Treating Sleep Apnea. by Ralph A. Pascualy, M D

Continuous positive airway pressure (Seepap) is the treatment of choice for most
people with obstructive sleep apnea. It is nearly 100 percent effective when
used every night.
• Surgery should be considered as the last treatment option. There are situations
where your sleep specialist and the surgeon will agree that surgery is your best
first option but these are the exception.
• The best treatment is the most conservative treatment that will work
for you.
• Nonsurgical treatments are more conservative than surgery, and may
work better.
• Get a second opinion from a sleep specialist before having surgery for
sleep apnea.
• Have a sleep study before and after treatment, for comparison, to verify whether
the treatment has successfully eliminated your sleep apnea.

Case Study.

M r. Kennedy had a complete sleep test at an accredited sleep center. The test
results showed that he had more than 250 apnea events during the night
while his sleep was being recorded. His sleep specialist told him that he had moderately
severe obstructive sleep apnea with a minor central apnea component, as well as cardiac
arrhythmia. The specialist recommended that he undergo treatment.
At this point, Mr. Kennedy had answers to the first two questions on the pathway
to successful treatment of sleep apnea:
1. Is his condition actually sleep apnea, and does he have any other conditions
that will have a bearing on successful treatment?

2. What kind of sleep apnea is it (central, obstructive, or mixed), and how severe
is it? (The answer to this question is important because it determines the kind
of treatment.)
Finally comes the third and crucial question:
3. What is the best treatment for Mr. Kennedy’s type of sleep apnea?

Choose the Right Treatment.

The best treatment for anyone is the most conservative treatment that will succeed
in his particular situation.
What is the most conservative treatment that will work for you? This is a complex
and individual question that should be explored carefully by you, your sleep specialist,
and perhaps your family doctor. The treatment should be chosen on the basis of the kind
of apnea, how severe it is, and your overall health. Your sleep specialist can describe the
various treatments that may work best for you and can tell you which ones are the most
conservative.
What do we mean by most conservative? This means the treatment that carries the
lowest risk for you.
Keep in mind that different doctors may have different treatment recommendations.
Every doctor has conscious and unconscious biases in favor of certain forms of treatment.
This is a natural result of his or her training, specialization, and personal experience.
For example, a surgeon is more likely than an internist to believe that surgery is the best
option; an internist might lean toward nonsurgical treatment.
Your job is to take these possible biases into account as you and your doctors weigh
the risks and benefits and choose the most appropriate treatment for you.
Seepap Is the Right Treatment for Most People
with Sleep Apnea
Seepap (continuous positive airway pressure) is the best treatment for most people
with sleep apnea. Seepap completely eliminates sleep apnea, and by doing so it removes
the serious risks of cardiovascular and heart disease that result from untreated sleep
apnea. Seepap also improves the person’s sleep, energy levels, and ability to enjoy life, so
that it is possible to resume activities and career goals that have been restricted by the
fatigue and exhaustion of untreated sleep apnea.
Seepap is the most conservative treatment: in the future, if other treatments are
tried and turn out to be effective, Seepap can be stopped. This is a big advantage over
irreversible treatments such as surgery.
Seepap is discussed in greater detail later in this chapter.

When Someone Mentions Surgery.

At the first mention of surgery to treat sleep apnea, remember that:
• The best treatment is the most conservative one that works.
• The best treatment for sleep apnea, for most people, is Seepap.
• All surgery carries risk and you need to understand clearly what those risks are
in your particular health situation.
Then read the section on surgery later in this chapter.
Does Insurance Pay for Sleep Apnea Treatment?
You will want to contact your insurance provider when you begin to consider
treatment for sleep apnea. Ask which treatments they will pay for and exactly what
that coverage includes. Most insurance providers now pay for the most common treat-
ments for sleep apnea if the treatment is prescribed by a sleep specialist. However, some
surgical procedures may not be covered.
Who Treats Sleep Apnea?
Where your treatment will be carried out will depend both on your sleep center, the
size of its staff and the emphasis of its programs, and on the particular treatment. Some
sleep centers provide both testing and treatment of sleep apnea, some do only sleep
testing, and some fall in between these two extremes, doing some types of treatment
in-house but referring patients elsewhere for others. See Chapters 16 through 18 for
more information on how to obtain the health care services you need.
In any case, you can expect the sleep specialist and sleep staff to work with you and
your family to plan your treatment and to recommend a treatment specialist. Your family
doctor may be brought into the process at this stage.
Your sleep doctor may begin by suggesting a number of treatments that you can
carry out on your own (stop smoking, lose weight, and so on). To help you with these,
the sleep center may refer you to a nutritional counselor, a smokers’ support group, or
other such organized programs.
If surgery is an option for you, and your sleep center does not perform surgery, the
center will probably suggest or recommend surgeons and other specialists with whom its
staff members work frequently, and these physicians will be brought into the picture to
help plan your treatment.
If your sleep center has surgeons and other specialists on the staff who can treat you
there, you may still want to talk with an outside physician, preferably one with some
familiarity with sleep disorders, for a second opinion before you agree to surgery.
If your treatment involves medications, the sleep center may prefer to start you on
the medication and then have your family physician take over the follow-up care and
monitor your progress.

The most common treatment involves the use of a breathing device. The device
may be supplied through the sleep center, or the center may arrange for a homecare or
medical equipment company to supply the equipment.

The First Step in Treatment: Eliminate the Obvious.

The first step in treating sleep apnea is to eliminate anything that is aggravat-
ing your problem. This may improve your symptoms enough that you can avoid more
complicated forms of treatment. The following can all make your sleep apnea worse:
• Alcohol, especially in the evening (even a single glass of wine with dinner),
can increase the number of apnea events and decrease the level of oxygen in
the blood during the night. A person with sleep apnea should avoid alcohol in
the evening.
• Smoking decreases the amount of oxygen in the blood. It also causes swelling
of the lining of the airway, which contributes to obstructive apnea. People with
sleep apnea would be wise to stop smoking.
• Allergies and respiratory infections also cause swelling and obstruction of the
airway. Treatment of allergies and upper airway infections can diminish the
symptoms of obstructive sleep apnea.
• Evening medications, such as tranquilizers and short-acting beta blockers,
sometimes can worsen sleep apnea. The sleep specialist may want to consult
the physician who prescribed the medication to see whether a change in
prescription or in medication schedule can help eliminate sleep apnea symptoms
(see Appendix for list of medications that affect sleep).
• Obesity contributes greatly to obstructive sleep apnea, and weight loss can help
or even eliminate sleep apnea. Weight loss is discussed in detail later in this
chapter and in Chapter 11.
• Shift work. Anything that interferes with the amount and quality of sleep (as
shift work does) can worsen sleep apnea symptoms. Ask your sleep specialist for
information on how to improve your sleep while on shift work. You may even
want to consider changing to a job that does not require rotating shifts.
Some of these aggravating factors involve lifestyles and habits that are difficult to
change or to give up. Often people have the best results if they are enrolled in an orga-
nized program to help them eliminate the habit. If you find yourself trying to deal with
a stubborn problem such as losing weight or stopping smoking, ask your sleep center to
recommend a program that has been helpful for other people.
Treatments for Obstructive and Mixed Sleep Apnea
The current treatments for obstructive sleep apnea are (from most conservative
to least conservative) change of sleeping position, weight loss, breathing devices, oral
devices, drugs, and surgery.

Mixed apnea generally is treated by first treating the obstructive apnea component.
Once the obstructive apnea is under control, the central apnea almost always ceases to
be a problem.
Change in Sleep Position
People with obstructive sleep apnea generally have more severe apnea events when
sleeping on their back; a few people have breathing difficulties only while lying on
their back. A change in sleep position may eliminate the problem for these few people.
However, there is no good evidence that this technique produces reliable results each
night.
Even if sleep testing shows fewer breath-holds in a particular position, airflow may
still be poor enough to cause sleep disruption. If you feel more rested on Seepap than you
do simply sleeping on your side without Seepap, you have good evidence that you need
more than just positional treatment.
Some people’s apnea is so severe that even brief periods of apnea are life-threatening,
and position training is not helpful.
Position change is helpful primarily to people who:
1. Have obstructive apnea that has been shown during a sleep study to occur only
while lying on their back
2. Can reliably sleep on their side
Learning to avoid a particular sleep position is a matter of conditioning. Several
sleep position monitors and alarms have been developed that alert sleepers when they
roll onto their back and train them to choose a different sleep position. Two simple
methods are sewing a small ball into the back of the pajamas or wearing to bed a small
rucksack containing a bulky object that will make you lie on your side. People usually
need a couple of weeks of practice before a new sleep position becomes a habit, and they
may need to “retrain” themselves periodically.

Weight Loss.

Who Can Be Helped by Weight Loss?
Weight loss can be effective for people with the Pickwickian syndrome (see
Chapter 11 and some other overweight heavy snorers:
1. Whose apnea is associated primarily with their weight gain rather than with an
anatomical obstruction of the airway (such as stuffy nose, large tonsils)
2. Whose life is not in immediate danger from the effects of sleep apnea, such as
sleepiness or heart disease (see Chapter 2)
The people who are most likely to be successful at weight loss are overweight apnea
sufferers who are highly motivated to improve their health and lifestyle.

Why Does Weight Loss Work?

