Night shift at the Sawmill

Here’s one of those things that I should have learned about in medical school, but really didn’t.  If my patient’s snoring isn’t caused by sleep apnea, then I’m tapped out as to what to do about it.  But Twitter and AMR inspired me to do a little research this week.

Some snoring is nearly universal, and up to 45% of us are habitual snorers.  So be careful before you criticize your spouse or parent too much, next time you have a cold, or get pregnant, or gain that extra 5 pounds, your criticism may come back to you.  Funny how that works.

The overall cause of snoring is increased upper airway resistance, and the reason for that can be pretty broad. Certainly OSA can also be a cause of the snoring, but may also be a result. The more resistance there is, the more likely that arousals and apnea are also present.  Nasal congestion, tonsillar hypertrophy, obesity, and craniofacial abnormalities like acromegaly can all increase resistance by just having less room for air to move through.  Sort of like a stenotic valve causes a murmur.

So why care?  Certainly we all know the health risks of untreated sleep apnea, that I won’t cover here, but what if there isn’t apnea?  There have been some mixed results, but there are few observational studies that link snoring (without apnea) to hypertension and atherosclerosis.  But in reality, it is often the bed partner who urges the patient to get some help.  Marital harmony and relieving embarrassment are real issues for patients and probably the place where treatment can have the most benefit.

Treatment for snoring can take a variety of approaches.  Weight loss alone can go a long way. A very small observational study showed statistically significant decreases in snoring with as little as 3kg of weight loss, and near absence of snoring in patients who lost 8kg.  Other lifestyle changes that are always good: quit smoking and drinking.  Snorers are more likely to use both substances.

Changing sleep position may work.  Many snorers sleep on their backs, which causes open mouths, and smaller airways.  About ½ of patients can be trained to sleep on their sides instead.  The entrepreneurs of the world have come up with a ton of products, but a simple home remedy is to attach a tennis ball to the back of a T-shirt.  You can pin a sock to the shirt, and then put the ball inside, or you can duct tape the ball on the back of the shirt.

Increasing nasal patency may do the trick.  During a cold, nasal decongestants can be helpful (although only for 3 days or you risk rhinitis medicamentosa). Nasal steroid may help some, and are worth a trial.  Some nasal dilators have been proven effective, particularly the external ones like Breathe Right strips. 

Finally, mechanical appliances (mouth guards, chin straps) or surgery may be the answer for some, if the above approaches don’t help.

A good bit of this information came from a great patient education website that I found. It is a great place to direct patients to find out info about all sorts of things that really don’t need a “medicine” to fix.  Sleep, diet, stress relief, even a variety of psychiatric topics such as ADD, bipolar disorder, and PTSD.

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A case for exercise, continued

So…. the whole commenting thing didn’t work out so well.  I choose to believe that many tried and failed, rather than that I’m talking to myself over here.   So, here’s my take on our case.  Disagree? Something to add?  Speak up on Twitter (follow @ihaterashes)

 Our case..

You have a 58 year old white male patient who you’ve seen 4-5 times in your continuity clinic.  He has diabetes (uncontrolled, with HbA1c 9.5%), HTN (typically reads low 150s/90s in clinic), and hyperlipidemia (guess what?  He refuses medicines).  Oh, and his BMI is 36.

You’ve been harping on the miraculous benefits of diet and exercise all this time, and he’s finally decided to give it a try. He tells you that he’s joined Crossfit and is ready to start exercising, once you give the OK.

Does he need some testing before you give the “OK”?  The commercials say, “Talk to your doctor before starting an exercise program.”  So what are we supposed to say or do?

For low/average risk patients there is no benefit to screening for asymptomatic coronary disease. The ACC has added stress testing in asymptomatic individuals to their list of tests to avoid in the ABIM’s Choosing Wisely Initiative. 

But our patient has diabetes, so he’s not low risk.  Not only that, but he has uncontrolled hypertension and hyperlipidemia, so he most certainly has as much risk for a cardiac event as someone who has had an MI.   In fact, if you follow the Choosing Wisely link above, you note there is a caveat for patients with diabetes over age 40.  So, should we screen him?

Some guideline writers, including the American College of Cardiology, recommend stress testing in asymptomatic diabetics over 40.   The ADA says that EKG exercise testing may be indicated for those diabetics starting an exercise program if: they are over 40, over 30 with signs of advanced diabetes (nephropathy, retinopathy), smokers, or have renal failure due to their diabetes.  

So the guideline writers would screen our patient.  Here’s my concern though, what are we going to do with the information?  He already needs aggressive medical therapy (which he’s not really getting). Perhaps we would do best to just focus on that. Should we revascularize if significant ischemia is found?  

There was one trial, DIAD, which randomized 1123 asymptomatic diabetic patients to screening with adenosine MIBI vs no screening. These patients were largely well controlled with aggressive medical management, and the overall cardiac event rate was only 3% for the whole group. There was no difference in the screened and unscreened groups, however, our patient is so uncontrolled on all risk factors, I’m not sure he fits in.  Our pre-test probability of coronary disease is likely higher than 3%, even without symptoms. 

What about the exercise itself?  I’ve not done CrossFit myself, but it looks fairly intense, with a lot of callisthenic type exercises done fast enough to get an aerobic benefit.  I would be afraid that if he jumped right into an intense “boot camp” like experience like CrossFit, that he might injure himself and then quit exercise all together. It is a tricky thing to encourage exercise, but in such a way that it is more likely to stick as a lifestyle change, rather than a month or so of intermittent involvement that quickly fades away.   

So, I would probably applaud him for his initiative, but ask him to take it a little easy and work on a simple paced exercise program to start.  I would ask a lot of questions to convince myself that he really is asymptomatic, and have a very low threshold for getting stress testing (ideally with exercise MIBI).  You could refer him to cardiopulmonary rehab, so that he could get close monitoring of his HR and BP during exercise (assuming he could pay for it- insurance likely will not).  At the same time, he needs to get his risk factors under control– start a statin, titrate his HTN and diabetic medicines. Certainly give him clear warnings of angina or even anginal equivalents that he might experience, with direction to stop if he does.

Thanks to all for the patience with my blog issues.  New site is coming soon, hopefully with fewer technical difficulties!