea so primary snoring is nothing but people who could not sleep because of snoring and usually it is an infrequent phenomena it doesn't happen daily to these people but people who are snoring regularly they are at the high risk of development of sleep apnea and the other important things even if you don't have these symptoms at present most of the time what happens that we have when we have this snoring problem it usually you know start from the middle a's or early part of the of the age but over a period of time it can you know persistent snoring can goes and you know you can develop all kind of signs and symptoms in the later part of the disease so it is not like that if you are not having symptoms today and you are snoring heavily you will not have symptoms tomorrow so it is very very important to look for these symptoms and what are these symptoms so this was a very interesting study in uh which was published in saudi medical journal where a dentist done this study they they actually you know consecutively uh took 200 patients who came to their clinic and who were snoring and they tried to find out that whom are the people who are whose snoring is habitual or we can consider it normal or how much are the patients who have this this risk of sleep apnea so out of 200 patients 18 of the female has this habitual snoring problem which is more common in males which was to the tune of 80 percent and there are reasons why males know more than females because the airway of males are longer that's why the collapsibility part is more uh and there are more tendency of obstruction in male patient as compared to female and the the snoring sound is always less in females as compared to males so female if they are snoring at all they are at risk of development of the sleep apnea but they find out that people who were snoring out of 81 percent 78 percent has this risk of os or obstructive sleep apnea and female as i told you that 18 of female has this problem of habitual snoring but the risk of sleep apnea was higher in these female 21 of these female has the risk of sleep apnea and why we care about snoring so it is not only annoying or embarrassing to you as well as your bed partner but people who snore has a 40 greater chance of dying early as compared to their peers and we we recently have this incidence we lost our famous singer because of sleep apnea so it is very very important when you are snoring you must evaluate that this is a primary snoring or the habitual snoring or you are developing some kind of symptoms so it is not always necessary that you go to hospital or to a doctor to assess this but these are the symptoms if this snoring you have any of these symptoms or higher is the number of symptoms more are the chances that you might have sleep apnea or obstructive sleep apnea associated with your symptoms and sometimes these symptoms are so vague that you correlate these symptoms with your you know overwork your loss of energy so the most ignored and most common symptoms in people who have sleep apnea is lethargy they feel lethargic throughout the day they don't feel like doing active uh work they they feel sleepy but they are not sleeping so they believe that people who are sleeping in the day only these are the people who have these symptoms but the earliest symptoms of sleep apnea is daytime lethargy poor concentration lack of concentration people who have restless sleep and the most short thought sign is witness breathing pause during the sleep so if you are having or you are observing your bed partner or your you know loved one that they are having pauses in between the sleep that is called apnea it is a short short sign that you are having objective sleep apnea other than this if your disease is severe then you can have excessive daytime sleepiness we see so many patients who are sleeping during the you know during the the during a during while driving or people who are sitting in the vehicle people they sleep on the airport so you have seen so many patients when we are going around that there are patients who are just sleeping in any and every conditions so these are the patients in which you define this as excessive daytime sleepiness poor concentration is one of the most important symptoms and most of us are struggling and believing that these are the symptoms are because of are overworked we we are pressurized with our work we are doing uh more work we are not able to concentrate but believe me that that if you don't have sleep apnea there is nothing like this that you are not able to concentrate on your work morning headaches are again a very important symptoms and although it is not common in most of the people but it is a symptoms which suggests that you have severe sleep apnea sore throat when you wake up in the morning dryness of mouth frequent urination in the night these are again the symptoms of sleep apnea restlessly you believe that you are sleeping eight hours in the night but the sleep is restless you are not able to wake up fresh in the morning these are again the symptoms of sleep apnea and it is not simple snoring that we are talking about gasping or choking in the night is the same thing as breathing pause sometimes these pro these are so long that they the body send a signal to brain that you wake up immediately and you wake up like you know in the frightening condition that what had happened i was choking so these are again the symptoms of sleep apnea not simple snoring people in the young age who develop hypertension one of the most important cause of this is sleep apnea chest pain in the night again a very important symptoms and i'll be coming to that that people can have cardiac arrest in the night and they are ignoring their sleep apnea frequent nighttime urination is again one of the important factor that most of us ignore because of that we are drinking lot of water because of the dryness of mouth and that's why we urinate more so all these things we always find some or the other reason but we never think that why it is