What we wish more people knew about sleep.

01  ·  CPAP alternatives

If you can't stand your CPAP, you are not failing at treatment

A 5-minute read

CPAP is excellent medicine. It is also, for a great many people, unusable. Studies of long-term adherence have found that a large share of patients aren't using their machines as prescribed within the first year. That isn't a character flaw — it's a mask on your face for eight hours a night, every night, forever.

The problem is what happens next. Patients who quit tend to quit quietly. The machine goes into the closet, nobody tells the prescribing physician, and the sleep apnea goes back to being untreated — with all of the cardiovascular consequences that come with it. Years pass this way.

There is a middle path. A custom mandibular advancement device holds the lower jaw slightly forward during sleep, which pulls the tongue base away from the back of the throat and keeps the airway open. It is a custom-fit device with no power cord, no hose and no mask. The American Academy of Sleep Medicine recommends it specifically for adults who are intolerant of CPAP or who prefer an alternative to it.

Head to head, CPAP reduces apnea events more completely than an appliance does. But treatment isn't graded per hour — it's graded per night. Patients wear appliances more consistently, and the total amount of treated sleep often ends up similar. The best therapy is the one that is actually in your mouth at four in the morning.

If your machine is in the closet, bring us your sleep study. You may not need retesting at all, and you don't need anyone's permission to ask.

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02  ·  Symptoms

Seven signs of sleep apnea that aren't snoring

A 4-minute read

Snoring is the sign everyone knows, and it is a poor one on its own — plenty of loud snorers have no apnea, and some people with significant apnea barely snore at all. These are the ones that bring people through our door and turn out to matter.

1. Waking to urinate two or three times a night

   Nocturia is one of the most overlooked signs. The strain of struggling to breathe against a closed airway triggers a hormone that tells the kidneys to make urine. Many patients have been to a urologist first.

2. A headache that's there when you open your eyes

   Morning headaches that fade over an hour or two are classic, and are related to overnight carbon dioxide retention.

3. Blood pressure that won't come down

   Hypertension that needs three medications and still won't behave is a recognized red flag for untreated sleep apnea.

4. Grinding your teeth

   Sleep bruxism and sleep-disordered breathing travel together often enough that a dentist seeing worn enamel should be asking about sleep. Often we're the first to notice.

5. Heartburn at night

   The pressure changes of an obstructed breath can pull stomach contents upward. Reflux that is worse lying down is worth mentioning.

6. Falling asleep the moment you sit still

   Dozing off reading, at a meeting, in front of the television at seven — or worst of all, at the wheel. This is not ordinary tiredness.

7. Irritability, brain fog and low mood

   Years of fragmented sleep look a great deal like depression, and are sometimes treated as it. Fixing the breathing is worth trying first.

None of these prove anything on their own. Together they build a case — and one night with a home sleep test will close it.

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03  ·  Testing

What a home sleep test is actually like

A 3-minute read

The phrase "sleep study" still conjures a night in a laboratory with two dozen wires glued to your scalp. That test exists, it's the right tool for certain questions, and it isn't what most people need to find out whether they have obstructive sleep apnea.

The WatchPAT One is a single-use home sleep apnea test. It is three pieces: a small band on your wrist, a soft probe on a fingertip, and a sensor that clips to your chest. You put it on at bedtime, sleep in your own bed on your own schedule, and in the morning the study uploads from your phone. There is nothing to return and nothing to clean.

Overnight it records your pulse, oxygen levels, body position, snoring and the subtle changes in blood flow that mark an apnea event. From that it estimates how many times an hour your breathing is disrupted — the number your diagnosis rests on. A board-certified sleep physician reviews and signs the result. You get the whole report; it belongs to you.

Two honest caveats. A home test screens for obstructive sleep apnea and not for the other sleep disorders — insomnia, narcolepsy, restless legs — so if your story points elsewhere, we'll say so and refer you on. And Medicare rules don't permit us to perform the test for Medicare beneficiaries; your physician can order it, and we take it from there.

Otherwise: one night, your own pillow, and an answer to a question that has probably been following you around for years.

More about home sleep testing  →

04  ·  Risk

What untreated sleep apnea does over time

A 5-minute read

Sleep apnea rarely announces itself. There is no bad day, no moment where something breaks. It works by accumulation, which is exactly why it goes untreated for a decade in so many people — including plenty who have already been diagnosed and quietly stopped treatment.

Here is what an untreated night looks like from the inside. The airway narrows and closes. Breathing stops for ten, twenty, forty seconds. Oxygen in the blood falls. The body reads that as an emergency and fires a burst of adrenaline to force you into lighter sleep so the muscles tighten and the airway reopens — usually with a gasp you won't remember. Then you drift down again and it repeats. In moderate apnea this can happen twenty times an hour; in severe apnea, far more. In the worst cases, four or five hundred times in a single night.

