Dr. Ellen Csepe // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses which patients are prone to sleep apnea, how to identify signs & symptoms, and when to know to refer & who to refer to

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EPISODE TRANSCRIPTION

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ELLEN CSEPE Good morning everybody and welcome to the PT on ICE daily show brought to you by the Institute of Clinical Excellence. My name is Dr. Ellen Csepe. I'm an outpatient physical therapist. I'm also a teaching assistant with the modern management of the older adults division. I'm coming to you live from Littleton, Colorado today, repping my Denver Nuggets playoff shirt. And today, my goal has been for several months now to make sure that physical therapists are here to support the growing patient population with obesity. I really want to make sure that physical therapists are involved in this conversation to meet their needs because this population is growing rapidly and the healthcare world needs all hands on deck to help support this patient population. Today, for today's Leadership Thursday, We're going to be talking about obesity and sleep apnea. So in a lot of our course conversations, we talk about the importance of sleep hygiene. We talk about how important sleep is to mitigate the risk of injury, to help with healing, to decrease pain. But I think it's a really missed opportunity if we don't talk about how obesity can cause sleep apnea and sleep disorders. And I think we should feel compelled as physical therapists to know those risk factors and also kind of be the first responders for our patient population to make sure we pass the baton to the right clinician to help them with a potentially life-threatening problem. So what you can expect today, we're going to talk about how sleep apnea and obesity are related, but not mutually exclusive. Then we'll talk a little bit more about what the symptoms of sleep apnea are in both adults and children. Next, we'll talk about our screening tools that we can use in the clinic to look for sleep apnea. And last, we'll talk about where to pass the baton to make sure that we refer patients to the right discipline to help manage this issue and what treatment might look like with them.

THE RELATIONSHIP BETWEEN OBESITY & SLEEP APNEA So first, obesity and sleep apnea are very closely related. Sleep apnea incidence has increased significantly in the past several decades, largely because of the increase in obesity rates in our country. Sleep apnea is basically a loss of breathing or difficulty breathing at night, which can be life threatening. Obesity is a disease and how we look at it. And that disease is kind of twofold. First, we look at obesity as an adiposopathy disease, which basically means sick fat disease. What that implies is that excess adipose tissue basically sends excessive chemical messengers throughout our bodies, which puts us at risk for diseases like cancer, heart disease. diabetes, also hypertension, all of those are chemically mediated from excess adipose tissue in our bodies. Then we also look at obesity as a fat mass disease. And what I mean by that is that excess adipose tissue puts physical pressure on our joint structures, like our joints, increasing risk factors for arthritis, But the way that sleep apnea is a disease is because excess adipose tissue in our bodies puts pressure on our chest, our throats, and even excess adipose tissue in our tongue can make breathing very difficult at night. I'd like to bring up this point that obesity isn't the only risk factor for sleep apnea. And as we're learning more about sleep apnea, there are lots of different things that can cause sleep apnea, from centrally mediated sleep apnea with risks of medications, to actual physical changes in our jaw and our throat structure which makes breathing difficult at night. So people with obesity aren't the only ones that can have sleep apnea and the rates are increasing for several different reasons. I'd like to bring up that those with a lot of muscle mass in their thorax or breast implants can also have obstructive sleep apnea, increasing that difficulty because of the physical pressure to breathe. So here's some annoying things about sleep apnea. It makes managing obesity way harder because we know how important sleep is for our overall health. But having disordered sleeping patterns or difficulty sleeping or literally stopping breathing while you sleep makes your risk of cancer, heart attack, having all of those increased risk factors because of poor sleep makes this even more difficult to manage. Additionally, when we're in a decreased sleep kind of pattern. And when we're sleep-deprived, our food choices kind of gear towards higher nutrient or higher calorie density foods. So if we're not sleeping well because we're struggling with obesity, we automatically go to higher calorie food choices because our brains are in a sleep-deprived state. And that's what we think we need. So sleep apnea makes managing obesity and the risk factors for lots of the sequelae of that disease significantly more difficult to manage. And in fact, people die from sleep apnea. I know this is really kind of hard to understand, but 38,000 people in the United States die annually because of unmanaged sleep apnea. That's about as how many people die in car accidents in the United States. That's a big number. And I feel like it's part of our job to see that risk and to know what the signs and symptoms are. So we know that people with obesity are more likely to have sleep apnea, but it's not the only risk factor. We know that a lot of other patient populations can have sleep apnea as well.

