Understanding Sleep Apnea

A Conversation with Dr. Stern, Founder of Blue Sleep

Guest: Dr. Stern — Sleep Specialist & Founder, Blue Sleep

Host: BetterSleep

Topic: Sleep apnea: causes, diagnosis, treatment, and prevention

Introduction to Blue Sleep

Interviewer: Good afternoon, Dr. Stern. It is so great to be here with you today. Thank you so much for your time. Can you please tell us a little bit about Blue Sleep?

Dr. Stern: Thank you for inviting me — it's a pleasure to be here. I love talking about sleep. Before I created Blue Sleep about 15 years ago, I was a throat surgeon, and I became a sleep specialist when I realized how many people suffered from poor sleep — sleep apnea especially, which is related to the throat.

Dr. Stern: I realized it was very hard to get diagnosed and very hard to find a sleep doctor. I thought, let's make this easy. Let's use telemedicine. Let's use technology. Let's have people make an appointment online, communicate through their phone or computer with our medical staff, and ship the best diagnostic technology directly to their homes to diagnose sleep apnea or other sleep disorders.

Dr. Stern: We started before COVID, but during COVID — when it was impossible to see a doctor in person — a lot of people found our services particularly useful, and we grew very quickly. We learned a lot: the best way to ship devices, to contact patients, to make sure they complete their sleep test, and to follow up. Over the past eight years, we've grown into what I'd say is probably one of the largest telemedicine sleep groups. People can make an appointment within an hour and follow up with us from nine U.S. states and the United Kingdom.

What Is Sleep Apnea?

Interviewer: What exactly is sleep apnea, and how would you explain it to someone who's never heard of it?

Dr. Stern: Sleep apnea is a term people have been hearing more often these days, but a lot of people don't know exactly what it is. It's a sleep disorder — "sleep apnea" literally means "no breath while sleeping." It's repeated interruptions of breathing when people are asleep, and since they're asleep, they usually don't know they have it.

Interviewer: So how can someone tell if they have sleep apnea?

Dr. Stern: That's a very good question. In most cases, the bed partner of the person with sleep apnea notices something unusual about the way they sleep. People with sleep apnea typically have loud snoring that occurs all night and is associated with pauses in breathing. A lot of our patients tell us that the reason they're consulting with us is that their bed partner has told them they stop breathing while asleep — they hadn't noticed it themselves.

Interviewer: What are the common signs or patterns that might show up day-to-day?

Dr. Stern: Because sleep apnea interrupts deep, restorative sleep, people with it frequently feel sleepy during the day. They feel unrested in the morning, fall asleep in the afternoon, have difficulty concentrating, struggle with memory, and have mood issues — they're grumpy.

Health Consequences of Untreated Sleep Apnea

Interviewer: What are some of the health consequences when sleep apnea goes untreated?

Dr. Stern: One of the most common consequences is high blood pressure. Sleep apnea has been shown to cause high blood pressure, and if you treat the sleep apnea, you can control the blood pressure — in some cases getting drops in blood pressure without medication. It also leads to many other chronic diseases associated with high blood pressure: heart disease, stroke, diabetes, weight gain, and more.

How Sleep Apnea Develops and Its Causes

Interviewer: How does sleep apnea develop over time?

Dr. Stern: It develops as the body changes — as we age and as we gain weight. The throat can narrow as a result of weight gain, and at night it can narrow due to less support of the tissues and muscles. It won't happen from one day to the next; it can take 20, 30, even 40 years.

Interviewer: What are the most common causes of sleep apnea?

Dr. Stern: Sleep apnea is caused by a narrowing of the throat, so anything that causes that narrowing can cause sleep apnea. It can be the shape of the throat, the shape of the jaw, the size of the tongue, or the size of the tonsils.

Dr. Stern: In children, sleep apnea is caused by large tonsils in the vast majority of cases. In adults, that's less of a problem — it tends to be weight gain, which is common. But even without weight gain, the shape of the face matters. A smaller top jaw (the maxilla) or lower jaw (the mandible) leaves less room for breathing in the throat. Some people have larger tongues, which take up a lot of space and make it difficult to breathe at night.

Dr. Stern: Some adults do still have large tonsils, and that's one of the causes of sleep apnea and snoring in adults. It's not that common, but it's one of the relatively easy curable treatments — by removing the tonsils, for example.