When it is effective, weight loss works for at least two reasons- there are others
that are under investigation. It relieves the abnormal loading on the abdomen that can
interfere with breathing reflexes and it reduces the fatty deposits in the throat tissue
that contribute to the development of obstructive apnea. However, weight loss is only
effective if:
1. Sufficient weight is lost.
2. The weight can be kept off permanently.
Insufficient weight loss and weight regained are the two main reasons for failure of
this treatment when it does fail. In fact, there may be a kind of weight “threshold” above
which extra weight causes apnea symptoms and below which the symptoms are relieved.
According to this theory, you need to reduce your weight far enough to fall below that
threshold before you can expect to see some improvement in your apnea symptoms.
However, because the upper airway is soft sided and collapsible, it can be affected
by factors other than weight gain—for example, a person whose small jaw crowds the
airway may not see much improvement from weight loss.
Losing weight and keeping it off may be difficult or impossible for some people as
long as their sleep apnea is untreated. Their fatigue, sleepiness, low energy, and reduced
vigor may prevent them from being physically active enough to burn calories, build
muscle, and successfully lose weight. In these cases, the combination of Seepap (discussed
later) and weight loss can have dramatic results (see illustration on page 72). (For more
on obesity, sleep apnea, and weight loss, see Chapter 11.)
Weight loss surgery is a radical way to lose weight. However, recent evidence
suggests that untreated severe obesity defined by a BMI greater than 40 may have greater
risks than having weight loss surgery. Even surgeons agree that weight loss surgery is not
a conservative treatment and this topic is discussed later in the section on surgery.
Seepap and Similar Breathing Devices
Seepap and similar breathing devices are the most effective and most important
treatment for sleep apnea. Breathing devices treat obstructive apnea by using air pres-
sure as a “splint” to hold the upper airway open and keep it from collapsing during sleep.
Some sleep experts believe that, in addition, the extra air pressure delivered by these
devices may stimulate the person’s breathing reflexes.
Seepap (pronounced “SEE-pap”) is the most common breathing technology for
treating sleep apnea. Seepap (continuous positive airway pressure) was developed in
1981 by Dr. Colin Sullivan and his research group at the University of Sydney Medical
School in Australia (1,2). It was first used to treat sleep apnea patients in the United
States in 1984.
Seepap is by far the most effective of all standard treatments, surgical or otherwise,
for sleep apnea. For that reason, Seepap has become the treatment of choice at most
sleep centers.

The standard Seepap system consists of a small, soft, pliable mask that is worn over
the nose (usually not the mouth) at night. The mask is connected by flexible tubing to
an air pump, which provides a continuous supply of slightly pressurized air through the
tubing and into the nose. As soon as the Seepap wearer begins to inhale, the air pres-
sure stabilizes his soft palate and tongue and prevents his airway from collapsing. The
pressure regulator is custom set for the patient during a night in the sleep laboratory so
that the Seepap delivers exactly the right pressure that the person personally needs to
eliminate apnea events but no more than is necessary.
New Seepap models appear each year (see illustrations on the next page). You can
see what some of the latest Seepap models and masks look like by going to the web sites
of the major manufacturers of Seepap equipment and accessories:
ResMed Corp.
www.resmed.com.
800-424-0737.
Respironics, Inc.
www.respironics.com.
800-345-6643.
To read about choosing a Seepap unit and selecting a mask that fits you properly,
please go to Chapters 17 and 18.

Seepap pressure is measured in centimeters of water (cm H2O), in much the same
way that barometric pressure is measured in millimeters of mercury (mm Hg). Typical
Seepap pressure settings range from 5 to 20 cm H2O.
Bi-level PAP (called BiPAP by the manufacturer, Respironics, Inc., see Appendix)
is a refinement of Seepap. This system allows the sleep specialist to set the air pressure
at two different levels: higher pressure for when the person inhales, to eliminate
snoring, and lower pressure during exhaling, making it easier to exhale.
In some severe cases of obstructive sleep apnea, oxygen may be prescribed in
conjunction with Seepap or bi-level PAP.

new type of Seepap is often referred to as auto-PAP or “smart-PAP.” This type of
machine attempts to change pressure in response to the user’s needs. The device senses
the user’s breathing patterns and adjusts pressure to accommodate changes in breathing
that occur throughout the night. There are several manufacturers of smart-PAPs, and
each one uses different breathing signals to regulate their machines. Some designs are
more comfortable for the user than others, and some are more appropriate for certain
types of users.
The cost of a smart-PAP is higher than for a standard Seepap. For many people with
sleep apnea, the advantages probably would not justify the extra cost, nor would most
insurance or health plans pay for the extra “bells and whistles” of a smart-PAP unless
one is specifically prescribed. However dual- and variable-pressure systems are now
the prescribed treatment of choice for more severe sleep apnea patients, and insurance
usually will pay the extra cost if the sleep specialist specifically prescribes one.
The technology in this field is changing rapidly. If you are a candidate for Seepap,
talk with the staff at your sleep center and with a homecare representative about the
various versions of breathing devices that are available. You may want to test more
than one and decide which one suits you best. See Chapter 17 for more on choosing a
Seepap.
Who Can Benefit from Using Seepap?
Seepap can produce a virtual “miracle” cure in people who have not slept and
breathed normally in years and are extremely ill from the long-term cardiac and
respiratory effects of sleep apnea. There are probably more than 3,500,000 people in the
United States using Seepap today, with the numbers growing by the tens of thousands
each year. However, many people find that adapting to the use of Seepap is a challenge
and requires patience and persistence.
Treatment with Seepap should be started and evaluated in the sleep center during an
overnight sleep study. This allows the sleep technician to adjust the pressure correctly,
establish a baseline for monitoring the effectiveness of the treatment, and avoid inap-
propriate or ineffectual use of Seepap. In time, Seepaps may be able to accomplish this
process accurately in the patient’s home. However, that time has not yet arrived.

Getting Used to Seepap.

The use of Seepap requires motivation and perseverance. A few minutes are needed
before going to bed each night (just like for brushing teeth) to wash the face so the skin
is clean and will not be irritated by the mask, and a few more minutes every morning
to wash the mask. Once Seepap is familiar, it becomes part of the bedtime routine. One
needs to make a commitment to use the system each night for reasons of better health
and longer life. See Chapters 17 and 18 for more on using Seepap.
Seepap users generally are willing to put up with the inconvenience once they
experience the results. In one follow-up study of 20 Seepap users after about a year, 16
were still using their Seepap all night, every night (3). Such a high degree of compliance
with the treatment reflects the users’ enthusiasm for its effectiveness.

A high degree of compliance usually also means that the sleep disorders center has
a policy of conscientious follow-up care to help new Seepap patients with problems and
questions that may arise.
The main drawbacks of Seepap are related to the notion that Seepap will be
cumbersome or inconvenient. Also, it may have a tendency to cause nasal irritation in
some people. Some people can get used to wearing the mask in just one or two nights;
others may take several weeks. The air pump motor makes a fanlike sound rather like
“white noise” that a few Seepap users find annoying. Newer Seepap machines have gotten
so quiet that patients who wake up in the night sometimes find that they cannot hear
their Seepap machine at all and, until they are accustomed to it, they feel they need
to check to be sure it is still working. Most people do not object to the sound or the
presence of Seepap, and their bedmates generally prefer Seepap over snoring.
When used all night, every night, Seepap provides positive results that are close to
an instant cure. After beginning to use Seepap, most people report that within days they
feel better than they have felt in many years. They report sleeping better, feeling rested
in the morning and alert during the day, and having the energy to do the things they
have been longing to do.
When regular Seepap users stop using it for a night—for example, during a power
failure—they generally are eager to return to Seepap because the apneas and their
symptoms promptly return. In fact, after using Seepap and then sleeping without it, many
people report that they had never been so aware of the choking they experienced with
each apnea event. Now if they sleep without Seepap, they dream that heavy weights
have been placed on their chest or they awaken feeling suffocated, so they are not often
tempted to give up their Seepap.
Please read Chapter 17 before you purchase a Seepap and Chapter 18 for suggestions
on sleeping comfortably with a Seepap.
What Are the Long-Term Effects of Using Seepap?
Since the introduction of Seepap in the 1980s sleep scientists have been watching
carefully for any unfavorable long-term effects. By now thousands of people have been
using Seepap for more than 20 years, and no serious negative consequences have been
reported in the medical literature. Of course, no one can guarantee the safety of sleep-
ing for 30 or 40 years under slightly higher air pressure, but so far the medical literature
suggests that the long-term risks from sleep apnea are much more dangerous than any
potential long-term risks from using Seepap.
How Much Do Seepap Devices Cost?
Seepap systems can be obtained by rental or purchase. It is a good idea to begin by
renting a system for 2 or 3 months, seeing how you do with it, and perhaps trying a couple
of different models. Costs vary around the country. Currently, Seepap unit rentals cost
approximately $250 to $350 per month, and the purchase price is in the neighborhood
of $1,500 to $3,000. You may have to purchase the mask and tubing separately (about
$200). The mask material tends to absorb oil from the skin and become stiff, so masks
require periodic replacement. Silicone masks may last up to 18 months. A heated
humidifier can cost $500, an unheated one closer to $100.
Your health insurance may cover most, if not all, of the costs of Seepap, both rental and
purchase. Talk to your insurance company representative to find out which equipment
and supplies they will cover (see Chapter 17 for more on selecting a Seepap).
How Can You Obtain a Seepap Unit?
You must have a doctor’s prescription to obtain a Seepap machine. Your sleep center
personnel can put you in touch with a homecare company that will supply you with a
Seepap system. The homecare company representative will teach you how to operate
your Seepap unit. They should provide same-day service in case of breakdown. (See
Chapters 17 and 18 on homecare companies.)
Some sleep centers rent or sell Seepap systems directly. However, most do not have
the desire or the staff that this requires.

Oral Devices for Treating Sleep Apnea.