The heart takes the brunt of it. Every one of those events spikes blood pressure and heart rate. Doing that nightly for years is why untreated sleep apnea is a leading cause of hypertension that doesn't respond well to medication, and why it is associated with atrial fibrillation, heart failure, heart attack and stroke. Cardiologists increasingly screen for it before they'll treat rhythm problems, because the arrhythmia keeps coming back if the breathing isn't fixed.

Metabolism follows. Fragmented sleep worsens insulin resistance and disturbs the hormones that govern appetite. Sleep apnea is strongly linked with type 2 diabetes, and it makes blood sugar harder to control in people who already have it. It also makes weight harder to lose — which is a bitter irony, given how often patients are told to lose weight instead of being treated.

Then there is the part that isn't in the lab work. Years of never reaching deep sleep look like irritability, a short fuse, low mood, and memory that isn't what it was. People stop reading in the evening because they can't stay awake. They stop driving to Portland at night. They take the spare room, and then it stops being temporary. Much of this gets filed under getting older, or under stress, or under a mild depression — and treated accordingly, for years, while the actual cause continues every night.

The most urgent risk is the most immediate one. Untreated obstructive sleep apnea raises the likelihood of a motor vehicle accident substantially. If you have ever arrived somewhere and not remembered part of the drive, that is not fatigue you can push through.

Now the other half, which we think is under-told: a great deal of this is reversible. Blood pressure often improves. Nighttime bathroom trips usually stop. Morning headaches go. Mood and concentration return over weeks, and partners tend to report the change before patients notice it themselves. Treatment doesn't undo everything — but it stops the accumulation, and that alone changes the shape of the next twenty years.

The point of all of this is not to frighten you. It's that the condition is common, the test is one night in your own bed, and the treatment is something you can hold in your hand.

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05  ·  Treatment

Your first month with an appliance

A 4-minute read

Nobody's first night is transcendent. You put a new object in your mouth and your mouth has opinions about it. Knowing what's normal is most of what makes the first month easy, so here is the honest version.

Week one. Expect extra saliva — sometimes a lot of it — or the opposite, a dry mouth if you're a mouth-breather. Both settle. Your teeth may feel slightly tender in the morning and your jaw may feel stiff for the first few minutes after you take it out. Some people wear the appliance for an hour in front of the television before bed just to get acquainted. That's a good idea, not a sign of trouble.

Your bite in the morning. This is the one that startles people. For the first several minutes after waking, your teeth may not come together the way they used to. It is expected, it is temporary, and it is why we give you a small morning repositioner to bite into for a minute or two while things return to normal. Do use it — the habit matters more than any single morning.

Weeks two to six. This is titration: we advance the jaw a fraction of a millimeter at a time and see what happens. Snoring usually goes first, often in the first week — your partner will notice before you do. Energy, morning headaches and nighttime bathroom trips follow more gradually. We're aiming for the smallest advancement that stops the events, never the maximum the device allows.

Then we check the work. Once you're comfortable and stable, we repeat the home sleep test with the appliance in. Feeling better is genuinely important, but it isn't data. We want to see your numbers with the device in your mouth, and so should you.

Two rules for the whole month: wear it every night, even the bad ones, and call us rather than suffering quietly. Nearly every early complaint has an easy fix, and the ones that don't are worth knowing about sooner.

06  ·  For partners

Your partner snores. What now?

A 3-minute read

Many of our patients didn't book their own appointment. Someone else did — someone who has spent years lying awake beside them, who has moved to the spare room, and who has watched them stop breathing in the dark and not known what to do about it. If that's you, this one is for you.

First: you are not being dramatic. Sleeping apart because of snoring is common enough to have a name in the sleep literature, and the sleep you lose is a real health issue in its own right. Second, and more usefully — you have information the patient does not. They cannot hear themselves snore, cannot see themselves gasp, and have no idea how often they go quiet and then start again. You are the only witness to the most important symptom there is.

Two things help when raising it. Record thirty seconds on your phone — the pauses are far more persuasive than any description of them. And frame it around health rather than noise. "I'm worried about your heart" opens a conversation that "you kept me up again" tends to close.

The resistance you're likely to meet is usually about CPAP — most people picture the mask and decide no before they've considered anything else. It's worth saying plainly that a mask is not the only treatment, that an appliance is a custom-fit device with no hose and no machine, and that one night in your own bed is all it takes to find out whether any of this applies.

You are also welcome to call us yourself, before they're ready. We can tell you what the process looks like so that when the moment comes, you have something better than an argument.

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