How Sleep Apnea Is Diagnosed

Interviewer: How do you diagnose sleep apnea?

Dr. Stern: The way to formally diagnose sleep apnea is with a sleep test. There needs to be a medical setup where someone observes your sleep and determines that you stop breathing a certain number of times, and that as a result, the oxygen in your blood has dropped or your brain has been aroused from sleep.

Dr. Stern: That used to be done in hospitals, but now it's done with home sleep testing technology that fits on your finger. It connects to an app on your phone and sends us the information about whether or not you have sleep apnea. It's super easy to diagnose, and you can sleep with it at home for multiple nights — because sleep apnea may not manifest every night.

Treatment Options

Interviewer: What are the treatments for sleep apnea?

Dr. Stern: In children, removing the tonsils can in some cases cure sleep apnea. In adults, it's usually not that easy — it's different for everybody. If someone has a very small jaw, in some cases they need surgery to correct it. In most cases, treatment involves techniques to keep the throat and airway open at night.

Dr. Stern: One option is a mandibular advancement device — a little mouth guard custom-fit to the teeth. The top and bottom are connected, and when placed in your mouth, it keeps the lower jaw forward so it doesn't drop back. As a result, it takes care of both the sleep apnea and the snoring. It's a very effective treatment.

Dr. Stern: The other treatment a lot of people have heard about — and that's kind of scary for a lot of people — is CPAP: continuous positive airway pressure. That's a mask that fits over the nose, under the nose, or over the nose and mouth, connected to a little machine that blows air in. It keeps pressure in the throat so it doesn't collapse. We tend to use CPAP for people with very severe sleep apnea who stop breathing more than 30 times an hour. For others, the mouthguard is very effective, very easy to use, and a great treatment for snoring, which is extremely common.

Lifestyle Adjustments

Interviewer: What are some lifestyle adjustments someone can make if they have sleep apnea?

Dr. Stern: In many cases, it's many years from the first symptom to the time we see a patient as medical professionals. For patients who are going to wait, I suggest trying some lifestyle adjustments that can help:

Dr. Stern: If you're overweight, losing weight may take care of the snoring and sleep apnea. If you like to have a drink every night, that will definitely make snoring and sleep apnea worse — have the drink at another time. Sleep position matters too: when you sleep on your back, the jaw tends to drop, which narrows the throat and makes things worse. Sleeping on your side is one of the key lifestyle adjustments.

Dr. Stern: Diet can also play a role. If you eat very spicy food and have a lot of acid reflux at night, the acid reflux can cause swelling of the throat, which causes snoring and even mild sleep apnea. Changing the diet can sometimes help.

The Role of Digital Tools and Apps

Interviewer: How can digital tools like BetterSleep help with early detection of sleep apnea?

Dr. Stern: I think sleep treatment changed when the first sleep app was invented — go back to 2008 with Apple. Suddenly people started getting information about their sleep and became aware that they weren't sleeping well and that maybe that's why they were having problems during the day: concentration issues, mood problems, physical or mental performance issues. I really credit sleep apps with the rise in awareness about the importance of good-quality sleep.

Dr. Stern: BetterSleep actually detects snoring, and snoring is one of the most common symptoms of sleep apnea. If you have significant snoring, you really should have an evaluation for sleep apnea. We've used BetterSleep to help notify users who snore that they may have sleep apnea. That's critical — there's no better way to reach so many people who may have an underlying disorder like sleep apnea, which can be a considerable medical problem.

Sleep Apnea and Insomnia

Interviewer: A lot of our users at BetterSleep come to us for insomnia. Is there any relationship between insomnia and sleep apnea?

Dr. Stern: Great question — absolutely there is. At least 30% of people who have sleep apnea also have insomnia. There are two types of insomnia: sleep-onset insomnia, where you get into bed and can't fall asleep, and sleep-maintenance insomnia, where you fell asleep but woke up at 3 or 4 in the morning wide awake and couldn't go back to sleep.

Dr. Stern: People frequently call that insomnia, but in many cases it's actually sleep apnea. You have to ask: why did you wake up at 3 or 4 a.m.? Often it's because you were struggling to breathe all night, your struggle became more difficult, the oxygen in your blood dropped, and your brain woke up — and now it won't let you go back to sleep because it wants you to keep breathing. That's actually sleep apnea disguised as insomnia. There's a very strong association between what people think is insomnia and what turns out to be sleep apnea.