A number of oral devices have been designed for treating sleep apnea, with the
objective of holding the lower jaw, the tongue, or both in a forward position during
sleep, hoping to make the upper airway less likely to collapse. These devices are likely to
work best for people whose obstructive apnea originates primarily in the lower pharynx
(throat) from the position of their tongue or lower jaw in relation to their airway.
Jaw Retainers (Mandibular Advancement Devices, or MADs)
Jaw retainers are dental appliances that hold the lower jaw forward (4,5). We will
call them MADs (mandibular advancement devices), although they are also called
mandibular repositioning devices (MRDs), anterior mandibular positioners (AMPs), or
oral airway dilators (OADs).
MADs look like the bite plates or retainers that sometimes are prescribed by
orthodontists. They are made of dental acrylic and may have metal loops over several
teeth to hold the device in place (see illustration on page 77). Many different manufac-
turers have designed their own MAD versions. Some models are adjustable for easy selec-
tion of the best forward position for the lower jaw. Most MADs must be custom fitted.
Definitive studies to pinpoint who will benefit from a jaw retainer or which devices
work best have not been completed. Studies of mandibular appliances in sleep apnea
patients have used small numbers of patients and different definitions of “success.” So
far, these limited clinical trials suggest that mandibular devices are about 50 percent
effective. That is, about half of patients who try them still have serious enough sleep
apnea symptoms that they need additional treatment. The adjustable models may be
more practical than models that are not adjustable. It is unlikely that any one design will
work equally well for all patients.
For these and other reasons, people who are considering an oral appliance would
be wise to locate a dentist who is experienced in using these devices for the treatment
of sleep apnea and who works in cooperation with a sleep specialist. The sleep specialist
(not the dentist) should make the diagnosis of obstructive sleep apnea and should
measure the effectiveness of the dental device after the dentist has fit the patient with
it. You can locate a dentist near you who has been trained in this field by contacting the
Academy of Dental Sleep Medicine (see Appendix).
Who Can Benefit from Using a MAD? The manufacturers of MADs and some
experimenters who have studied patients using them have reported some good results,
especially in patients who have mild to moderate apnea (5–8).
Because MADs focus their treatment on the lower jaw and/or tongue, people with
a smallish lower jaw that is set somewhat far back (called by orthodontists a class II
occlusion) are likely to have the best results.
MADs also have been used successfully in children born with irregularly formed
jaws who have difficulty with obstructive apnea.
Three-quarters of people with sleep apnea have airway obstructions in more
than one place. People whose obstructive apnea results mostly from nasal problems or
from the upper pharynx (large tonsils, adenoids, soft palate, uvula) are not likely to be
treated successfully with an MAD and will need further treatment. In fact, you must be
able to breathe through your nose to use the retainer; a person with a nasal obstruction
or a stuffy nose from an allergy or a cold will be unable to wear one. Even some people
who seem likely candidates for MADs continue to have apnea events, as shown by
heavy snoring. Also, it is necessary to have enough teeth to be able to hold an appliance
in place.
One group of people who may want to try an MAD are those who have been unable
to use Seepap despite a wholehearted effort. However, if a nasal obstruction is preventing
you from successfully using Seepap, you will also be unable to use an oral appliance unless
you can eliminate the nasal obstruction by surgery or medication.

There may be a place for occasional use of an MAD, even if it is only partially
effective, for example:
1. When Seepap is unavailable (backpacking, primitive travel)
2. When the device allows the patient to use a lower Seepap pressure
3. When screening patients for mandibular advancement surgery (to simulate the
possible results of surgery)
Objective studies of the benefit in these situations are not yet available.
Getting Used to a MAD. It may take from several nights to several weeks to get
completely accustomed to wearing a MAD. Excess saliva will probably be an early side
effect. Any foreign object in the mouth, such as a retainer, causes the production of
excess saliva at first, but this generally tapers off after a night or two. However, it may
take as long as 2 or 3 weeks for jaw muscles and other muscles to become accustomed to
wearing a MAD. You may need to wear it at least that long to carry out a fair trial and
decide whether it is effective.
A disadvantage of the MAD is that you cannot rent one to try it out. One “do-it-
yourself” brand, which is available by prescription, can be adapted to fit by warming it
in hot water. It works well enough to offer some idea of effectiveness, but it is not very
durable. Otherwise, you will not know whether a MAD works for you until you have
paid to have one made. If it does work, you will be delighted. A MAD is less restrictive
of movement, much smaller, less expensive, and more convenient to deal with than a
breathing device. If it does not work, other options are available.
How Much Do MADs Cost? MADs are less expensive than Seepap units, but still
surprisingly costly. The do-it-yourself brand costs about $25. Some sleep centers have
trained technicians who can fit an adjustable model for $300 to $400. Some manufacturers
charge as much as $600 for a custom-fitted appliance, and with the dentist’s markup it
may cost you more than $1,000. That is approximately twice the cost of an ordinary
orthodontic retainer and does not include the cost of having your orthodontist or dentist
take jaw impressions, or the cost of additional visits to check or adjust the fit of the
appliance. This can add another several hundred dollars to the cost. Check with your
insurance company in advance to see if they will cover part or all of these costs.
Should You Try a MAD? If you and your sleep specialist think you are a likely
candidate for success with an MAD, here are some questions to answer:
1. Have you had a sleep study to measure the baseline of your sleep apnea before
treatment?
2. Is your sleep apnea mild?
3. If your sleep apnea is moderate to severe, have you tried Seepap (a more effective
treatment)?
4. Do you have nasal obstructions that would prevent you from breathing through
your nose?

5. Do you have temporomandibular joint (TMJ) syndrome or dental problems
that might be aggravated by using an MAD?
6. If you have TMJ or dental problems, can your sleep specialist refer you to a
dentist who is experienced in fitting oral appliances for sleep apnea?
7. Has your sleep specialist scheduled you for a follow-up sleep study while you are
wearing the oral appliance to verify its effectiveness?
8. Have you added up and talked with your insurance agent about the full
costs of an oral device, including fabrication, fitting, office visits for adjustments,
and a follow-up sleep test? Do you consider this a cost-effective treatment
option?
These questions are based partly on standards suggested by the American Academy
of Sleep Medicine for the use of oral appliances (9).
Is Your MAD Really Working? Soon after you become accustomed to using an
MAD, you should return to the sleep center for a follow-up sleep study to determine
whether the appliance is effectively eliminating your apnea. The sleep study must assess
whether the MAD works both when you are sleeping on your back and when you are
sleeping on your side.
An important disadvantage of MADs is that their effectiveness tends to decrease
over a period of a year or two (10). Consequently, you should consult your sleep spe-
cialist about when to schedule a follow-up sleep study to make sure your MAD is still
eliminating your sleep apnea.
Other Oral Appliances
The Tongue-Retaining Device. The tongue-retaining device (TRD) is made of
soft plastic and consists of a tongue-sized suction cup that is supposed to pull the tongue
forward and hold it in that position. It is gripped by the teeth and held in place during
sleep (11,12).

In this picture, A Samelson-type TRD. The tongue is drawn forward into the bubble and held by suction.

Many people who have used the TRD in experiments have found it moderately
uncomfortable to wear. For this reason, it was worn only half the night in some
experiments. Despite its drawbacks, the TRD was found to decrease the number of
apnea events by approximately 50 percent. This means that the TRD could be about as
effective as uvulopalatopharyngoplasty (UPPP), a type of surgery described later.
The TRD has not excited a lot of enthusiasm in the sleep research community,
and so far it has not become widely used or available. Part of the reason for this prob-
ably is that the TRD apparently is useful only to a small group of obstructive apnea
patients.
The people who are most likely to be helped by a TRD are those who are not
obese, have no nasal obstructions, and have only mild to moderate apnea that is strongly
influenced by sleeping position—that is, the apnea is much worse when sleeping on the
back than when sleeping on the side (12). For this group of people, apnea apparently
is strongly affected by tongue position; therefore, holding the tongue forward with the
TRD might be helpful. In some cases, more severe apnea has been controlled with the
use of a TRD.
Oral Positive Airway Pressure Appliance. The oral positive airway pressure
(OPAP) appliance treats obstructive sleep apnea with a mouthpiece instead of a nose
mask. It consists of a small mouthpiece that can be worn either by itself or connected
to Seepap tubing and a Seepap machine. By itself, the OPAP appliance can be used like a
jaw retainer to hold the lower jaw in a forward position if desired. Attached to a Seepap
unit, it holds the airway open with air pressure, just like a Seepap unit (13).

Who Can Be Helped by an OPAP Appliance? The OPAP appliance may be an
alternative for people with mild to severe obstructive sleep apnea who would otherwise

be using a standard Seepap mask, or have had difficulty using Seepap, or have had
unsuccessful surgery for obstructive sleep apnea. Worn by itself, the OPAP appliance
might be considered an alternative dental appliance to treat obstructive sleep apnea.
The advantage of the OPAP appliance is that it bypasses the nose, where many people
have nasal obstructions that make Seepap use difficult. It also avoids the mask-fitting
issues of Seepap and the skin irritation that some people experience from wearing the
Seepap mask against the face. The OPAP appliance does not require headgear, so it may
be more comfortable, and it eliminates the “bad hair day” that can greet a person in the
morning after wearing Seepap headgear all night.
What Are the Drawbacks of OPAP? OPAP is so new that very few patients
have had a chance to try it. Excessive production of saliva is likely the most obvious
drawback. Long-term effects are not yet available. Questions remain about how OPAP
affects the teeth and the temporomandibular joint (TMJ). People with TMJ problems
should consult their dentist about using an OPAP appliance.
How Much Does an OPAPAppliance Cost? At present, an OPAP appliance is
custom fit like a dental appliance, which can be costly. The cost will probably be in the
neighborhood of $600. A less expensive, off-the-shelf model may be available in the
future. If you are considering an OPAP appliance, you should contact your insurance
company and ask whether they will cover the cost.
How Can You Get an OPAP Appliance? Ask your sleep specialist whether an
OPAP appliance would be appropriate for you. If so, she should be able to refer you to a
dentist who is trained to fit an OPAP appliance. If not, contact the Academy of Dental
Sleep Medicine (see Appendix) for the name of a dentist who is trained to treat sleep
disorders and familiar with these devices.
Orthodontic Treatment to Remodel the Jaw
Orthodontists are playing an increasing role in the treatment of obstructive sleep
apnea. Sleep apnea patients who have a small jaw—class II malocclusion–have a
crowded, easily obstructed airway. Orthodontic treatment is able to remodel the jaw
by moving teeth apart and using implants to fill the spaces (14). This treatment, alone
or combined with jaw surgery (see below), may enlarge the jaw sufficiently to reduce or
eliminate obstruction of the airway.
Orthodontists have begun to recognize the risk of inviting obstructive sleep apnea
in the future by removing childhood teeth to “make room” in the jaw. The problem
with this practice is that, over the years, the jaw bones tend to restructure themselves
in response to the actions of chewing and movement of the tongue muscle. With fewer
teeth occupying space, the jaw may end up smaller, with crowded teeth, overbite, and a
crowded airway. The unintended consequence may be obstructive sleep apnea.
In the future, a more common solution to childhood’s crowded jaw may turn out to
be preservation of the size and architecture of the jaw rather than removal of teeth.

