Historic

Next week, I’ll undergo a significant surgery (MMA: MaxilloMandibular Advancement – also called ‘Bi-Max’ or MMO). The way which led me to this decision was long and tortuous. Here’s a brief resumé.

In 2004, I started sleeping less. I used to go to to sleep normally but I often woke up and I couldn’t go back to sleep. A bad night here and there is nothing unbearable but things went worse and worse.

At the end of 2004 and in the year 2005, I started watching my food and sports regime and I paid more attention to the way I slept. Things changed a bit but the problem didn’t disappear. In 2006, I consulted my Family Practice who prescribed sleeping pills for three months to help me getting a better rhythm. It didn’t really helped : I didn’t wake up so often but I felt completely exhausted. In the first months of 2007, I tried acupuncture. My Chinese physician took it seriously and he added to acupuncture Chinese herbal tea : I had to boil for 30 to 45 minutes in the morning and before going to bed different sorts of herbs, shells and other ingredients. Then I swallowed them in spite of their taste because I trusted him. The improvement didn’t last very long.

In the middle of 2007, I consulted an osteopath some of my friends considered a true magician. He didn’t find any point of unbalance ; however he put back in place a bone in my jaw. I spent a very good night but it was only one night…

Finally, in September 2007, I went to the Stanford Sleep Clinic. It was founded in 1970 by Professor Christian Guilleminault, a French physician specialized in the problems of insomnia. In less than 10 minutes they announced me I was certainly suffering from sleep apnea. They wanted to confirm this diagnosis by an observation of my sleep ; they gave me some brochures about this problem. I came back home very pleased because someone had found what happened to me. I only started realizing how complex the illness and its treatment were after reading the brochures and surfing the Net.>

On October 10th, 2007 it was my first sleep study. I spent the night at the hospital, covered with 50 sensors on my body. Weeks later, I received the conclusions : 12 apneas and 119 hypo-apneas for the whole night that’s to say an average of 21,1 apneas and hypo-apneas per hour which means an average apnea. The rate of oxygenation was 91 %. I thus became a candidate for the CPAP: Continuous Positive airway pressure device.

On November 11th, 2007, I went for my second sleep study to find the adjustment for the CPAP. The night was uncomfortable because the operator wanted me to wear a nasal mask even though I tended to breathe through my mouth … In brief, I got a prescription for a CPAP adjusted to a pressure of 13 cm H2O and a nasal mask.

On November 24th, 2007, I took the CPAP and the mask home. The first nights were difficult: my mouth was dry because I didn’t breathe by the nose. After some days (because of Thanksgiving), I managed to change for a full face mask (including the mouth and the nose). It took me a long time to get accustomed to it and even though I could sleep better, I couldn’t stay asleep all night long.

In April, 2008, I decided to have my tonsils and adenoids removed by the Dr Kasey Li, who rectified my nasal septum too. I hoped I would soon get rid of the CPAP …

June 2008 : no real progress. Doctor Li urged me to be patient and I went to France on vacation, then to India for my job with my CPAP…

September 2008, back in the Bay, I decided to see other physicians to confront points of view and find a solution.

I visited Dr Riley a surgeon like Dr Li. Thanks to a fiber-optic nasopharyngoscopy, I discovered my trachea was narrow and consequently, obstructed by my tongue.

Fiber-optic nasopharyngoscopy : the picture on the left represents the trachea at rest and the tongue ; the picture on the right shows the trachea when I pronounce the sound “i” when everything is completely open. You can make out the vocal cords and the glottis. When at rest, it should be more open as if I was pronouncing “i”. Note that these photos were taken when I was awake and we don’t know what’s going on when I’m asleep.

Dr Riley recommended an operation to move the tongue forward before a MMA.  Dr Li and Guilleminault reached a similar conclusion without taking any pictures, just by looking at my face and its bone… Dr Li and Guilleminault, usually recommend to do the MMA first and if needed to tune it by moving the tongue forward if necessary. As these are significant surgeries, I decided to do more research.
I went back to the Stanford sleep clinic to hear their analysis. I surfed a lot on Internet too and I found there the medical manual of my CPAP. With my doctors ‘agreement I decided to try different levels of pressure and to save the CPAP data after each night to find the best level of pressure. That’s very difficult because there are quite a lot of variations according to what happens every night as shown on the graph below (It is a set of my own data roughly from mid-September to mid-October)

I then discovered the devices with automatic positive pressure (APAP) which not only adapt the pressure according to the demand but are very silent, which is better for the spouse !

After one hour and a half of bargaining, I finally convinced my doctor to prescribe me an APAP and a prescription for a sleep inducing medicine (tartrate of zolpidem) which spreads slowly in the body and which helps staying asleep. It was the result of a compromise. I accepted sleeping pills and the doctor agreed with the APAP.

The improvement was significant during approximately the 30 first days ; then I began to have feelings of suffocation, losses of memory and to feel fewer and fewer rested in spite of the more silent APAP … I decided to stop sleeping drugs. I had troubles for one week, feeling weak, with headaches ; then everything turned better. Unhappily, the APAP level of pressure came up to 15 cm /H20 in average ( and up to 17 cm/H2O for at least 2 nights) which is unpleasant because of the leaks and of abdominal winds.

In October I met Dr Guilleminault at Stanford and we had a very interesting conversation. I didn’t understand why the CPAP or APAP had to be regulated to such a high pressure and why they seemed so inefficient in spite of my efforts. I wanted to know what choices I had left. To prove my problems were linked to apnea, I wanted to spend some good nights with the device before committed to a surgery. The devices or sleep study report indexes but are these the main cause of my problems? I in fact realized I’ve suffered from apnea since I was a child (and that my daughter is suffering from it too). Till 2004, I could bear it… Nevertheless, as things are going on, I can remember how I felt sleepy at the University during conferences in the afternoon, how I went to sleep during conversations or during a film, etc…

Professor Guilleminault then explained me that the respiratory canal was a complex system. It was often schematized (and even modeled in the APAP) as a simple pipe but it is in fact a continuation of ducts with bends and strictures which can create whirlpools and thus turbulence. The more the pressure is strong, the more the disturbances are strong and thus the CPAP has its limits! On the other hand, at the level of the throat, a sort of local nervous system may react to the pressure. It possibly could decline with the age, maybe because of backward surges of acid from the stomach which could explain the growing intolerance to apnea with the age … What I’ve just written is probably scientifically inaccurate, but it means that there is really no simple treatment except the MMA according to professor Guilleminault.
That’s why, in October I consulted a specialist in orthodontics, Dr Inouye. He made a device which blocks the lower jaw so as to open the trachea. It fits to the teeth and can be adjusted thanks to a screw and a rack. See pictures in J-2 and the set of devices approved in the USA here . After about ten days (I went a little faster than what the dentist had considered), I had a 5 mm progress, the pressure of the APAP did not rise over 10 or 10.6 cms of H2O and I began to sleep better: I woke up four hours after going to sleep and I went back to sleep rather easily. It was for me the proof that the MMA (which has the same purpose) was the solution. I hope the future will prove I was right..

Here’s the end of the resume. I did not describe every step but only those which seemed the most important ones to me. However I ‘ll have to speak one day about my discussions or meeting with Professor Mignot, Dr Jean Le, Mamta Sha, Kathy Winslow, and a patient, Marine.