Teresa Paiva. “Snoring is not normal”, warns Portugal’s leading sleep specialist

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Teresa Paiva. ” data-title=”Teresa Paiva. – Teresa Paiva. “Snoring is not normal”, warns the biggest sleep specialist in Portugal – SAPO Lifestyle”>

What is Obstructive Sleep Apnea Syndrome (OSAS)?

In its simplest form, the clinical syndrome encompasses snoring and breathing stops during the night, which, as confirmed by polysomnography, last for more than 10 seconds and are more than 5 apneas per hour.

What are the symptoms of OSAS?

Sleep apnea is a disease that is manifested by nocturnal symptoms, which include, as mentioned, snoring and breathing stops during sleep, but also other effects such as suffocation, heartburn, nocturia and agitation itself. In fact, it is compatible both with the feeling that one is sleeping very well and with insomnia. OSAS also presents symptoms when waking up, among which, at a first level, headaches, fatigue and drowsiness stand out – all consequences of non-restorative sleep. But we can go a little further, as OSAS also leads, among many other things that could be pointed out, to problems with concentration and memory, and in children to hyperactivity.

In this sense, when talking about the symptoms of OSAS, we are automatically led to mention its risk factors, namely: gender (male), race, obesity, allergies, craniofacial anomalies (with recessed chin), hooked or crooked nose. , wide neck. For this reason, it is especially prevalent in premature babies and the elderly, but also when there are developmental diseases (eg mongolism).

What are the treatment options for a patient with OSAS?

Some treatment options are immediately available to everyone, namely, losing weight and not drinking alcoholic beverages at dinner – which is very relevant. At the same time, and depending on the specifics of the cases, the following therapies are added: myofunctional; posture and/or elevation of the head; positive pressure (CPAP/APAP); mandibular advancement devices; nasal ENT treatments (medical treatment, deviated septum, turbinates) and surgical treatments with new techniques (the classic UPPP (uvulo-palate-pharyngoplasty).

In which situations is treatment using positive air pressure treatment necessary?

Therapeutic decisions depend on the severity and characteristics of the patient. Therapy with positive air pressure or PAP should be considered when there is excessive daytime sleepiness or when there are evident cardiovascular risks and, if these factors do not exist, in moderate or severe apneas themselves. In all cases, the adaptation and acceptance of the treatment by the patient must be evaluated. However, if a patient does not accept or does not adapt to the treatment, other adapted therapeutic modalities should be used. You should never say “if you don’t use it, you’ll die”, or “there is no alternative”, even though PAP therapy is the most indicated.

What are the comorbidities resulting from the appearance of OSAS?

They can be different. But the most frequent complications (medical and others) include hypertension, arrhythmias or other heart diseases, strokes, hypercholesterolemia, diabetes, sexual disorders, cognitive defects and dementia itself, and esophageal reflux. Given the nature of comorbidities, these sometimes result in traffic accidents, work and/or domestic accidents, and may even potentiate discussions and/or family separations.

Teresa Paiva

Teresa Paiva, neurologist and sleep medicine specialist

” data-title=”Teresa Paiva – Teresa Paiva. “Snoring is not normal”, warns the biggest sleep specialist in Portugal – SAPO Lifestyle”> Teresa Paiva

Teresa Paiva, neurologist and sleep medicine specialist

How can OSAS be prevented?

Prevention is always done according to the age group and the specificities of patients through preventive therapies, that is, treatments that are justified precisely by the identification of different risk factors that are already present. In premature infants, for example, in which the prevalence of sleep apnea is very high, myofunctional therapy should be performed. In children with arched palate, perched teeth and retropositioned mandible, orthodontic therapy with midline palate diastasis should be considered. These are specific cases, I understand, but I think it may be important for readers to learn about typical cases – which can help with prevention and treatment.

I therefore give the following examples: children and adolescents with a sedentary lifestyle should be advised to exercise outdoors to avoid being overweight. When they snore, have large tonsils and/or frequent infections, a tonsillectomy should be considered. When they have asthma and allergies, they should be treated with the recommended criteria to avoid the risk of apnea. For children with developmental difficulties, hyperactivity, or autism spectrum disorders, the possibility of apnea should always be examined and, if confirmed, treated.

As last important examples, I only mention that in children and adolescents and adults, myofunctional therapy can work as a prophylactic. But all people with craniofacial anomalies must be surgically corrected by maxillofacial surgeons. In adults who snore, the existence of possible apnea must be considered and, if not, the snoring must be treated according to the respective causes. And finally, in adults who snore, have abundant and late dinners and/or washed down with significant amounts of alcoholic beverages, dinner less, earlier and without alcohol should be advised.

What is the reality of patients with OSAS in Portugal regarding access to diagnosis and treatment of the disease?