Drugs for Treating Obstructive Sleep Apnea.
So far, drugs generally are not very effective in treating obstructive sleep apnea.
However, several of the drugs that have been tried unsuccessfully as treatments for central
apnea (described previously) have met with at least mixed success in obstructive apnea.
The hormone medroxyprogesterone has been found to be somewhat effective in
some people with the Pickwickian syndrome (see Chapter 11). It has been reported to
improve the breathing drive, to decrease the number of apnea events, and to improve
the patient’s symptoms (15–17). However, some researchers have reported no improve-
ment in apneas, so the results with this drug are conflicting (15–18).
Medroxyprogesterone has some undesirable side effects. It can cause fluid retention,
nausea, and depression in some people. Because it is a sex hormone, it may cause extra
hair growth and breast tenderness. It should not be used by people with blood-clotting
disorders or liver disease, by pregnant women, or by people known or suspected to have
genital cancer.
Protriptyline is an antidepressant that is variably effective in mild cases of sleep
apnea. It is only a treatment option if the person’s life is not in immediate danger from
the effects of sleep apnea.
Drawbacks of protriptyline are that it decreases the amount of rapid eye movement
(REM) sleep and has a high incidence of other side effects, including dry mouth, consti-
pation (mild to intolerable), difficulty starting urine flow, and impotence (16,19). It can
cause confusion, especially in elderly people. It may not be appropriate for people with
arrhythmias, very high blood pressure, glaucoma, or prostate disease (17).
Oxygen alone is not an effective treatment for obstructive sleep apnea; in fact, it
can make obstructive apnea worse.
Surgery for Obstructive Sleep Apnea.
Surgical Risks to Consider.
Surgery is the least conservative treatment for obstructive sleep apnea, and for most
people it is not likely to be as effective as Seepap. It would be wise to understand the
other alternatives before selecting this one. And by all means get a second opinion from
a different physician before deciding on surgery.
The most conservative treatments for sleep apnea do not involve surgery. They
may involve some inconvenience or perseverance, but they do not expose the patient
to the risks of pain and possible complications or death that are inherent in any surgical
procedure.
A conservative surgical procedure meets most or all of the following criteria:
• It is a routine procedure that has been carried out for many years rather than a
new or experimental type of surgery.
• It does not involve cutting major blood vessels or nerves, dealing with major
organs, or entering a body cavity.

• It normally has no serious postoperative complications.
• It can be performed by a surgeons who are experienced with this particular
surgical procedure without much variation in outcome.
• It can be done safely on an outpatient basis or involves, at most, a minimal (one-
or two-day) hospital stay.
Surgery has many potential pitfalls: pain, excessive loss of blood, reactions to medi-
cations, nerve or muscle damage, infection, wound breakdown, and other complications
(20,21).
One of the biggest risks from surgery is general anesthesia (20). This is particularly
true for a person with sleep apnea. Anesthetics depress the breathing reflexes, and a
person with sleep apnea already has some degree of respiratory difficulty. Anyone with
sleep apnea who is having surgery should warn the surgeon in advance that he has sleep
apnea. Better yet, the person could ask the sleep specialist to consult with the surgeon.
The surgeon and the anesthesiologist should both be aware that this person’s breathing
will need to be monitored very carefully during and immediately after surgery.
So even “simple” surgery should be considered very carefully. Surgery may be the
only option that makes sense for a person who is very sick as a result of sleep apnea—it
may be necessary to save his or her life. For other people who are not in immediate
danger from the severe long-term effects of apnea or who may simply want to “stop
snoring,” the potential risks involved in some of the surgical procedures may outweigh
the possible benefits.
Can Surgery Cure Sleep Apnea?
Help versus Cure? It is important to distinguish between an attempt to help sleep
apnea and an attempt to cure sleep apnea (that is, eliminate all disease, including the
high risk of stroke, heart attack, and other cardiovascular disease caused by untreated
sleep apnea). For example, patients A and B might both show a significant decrease in
sleep apnea after surgery. However, patient A might have started out with mild apnea
and may not need further treatment despite some remaining sleep apnea. (An example
would be a person who goes from a sleepy patient with a respiratory disturbance index
[AHI] of 40 before surgery to an alert patient with an AHI of 10 after surgery.) Patient
B, on the other hand, might have started with more serious apnea and may still need
to use Seepap after surgery. (An example would be a person whose AHI of 60 improves
to 30 after surgery but who still has low blood oxygen at night, still has a high risk of
cardiovascular disease, and is still drowsy.)
Results Vary Among Individuals. The surgical procedures for sleep apnea are
not equally effective for all people. For example, an early surgical procedure that was
used for sleep apnea and is still being used today is uvulopalatopharyngoplasty (UPPP)
(described later). As a treatment for sleep apnea, UPPP has about a 50 percent failure
rate, and after 5 years, the success rate may fall to as low as 25 percent. This means that
50 percent of the people who undergo this surgery still have a significant problem with

sleep apnea immediately after surgery, and the percentage of people with problems will
increase with time.
Surgery for reconstructing the lower jaw (mandibular advancement and its
variations) also has a fairly high nonsuccess rate but when combined simultaneously
with maxillary surgery it has helped individuals with even severe sleep apnea.
There are several reasons for the failure of surgery to correct sleep apnea. One is
simply inappropriate choice of treatment. There are some patients for whom it can be
predicted in advance that UPPP is not likely to cure their apnea. Yet, some of these
patients choose to have surgery anyway. Quite often, after a person is diagnosed with
sleep apnea, she is not ready to accept the reality of having a long-term health condi-
tion, and may seize upon surgery as a hopeful “quick fix.” Or the person may be referred
directly to a surgeon by a family doctor who is unfamiliar with or biased against non-
surgical treatments for sleep apnea. Poor surgical candidates usually find that their sleep
apnea returns after surgery and that they still need long-term treatment.
Another reason for the low success rate of surgery is the newness of treating sleep
apnea with surgery. There still are not enough data to be able to predict accurately
which people will be cured by a particular reconstructive procedure.
Before you choose surgery for the treatment of sleep apnea, ask your sleep specialist
about the chances of success for you, and listen carefully to the answer.
To summarize, be sure you are an excellent candidate for the particular kind of sur-
gery you are considering before you take the risk of having it. A second opinion from a
qualified sleep specialist who will not be performing the surgery is strongly advised.
One final point on choosing a conservative treatment: If you are considering
being treated at a medical school, you might keep in mind that medical schools may
lean toward more aggressive, more experimental, less conservative treatment options.
Although this is fine from the point of view of advancing medical science, you should
ask yourself whether you want to risk being part of that process.

Five Categories of Surgery for Sleep Apnea.

ive general types of surgery are used to treat obstructive sleep apnea:
1. Nasal surgery
2. Palate and tongue surgeries
• UPPP (uvulopalatopharyngoplasty)
• LAUP (laser-assisted uvulopalatoplasty for snoring)
• Somnoplasty (radiofrequency thermal ablation)
3. Jaw surgery and other maxillofacial surgeries
4. Tracheostomy
5. Weight loss surgery
Nasal Surgery Nasal surgery actually may refer to several different ear, nose,
and throat (ENT) procedures. These can include repair of the nasal septum (the wall
that separates your left and right nasal passages), turbinate surgery to remove bony

obstructions, removal of polyps, surgery on the nasal sinuses, or submucous resection
(removing loose tissue under the lining of the nasal passages).
Nasal surgery may be a necessary first step to allow some people to use Seepap. People
with nasal obstructions may feel “claustrophobic” or suffocated while using Seepap, or
they may unconsciously pull off the Seepap mask during sleep. Seepap users who have
these problems should ask their sleep specialist whether nasal surgery might make them
more comfortable with Seepap.
Nasal surgery may also permit a person to wear an oral appliance (mandibular
advancement device) that would have been impossible before surgery. A person who
has poor airflow through the nose would feel suffocated wearing an oral appliance.
By itself, nasal surgery usually is not an effective treatment for sleep apnea or snor-
ing. Some people occasionally report a decrease in snoring after surgery on their nose,
only to have the symptoms return over several months.
However, improved airflow through the nose can have a significant effect on overall
airflow, and it should also be considered as part of an overall surgical approach if palate
surgery (see the next section) is going to be carried out.
Palate and Tongue Surgeries U V U L O PA L AT O P H A RY N G O P L A S T Y. UPPP
was the first and remains the most common type of surgery for sleep apnea. Under
general anesthesia, a scalpel is used to remove approximately the rear third of the soft
palate. The back of the soft palate is left in a streamlined shape that will be less likely
to collapse during sleep.