happening to us if you are snoring so loud that it is disrupting your partner's sleep then it is again a very very important thing you must understand this also in children children do get sleep apnea so my thesis or the research was also on pediatric sleep apnea so in pediatric population the symptoms are little different these these these kids are hyperactive they they don't sit at one particular place uh properly although the scores are very very good in schools but somehow they are not able to concentrate properly and they most of the time sleep with open mouth the reason for sleep apnea and pediatric population is different from adults but if your child is snoring then there are a lot of problem that can happen to him other than the neurological problem there are failure to thrive child might not gain weight appropriately poor concentration hyperactivity there are change in the morphological profile of the face which may predispose these patients into adult also to develop sleep apnea so these are the things that we need to look into so when when this snoring you know converted into sleep apnea actually we don't know initially and most of the time these symptoms you know these symptoms progress so slowly that we accept such kind of change in our life as a normal routine what we expect that we will be lethargic most of the time the work is so much that i don't want to work anymore we can sleep or take naps in the day still we don't feel fresh most of the time and the most important thing is that you you develop some kind of disease like hypertension diabetes poor concentration lack of memories there are number of things that you can develop and you believe that this is the natural course of the disease and when we never go back to why it is happening to us and sleep apnea is one of the most ignored condition worldwide right so when do you develop sleep apnea when you are snoring when your snoring is causing recurrent interruption is your breathing during sleep which is complete to partial obstruction of upper airway leading to repeated hypoxia means decrease in the oxygen level which sends a signal to your brain that you should wake up you wake up sometimes you realize that you have waked up sometimes only your brain wakes up and these signals causes lot of dynamic changes in the body the physiology changes when you are sleeping and your sleep is constantly disrupted because of your snoring and obstruction and these things can happen hundreds of times during the night leading to fragmented and non-restorative sleep so you will even you are sleeping for eight hours in a night but because of this disruption your sleep is never complete it is never sound and all these sleep deprivation non-restorative sleep leads to daytime symptoms in the patient so this is the cycle which you can see when you are having sleep apnea there are airway collapse multiple times leading to decrease oxygen in the blood which sends signals to heart brain body struggles brain arouses and leading to awakening which awake when but you once you awake then you again go back to sleep the same cycle repeats again and these are the cycle which keeps on going inside the body when you are sleeping and this disruption in sleep awakening put a lot of stress to your heart brain other part of the body and leads to consequences which may leads to symptoms in the patient so what are the consequences in a very nutshell way if you have sleep apnea it leads to sleep fragmentation leads to cardiovascular morbidity increased cardiovascular events and daytime symptoms ultimately what it causes it causes increased morbidity and mortality in the patients what can happen if you ignore your sleep apnea so these are the condition which you can develop when you you ignore your sleep apnea hypertension stroke heart failure coronary artery disease in terms of myocardial infarction or other cardiac disease pulmonary artery hypertension rhythm disorders diabetes reflux gerd nocturnal angina hypothyroidism neurocognitive difficulty so almost every part of the body all the vital organs of the body get affected when you are not giving attention to your sleep if you have any of these diseases then most of the time these diseases are very poorly controlled because of the hormonal changes that sleep apnea causes in your body which is most of the time insulin resistance uh change in the ghrelin hormone in the body which which which leads to increase in the weight gain again and and all these diseases which are poorly controlled can lead to increased morbidity and death in the patient a most important uh you know symptoms which we do not know or we do not observe is the number of accidents so the chances of accident while you are driving the car is 10 times more if you are having sleep apnea versus people who are normally driving so it is not a you know health hazard to you it is a health hazard to community so in u.s there is a norm that if you are applying for a driving license as a commercial vehicle or as for these truck drivers sleep apnea evaluation is must there and this is what i was talking about sudden cardiac that many times we heard that the person sleep in the night and never wake up in the morning so it has been observed and this was published in 2005 in new general uh new england journal of medicine that 50 percent of the osa related deaths occurs during 12 a.m to 6 a.m in the morning while the normal heart attacks that most of the people develop in the morning it occurs from 6 a.m to 12 noon so this is again very very important that you might you know died because of sleep apnea if you you are ignoring this and probably this has happened to our celebrity also who passed away a few days or a few months back and this is the real world data from usa where they have find out that people who has diabetes and not controlled properly out of 10 adults 7 has associated osa and it is a predominant cause of poorly controlled diabetes in them when we talk about hypertension every fourth uh you know every uh four person