Portugal has 4 very good things. First, the competence in Sleep Medicine given by the Ordem dos Médicos after a theoretical exam that currently includes about 100 doctors. Second, a very high number of professionals with European Certification by the European Sleep Research Society. Third, the tradition of postgraduate studies in SONO, with the 1st World Masters in Sleep at the Faculty of Medicine of Lisbon from 2005 to 2012 with the formation of a significant number of Masters in Sleep Sciences; and later several postgraduate courses (Universidade Católica, Escola Superior de Saúde da Cruz Vermelha, CESPU) and training courses by many entities, among which the APS (Portuguese Sleep Association), the SPDOF (Portuguese Society Facial Pain and Sleep) the Instituto Criap, etc. Fourth and last, a scientific production that has been increasing exponentially since the first publications in the 80s.

That said, many practical problems undoubtedly remain. First of all, in the public Sleep Medicine Centers, the delay in care is very high – it takes many months – and the National Health Service is going through a very difficult crisis, in which there is, in addition to multiple causes, great overload and pressure about health professionals; as a whole, these situations are not favorable to the good practice of Medicine. Short consultation times, excess work, fatigue, and the volume of bureaucracy are not conducive to diagnostic accuracy, nor to a good doctor-patient relationship with repercussions on therapeutic success. Private medicine is currently dominated by large economic groups, which undoubtedly demand quality, but also practical results.

In my experience, as I am in a referral center, delays in the diagnosis of OSAS are greater in children, in women, and, in both sexes, in complex cases associated with insomnia, psychiatric illness, medical illness or medication, stress or burnout.

What are the reasons for such a high rate of underdiagnosis and what are its consequences?

The first reason comes from the fact that snoring is considered “normal”. But snoring is not normal. The second reason has to do with the permissiveness of drowsiness. Falling asleep frequently under inappropriate circumstances is not normal. Second, it has to do with the fact that sleep problems are not taught in medical and nursing courses.

As a result of this, many specialists with cases in which it would be mandatory to detect sleep apnea, as it is a risk factor, do not do so. Examples: High blood pressure, stroke and heart attacks in young people, nocturia, esophageal reflux, unexplained arrhythmias, obesity, diabetes, morning headaches, middle-of-the-night insomnia, childhood developmental disorders (mongolism, etc.), sleepy or hyperactive children, etc. . The consequences of underdiagnosis are sleep apnea morbidities and, therefore, non-diagnosis and non-treatment will lead to more serious diseases and multimorbidities, which will be more expensive for health services and have very serious costs for health, well-being and patients’ quality of life.

Are there differences in access to treatment and diagnosis provided through the public and private sectors?

The problems are posed differently for the different types of treatment. For general measures, adherence requires explanation and convincing of the need for adherence. I don’t know where it’s done better, but it will never be done in a rush query. As for CPAP/APAP, if the patient has ADSE, MEDIS-CTT, Multicare PT-ACS and insurance that covers PAP treatment, he can have a direct prescription for the treatment in private consultations. If the patient is only a beneficiary of the SNS, the problem is complicated if he is being followed in private medicine: in the past, before a movement in a professional sector, everything worked reasonably well. Diagnosis made, PAP therapeutic recommendation, phone call to a ventilation therapy company, letter to the family doctor (GP), and the patient had the equipment on that day or the next day and prescription for the GC in a consultation that took place shortly afterwards, with free treatment.

Currently, however, access to treatment with CPAP/APAP has unacceptable rules. For example, a person diagnosed in the private sector, by a doctor duly accredited by the Portuguese Medical Association and entitled to free treatment by the SNS, has to go to a public hospital consultation (with a delay of many months) so that in that hospital credential for the treatment (the hospital doctor who passes it may or may not have differentiation in Sleep Medicine). In principle, this doctor will be from the specialties closest to Sleep (Pneumology, Neurology, ENT, etc.), but not necessarily. After this first credential, the patient, for the continuation of the treatment, can then go to his family doctor.

Some family doctors can only make changes in agreement with the Hospital Doctor. So now, diagnosis made, therapeutic recommendation of PAP, phone call to a ventilation therapy company, explanation that you have to go to a public hospital directly or by appointment of the family doctor; the patient, despite having the equipment on that day or the next day, knows that he can wait a few or many months for the aforementioned procedures, that only after that will the treatment be free, as he will have to pay until he has a prescription, or, alternatively, wait for she untreated.

In summary: if they ask me if these procedures improve the quality of treatment, I answer “No” (those who issue the prescription may have less preparation than the person who proposed it). if you ask me if these procedures improve the control of the SNS, I answer “No” (the SNS is unnecessarily overloaded which is particularly serious in the current situation). if you ask me if these procedures advantageously reduce the costs of the SNS, I answer “No” (The SNS pays less in the short term, for doing it later, but in the medium term it will pay the costs of aggravations and morbidities).

For myofunctional therapy, MADs (mandibular advancement devices) and ENT surgeries, as far as I know, should be performed mostly in the private sector, with a relatively small number performed in the public sector, with the possible exception of tonsillectomy in children.

See also: 10 things healthy people do before bed

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