Who Can Be Helped by UPPP? Whether a person can be helped by UPPP depends
on the reason for surgery and on how one defines being “helped.” If the surgery is for
purely “cosmetic” purposes (that is, simply to cut down on snoring) and if a sleep study
has shown that the person has only snoring and not sleep apnea, UPPP stands about a
90 percent chance of being successful. The bedmate’s report that snoring has disappeared
after UPPP does not necessarily mean the disappearance of sleep apnea.
If the purpose of surgery is to eliminate sleep apnea completely, the chance of
success is much lower and much more difficult to predict, but probably is less than
20 percent. People who are the most likely candidates for success with this type of
surgery meet the following criteria:
1. They are not more than 25 percent or 30 percent over their ideal weight, and
they do not gain weight after surgery (22,23).
2. They have only mild to moderate apnea, and it is all obstructive apnea.
3. Their apnea arises mostly from some obvious anatomical obstruction of the
upper part of the pharynx (throat)—the soft palate or upper throat area (24,25).
This includes people with enlarged tonsils or adenoids (tonsils and adenoids
often are removed during UPPP); people with a very long soft palate or a large,
fleshy uvula; and people with excess fleshy tissue in the throat region. The
combination of abnormally large palatal tissue with large obstructive tonsils
may give the best outcome- UPPP combined with tonsillectomy.
In contrast, people with very severe apnea or those whose apnea arises from places
other than the area of the soft palate are not good candidates for UPPP. Those with a
lower jaw that is very short or placed far back, or with a tongue that is large or is posi-
tioned fairly far back and low in the neck, or with apnea arising in the lower pharynx
are less likely to be successful with UPPP (25,26).
Weight gain is an extremely important factor in the success of UPPP. Extra loading
of the abdomen, which interferes with the breathing reflex, plus fatty deposits in the
neck, which help obstruct the airway, can overpower any positive results that may be
gained from UPPP. Therefore, people who have UPPP and then gain weight are likely
to see the return of obstructive apnea (22).
Until recently, not much was known about which people could best be helped by
UPPP. With the aid of cephalometry (measurement of size and placement of structures in
the head using radiographs, computed tomography (CT), or magnetic resonance imag-
ing [MRI]) and fiberoptic examination of the inside of the airway, doctors are gradually
gaining more information about how to choose the most likely candidates for successful
UPPP (26–30). Nevertheless, no one can accurately predict the success of UPPP.
Determining whether you are a good candidate for UPPP must be done by consulting
your sleep expert and a good otolaryngologist (ENT specialist) who has experience not
only with eliminating snoring but also with sleep apnea problems. The otolaryngologist
should examine your throat internally. He may order a radiograph, MRI, or CT scan of
your head so that he can measure the sizes and relationships between various anatomical
features that cause your obstructive apnea. This will help to determine your chances of
being helped by UPPP.
What Are the Drawbacks to Uvulopalatopharyngoplasty? Compared with many
surgical procedures, uvulopalatopharyngoplasty is not particularly risky. It does not
involve any large arteries or nerves. It may be performed as outpatient surgery in healthy,
uncomplicated cases. A hospital stay of 1 or 2 days may be necessary for some patients.
As mentioned previously, the greatest risk probably is from the anesthesia.
The more narrow the airway, the greater the risk from preoperative medications,
from anesthetics, and from painkillers and sedatives given immediately after the
operation (20).
The reason for this increased risk is that anesthetics and some other drugs interfere
with the breathing reflexes. If you have sleep apnea, you already have breathing reflexes
that may not operate quite normally. This means that you are at somewhat greater than
normal risk from anesthesia. This breathing abnormality, coupled with existing apnea,
possible throat obstruction from postoperative swelling, and perhaps pain medication
could add up to serious complications.
Pain is another consideration with UPPP. People who have had UPPP report that
the pain after the operation is very severe—more painful than expected (for example,
more painful than a tonsillectomy). Severe pain can last as long as a week.
All patients report difficulty with swallowing after surgery. The removal of the uvula
at the back of the mouth cavity makes it easier for food or liquid in the mouth to be
pushed up into the back of the nasal cavity during swallowing. This is a common prob-
lem for the first 2 weeks after surgery, but it should correct itself with time, particularly
if the surgeon is skilled and experienced with the procedure. A few people continue to
have swallowing problems. However, most who do have a little difficulty swallowing find
that they overcome the problem with some practice and if they eat properly (20,23).
There have been reports of airway obstruction becoming worse or more difficult to
treat with Seepap following UPPP.
Why Have Uvulopalatopharyngoplasty If the Odds Are Poor? Even if you have
only a 50/50 chance of being helped enough not to require further treatment, you may
prefer taking that chance in the hope of avoiding other treatments, such as Seepap, oral
appliances, or other surgeries.
UPPP has a very low risk when performed on patients who have been carefully
tested at a good sleep center, and when the surgery is performed by an experienced ENT
surgeon. For example, currently we are not aware of a surgical fatality or a serious com-
plication from this surgery at the Swedish[sws7] Medical Center.
How Can You Arrange for Uvulopalatopharyngoplasty? It is not wise to have UPPP
as a treatment for sleep apnea until you have been thoroughly examined by a physician
who understands the causes of sleep apnea and knows how to weigh the benefits against
the risks in your particular case. The sleep specialist, in turn, can refer you to a surgeon
who is experienced with UPPP if you appear to be a good candidate for successful
treatment by this procedure.

Laser Surgery to threat snoring.

. Laser-assisted uvulopalatoplasty
(LAUP) is a technique for surgery on the soft palate that has been promoted as a harmless
way to eliminate simple snoring. However, snoring is a symptom of sleep apnea, and in
definitive studies LAUP has not been shown to be an effective treatment for sleep apnea
(31,32).
The distinction between simple snoring and sleep apnea is not always clear. People
who appear to have “simple snoring” frequently turn out to have significant sleep apnea
(31). LAUP surgeons often try to screen out those patients with a questionnaire on
snoring. However, questionnaires cannot accurately diagnose sleep apnea and tend to
underestimate it. Consequently, many patients with undiagnosed sleep apnea have had
LAUP surgery and have been left with a serious underlying disorder. To avoid unneces-
sary, possibly harmful LAUP surgery, people who snore should first be evaluated by a
sleep specialist to rule out sleep apnea. LAUP should be considered only after sleep
apnea has been ruled out.
LAUP has been promoted as a substitute for conventional palate surgery (that is,
UPPP, as described previously). Patients whose sleep and ENT specialists consider them
good candidates for UPPP for treatment of snoring may want to consider LAUP for this
purpose, but not to treat sleep apnea.
What Is LAUP? LAUP involves several lengthwise laser “cuts” making a V-shaped
pattern on the soft palate. Several sessions usually are needed. The laser cauterizes
(“cooks”) the tissue, leaving narrow scars that stiffen the soft palate and presumably
diminish the vibration that causes snoring.
Does LAUP Eliminate Snoring? Proponents claim that it does in 80 percent to
90 percent of cases, but there are reports that snoring may return within 2 years after
surgery.33
How Does LAUP Compare with Conventional UPPP? LAUP is less risky—it
involves less time, less bleeding, less tissue removal, no general anesthetic, and no
hospitalization. It is somewhat less expensive (expect charges of approximately $1,600
for the surgeon, plus an additional fee for the surgical facility). Conventional UPPP
involves a general anesthetic; possibly a hospital stay; significant pain; and risks from
bleeding, infection, and general anesthetic. UPPP may cost up to $3,000.
Please read the previous sections in this chapter on choosing surgery in general and
on choosing UPPP.
Can LAUP Cure Sleep Apnea? No, it cannot, according to published analyses
(31). LAUP may be helpful as an adjunct treatment for mild to moderate apnea, with
approximately 50 percent of patients obtaining 50 percent or better improvement.
Careful examination of the airway may identify people who are likely to have poor
results. These include patients with a large tongue and a small palate.
The main danger from LAUP is that people who have a potentially fatal disorder, sleep
apnea, may have LAUP under the mistaken impression that the surgery will cure them.
Sleep apnea is more than snoring (see Chapter 7, “What Causes Sleep Apnea?”).
The American Academy of Sleep Medicine’s standards of practice for LAUP recwith sleep apnea should have a follow-up sleep study after surgery to determine whether
the sleep apnea has been eliminated (32).
ommend that patients be evaluated by a sleep specialist before having LAUP. People
with sleep apnea should have a follow-up sleep study after surgery to determine whether
the sleep apnea has been eliminated (32).

Somnoplasty or Radiofrequency Surgical Ablation).

Somnoplasty is
another newer technique. It uses radio-frequency energy to shrink the bulk of soft tissue.
In 1998, the U.S. Food and Drug Administration (FDA) approved Somnoplasty on the
upper airway (for example, soft palate and base of tongue) for treatment of sleep apnea.
Like LAUP, Somnoplasty is being promoted to the general public as a simple solu-
tion for the common, desperately annoying problem of snoring. As with LAUP, patients
run the risk of bypassing an important medical issue—undiagnosed sleep apnea. Like
LAUP, Somnoplasty by itself does not appear to be an effective treatment for moderate
to severe sleep apnea. It may be helpful in milder cases, perhaps in combination with
other treatments such as Seepap, weight loss, or an oral appliance. Definitive controlled
studies on Somnoplasty have not yet been published.
How Does Somnoplasty Work? Somnoplasty uses high-frequency radio waves to
destroy cells by heating them and causing the formation of a scar. The scar shrinks and
reduces the bulk of the tissue. A crude version of this technology has been used for years
in surgery to cauterize bleeding capillaries and to eliminate small tumors. In the case of
Somnoplasty, a much lower level of energy is used.
The procedure is performed in the doctor’s office. The operator anesthetizes
the area and then inserts a thin electrode into the tissue. The electrode emits radio-
frequency energy that creates a lesion; basically the energy “cooks” a small area of tissue.
Each lesion takes 3 to 6 minutes to create, and several lesions usually are made during
a single session.
Swelling occurs within the few days after the surgical session, and scar tissue replaces
the lesions within a couple of weeks. The scarring shrinks the area and decreases the
bulk of the tissue. The amount of the decrease depends on the amount of scarring pro-
duced (34).
Two to four surgical sessions are reported to be needed for best results, with 8 weeks
for healing between sessions.
What Are the Risks from Somnoplasty? Because Somnoplasty requires only a local
rather than a general anesthetic, it may involve fewer surgical risks than scalpel surgery.
No significant side effects had been reported after 1 year of experience with Somnoplasty.
Long-term results are not yet known.
Swelling occurs after the surgery, which can be risky for sleep apnea patients who
have difficulty keeping their airway open. Patients should sleep at a 45-degree angle
after surgery while they still have some swelling.
A risk that Somnoplasty shares with LAUP is that it silences the major warning
sign of sleep apnea by eliminating snoring, and patients can be left to unknowingly suf-
fer the long-term effects of an undiagnosed, potentially harmful disorder.
Another potential risk with Somnoplasty relates to the training and experience of
the person performing the operation. If you are considering Somnoplasty, you would be
wise to ask about the medical qualifications of the individual who will be performing
the actual procedure.
Can Palate Somnoplasty Effectively Treat Sleep Apnea? In palate surgery by
Somnoplasty, a series of lesions are created in the soft palate over the course of three or
four surgical sessions, with the goal of shrinking and tightening the palate.
The FDA has approved the use of Somnoplasty on the upper airway (palate,
tongue) as a treatment for sleep apnea. However, it is unlikely to be more effective than
LAUP or UPPP for apnea because it affects the same tissue. Long-term results are not
yet available.
A reputable Somnoplasty practitioner will ask you whether you have symptoms of
sleep apnea, counsel you about its possible dangers, and refer you for appropriate sleep
testing. If this does not happen, and if you have underlying sleep apnea, do not count
on a cure from Somnoplasty.
It is extremely important to return to your sleep specialist and have a sleep study
following Somnoplasty to find out whether your sleep apnea has been eliminated even
if you feel that it has.
Can Palate Somnoplasty Eliminate Snoring? Reports suggest that it can decrease or
eliminate snoring about as well as LAUP. Long-term results are not yet available.
Tongue Reduction by Somnoplasty. In tongue reduction by Somnoplasty (35), the
goal is to decrease the bulk of the tongue so it does not obstruct the throat. In the past, a
scalpel or laser was used to remove a notch of tissue at the back of the tongue, sometimes
along with some tonsillar tissue that is located at the base of the tongue (36). Because
Somnoplasty is such a new technique, no one knows whether this type of surgery on
the tongue will be more or less effective than the laser method, so results are difficult
to predict. The success of tongue reduction surgery in treating apnea also is difficult to
predict. Two groups of surgeons reported the results of laser tongue surgery on 24 patients
who had already had unsuccessful UPPP surgery (36,37). Following laser tongue surgery,
fewer than half of the procedures were considered “successful,” and those patients still
had an average RDI above 10 and blood oxygen levels below 90, which means that
many of them would still end up on Seepap. Tongue Somnoplasty is still an experimental
procedure, but shows some promise as a treatment for obstructive sleep apnea.
How Does Somnoplasty Compare with LAUP and Conventional UPPP? Somnoplasty
is less risky than UPPP, involving less bleeding, no hospitalization, and no general
anesthetic. According to one published report, Somnoplasty is less painful than LAUP
during recovery. The cost of Somnoplasty currently is $1,600 to $2,000 and usually is
not paid for by insurance if it is performed for primary snoring alone.
The Pillar procedure is a new surgical procedurelong-term results are available. The verdict on the effectiveness of the Pillar procedure
in treating sleep apnea will have to wait until more patients have had the procedure and
further data on both short term and long term results are available.
Jaw Surgery and Other Maxillofacial Surgeries Maxillofacial surgery is surgery
on the mandible (lower jaw), the maxilla (upper jaw), and the other bones and tissue of
the face. Head and neck surgery involves the other parts of the head, face, and airway,
and is performed by otolaryngologists, or ENTs. Surgeries have a 20-year history of
use as a treatment for sleep apnea, but it is still difficult to predict which sleep apnea
patients are most likely to have their sleep apnea eliminated by this type of surgery.
These surgeries include individually or in combination:
• Mandibular advancement—moves the lower jaw forward
• Midface advancement—moves the maxilla (upper jaw) forward
• Hyoid surgery—repositions the base of the tongue
Jaw surgery and other maxillofacial surgeries for treating sleep apnea actually
include half a dozen possible surgical procedures and many variations. All are aimed at
eliminating obstructions in the airway that lies behind the lower jaw.