out of ten has sleep apnea especially when you are feeling that you are taking more than three drugs which is called resistance hypertension so if you are taking three or more than three ducks and your blood pressure is not not well controlled or you're requiring more than two antihypertensive then you must think about sleep apnea because it is most common cause which is ignored in this patient and we keep on increasing the dose of our antihypertensive rather than looking into the sleep apnea part this is a sad reality of osa in snorers that they believe that snoring is common common but it is doing no harm to them despite they are taking medication for blood pressure diabetes thyroid cardiac but they never feel that their snoring is creating any problem to them and this is not the scenario in india this is the scenario in united states also eighty percent of the patients who has moderate to severe osa are still undiagnosed they never feel that snoring is a problem and this is this is probably the myth that we feel that people who snores they have a very sound sleep but this is the other way around if you snore and you if if you have any kind of medical disease probably it is doing more harm to you rather than any good when your snorings can be sleep apnea there are certain points that you can always think of or you can always get evaluated people who are obese and their bmi is more than 30 kg per square meter they are the most common people who has the highest chances of having sleep apnea so there's a notion that people who have 30 bmi 80 of these patients have the chances of sleep apnea in them and there are primary risk factors also that i'll be talking about next circumference is again a good marker which which which act as a screening for you if your next size is more than 17 inches in male and 16 inch in females then you are more likely to have sleep apnea age more than 40 male gender structural factor which is related to craniofacial or upper airway profile is again a risk factor for sleep apnea i'll be talking about that and the family history of sleep abner snoring so people very proudly say that the snoring runs in our family and there is no problem with this but most of the people when you see in this family has diabetes hypertension poorly controlled stroke cardiac factor all these things we need to see and evaluate but most of these people say that as snoring runs in our family diabetes runs in our family hypertension runs in our family cardiac decisions in our family but they are always you know missing this common link between all these diseases and sleep apnea this is very very important that that and even the physician uh you know miss sometimes that the sleep apnea can be a cause of this so this is very very important that we should always think about this we have our indian guidelines regarding this inosa guidelines are the guidelines who has been made for sleep apnea patient that how to screen this patient and how to evaluate this patient and how to you know treat these patients so these guidelines are there in india also but i'm sure 80 to 90 percent of the physician is not about aware about this so how do you diagnose sleep apnea when you are having sleep snoring and you feel or you want to know whether you have sleep apnea or not then there are four parameters that you need to see the clinical evaluation and there are a fixed set of screening questionnaires that you can fill even at home and decide that whether you are likely uh whether you are likely to have this sleep apnea or not then physical examination which often appears normal if you are not aware about that what to look for in sleep apnea then there are risk factors that you need to look into whether these risk factors are there then the chances of having sleep apnea with snoring is even higher and polysomnograph your sleep study is the goal standard which you need to see and confirm whether you have sleep apnea or not so this is a very very you know simple questionnaire which has a nomenclature of stop bang so stop stands for snoring tiredness in the daytime somebody has observed you for stop breathing and if you are having hypertension these are the four factor then in bang if your bmi is more than 35 age more than 50 next circumference more than 40 centimeter and male genders so if you have any of three or more than three items ticked in this then you are likely to have sleep apnea and you must evaluate yourself with a sleep specialist the other questionnaire which is a very very well studied questionnaire in various research is ess or ever sleepiness core where you need to score your condition they have given a condition in which you need to score that what are the likely chances that you will sleep in these condition if you you are in these condition like sitting and reading watching television staying inactive in the public places as a passenger in the car for an hour without a break lying down in the rest in the afternoon sitting and talking to someone sitting quietly after lunch when you have no alcohol in a car while stopping in the traffic and you look into the chances that what are the chances that i'll doze off during this situation if your score is more than equal to 10 then again you have a higher chances of getting sleep apnea and you must evaluate yourself with sleep specialist so these are the two most common score which can be utilized even at home you can ask your patient to see look into these scores if the scores are higher you go further to decide whether your patient has sleep apnea or not other than this physical examination is again the most important thing and most of us see a patient and feel that everything is normal because you truly cannot pick these patients with the conventional examination so what we are doing in conventional examination we are auscultating chest we are looking for eyes paler sinuses general physical examination and systemic examination but when it comes to sleep apnea you need to look into these factors the most important