(235) Sleep Apnea

[HB KIM]

TCM PATTERNS
It's hard to find Sleep Apnea topics in the Chinese Medicine textbooks. However, since the 1990s, there have been many articles published in various Chinese medical journals on this condition.  Let me introduce some TCM patterns according to the articles:

1. External Wind-Heat: Wind-Heat pathogen may congest and obstruct the Qi mechanism and the orifices.  Therefore, there is a failure in the transportation of Yin fluid which collects and inhibits the free flow of the throat.

2. Internal LV & LU Heat + External Wind Cold: LV/LU Fire is blocked by Wind-Cold, then internal and external pathogens may join together to block the throat and nose.

3. Yang deficiency: Internal damage due to medication, diet, or overwork may lead to Yang deficiency which may also lead to failure to move and transform Yin fluids.  These fluids can be transformed into Phlegm, and lodged in the throat and block its free flow.

4. Deficiency (SP Qi) + Excess (Phlegm, Stasis):  SP Qi deficiency leads to lack of transformation and transportation.  This leads to phlegm, stasis, and inhibition of the Qi mechanism.  So the root is deficiency and the branch is excess.  In its early stage, there is a SP/LU Qi deficiency or LU/KD Qi deficiency, while in the later stage, LU, SP, KD are all deficient.

5. Dampness: Being overweight, smoking, and drinking as a lifestyle can cause Phlegm Dampness, Qi stagnation, and Blood stasis.

6. Phlegm and Heat: These two pathogens mutually binding and causing depression and obstruction of the Qi passageways.


HERBAL FORMULA
Basically, you can choose formulas according to the patterns of TCM.  I want to introduce one of my favorite formulas from the articles. 

8g  Ma Huang
9g  Yi Mu Cao
6g  Jie Geng 
6g  Gan Cao

1. Ma Huang (Hb. Ephedra)
TCM: Disperses the LU Qi, like its shape of a tube, it opens the airway
BIO: Soothes and opens the bronchi, relaxes the smooth muscles, and harmonizes the respiratory center

2. Yi Mu Cao (Hb. Leonuri Hterophylli)
TCM: Activates the blood and transforms stasis
BIO: Excites the respiratory center and improves microcirculation

3. Jie Geng (Rx. Platycodi Grandiflori)
TCM: Diffuses the LU and disinhibits the throat, dissolves phlegm
BIO: Mucolytic effects, anti-inflammatory, antitussive

4. Gan Cao (Rx. Glycyrrhizae)
TCM: With Jie Geng, disinhibits the throat, resolves toxins
BIO: Mucolytic, anti-inflammatory, antitussive

In Oriental Medicine, no matter what is the cause, Sleep Apnea is due to inhibition of the Qi mechanism of the throat and non-diffusion of the Lung Qi.  This formula focuses on the symptoms (Qi, Blood, Phlegm accumulation in the airway).  If you know the root problem, modify this formula accordingly.


ACUPUNCTURE
I would personally use Korean Yin-Yang Balancing and Five Element Haromnizing treatments for this case.  Most Sleep Apnea is the obstructive type, not central type, and the problem is in the Lung channel.  You can press both LU1 points (front-mu of Lung) and find the more painful side.

1. Yin-Yang balancing: Tonify LU10(fire) and LU5(water) on the more painful side, and sedate LU10(fire) and tonify LU5(water) on the opposite side.  This is Korean Yin-Yang balancing theory. 

2. Five-element harmonizing: For Five Element treatment, there is a very special and intricate pulse reading technique so I can't explain it here, but you can use the Four Needle Technique of Tonification of LU (tonify SP3, LU9, sedate HT8, LU10) by using the five-element points.  When you do this treatment, apply it on opposite side from the more painful LU1.


WESTERN MEDICINE REVIEW
DEFINITION: Repeated temporary interruption of breathing during sleep, which occurs 10 seconds at least 5 times/hour. This condition may be life-threatening if low oxygen level reaches a critical point.
● Age: 30-50 years; also in children
● Gender: More common in males
● Lifestyle: Being overweight, drinking, alcohol, and smoking are risk factors
● Genetics: Not a significant factor

TWO TYPES: OSA & CSA
(1) OSA (Obstructive Sleep Apnea)
● OSA occurs when the air passages in the upper respiratory tract become obstructed during sleep; the most common culprit is the soft tissue of the pharynx.
● Obstructed breathing leads to low levels of oxygen in the blood, causing a person to respond by waking up and taking a deep, snorting breath.
● Being overweight (particularly around the neck area) or having a large tongue or a small mouth can also cause or contribute to the obstruction.
● In children, enlarged tonsils or enlarged adenoids are the most common causes leading to OSA.
(2) CSA (Central Sleep Apnea)
● If the region of the brain and the nerves that regulate breathing do not function normally this causes breathing to be impaired.
● Causes of central sleep apnea include brain damage as in head injury or a stroke.

SYMPTOMS: The symptoms of OSA develop gradually.  CSA may develop suddenly, depending on the cause.  Often another family members notices the problem before the patient does.
● Symptoms of both types can include: restless, unrefreshing sleep, daytime sleepiness, poor memory and concentration, headache in the morning, loud snoring, change in personality, impotence , frequent night time urination
● Severe cases, can cause daytime sleepiness enough to cause accidents when driving.  Taking sleeping drugs or drinking alcohol may aggravate the symptoms.
● Left untreated, complications such as an irregular heartbeat, high blood pressure, and pulmonary hypertension can occur. 

DIAGNOSIS: Endoscopy of the nose and throat, X-ray or CT scanning of the head and neck, Sleep studies, Oxygen levels in the blood, Heart rate

TREATMENT
● Mild OSA: avoid sleeping drugs and alcohol
● Overweight: losing weight may help, try to sleep on the side, which may relive the symptoms
● Caused by high altitude: SA should disappear when you acclimatize or return to lower altitudes
● Caused by enlarged tonsils or adenoids: surgery may be necessary to remove them. In some cases, OSA is treated by surgically reconstructing the soft palate.
● If the cause is not treatable, or if you do not wish to have surgery: CPAP (Postive Airway Pressure Device = Positive Pressure Ventilation) may help and is often the first treatment offered.  Dental appliances are another option.
● CSA: drugs that stimulate breathing may help
● TCM: CSA is difficult to treat with western medicine, but is a better candidate for treatment by TCM than OSA.  For Central Sleep Apnea, studies have shown that sleeping in the lateral position can be helpful.  More research must be done.