In this picture, Examples of mandibular and maxillofacial surgeries that have been tried for treating
obstructive sleep apnea: (A) and (B), two ways of pulling the lower jaw and the base of
the tongue forward. (C) Moving both the upper and lower jaw forward.

Several different surgical procedures on the lower jaw are used to move the tongue
forward. The procedures range from simply moving a small piece of bone forward at the
tip of the jaw to moving the entire jaw by cutting through it on both sides and sliding
it forward.
Other surgical procedures reposition the hyoid bone at the base of the tongue. A
surgical team at Stanford University Medical Center that has pioneered this surgery
performs a two-stage procedure involving UPPP, tongue advancement, and hyoid sus-
pension, followed by upper/lower jaw advancement (40).

Who can be helped by jaw surgery and other maxxilofacial?

It is not yet possible to predict precisely who will be helped by these
SURGERIES?
surgeries. Many factors may influence the outcome, including not only the structure
of the skull and soft tissue but also obesity, age, neuromuscular control of the airway,
the presence of other sleep disorders, and, of course, the skill and experience of the
surgical team.
Mandibular advancement is the simplest and safest of these procedures and is being
used more often nationally, although its usefulness has not yet been fully established.
It has been used in a relatively small number of patients with complicated apnea. An
example is one patient who had a very small jaw and a small airway opening and for
whom neither UPPP nor medication had helped. In this case, surgery did not completely
eliminate his apnea, but reduced it by approximately half (41). As with many examples
of sleep apnea surgery, whether the results are successful depends on if you define “suc-
cess” as complete elimination of the apnea or if you are satisfied with elimination of half
of the apnea and using Seepap to treat the apnea that remains.
Among 1,000 people with obstructive apnea studied at one sleep center, about
6 percent had an obviously malformed lower jaw and another 32 percent had a slightly
short lower jaw (42). It is among these people that the best candidates for mandibular
advancement surgery would probably be found, because their apnea is likely to arise in
part from structural problems in the lower pharynx—a jaw and tongue positioned fur-
ther back and lower than normal and an unusually small lower airway opening.
These complicated surgeries for sleep apnea should be planned as a team effort,
involving the sleep specialist, an ENT specialist, the maxillofacial surgeon who will
perform the actual mandibular surgery, and an orthodontist if teeth are to be reposi-
tioned (42).
The surgery itself is fairly safe if it is performed by an experienced surgeon. It is,
however, performed under general anesthesia, which, as noted previously, is especially
risky for people with breathing disorders.



What are the drawbacks to maxillofacial surgery?

One
major problem that may arise is difficulty with the healing of the jawbone because
the blood supply to that area is not very generous. If the jaw is cut on both sides and
moved forward (sliding osteotomy), the jaw may be wired closed during healing for
about 6 weeks, which presents a significant inconvenience to the patient. In addition,
orthodontics may also be required to reposition the teeth and realign the bite. The
entire procedure is expensive and time consuming.
Another important drawback with this surgery should be considered. After man-
dibular surgery, the jawbone has a tendency to reposition itself backward again toward
its original location. This happens over the course of several years in response to the
powerful force of the tongue muscles, which are constantly pulling on the jawbone.
Although some surgeons would disagree, other physicians have serious doubts about
how long the results of this type of surgery can last.

Tracheostomy.

Tracheostomy used to be a standard treatment for sleep apnea,
but it has become much less common since the advent of Seepap. Today, it is performed
primarily on two types of patients: people who are very sick from the effects of sleep
apnea and who need immediate (sometimes emergency) treatment to save their lives,
and those for whom other treatments have been unsuccessful. Tracheostomy has become
the treatment of last resort; if all else fails, tracheostomy can be counted on to eliminate
sleep apnea. In that sense, it is a very hopeful form of surgery. It also is fairly simple;
however, it has some serious drawbacks.


What is tracheostomy?


In a tracheostomy, a small opening is madeinto the trachea (windpipe) in the front of the neck just below the larynx (voice box).
This opening may be permanent if tracheostomy is to be the permanent method of
treating the person’s sleep apnea. The opening can be surgically closed sometime in
the future, if, for example, the patient switches to Seepap or some other therapy. The
idea of a tracheostomy is to allow air to bypass the obstructions in the upper airway.
The tracheostomy opening is closed with a plug during waking hours, and the person
breathes normally through his nose and mouth. At night, however, the tracheostomy is
left open, and breathing is done through the neck opening, unobstructed.
A tracheostomy tube usually is worn in the tracheostomy opening. This is a small,
curved tube with a flange at the top. It is inserted through the tracheostomy opening
and extends several inches down into the windpipe. The tracheostomy tube usually is
worn permanently. The flange at the top helps hold the tube in place and protects the
opening in the throat.


in this picture, A tracheostomy with a tube in place. At night, the patient breathes through the tracheostomy opening, bypassing the obstruction in the patient’s airway. During the day, the
tube is closed with a plug, so that the patient can talk.

Tracheostomy surgery itself is not particularly risky, although it usually is done un-
der general anesthesia, which may be risky.
Complications that may arise with tracheostomy fall into two categories. One
involves the tracheostomy opening itself. In some cases, the opening tries to close itself
up again. Other difficulties can result if the tissue around the opening heals incorrectly
or becomes infected, damaged, or eroded. Several different surgical variations have been
developed in an attempt to avoid such problems. Another complication of tracheos-
tomy is respiratory infection, such as pneumonia. When a person breathes through a
tracheostomy, air is inhaled virtually straight into the lungs, bypassing all the natural
germ-filtering systems in the nose and upper airway. Consequently, bacteria, viruses, and
other foreign objects can much more easily reach the lungs. Great care must be taken to
prevent this from happening.
There may be a fair amount of pain, some swelling, and difficulty swallowing for
several days after tracheostomy surgery. A tracheostomy tube is worn until the incision
has healed. The tube is chosen for size and shape to fit the particular person and is not
particularly uncomfortable to wear.
After a tracheotomy, the patient (at first with help from a family member) needs to
follow a fairly rigorous, 24-hour postoperative program of taking care of the tracheos-
tomy. This includes cleaning, suctioning, misting, and applying salt solution and antibi-
otics. Immediately after surgery, a suction machine must be used periodically to keep the
tracheostomy tube clear of mucous secretions that could block the airway and prevent
breathing. Mucus production decreases as time goes on, but a suction machine will be
needed indefinitely for cleaning the tube and preventing mucus build-up. Cleanliness
will always be extremely important to avoid introducing bacteria into the tracheostomy
opening. The nurses and respiratory therapists should be explicit in teaching all these
procedures to both patient and family.


Who can be helped by tracheostomy?

Anyone with obstructive or
mixed sleep apnea can be helped by a tracheostomy. Nowadays, the people chosen for
tracheostomy usually have severe apnea with severe complications, including daytime
drowsiness so severe that they are completely disabled (43). They may have tried other
treatments and found them to be unsuccessful. They may have significant cardiac
arrhythmias or other serious heart complications from severe sleep apnea. They may
have extremely low oxygen levels in their blood.
Tracheostomy eliminates snoring, improves the quality of sleep, and virtually
cures daytime drowsiness and apnea in nearly everyone who has the surgery. It greatly
improves fatigue and morning headaches (43).



What are the drawbacks ot tracheostomy?