SIGNS & SYMPTOMS OF SLEEP APNEA Next, let's talk about some of the signs and symptoms that we'll see in those with sleep apnea. So as adults, we'll hear a lot of Okay, they're snoring really loudly, louder than they would talk. You can hear them on the other side of the door, so snoring. Patients with sleep apnea often express daytime sleepiness, fatigue, difficulty concentrating, depression, anxiety, because they're in a sleep-deprived state constantly. They cannot breathe. Additionally, they'll likely have hypertension, walking headaches. they'll likely be more likely to get sick in their daily routine. So those adults with sleep apnea are more likely to be tired, snore, have apneic events that are observed by other people. Like, dude, you stopped breathing for an entire minute when I was sleeping next to you the other day. So being mindful of what that looks like as an adult is really important, but sleep apnea and sleep disorders are affecting children more. As we kind of go into the weeds, we know that sleep apnea is related to our jaw shape and our upper airway shape, both of which are influenced by our food choices. And with foods becoming softer and softer throughout the past millennia, We don't have to develop why jaws and our airway and our tongue and our palate all change because of that. If you've read the book, Jaws or Breath by James Nestor, it kind of talks about, okay, our jaw size is very closely related to our risk of sleep apnea and breathing disorders. So in children, sleep apnea can look similar. You know, stopping breathing, snoring, mouth breathing at nighttime, more likely to have allergies and throat infections. Bedwetting is another really common side effect of having sleep disorders as a child. Additionally, ADHD and inattention are very closely related to sleep disorders. In an adult and neurological conditions, pediatric neurological conditions, we always like to know how well they're sleeping because we know how impactful sleep is for our overall health and our brain specifically. So, okay, we talked about what symptoms patients might come to if they have sleep apnea.

SCREENING TOOLS FOR SLEEP APNEA Next, let's talk about some screening tools that we as clinicians can look out to see, okay, is this patient struggling with sleep apnea? How can we get them to the right place? The questionnaire that I often use in the clinic is the STOP BANG questionnaire. So, STOP BANG looks at sleepiness. So, we like to see, okay, are we having snoring at nighttime or apneic events? So, STOP looks at, the letters are kind of mixed up. But looking at daytime or nighttime snoring, we like to look at hypertension because adults with sleep apnea are likely to have hypertension. We look at daytime sleepiness. If they're having a lot of daytime sleepiness, that could be an indicator for sleep apnea. And then the BANG stands for BMI, so if they have a BMI over 35, that's problematic. The O stands, or I'm sorry, BANG, B-A, looks at age. If they're over 50, that puts them at a likelihood of having sleep apnea. N is for neck circumference. So if your neck is bigger than 17 inches, that's problematic and puts you at an increased likelihood of having sleep apnea. And then G stands for gender. Males are far more likely to have sleep apnea than females. So that's a really great screening tool. I'll put a link in the comments on Instagram so that you can use it in the clinic if it's helpful. A few other clinical features that we can look at in our patients is looking at the tongue. If their tongue is having a lot of scalloped edges or wavy edges, that could be a risk factor for sleep apnea. If they have venous pooling under their eyes, so a lot of purple dark bags under their eyes, could be indicating that they're not getting quality sleep. And then the MalinPati score, so if you have your patient open their mouth as wide as they can and stick out their tongue, you want to be able to see their uvula and their soft palate. You want to be able to see a lot of structures at the back of their throat. I'll link this score as well, but if you can't see their soft palate, their uvula, and can only see their hard palate because their tongue is in the way, that is a really strong predictor with excellent specificity that that person is likely to have obstructive sleep apnea. So those clinical tools are very helpful for us as physical therapists to be able to pick up on these problems. So next, let's kind of talk about who we would pass the baton to. If we were thinking, okay, yeah, this person is having episodes of sleep apnea, they're snoring really loudly, they're having a lot of daytime sleepiness, they're high blood pressure. We've got problems here. Their tongue is really impeding their airway flow. They even have that weird scalloping on their tongue.