factor is upper airway profile evaluation in which as as we do it for the malampathy scoring is for anesthesia patient we do it for sleep apnea also where it is called friedman scoring and it is a modified mulan party score where you don't ask your patient to protrude the tongue out you just look into the anatomy inside that how much you are able to see and on the basis of this you decide the grade of uh friedman scoring there and other than this you can see the in the picture that there is a the person who has a belly and there are multiple factors which we often ignore double chin and large uvula large tongue nasal congestion nasal polyp central obesities next circumference short neck overweight these are some of the points that we often miss in our patient while we are routinely seeing these patients unless you have this thing in mind you will never you know look in that direction and you will never think about sleep apnea in these patients but there are limitations with these scores also that these are not 100 confirmatory higher the chances of a higher the number of these scores in you higher the chances that you have sleep apnea but for confirmation you need a study which is called polysomnography it is a gold standard study that this is the conformity test and you need it for two reasons one that the confirmation of sleep apnea and other if you require therapy then it can even titrate the therapy and before that there are people who believe that or even after scoring you believe that your patient might have sleep apnea so we can now start doing we have now started doing screening tests for them in which you just have to see the heart lung interaction which is called nocturnal oximetry if your patient has persistent uh longer hypoxia event in your patient then these are the patient who might have sleep apnea and these patients should go for full night uh polysomnography otherwise uh post coveter most of these studies are being done at home so these are called level two studies but technician is also going and they are observing the patient in night so it is as good as level 1 attended full night study multiple channels has been put to you in terms of looking for your brain activity muscular activity nasal flows breathing movements ecg positioning and on the basis of that you know what what comes is is the scoring which is called obstructive sleep apnea hypopnea and ahi on the basis of ahi you decide whether you have mild moderate or severe obstructed sleep apnea which which basically define on the basis of number which you see on the basis of these montas or the number of channels that we are evaluating the other thing is that since since this this entity is increasing people started doing automatic studies where they are not going home they are just providing a machine to the patient or putting the machine and coming back and these are the study which has multiple errors so it can overestimate or underestimate your disease and the titration is most of the time is not good so do not go for a automatic sleep study always ask for level one or level two study where everything has been monitored real time in house or in hospital by the technician and modified according to the need of the patient and titration is always always done with the help of manual titration rather than going for auto cpap auto cpap has only simple indication where you feel that your patient has no other common comorbidities very high likely chances of sleep apnea then you can probably go for these automated sleep study otherwise always always go for level 1 and level 2 studies so how do you manage this so once we have come to this point that it is not a simple scoring snoring but we are talking about sleep apnea and the severity of sleep apnea has been classified mild moderated in severe so in mild disease you just have to you know lose weight do regular exercise no sedatives in terms of alcohol or you know people used to take sleeping pills also because they feel that their sleep is often disturbed but it precipitate and further increase or sleep apnea so lifestyle modification is one of the factor which is very very useful in mild sleep apnea and though there is no other therapies required which so there are modifiable risk factor which includes obesity smoking alcohol use and upper airway collapsibility and there are certain factors that you cannot truly change so these are the factor which which remains there even if you are trying to do everything and trying to improve your weight and you know trying to tackle this sleep apnea so but if the other thing that people usually go for is a you know it's a shortcut that i am not able to lose my weight so let let me undergo a surgery and i'll lose my weight so it has been seen that when you undergo any kind of bariatric surgeries your weight comes down and there are chances that most of your underlying diseases which are uncontrolled is gets controlled but sleep apnea can reoccur again and there are ten percent morbidity and one percent chances of dying if you are undergoing any kind of surgery so it is always better that you should lose weight do regular exercise and change your lifestyle so these are all habit-forming things many times the patient comes to us and say that i am not able to lose my weight despite whatever i am doing and this is purely fine we can understand this because a patient who has moderated to severe osa they have a hormonal changes in terms of leptin and drilling which shift the balance that the people are not able to lose weight rather even if they are eating slow they are gaining weight because of the poor sleep quality increased grading hormones in the body so sometimes it is very very difficult so in these patients other than weight reduction program these patient needs true therapy for the sleep apnea which is with the help of positive airway pressure or commonly we call it as cpap therapy it is again a gold standard therapy most of us when prescribe these therapy to our patient patients are very very