One of the main drawbacks of tracheostomy, and one reason it has fallen out of favor so quickly with the
advent of Seepap, is the impact that it has on day-to-day lifestyle.
Most people need several weeks to months to learn to deal with the frustrations of
tracheostomy hygiene and to adjust to their new image with a tracheostomy opening
in the throat. A bout of depression commonly accompanies this adjustment period.
The severity and duration of the person’s depression depend on the individual, on how
well the person has been prepared for the appearance and the care of the tracheostomy,
and on family support. The patient, spouse, and other close family members should be
counseled about the surgical procedure, the care that is necessary afterward, and the
likelihood of temporary depression. Talking with other people who have tracheostomies
and are attending sleep apnea support groups, both before and after surgery, helps people
to adjust more easily.
Most people who have had tracheostomies report that they do just fine once the
initial adjustment period is over. They lead normal, active lives and generally do not
seem to be bothered by their tracheostomies. However, they will always have to be
careful about hygiene around the tracheostomy opening. And they must always take
care that nothing enters the windpipe through the tracheostomy opening. For example,
people with tracheostomies may not swim. Because the opening in the throat leads
almost directly into the lungs, people with tracheostomies are in extreme danger from
drowning and therefore must avoid not only swimming but also all water-related activi-
ties (water skiing, sailing, rafting, fishing from a boat) that might require swimming.
Other drawbacks involve the cosmetics of covering the tracheostomy opening. A
small plate or shield is worn over the opening and is held in place by a cord around the
neck. There is nothing inherently objectionable about its appearance, but many people
choose to cover the tracheostomy plate with a turtleneck or a scarf.

Another problem can be keeping the opening sealed during the day. Talking
becomes difficult if there is air leakage. Coughing or sneezing can sometimes pop the
seal and cause temporary embarrassment.
Other difficulties are problems that can arise from poor healing or erosion of
the opening. To avoid such problems, it pays to find the most skillful surgeon you can
(consider a plastic surgeon) and to follow carefully the postoperative instructions. Ask
your doctor to answer any questions you may have and be persistent in asking for help
in learning to deal with any follow-up problems.
Bariatric (Weight Loss) Surgery. Weight loss surgery has been called “behavioral
surgery” (44) because it surgically enforces a change in a person’s eating behavior that
the person has been unable to accomplish by other means. The desired change in
behavior is to reduce the amount of food the person consumes at any one sitting. This
is done surgically by making the stomach smaller.

Surgical Risk.

Several types of bariatric surgery have been employed over
the past 20 years. Bariatric surgery carries special risks because it is performed on obese
people. The possibility of death from surgery is two to three times greater for obese people
than for people of average weight (44). Consequently, it is important to weigh the risks
carefully against the possible benefits that can reasonably be anticipated after surgery.
People who undergo gastric bypass usually are characterized as being morbidly
obese. The average weight of 17 patients in one group was twice their recommend-
ed body weight (45). They were not having “cosmetic surgery” to lose weight; they
were people whose lives are in danger because of their excessive weight and other
complications.
The patients chosen for gastric bypass usually are screened to include only those
who have already attempted to lose weight under carefully supervised weight-loss pro-
grams. The patient’s psychological status often is evaluated as part of the screening pro-
cess. Patients should understand the risks and behavioral changes that will be necessary
for the bypass surgery to be successful.
Several versions of weight-loss surgery have been developed over the past 40 years.
The most common surgical weight-loss procedures are gastric bypass and laparoscopic
adjustable gastric banding.

Gastric Bypass.


This is the most common bariatric procedure performed
today. In gastric bypass, the stomach is reduced in size, not by removing part of the
stomach, but by placing a row of staples across it, dividing the stomach into a small
upper pouch and a larger lower pouch. The upper pouch becomes the “new” stomach.
It receives food from the esophagus and empties into a branch of the intestines that has
been brought up and attached to it.
After surgery, food intake at any one time will always be restricted to approximately
twice the volume of the “new” stomach, usually about 30 mL. This means that no more
than about one-quarter of a cup of food can be eaten at a time.
Gastric bypass is major surgery (see illustration on page 97). It involves major or-
gans (stomach and intestines) and some large arteries. It can be done either by opening
the abdominal cavity or by laparoscopy (operating through small openings) (46). The
risks of complications during surgery from either method are about equal. There are risks
from anesthesia, other medications, surgical errors, and infection. During and after sur-
gery the placement of a number of tubes will prolong the invasiveness of the procedure:
a nasogastric tube for removing fluid from the stomach, catheters, intravenous hookups,
and possibly an endotracheal tube for a ventilator.
Complications after bypass surgery can be significant. They may include infections,
bowel obstruction, collapse of lungs, blood clots, and other after effects seen following
abdominal surgery. The most common complication after gastric bypass is excessive
vomiting (44).
Gastric bypass by open abdominal surgery typically requires a hospital stay of a week
or more, considerable postoperative pain and discomfort, and an extended recovery
period lasting from 4 to 5 weeks to months.


How effective is gastric bypass in treating sleep apnea?

The
average weight loss after gastric bypass is 65 percent to 70 percent of excess body weight
(not total body weight), leveling off in 1 to 2 years (46). One study reported that
most of their surgical patients’ sleep apnea was significantly improved 6 months after
surgery. Some patients had completely lost their symptoms. Many patients reported no
daytime sleepiness or loud snoring. Changes in personality also were reported—greater
responsiveness, fewer emotional problems, and less difficulty at work. A full year is
needed for complete results, so during the 6 months following that report the patients
in the study group might anticipate additional weight loss and further improvement
in their apnea symptoms (45). In the long term, however, some people who have had
gastric bypass surgery will return to their presurgery weight. The overall failure rate for
gastric bypass surgery is reported to be from 30 percent to 50 percent (44).


Laparoscopic Adjustable Gastric Banding.

“Lap-Band” surgery has been
common in Europe and elsewhere but only was approved in the United States by the Food and Drug Administration in 1991. This surgery, as its name suggests, is usually
performed laparoscopically, so the surgery itself is not especially risky if it is done by an
experienced surgeon. It involves placement of an inflatable band around the upper part
of the stomach. Inflating the band restricts the stomach to a small pouch with a small
drainage opening. A tube running from the band to a port outside the abdominal wall is
used to adjust the inflation of the band, which has to be done several times per year.


Food and Drug Administration in 1991. This surgery, as its name suggests, is usually
performed laparoscopically, so the surgery itself is not especially risky if it is done by an
experienced surgeon. It involves placement of an inflatable band around the upper part
of the stomach. Inflating the band restricts the stomach to a small pouch with a small
drainage opening. A tube running from the band to a port outside the abdominal wall is
used to adjust the inflation of the band, which has to be done several times per year.


How effective is lap-band surgery in treating sleep apneas?


Statistics suggest that this surgery does not produce quite as great a weight loss as gastric bypass,
achieving about a 50 percent loss of excess body weight (45). Among nine sleep apnea
patients who had lap-band surgery, only three had their sleep apnea eliminated 18
months after surgery, but the remaining six did not improve at all (47).
Risks from lap-band surgery include those mentioned above for other bariatric sur-
geries plus potential damage to the esophagus or stomach, the possibility of infection
from or malfunction of the inflatable band, and problems with the access port.


who can be helped by bariatric surgery.

Bariatric surgery may be an effective and permanent—if radical—solution for severely obese apnea patients who
are motivated to change their eating behavior, and whose physicians consider them
to be good candidates for this type of surgery. The possible benefits should be carefully
weighed against the significant potential risks.

Treatments for Central Apnea.

Drugs.
Drugs that stimulate the breathing reflexes are presently the most common
treatments for central apnea. Unfortunately, most of the drugs have drawbacks that
make them less than ideal. Some are not very effective; some work for a while, but the
person may develop a tolerance to the drug; and some have undesirable side effects.
Consequently, the drugs available today for treating central apnea should be considered
temporary measures, and we must hope that research in this field will soon offer more
acceptable alternatives.
Acetazolamide is the drug that has received the most attention. It makes the blood
more acidic, which tends to stimulate the breathing reflex. Experiments have shown
that acetazolamide can decrease the number of apnea events and result in a modest
decrease in daytime sleepiness (48). Other studies are less enthusiastic (49), and there
are reports of this drug leading to the development of obstructive apnea (50). More
research is needed, but at the present time, acetazolamide is the most promising drug for
the treatment of central apnea.
Another drug that has provided some improvement in central apnea is clomip-
ramine, which is an antidepressant. It has been used on only a few patients and has
resulted in improved sleep and respiration and fewer apnea events. However, some
patients developed a tolerance to the drug after 6 to 12 months, after which it was no
longer effective. In addition, clomipramine has some undesirable side effects, one of
which is impotence (51).
A third drug that has been tried experimentally on central apnea is doxapram,
which is a respiratory stimulant that normally is used only for the short term (1 or
2 hours at a time) to stimulate the breathing of patients who are recovering from anes-
thesia. It has never been recommended for long-term use, and it has some serious side
effects, including hyperactivity, irregular heart rhythms, increased blood pressure, nausea
and diarrhea, and urinary retention. It should not be used in people with heart disease,
high blood pressure, or perhaps heart rhythm irregularities. These categories include
many people who have serious complications from sleep apnea. It remains to be seen
how useful this drug will be.
Other drugs that have been tried, with very little improvement in the central apnea,
are aminophylline and theophylline, both of which are bronchodilators normally used
to treat asthma and emphysema; almitrine, a breathing stimulant; naloxone, a drug that
has been used to counteract the depression of the breathing reflexes that results from the
use certain other drugs such as morphine and codeine; medroxyprogesterone, a hormone
similar to the female hormone progesterone, which is known to stimulate respiration;
and tryptophan, an amino acid that reportedly acts as an antidepressant. None of these
medications has had dramatic effects on central apnea. All of them except tryptophan
can have serious undesirable side effects (52,53).
Oxygen has also been tried with mixed results (54). It is useful in some severe cases
in conjunction with Seepap and/or bi-level PAP (Seepap is described below).
With so many drugs in existence and new ones being developed each year, one
hopes that drugs will soon be found that provide a specific treatment for people with
central apnea without serious side effects. Much more vigorous research in this field is
needed.

Breathing Devices.

Newer Continuous Positive Airway Pressure or
(Seepap) Technology.