REFERRING PATIENTS WITH SLEEP APNEA What do I do next? So of course you could refer the patient to their primary care doctor. That's an easy pass there. Additionally, I have found dentists to be hugely helpful. I'd like to give a shout out to my favorite referral source, or place to refer, Dr. Pat Prendergast. He helped me kind of prepare this podcast this morning and wish me luck. But we talk a lot together about how to manage patient sleep apnea without using things like CPAP machines or oxygen at nighttime. And dentists are taking kind of the charge here and looking at airway disorders and breathing problems at night because this is such a huge problem in our communities and in our world. So dentists are another great referral source or another great place to refer patients to if you're concerned that they have sleep apnea. And then obviously pulmonologists, ENTs would be appropriate disciplines for patients to see if they had structural problems or pulmonary problems that could contribute to their sleep apnea diagnosis. So treatment can look different from person to person. So Depending on the findings, we might suggest that a patient lose weight to manage some of their obstructive sleep apnea. That is a really exciting new thing that we're finding, that managing weight can be hugely helpful in minimizing the risk of sleep apnea. New medications like the GLP-1 agonists, Ozempic, Wegovy, those have been helpful in managing sleep apnea, and bariatric surgery is helpful in managing sleep apnea too. So understanding that those weight loss efforts will likely impact somebody's sleep is huge to recognize. Additionally, we have options from jaw devices or oral appliances likely created by a knowledgeable dentist like Dr. Pat. Mandibular advancement devices kind of pull your jaw forward to open your airway more. You could have a retainer or different options that they would fabricate to kind of improve your tongue positioning. Additionally, there are other techniques like vivos, which is actually here in Highlands Ranch, Colorado, to basically spread out your palate and change the shape of your upper airway and your jaw to make it so that your airway is more open and allow breathing. Additional interventions, there are CPAP machines and other machines like it which basically force air into your airway, into your nose and your mouth. Some attach only at your nose, some attach throughout your nose and mouth. Those, as physical therapists, we like to know if those are changing or new because they can put excess pressure on the suboccipitals. change pressure there. But we really want to encourage our patients to use those because they can be life-saving and if that's what their primary care doctor recommended, we don't want to ignore that recommendation. Additionally, there are surgeries that can be performed to get more airway through that upper airway and even newer technologies, newer interventions like the Inspire which basically has a battery pack, monitors your pulse oximeter, looking at your oxygenation in your blood, and has an electrical stimulation to your tongue that if you were having an apneic event it would stick your tongue out and get it out of the way so that you could breathe. I've had several patients have the Inspire procedure and been really happy with that intervention.

SUMMARY So we talked about a lot today. We recognize that patients with obesity are far more likely to have sleep apnea, but not everybody with obesity will have sleep apnea, and not everybody with sleep apnea will have obesity, and it's a growing problem in our culture, in our world, and with our patient population, and we need to care. So we recognize that obesity and sleep apnea are related, but not mutually exclusive. We talked about some of the symptoms of sleep apnea in both adults and children. We talked about the screening tool, the stopping screening tool, and looking at that Malin-Potti score. looking at the tongue and other clinical features like bags under the eyes, that venous pooling, those are the things that we want to look at in our patient populations. And then we talked about who's the right person to take it from here, knowing that dentists are underrated and how they could be helpful in managing this if they're aware of sleep dysfunction and how to treat it. So we recognize that there are a lot of different interventions and those will likely impact our patients in some way, whether or not that's going to impact their jaw positioning and potentially need treatment for their jaw or their upper neck, their suboccipitals. So thank you guys so much for joining me this morning. I hope that this information is helpful in managing this growing crisis that we see in our patient population. Have a great rest of your morning and go Nuggets.

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