anxious that how will i use it but believe me once they start using it they feel comfortable in the night they feel very very active in the day and most of their diseases and symptoms are well controlled when they are using it at accurate pressure so again when we are applying this mask or cpap therapy to our patients it is very very crucial that the sleep study has been done with a good hand so that we truly know the exact pressure it is like giving uh you know specs to your patient they require specs but if the number is higher or lower they will not accept this the the benefit will not be as good as with the accurate number so that accurate number in terms of pressure is also required for patients who have sleep apnea and they require cpap therapy these are the patients who has moderate to severe sleep apnea other important thing is compliance and complication so as soon as so so this is this is a norm that even even in two or three days patient feels very very good in the day and then the electricity comes that let's not use this machine so adherence rate is on as high as 50 percent so is the non-adherence state so what happens that over a period of time when patient feels good they try to avoid these things but these symptoms can reoccur again so you need to have a continuous dynamic counseling with these patients and if they feel any kind of difficulties while putting this mask then you need to sort it out so there is a saying that once you prescribe this machine to your patient you always ask your patient to come back after a week with all the complication fear anxiety they're feeling in the night and you need to try to tackle these so the most common thing is that people are not very very acceptable because of the poor titration so if your study has been done well with titration they there are more likely chances that they will use the the machine the other important thing is correct machine so we believe that everything is good but whatever is automatic so most of the time i have seen that people are prescribing auto cpap to this patient which is not required for most of the patient auto cpap is a device which is used mainly for the patient who has positional apnea means that apnea value is different in supine position and in lateral position so it is very very important that you must choose the machine right and india there is a policy that you cannot just you know replace these machine correct mass is again very very important there are n number of types of masses which is available so on the basis of your patient preference compliance and acceptability you can choose the mask humidification five percent of these patients feels dryness while they are using these devices so humidification is most of the time now is coming up with each and every machine you just have to tell them that how to monitor or you know set these humidification in the night routine follow-up is very very important to ensure the compliance of your patient and education and understanding is again very very important there are surgical management which has been tried but these are not very very successful especially in the other adult patients in terms of nasal airway surgeries uvelop paletto pharyngoplasties tongue reduction surgery genoglossal advancement thyroid suspension but most of these surgeries has been compared with cpap and it has been found that they are not as effective and people have to undergo a knife so these are real-time surgery you cannot really you know reverse it when when these surgeries are not successful so these are still under research there are devices which you can see on amazon other portal side even you know dentist but you can understand if somebody is not accepting the mask over the nose it is very very difficult to accept these devices you know sleeping with the devices inside your mouth so it is very very important that the acceptance rate of these devices is even poorer and these are the devices which is mainly useful in the patient who has some kind of craniofacial abnormalities rather than pure sleep apnea because the obstruction of pure sleep apnea is at the neck level not at the teeth level and this is this i always put in all my presentation he was my friend when i was doing my mbbs he was fat chubby always sweating always in front of the ac and he had met two accidents when i realized this once i completed my dm and then we learned about the sleep medicine i i asked him that you please start using cpap machine and by that time he also had two accidents because of snoring his you know his wife was not sleeping with him so all these problem he was facing so after using this machine i think for a week or so he he messaged me this today i sleep with the cpap machine i do not snore my wife sleep better as the cpap machine is less noisy than my previous snoring i see other falling sleep at the moon while i was awake and fresh i do not have to wake up in the night to urinate i am not depressed and no longer use medications even though my work schedule is just as busy at the time of my car accident i can drive without being tired so i wonder how my life could have been different if my osc has been diagnosed earlier so this is the true message that has been sent to me and i always quote this message to make everyone realize that your life can completely change before and after getting treatment for your sleep apnea uh so so just to sum it up this is a wake up for a call for everyone who is snoring and having any kind of these symptoms that we have prescribed or described or this is even a wake-up call for our colleagues or physicians or you know doctors that we must also keep this differential diagnosis in all our patients who are having diabetes hypertension stroke cardiac illness grd and other symptoms because these are common diseases which which is associated with most of the diseases consequences can be dangerous and early recognition is very well acceptable and you can even prevent most of the disease in these patients once you recognize this