Common Misconceptions About Sleep Apnea

Interviewer: What is one misconception about sleep apnea that you'd like to dispel?

Dr. Stern: Can I dispel more than one?

Interviewer: Sure.

Dr. Stern: First: sleep apnea is not a disorder of elderly men. It can affect children, as I mentioned. It certainly affects women — including women in the third trimester of pregnancy, who start snoring and can develop sleep apnea, which can lead to problems with the baby and delivery. Sleep apnea is a disorder that affects men and women of all ages.

Dr. Stern: Second: diagnosing sleep apnea is as easy as getting a home sleep test, putting it on your finger, connecting it to an app, and getting the result.

Dr. Stern: Third: the treatment does not have to be the CPAP mask that a lot of people are afraid of. It can be the oral appliance that you just put in your mouth.

Cost and Insurance Coverage

Interviewer: Can you talk about the cost and insurance side of this? Is that a barrier for many people?

Dr. Stern: Insurance is different in different parts of the world and different countries, and in the United States it's different in every state. Insurance coverage has the reputation of being pretty terrible in the U.S., except it actually does cover the treatments for sleep apnea and home sleep testing. Home sleep testing has been covered by Medicare since 2008.

Dr. Stern: Oral appliance therapy like this one is also covered by medical insurance. It won't be covered if you go see your dentist, because dentists don't really participate with medical insurance — but at Blue Sleep, we're a medical team, and this is covered. It's not covered by insurance all over the world, but it is in the U.S. These are medical treatments, and as long as they're performed by medical staff, they're covered by insurance.

Advice for Better Sleep Tonight

Interviewer: What advice would you have for someone who wants to start improving their sleep tonight?

Dr. Stern: Prioritize your sleep time — try to get ready to go to sleep at 10 or 11 p.m. Breathing while you're asleep is very important, so if you have chronic nasal congestion, as soon as you lie down it's going to get worse; you'll have to breathe through your mouth, which will make your sleep worse. Having a decongested nose is really important. If your nose is always congested, you may need to see an ear, nose, and throat doctor.

Dr. Stern: Falling asleep requires relaxation. There's no magic where you get into bed, turn off the light, and fall asleep just because the light is off. You have to already be relaxed — you have to be within your bedtime routine. Mobile phones and laptops in bed usually don't help. The blue light from phones actually prevents your brain from producing melatonin, the hormone that makes you sleep. Stay away from phone blue light — many phones have an orange filter you can enable.

Dr. Stern: Exercise, but not too close to bedtime. Think about what you've eaten — don't eat a big meal close to bedtime. Think about alcohol — even one or two glasses just before sleep can decrease sleep quality. Caffeine keeps you awake and stays in your body a long time, so try to avoid caffeine as you get closer to noon or 1 p.m.

Dr. Stern: If you like to nap — which is actually good for your health — avoid napping at least 3 to 5 hours before bedtime.

On Napping

Interviewer: Why is napping good for your health?

Dr. Stern: Lots of people have napped. Salvador Dalí had an interesting way to nap — a very, very short nap. He'd sit in a chair with a saucer on the floor and hold a spoon in his hand. As soon as he fell asleep, the spoon would fall into the saucer and the noise would wake him up. That's called the Salvador Dalí nap, and it was just a couple of minutes. By chance, that's about the amount of nap time I need to feel refreshed when I'm very sleepy.

Dr. Stern: Short naps are better. If you take very long naps and don't feel refreshed, you may have an underlying sleep disorder. But short naps — ideally 20 minutes, and usually not past 3 or 4 p.m. — are very helpful and have been shown to increase cardiovascular health.

Closing

Interviewer: That's fantastic. Thank you so much for your time today, Dr. Stern. This was such an insightful conversation. Where can our listeners learn more about your work?

Dr. Stern: A pleasure to be here. Go to bluesleep.com or bluesleep.uk. We have lots of information on what we've done — blogs, videos, and some of the research we've published in the peer-reviewed medical literature. If you have a question that doesn't have an answer on our website, contact us at [email protected] and I'll be happy to answer.

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