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Restless Nights

Restless Nights: Understanding Snoring and Sleep Apnea

Translated from the Hebrew by Anthony Berris
Copyright Date: 2003
Published by: Yale University Press
Pages: 288
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  • Book Info
    Restless Nights
    Book Description:

    People with severe sleep apnea may struggle for breath all through the night, not breathing for as long as ninety seconds at a time during their sleep. This syndrome, which affects at least four percent of men and two percent of women, can cause daytime fatigue, traffic and work accidents, deteriorating cognitive abilities, and cardiovascular problems. Yet until now there has been no accessible discussion of the history, physiology, and risk factors of sleep apnea. In this book Peretz Lavie, an expert in sleep research, tells the complete story of sleep apnea for the first time.The book provides:

    • an explanation of the symptoms of sleep apnea, including the most important one, snoring;

    • an up-to-date description of the risk factors;

    • a clear explanation why sleep apnea causes cardiovascular problems;

    • a discussion of children's breathing disorders in sleep;

    • advice on how to get a consultation and diagnosis;

    • evaluations of the treatments currently available;

    • practical recommendations on how to live with the syndrome;

    • interviews with the key figures in sleep apnea research;

    • and more.

    eISBN: 978-0-300-12895-6
    Subjects: Psychology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-x)
  4. 1 The Breath of Life
    (pp. 1-12)

    Why did the author of the Book of Genesis make a point of stating that God brought the first man to life by breathing into his nose? We also breathe through our mouths, after all, and the volume of air inhaled through the mouth would appear to be greater than that inhaled through the nose. Part of the answer is that the ancients believed that breathing through the nose was more vital to existence than breathing through the mouth. “The matter of life depends on the breath of the nose, for hot air is expelled from the heart through the...

  5. 2 Respiratory Control
    (pp. 13-20)

    Once the role of breathing in sustaining life had been clarified, the next step was to determine the nature of the mechanisms that control it. These mechanisms ensure sufficient absorption of oxygen and efficient emission of carbon dioxide in situations that can be radically diverse, such as vigorous physical activity, while talking, and while sleeping. The early theories attributed respiratory control to the effect of carbon dioxide on either the vagus nerve, one of the brain’s nerves that is part of the parasympathetic system, or the entire nervous system. The first to propound the hypothesis that a special nerve center...

  6. 3 The First Pickwickian
    (pp. 21-36)

    It is easy to understand why the periodic breathing of heart patients caught the eye of Hunter, Cheyne, and Stokes even two hundred years ago. Heart patients, especially in the terminal stages of their illness, are under the close supervision of either their family or their doctors. People close to heart patients while they are asleep cannot avoid noticing their strange breathing. The patient’s chest pumps like a bellows for about half a minute, and then, very slowly, its activity wanes or stops completely for a similar period, over and over again. Sleep apnea syndrome, which is likewise characterized by...

  7. 4 Rediscovery of the Pickwickian Patient
    (pp. 37-52)

    The only exceptions to the theory holding that sleepiness is always a symptom of central nervous system damage, or disease, were the obese sleepyheads. As in the nineteenth century, the combination of obesity and sleepiness, often in the most embarrassing circumstances, captured the attention of twentieth-century physicians who were lovers of Dickens and who occasionally “rediscovered” the Pickwickian syndrome.

    To this day the most oft-quoted article on the subject is one written by Sidney Burwell and his colleagues in 1956. The article, titled “Extreme Obesity Associated with Alveolar Hypoventilation—A Pickwickian Syndrome,” describes the case of a sleepy, obese patient...

  8. 5 Western Innovations
    (pp. 53-63)

    Sleep research is one of the few scientific fields that can be traced with great accuracy to a particular starting point, after which things were totally different. Scientific sleep research began in 1953, when Nathaniel Kleitman and his student Eugene Aserinsky first described dream sleep, or rapid eye movement sleep, in a now-classic article published inScience.