early and it is fully treatable so thank you very much for your patient listening if you have any other query i'll be very very happy to answer thank you sir that was a very nice session on understanding that snoring cannot always be casually taken you need to think about and you need to go for the diagnosis of osa like you said uh i'll just request all the audience members if you have any questions you can put up in the comments section dr mustafa i'm accepting your request you will get an audio video on prop up or a prompt please switch on your audio and video dr mustafa can you hear it can you hear me now operation and we are really happy about it i just had one query that how do you explain increased nocturnal see if urine in essay i think it is a very very important question and this question was asked in my exam and i was doing my dm so very simple answer that most of the time this urination increases because of the stress on heart and there is a hormone called anp atrial neutral peptide which is released while the patient is undergoing this kind of frequent you know hypoxia related stress on the heart and it increases the frequency of urine by making more urine because of anp hormones which which release due to the stress on the cardiac wall okay thank you so much thank you sir thank you i can see a few questions on the board so like how psg is done at home is asking that question so most of the time what happens that since pre-covered era we were not very very comfortable doing these criteria at home but there are few agencies which are doing these studies at home now and they do it uh while coming to your house in the night the technician stays there they look for all the events real time and if if they believe that the civility is moderate to severe they can even apply the therapy part in the next part so this is called split night studies so most of our study are now being done at home and they are coming with good results also okay great apologies from my side the some internet issue and i was just taken out of so sorry for that dr himalayan is asking what is the general cost of psg so general cost of the psg depends on you know the area to area but most of the time a good quality study is costing somewhere around eight to three ten thousand rupees and which includes the titration part also but there are companies which are doing it at a lower cost but as i told you that most of these studies are not uh in good quality as most of these studies are done as on automated view which which can you know give you falsely high or falsely low severity of your disease okay uh there's one more raise and request dr shiva koli i am accepting your raise and you will get a prompt to switch on your audio and video you can do so dr ashok is asking whether modafilin during daytime would it be of any help oh absolutely this is again a very very important question because modafili increases your alertness but this is not the drug for sleep apnea this is a drug for narcolepsy where you have this rem sleep intrusion while you are awake that is totally a different disease and modafinil if you use in the daytime and you are forcefully making you awake then you have more chances of sleep apnea in the night so it rather causes worse symptoms in the night and just by alerting yourself you are not improvising the overall quality of your sleep or the events that is happening in the night so modafinil is not the drug of choice most of the time we have seen this that there are few physicians who are prescribing modafinil to sleep apnea patient but it is not right it is only a last disorder drug in patients whom we have used everything otherwise it is a drug specially used for narcolepsy patients my son has undergone a sleep apnea surgery he is one advancement of mandible yes i am from hubli so it was it was done in the dental college of dharma because the first time he when he got his sleep study so we found that that was causing him that sleep apnea is causing him a complication on hearts on his heart so then we thought of uh instead of cpap c cap or cpap we better go for a surgery so my suggestion for the people who are severe type of sleep apnea should go for surgery it is not a complicated surgery it is done in bangalore it is done in hubli and cost is not very high cost is around about 1.5 to 2 lakhs depending upon the type of room you take and it is one year's treatment because not only the mandible has been advanced even his teeth has to be realigned because the alignment of teeth get disturbed so the ortho dentist did this job now his snoring has come to zero no he doesn't snore at all because he was snoring so much that even his children were not ready to sleep with him when he was going traveling in train people used to wake him up and say stop snoring when he goes to overnight journey the people used to say uh stop get up and stop your snoring there was a more than that i i myself is an ophthalmologist more than that i was worried about the sleep apnea causing on the cardiac problem so now after that we have gone uh once again post-op sleep apnea i mean sleep study study sleep study and it has come very nice i wish i could have shown the x-rays taken by those sdm people how much gap it has created and how easy he is he has feeling now this is most uh acceptable surgery i would say because there is no complication but the surgery surgical time is a little more it takes so absolutely i think you have shared a very important information that sleep apnea causes heart disease even in younger patients one thing yeah yeah second thing is surgery is always an option for patients who are not accepting cpap but for that you need to have a surgical evaluation because there are different reasons for sleep apnea people who are obese who has this retrogan india people who have overcrowding teeth then these are the factor which can be correctable but as you said that the response is very very good i'm very very happy for him but if you see into the research then the data is only 