For as long as he could remember, Christian Roth needed a very long time to fall asleep. "You learn to adapt," he said. "I thought I was wired this way and I felt pretty powerless."
He tried all sorts of approaches: no caffeine after 3 pm, no electronics use within an hour of bedtime, over the counter sleep aids, candles and lavender, hot baths, even a pre-sleep shot of whiskey.
Even when he was able to get some sleep, he said "I never felt refreshed, I really had to pace myself at work, and if I wanted to go out at night with friends, I'd have to take a nap in the afternoon."
Going to sleep became something he dreaded, "and nighttime was the longest part of my day," he said.
The rest of his life was good: He met his wife, Liza, in college. They'd married and almost three years ago, their daughter, Emily, was born. Roth's insomnia and lack of sleep was a challenge. "During the day, he'd be in this fog," Liza said. "It became harder and harder for him to fall asleep." He'd put on some weight over the years and, unusual for someone his age, developed high blood pressure. The snoring his wife had learned to tolerate, despite its progressive worsening, evolved into something else, something frightening. "He'd stop breathing," she said. "There'd be loud snoring then all of a sudden just nothing. Then there would be a big burst of air, like he'd been holding his breath. It didn't dawn on me he had sleep apnea. He was a pretty active guy—a non-drinker and a non-smoker."
Hearing about that breathing stop and subsequent gasp for air pushed Roth to call a doctor. "That's when I took it seriously, and the dominoes started to fall." He went to Stanford's Sleep Medicine Center in Redwood City, just a few miles from his home and the nation's first medical clinic established to specialize in sleep disorders.
After describing his symptoms to physicians there, he was asked to spend a night in one of its state-of-the-art bedrooms so a more detailed and technical picture of his sleep health could be built, in part through dozens of electrodes attached to his body. The results were striking: Roth was demonstrating the kind of obstructive sleep apnea more typically seen in someone 50 years his senior. His Sleep Center physician, Robson Capasso, MD, board certified in sleep medicine and an otolaryngology surgeon, had found a long list of physical impediments that stacked the odds against Roth ever drawing a fully-functional breath.
His tonsils were obstructively large, his palate was too soft and his septum—the wall that separates one nostril from another—was deviated far beyond normal. His tongue was set far back in his mouth; his jaw was also set back in a way that narrowed his airway. Any one of those conditions would have been a significant barrier to the flow of air in and out of Roth's nose and mouth. His physiology was a veritable basket of bad news that added up to a case of severe sleep apnea whose effects had already reached beyond just feeling sleepy.
Roth's problems with sleep made him one of many millions. Capasso said that one in four middle-aged men suffer from some form of sleep apnea—those moments when our breathing either pauses or becomes shallow, limiting the amount of oxygen coming into the body. That normal out-with-carbon-dioxide and in-with-oxygen balance is disrupted, with serious consequences. The brain needs oxygen to function and an excess of carbon dioxide in the blood derails the respiratory center in the brain. The struggle inside the body to reset itself includes the heart, whose regular rhythm is then altered, triggering another set of physical changes.
"Having sleep apnea diagnosed and treated is very important," said Clete Kushida, MD, PhD, Medical Director, Stanford Sleep Medicine Center and Director, Stanford University Center for Human Sleep Research. "It can have profound impacts on the cardiovascular system. There is also evidence that people can have problems with brain function."
Typically, the first step in treatment is the CPAP machine—a continuous positive airway pressure pump that gently pushes air into the nose and down the airway to prevent it from collapsing.
Finding a solution
Surgery is not what Capasso suggests as a first option for his typical patient. "Surgery comes with its own side effects and results are not completely predictable," he said. If someone can learn to use the CPAP machine, that can be the easiest solution. For others, their sleep apnea may be caused by their weight; Stanford has a 12-week weight loss program Capasso suggests to patients.
However, if someone young and not substantially overweight has sleep apnea caused by physical abnormalities, and that person has tried and failed with the CPAP, the surgery becomes a more sensible possibility, in some cases even the initial treatment approach.
Capasso straightened Roth's septum, removed his tonsils and reorganized his soft palate tissue. The results were even better than Capasso thought they would be. "The first night he was home after the surgery," Lisa said, "I almost couldn't sleep because it was so quiet in the room. I just kept staring at him to see if he was still breathing."
Roth was back to work two weeks after his surgery. He has seen the benefits of getting enough sleep, and healthy sleep, from the moment he wakes up to when bedtime comes. "It's been pretty remarkable,” he said. "I have plenty of energy; I don't feel deflated by early afternoon. I have more energy with my family when I come home from work. I can run and bike and play volleyball—it's like night and day."
Roth's investigation into his sleep problems prompted his brother to do the same, and physicians found that his four-year-old was already suffering from apnea. He has been treated.
Apnea does have a strong genetic component, but it goes beyond the obvious skull and airway features, Capasso said. "There are researchers here at Stanford who are looking at the genetic role in how you control the muscle strength in your upper airway, to keep it open while you sleep, and how your brain responds to variations in oxygen and carbon dioxide. The whole mechanism of obstructive sleep apnea is very complex."
Researchers are also working on a way to capture sleep on an MRI video. "It's under investigation, but we've had some interesting results," Capasso said.
Innovations in the works
CPAP machines are continually developing, becoming smaller and lighter and more comfortable. Beyond that treatment method, however, are new ideas that give Capasso and his Sleep Center colleagues great hopes for very different options. Stanford is part of a multi-center randomized controlled trial to test a nerve stimulator that would act as a pacemaker for the nerve of the tongue. The device pushes the tongue forward to instigate breathing if it senses that a patient is not breathing well during sleep. The pacemaker would be implanted in the chest, with one silicon wire going up to a nerve in the neck and the other to the rib cage. "We are very excited about that technology," Capasso said.
The best future for the treatment of sleep apnea will be those new technologies combined with methods to better evaluate what treatment will work best for an individual patient, Capasso said. "The important thing is to have all possibilities available."
Roth still marvels at his own history with sleep. "It's amazing how many things are tied to it—so many symptoms just all went away after my surgery." He'd done what so many do—learned to live with it—"until I realized it was life-threatening," he said.
"When Christian mentioned sleep apnea, I looked it up on the Web and read about it and it mentioned all the different health effects," Liza said. "It was an 'aha!' moment."