    During the 1960s, the few researchers engaged in studying the sleep of people suffering from sleep disorders focused on narcolepsy. In 1967, three independent groups from three

    continents—Rechtschaffen and Dement in the United States,Passouant and his colleagues in France, and Hishikawa and...

  9. 6 The Dog Dropped Off and the Experiment Woke Up
    (pp. 64-78)

    We have already seen that the transition between wakefulness and sleep is bound up with variations in respiratory functions. Breathing becomes irregular while a person is falling asleep, with occasional short suspensions, until sleep deepens and stabilizes. Numerous early researchers surmised that this irregularity was caused by a variation in the sensitivity threshold of the cerebral respiratory center to carbon dioxide concentration in the blood, which required a period of adaptation during the transition between wakefulness and sleep. There were those like Kuhl and Jung who assumed that, in people suffering from apneas during the entire course of sleep, the...

  10. 7 From an Exotic Syndrome to a Public Health Issue
    (pp. 79-89)

    The reports published in scientific journals in the 1970s about patients suffocating in their sleep, and stating that the only way to diagnose them was by means of examination during sleep, did nothing to change the medical world’s attitude toward the subject of sleep. The excitement of sleep researchers did not infect their colleagues, and hospital administrations did not hasten to establish laboratories for the diagnosis of sleep disorders. In many countries there was no sleep medicine at all, and worldwide it was the occupation of only a few hundred sleep researchers. Most of them were engaged in basic sleep...

  11. 8 Risk Factors for Sleep Apnea
    (pp. 90-114)

    On long transatlantic flights, I make a point of walking several times from one end of the airplane to the other to stimulate my blood circulation. As I pace, I occasionally play a guessing game and ask myself which of the passengers seated on either side of the aisle suffers from sleep disordered breathing.

    Extremely obese people with a short, thick neck, or a small and sunken lower jaw, and people who have fallen asleep with their mouths wide open are awarded particularly high marks in my guessing game, especially if they are middle-aged men. I am convinced that any...

  12. 9 The Syndrome’s Symptoms
    (pp. 115-125)

    The diagnosis of any illness begins with the patient’s complaints, which provide the doctor with one end of a thread that will finally lead to an accurate diagnosis and appropriate treatment. As sleep apnea syndrome is manifested by suspensions of breathing during sleep, one might expect people afflicted with it to complain that they awaken from sleep because of shortness of breath or a suffocating sensation, but this is not so. People with the syndrome are totally oblivious of their nightly drama, they are usually very surprised to hear about it, and their response is something like, “But Doctor, I...

  13. 10 The Price of Awakenings
    (pp. 126-134)

    Anyone who has experienced a sleepless night does not need the scientific term “daytime sleepiness” explained. The greater the lack of sleep, the greater the struggle against drooping eyelids during the day. In this state, the need for sleep exceeds the need for food or drink.

    Sleep apnea syndrome patients do not suffer from sleep deprivation. On the contrary, most patients claim that they get sufficient sleep and perhaps even sleep longer than healthy people, but they are unaware that they awaken every minute during the night. These awakenings are the price the brain pays to ensure resumption of breathing....

  14. 11 At the Temple of Morpheus
    (pp. 135-150)

    Diagnosing sleep apnea syndrome has become the principal occupation of experts and doctors who treat sleep disorders. The vast majority of sleep laboratory examinees seek advice because of suspected sleep apnea, and in many hospitals, particularly in departments treating pulmonary and ear, nose, and throat illnesses, recent years have seen the establishment of sleep laboratories for diagnosing the syndrome. The term “sleep apnea syndrome” has in fact replaced “narcolepsy” as a synonym for chronic sleepiness.

    But a day-to-day preoccupation with only one syndrome, prevalent though it might be, is liable to conceal the fact that excessive sleepiness may derive from...

  15. 12 Children and Sleep Apnea
    (pp. 151-165)

    It is customary to say of someone sleeping peacefully that they are sleeping like a child, or sleeping like a baby. Throughout history, artists have often used the image of a sleeping child or baby to express tranquillity and serenity. But children with sleep breathing disorders are not enjoying tranquil rest.