50 that it is not necessary that every time the sleep apnea goes completely away but yes people who are not using cpap and they are having the risk of cardiac disease and other factors you can go for surgery no see i've read an article about cpap also for a long time if you use it you may have some uh problems uh i don't remember exactly what problems complications most of these problems are related to machines i think one thing i have come to know that it is a marketing strategy everyone then also had told that go over sleep app don't worry it will be all right when only we said no we want surgery only we want permanent and his cause was there was gap little gap and because his tongue was more larger than normal he has got that's why it was causing more problem now absolutely absolutely he's fine absolutely fine we feel worth spending on one to one unfortunately it is not covered by the insurance people yeah the medical medical should work towards the insurance company that they allow at least for uh mandible advancement surgery they don't know advance for ortho dentistry and all they don't reimburse at least this surgery they should do it because it is a life-saving type also i would say because papillary died because of that everybody knows music director bobby lavery died because of sleep apnea only yes thank you dr shiva thank you so much for sharing your experience and we are really happy to know that your son is doing well now thank you so much we'll be moving on to the next questions now uh don't want to take too much of time off sir as well so the next question by dr nekat fatima what are the risks associated with surgery for osa so it depends on that what kind of surgery you are undergoing so there are so and again it depends on the upper airway morphology of the patient it is not like that every patient goes for the surgery and they get the good benefit and the sleep apnea comes to zero so most of the time the surgery is very very beneficial for the pediatric population where you have adrenal tonsils as a cause of objective sleep apnea in these patients but in adults cpap still the gold standard by u.s standards and surgery always has this risk just consider this that your mandible will be cut it will be advanced you have one year of surgery time recovery which is very very difficult so when people are you know very very afraid of getting any kind of cut these surgeries are risky absolutely risky and every surgery has the risk of anesthesia every surgery has the risk of other things that that that is there but people in which we believe that the the the sleep apnea is so severe that you cannot control it with the help of cpap which is an external device and it is not doing that much of harm or rather i would say there is no harm and versus surgery which has its own complication general anesthesia cut big these are all major surgeries and the other important thing is that there are not much centers in india which are expertise in these so so so these are the things that you should always keep in mind so surgery versus cpap people should always or towards cpa because it is risk-free right true dr singh has a question that is there any medical management of snoring without using any machine yes absolutely the only management is that you should lose your weight to an extent that your bmi should come down less than 25 but as i told you in my presentation when you have moderate to severe sleep apnea losing weight is difficult because of the hormonal changes so what what i always advise to my patient when you have sleep apnea you are very very reluctant to use machine but you cannot lose your weight until unless this cycle of sleep apnea will go down because the hormonal changes is such it will not able to lose your weight so i i ask them to use cpap machine for the time being and start losing your weight if you use if you lose 10 percent of your body weight then your sleep apnea goes down by 25 so this is how it is but without being active in the day you will not able to lose your weight diet has a very important role in this because we all are indians and we all have this habit of eating till our neck rather than till the stomach so this is also a very important factor so these are all you know behavioral modifications that you need to do and over a period of time when you are doing all these things you can get rid of your sleep the cpap machine right uh so dr saab i hope that answered your question also dr dipali singh you had a similar question that what is conservative management of sleep apnea so i think losing weight the way sir sir and that's the conservative management doctor nicholas has another question that the surgery for os and does it include resection of epiglottis too yes there are surgeries in which people who have no not epiglottis it is the uvula part which which is being uh you know resected in this epiglottis you cannot reset if you reset your epiglottis then the voice problem will always be there okay dr vaneta is asking what are the problems associated with the long-term use of cpap so the most important problem is the adherence problem because as soon as you feel that you are good you don't you want to use this machine other problem is with the you know sometimes the pressures are so high when it has it is not well corrected or well calibrated then you often feel dryness of the mouth more uh the air leak is in your eyes nasal congestion these are all minor symptoms which can be very well managed other important thing is if you are not taking care of your machine it is in the open then you have these chances of infection going inside because you are using that machine in the night over your nose and mouth but in the daytime if you are not carrying them well you are not taking care of good hygiene of your machine there are chances of infection but most of these are correctable and preventable there are no long term side effect which would which i would say is harmful or serious in these patients but there are certain contraindications