Sleep Apnoea Syndrome
In March 1997, I spent at day at a sleep laboratory with Dr Vesselinova-Jenkins at the Lister Hospital in London. Dr Vesselinova is a fascinating person. She developed an oral diptheria vaccine in Bulgaria before coming to UK through marriage. She then set up the first sleep laboratory in UK and was the first person to describe central and obstructive sleep apnoea. She also was the first in UK to use melatonin to treat sleep disorders and brought melatonin here. She is primarily a researcher and has produced many papers on sleep problems.
I was interested in Dr Vesselinova's work because I know I do not treat the sleep problems of my patients particularly well. She was interested in me because she was doing new research into food allergy, had found that many sleep disorders were related to food intolerance and these patients did well on EPD. She wanted to learn about EPD.
Patients Who Don't Sleep
Dr Vesselinova has been measuring blood and salivary melatonin levels through the night and found them to be depressed in CFS patients. This is to be expected since we know that hormone output from the hypothalamus/pituitary/adrenal axis is abnormal, so the pineal, a similar gland, is likely to be affected. She uses low dose melatonin 2mg at night. This helps restore the normal sleep rhythm. Patients must put themselves to bed at a more "normal" hour, darken the room (or wear shades), cut out noise etc to allow sleep to come naturally. She tells me most patients can reduce their sleeping tablets and then stop them once they are on melatonin.
It is now possible to measure melatonin levels by a salivary test melatonin profile. This tells us when you are producing melatonin and how much, but it is expensive. I am happy to prescribe melatonin "blind" for my patients only. However, some patients get depressed on melatonin - so this needs watching out for.
See article Melatonin
Patients Who Sleep Excessively
These are the patients she monitors for breathing disorders. What Dr Vesselinova is finding is that these patients stop breathing whilst asleep. There are two common reasons for this. One is called "obstructive sleep apnoea" and occurs when the body is trying to breathe (the respiratory muscles are active), but there is a blockage and no air passes through. Often these patients snore and may be overweight.
The other type of sleep disorder is called "central sleep apnoea". In this case patients have abnormal respiratory centres which simply forget to tell the body to breathe. This may be caused by viral damage or toxic damage from chemicals. This is the common type of sleep disorder in patients with CFS. It is part of the autonomic neuropathy we see in CFS.
When the body stops breathing, oxygen levels fall in the blood. Dr Vesselinova can measure this using a pulse oximeter and showed me some recordings. It is quite extraordinary to see how patients just stop breathing with no muscle movements and no respiratory efforts whilst the level of oxygen in the blood steadily falls by more than 10% of what it should be. Suddenly the body "wakes up" to this dire situation and starts to breathe again. Patients have no idea they are doing this but their sleep is abnormal, they often wake regularly through the night without realising why, they do not feel refreshed in the morning, often waking with morning headache. There is also excessive daytime sleepiness and intellectual deterioration. This is hardly surprising because low levels of oxygen will damage brain cells - the cells in the body most sensitive to oxygen levels.
Treatment Of Sleep Apnoea
Some patients have sleep apnoea because of food intolerance. The commonest foods are wheat and dairy products. However, if avoidance of these foods does not correctly "reset" the respiratory centre, then other things can be tried. The first is low dose aminophyline which is a mild respiratory stimulant. Too much causes sleeplessness. She suggests using Slo-phyllin 60mgs at night. Another possibility for obstructive sleep apnoea is low dose amitriptyline 5mgs, which improves the muscle tone of the airways and helps prevent the airways collapsing.
However, Dr Vesselinova's main treatment for sleep apnoea is to use oxygen at night. This prevents the very low oxygen levels developing and so sleep becomes more normal. She insists this must be done every night for at least 6 months to allow the respiratory centre to adjust back to normal. Most patients just need 6 months of oxygen, but some need long term oxygen at night. But since they feel so much better and are able to function as normal human beings, the effort is well worth it.
Oxygen is given via an oxygen concentrator. This is a machine which concentrates oxygen from room air and delivers it via nasal prongs into the nose at a rate of 1.5 litres/min.
Patients are not breathing 100% oxygen, merely enriched air. These machines are available on the NHS, usually for patients with severe airways obstruction. They can be purchased privately. However, they will not be cheap and an accurate diagnosis is vital before investing this sort of money. My experience is that once the Ketogenic diet - the practical details is in place and issues of allergy and hypoglycaemia sorted out, oxygen is rarely required. Please see also My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds.
Ideally all patients should be worked up in a sleep laboratory and the exact nature of their sleep disorder worked out. However, this is simply not possible as not all Health
Authorities have access to a sleep laboratory and the Lister Hospital laboratory is private.
However, just watching a patient sleep may give valuable clues and it could well be worth arranging for this to happen. The observer does not need to be especially skilled. Or you could video yourself asleep.
A healthy person sleeping normally breathes in and out slowly, rhythmically and regularly and each breath is even. For sleep apnoea, look for cessation of breathing or so called "Cheyne-Stokes" respiration, where the breathing becomes progressively heavier, then progressively lighter before stopping a while before building up again to heavier breathing.
Any of these observations would support a diagnosis of central sleep apnoea.
For obstructive sleep apnoea (i.e. the airways are blocked) you will see the patient making muscular efforts to breathe (ribcage, chest and abdomen working hard) but no air passes through the mouth or nostrils. When air suddenly gets through, there may be a grunt or snore and the patient may partly wake.
The commonest causes of obstruction sleep apnoea are allergy (no PK diet) and being overweight.
Please refer to the Food allergies section in this website also.
- Ketogenic diet - the practical details
- Ketogenic diet - the practical details and My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds
- Food allergies
- SleepRight Nasal Breathe Aid - in the words of the product description on the website of the British Snoring & Sleep Apnoea Association: "Gently opens nose for increased airflow to reduce snoring and relieve nasal congestion".
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