    In the late 1970s, when we struggled to heighten the Israeli medical community’s awareness of the existence of sleep disordered breathing, I used to incorporate a short film into my lectures. The film documented the sleep of a six-year-old boy before he underwent a tonsillectomy and after it. The...

  16. 13 Sleep Apnea, the Heart, and the Blood Vessels
    (pp. 166-178)

    The first researchers to make sleep records of Pickwickian patients were aware of the significant effect apneas had on the heart’s activity during sleep. Both Gerardy and his colleagues and Gumnit and Drachman reported that the heart rate of Pickwickian patients changed drastically, becoming slower during the apneas and greatly accelerating with the resumption of breathing. Later, Lugaresi and his colleagues showed similar changes in general and pulmonary blood pressure, both of which dropped during apneas and were elevated drastically when breathing resumed. Furthermore, tracheostomy in hypertensive apneic patients sometimes resulted in a dramatic reduction in blood pressure, as was...

  17. 14 From Baroreceptors to Free Radicals
    (pp. 179-187)

    The prevalence in sleep apnea patients of hypertension, strokes, coronary cardiac diseases, and calcification of the carotid artery is an indication that the syndrome is a risk factor for cardiovascular diseases in general. What, then, is the risk factor common to all the diseases linked to the heart and blood vessels in sleep apnea syndrome patients? In recent years numerous studies have investigated the physiological mechanisms involved in increased cardiovascular disease in these patients. The two most prominent of these mechanisms, the studies have revealed, are the autonomic nervous system, particularly the subsystem known as the sympathetic autonomic system, and...

  18. 15 Death at an Early Age and the Paradox of Old Age
    (pp. 188-194)

    In spite of their nocturnal battle for survival, sleep apnea patients do not usually die in their sleep as a result. The monitoring systems in their brains, which meticulously check the levels of carbon dioxide and oxygen in the blood, sense the approach of danger in good time and muster the assistance of the brain’s wakefulness mechanisms. These power up before any physical damage can be done, awakening the sleeper and causing an immediate resumption of breathing. The awakening is so brief that it is not even recorded in the patient’s memory. The brain, however, does remember these nocturnal awakenings,...

  19. 16 Treatments for Sleep Apnea Syndrome
    (pp. 195-211)

    A wide gap exists between the great ease with which sleep apnea syndrome can be diagnosed and the equally great difficulty in finding an effective treatment for it. This is not because effective treatments are lacking, but rather because of the discomfort they impose on patients.

    A good example is weight reduction. There is no doubt that losing weight improves the condition of the sleepy patient, as ample evidence has shown beginning with the first Pickwickians in the nineteenth century. Modern studies reveal that a reduction of 10 to 20 percent of body weight results in a 50 percent decrease...

  20. 17 Sleeping Under Pressure—The Big Promise
    (pp. 212-226)

    About ten years ago, I traveled to Sydney, Australia, for a scientific conference on sleep apnea syndrome. When I landed at the airport, I noticed a strange phenomenon. Wherever I looked there were people wearing red plastic noses, like circus clowns. At first I assumed that I had happened upon some kind of local carnival, but there didn’t seem to be any other fancy dress involved. It turned out that I had arrived on Red Nose Day, which marks the Australian national fundraising drive for the fight against crib death.

    In addition to heightening awareness of crib death, Australia has...

  21. 18 A Whole New Understanding
    (pp. 227-240)

    By any possible yardstick, the past ten to fifteen years have seen a complete turnabout in medicine’s approach to sleep apnea syndrome. From being considered a rare and exotic condition it has become a routine term in the lexicons of physicians from many and varied branches of medicine. This change did not come about easily. Doctors are not readily impressed by new syndromes or treatments, and it takes a long time for scientific papers to change the characteristics of a diagnosis and treatment. It is therefore hardly surprising that seventeen years elapsed between the establishment in 1961 of the American...

  22. References
    (pp. 241-252)
  23. Index
    (pp. 253-274)