where you should not use these machines like people who are not comprehend well people who has parkinson's patient who has neurological diseases where you they are not able to comprehend well bedridden patient the machines can be used for other reasons like patient who has copd bypass can be utilized in these patients but if you are not able to the person is not able to comprehend well able to maintain his secretion probably this is not the the right time you must always ask your doctor to decide whether the cpap will be beneficial to these patients or not okay there is one more question by dr himalayan that what are the indications of stopping use of cpap so stopping use of cpap because most of these machines are now modern machine as i said that the most common reason of your sleep apnea is your weight when you believe that you have able to you know reduce your weight by 10 to 20 percent of the exact weight you can undergo this sleep study again and see whether the sleep apnea is persistent or not if your sleep apnea is not there you can very well stop this machine but there has to be some correction before you believe that you will undergo a study so you just just by using this machine for three months and then again going for the study without losing weight or changing your lifestyle doesn't make any difference so it is very very important that you should have this weight lot loss policy along with your cpap for the management of your sleep apnea once you believe that you see that your weight is well under control probably after three months six months or a year you can undergo a screening sleep study and you can stop your machine if the ahi is normal okay thank you so much uh dr puja fabio i've accepted your raise and request kindly turn on your audio and video when requested to do so i want to ask you sir i have a daughter she had adenoids at the age of five we got it operated then again we got it operated it was not a successful surgery again we got it operated at age of 12 but from the beginning the problem is mouth breathing even after uh getting it getting the surgery done twice she does the mouth breathing without snoring so i would like to know the people who breathe through mouth whole night do they go for a sleep apnea though they don't snore so my concern for her is that is she having a sleep apnea so most of the time what happens this is a very pertinent question and the research is going on in us so our conception regarding this disease in india is little different we all know that the adenoid goes by the age of 11 or 12 years but if the patient is snoring and this obstruction is happening at the age of three to fourth when these adenoids appears patient has this morphological changes in terms of higher spelling oral uh poor oral attention large uvula these cheekbones becomes enlarged and these are the changes which becomes permanent out of which mouth breathing is the most important thing because even if you once the patient develop this mouth breathing even if you remove these disease and the sleep apnea has gone this is now a psychological thing that the kid is doing while breathing so it it has person no harm but but because of this mouth breathing the palate will be highest and the dentition will be occluded in such position so now there are you know pediatric physiotherapists which gives you such kind of therapy they they give some kind of devices and they ask the kid to breathe through the nose and it is a training process by which this can change because it has come into the you know this this is the cycle that has made in the kid because of the sleep apnea that patient needs to breathe through mouth so now with the training this can go away but the surgery generally has no effect after the age of eight years or nine years when you have permanent facial changes because the phase develops uh till the age of 10 to 11 years so once these permanent changes has come probably you are not able to change morphology much but yes with the help of training this mouth breathing can be getting away great i hope dr puja that answered your question and those were the questions today the one question is is there any association with taking tablets like resty to induce sleep would that cost you sleep so that is a totally different question because if you want to induce sleep then then these and if you have sleep apnea then most of the time your sleeping pills increases the risk of sleep apnea so if you believe that you are you know you are going with the sleep apnea things and you want and sometimes 25 percent of such patient has this complaint of insomnia that they are not able to sleep but again as soon as you correct the the [Music] sleep apnea part with the help of cpap or other weight reduction measures this will go away so sleeping pill always deepens your sleep and it increases the chances of all the events that is happening in sleep apnea that i have described so sleep apnea is not a treatment for people who have disturbed sleep because of sleep sleeping pill is not a treatment option okay great so for all the audience members sir has very kindly put up his email id as well if you have any doubts you can surely reach out to sir and get your queries answered so we have some amazing comments that this session was amazing and they have uh learned a lot and we have very informative enlightening session thank you and all so thank you so much sir on behalf of netflix for taking out time for this session with that i would like to thank our today's faculty dr rahul sharma and i would like to thank our audience thank you so much thank you very much you

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dr. Rahul Sharma

Dr. Rahul Sharma

Senior Consultant & Head | Pulmonology, Sleep & Critical Care Medicine | Yatharth Super Specialty Hospitals, Noida

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dr. Rahul Sharma

Dr. Rahul Sharma

Senior Consultant & Head | Pulmonology, Sleep...

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