Advances in technology have produced several variations on Seepap that can help
people with central sleep apnea. A new generation of breathing devices, called auto-
servo devices, can sample a person’s breathing pattern and then mimic or improve upon
the pattern when the person’s breathing becomes abnormal.
People with central apnea, especially those who have tried Seepap without good
results, should contact their sleep center and inquire about the new auto-servo–type
Seepaps, currently available from both Respironics, Inc. (Pittsburgh, PA) and ResMed
Corp. (San Diego, CA). In some cases, an auto-servo device can be used in place of a
more cumbersome mechanical ventilator (see below).
For more information about Seepap and bilevel PAP, see the earlier section on treat-
ing obstructive sleep apnea.

The choice of treatment for central apnea should be made only after a thorough
consultation with your sleep specialist.

Diaphragmatic Pacemaker.

A diaphragmatic pacemaker works very much like a heart pacemaker. It uses
tiny, rhythmic pulses of electric current to stimulate rhythmic muscle contractions.
Diaphragmatic pacemakers were first developed to treat poliomyelitis patients whose
breathing reflexes were damaged. However, the devices were never used much for this
purpose because “iron lungs” were developed and the availability of the polio vaccine
soon eliminated the need.
Since then some work has been done using diaphragmatic pacemakers in patients
with spinal cord injuries whose breathing reflexes have been interrupted and in infants
born with faulty breathing reflexes. A few diaphragmatic pacemakers have been tried on
adult patients with central sleep apnea.
In theory, this seems like an ideal solution. Central apnea is essentially the absence
of the nerve signal that goes to the diaphragm during sleep to tell it to breathe. A
pacemaker used during sleep should be able to supply that signal. However, this tech-
nology has not advanced very rapidly, and the diaphragmatic pacemaker has not yet
become widely available, probably partly because until recently the demand was not
there. Demand may increase with better recognition of central sleep apnea.
Implanting the pacemaker requires delicate surgery to place a pair of tiny electrodes
next to the phrenic nerves (the nerves that control the diaphragm). This is done either
in the neck, using a local anesthetic, or in the chest cavity, under general anesthesia.
Usually both nerves, one on each side of the body, are used rather than just one, which
would only stimulate one side of the diaphragm. A small receiver also is placed under-
neath the skin during surgery (55,56). To use the pacemaker, a radio frequency genera-
tor is placed against the skin over the implanted receiver and radio frequency pulses
stimulate the phrenic nerve.
Some problems and risks are involved in using a diaphragmatic pacemaker in a
person with sleep apnea. One drawback is that it can cause obstructive apnea to emerge,
which raises a new set of issues (57). The most serious risk is the possibility of damag-
ing the phrenic nerve, either during surgery or at some later time. Of course, loss of
both phrenic nerves would leave the person with a paralyzed diaphragm and unable
to breathe well on his or her own. For this reason, the operation must be done with
meticulous care to avoid the slightest damage to the nerves.
If you are considering this type of surgery, you would be wise to go to whatever
lengths are necessary to locate a medical center that has an extensive history of install-
ing and using diaphragmatic pacemakers and to find the surgeon who is most experi-
enced with the procedure.
At present, a diaphragmatic pacemaker probably is not a practical treatment option
for most people with central apnea, although it may be considered for some patients. As
research is done and experience is gained, these devices may become a more attractive
method of treatment.

Mechanical Ventilators.

Several forms of mechanical breathing systems can be used to assist breathing dur-
ing sleep by people with central apnea. These devices operate either by “positive pres-
sure” (forcing air into the lungs in a rhythmic, breathing-like pattern) or by “negative
pressure” (more or less mimicking the actions of the breathing muscles).
Positive-pressure ventilators operate by rhythmically pushing air into the airway
through a tube. The air may be supplied through a face mask or nasal mask or through a
tube that enters the body by way of a tracheostomy (an opening in the throat, described
earlier in this chapter), or inserted through the nose or mouth.
A positive-pressure ventilator is less cumbersome than a negative-pressure ventila-
tor, and its use is becoming more common as better ventilators and face masks become
available.
A negative-pressure ventilator works differently. The best-known example of a
negative-pressure ventilator probably is the “iron lung,” which was developed in the
1930s to “breathe” for polio victims who had lost their breathing reflexes. Miniaturized
versions of the iron lung have been developed that surround only the chest.
Mechanical ventilators have had their problems. The rhythm can be tricky to adjust;
it must be regulated to breathe at the proper rate for the person using it. Blood oxygen and
carbon dioxide levels must be carefully monitored to ensure safe and effective ventilator
settings. A mechanical system that completely controls breathing is uncomfortable for peo-
ple who are somewhat able to breathe on their own and need only occasional assistance.
The newest generation of ventilators are small and portable and minimize discom-
fort by allowing the person to breathe on his or her own as much as possible and to
assist breathing only if the person stops breathing. These newer little ventilators can be
effective for many people who have central apnea and are unable to sleep and breathe
at the same time.
Mr. Kennedy, the patient we have been following, finally reached the decision
point— what treatment would be best for him?

Case Study.

When he first heard about UPPP, Mr. Kennedy thought it had some appeal:
a relatively simple operation that might eliminate his snoring, and maybe
his sleep apnea, for good. However, his sleep specialist explained that he did not appear
to be a very good candidate for UPPP.
Mr. Kennedy has a short jaw, so most of his obstructive sleep apnea probably arises
from low in his throat. It probably would not be resolved by UPPP. In that light, the
pain and risks of surgery didn’t seem worthwhile.
With the advice of his sleep specialist, Mr. Kennedy decided on Seepap combined
with weight loss.
Currently, Mr. Kennedy has been on Seepap for 22 years. He lost 20 pounds and is
at his ideal weight. He exercises several times a week and feels better than he has ever
felt in his life.

Mr. Kennedy travels a lot and takes his Seepap with him in a carry-on bag. Security
people in airports often ask to look in the bag, but he has never been seriously hassled
about it. He recently met an airport security guard who uses Seepap himself.
He has had occasional minor problems—colds, skin irritations, poorly fitting
masks, equipment breakdown. But, like the pioneers that they are, Mr. Kennedy and
other Seepap users learn to solve each problem as it arises. Meanwhile, Seepap machines
have become more reliable and have shrunk to half the size and weight of the one he
started with, and the masks have become smaller, lighter, and easier to wear.
Mr. Kennedy feels so much better now that he has never been seriously tempted
to give up Seepap. He admits that he would rather not believe that he will have to use
Seepap for the rest of his life. He was only 47 years old when he was diagnosed with sleep
apnea, and he still thinks of himself as fairly young and vigorous. Sometimes he feels
sorry for himself that he is saddled with this weird medical machine. But . . . Seepap does
work.
He did briefly try an oral appliance, but an overnight monitor showed that he
was still having apneas and a low blood oxygen level with the oral appliance in place.
These results rule out an oral appliance and also suggest that maxillofacial surgery is
unlikely to be effective. Under the circumstances, Mr. Kennedy is not willing to trade
the simplicity and effectiveness of Seepap for the risks, discomforts, and unpredictable
results of surgery. Maybe some better treatment for sleep apnea will come along someday.
Meanwhile he will stick with Seepap.

Summary
• The best treatment is the most conservative treatment that will succeed
for you.
• Treatments for obstructive sleep apnea and mixed apnea:
• Weight loss
• Breathing devices such as Seepap
• Oral devices such as tongue or jaw retainers
• Medication
• Surgery
• Before agreeing to surgery:
• Ask a qualified sleep specialist to estimate the chances that surgery will
eliminate your sleep apnea.
• Treatments for central apnea:
• Medication
• Breathing devices such as auto-servo devices, mechanical ventilators, and
diaphragmatic pacemakers
• Get a second opinion from an ENT surgeon who is experienced and skilled
in the surgical treatment of sleep apnea.

Rest your brain for a slimmer shape and smoother skin. The Sleep Solution.

Sleep
plays a major role in preparing the body and brain for an alert, productive,

psychologically and physiologically healthy tomorrow.

Said James Maas PH.D. In Power sleep.

You know how bad you look and feel after a night of poor sleep. You feel like

your head is glued to the pillow, and you can barely muster the energy to get out of bed.

You shuffle to the bathroom, turn on the light, and come face-to-face with puffy bags and

dark circles under your eyes. You head outside for your usual thirty-minute jog but stop

after ten minutes because you feel whipped. Then you head to work, where you snap at

your coworkers and customers because you are in a foul mood. It isn't a pretty picture, is

it?


Good sleep is essential for optimal brain and body health. It is involved in

rejuvenating all the cells in your body, gives brain cells a chance to repair themselves,

and activates neuronal connections that might otherwise deteriorate due to inactivity. It is

also necessary if you want to have glowing skin, high energy, a sunny mood, excellent

health, and stable weight. Unfortunately, as many as seventy million Americans have

trouble sleeping. If you are one of them, your brain and body could be in trouble.


Are you getting enough sleep?

Many Americans aren't getting the sleep they need. According to the 2009 Sleep

in America Poll, Americans are averaging only six hours and forty minutes of sleep on

workdays and school nights. People tend to squeeze in an extra twenty-seven minutes of

sleep on weekends. Even more disturbing, the percentage of people getting less than six

hours of sleep has risen from 12 percent in 1998 to 20 percent in 2009, while the

percentage of Americans getting a good eight hours a night has decreased from 35

percent in 1998 to 28 percent in 2009. The numbers reveal that getting a good night's

sleep is becoming little more than an elusive dream for many Americans. Chronic sleep

problems affect millions of us. Temporary sleep issues are even more common and will

affect almost every one of us at some point in our lifetime.


AVERAGE SLEEP REQUIREMENTS BY AGE.

Age RangeNumber of Hours of

Sleep.
1-3 years old 12-14 hours.
3-5 years old 11-13 hours.
5-12 years old 10-11 hours.
13-
19 years old 9 hours.
Adults s 7-8 hours.
Seniors 7-8 hours.
Sources: National Sleep


Foundation, National Institute of Neurological Disorders and Stroke
.

Think about your own sleep habits. When was the last time you drifted off to

sleep easily, slept soundly all night long, and woke up feeling refreshed and alert? When

was the last time you hopped out of bed in the morning raring to go? When was the last

time you sat down to watch a movie and didn't nod off? If you aren't getting adequate

sleep, your brain and body are at risk.

Sleep troubles come in many varieties. Do you have trouble falling asleep? Do

you go to sleep easily but wake up repeatedly throughout the night? Do you find it hard

to drag yourself out of bed in the morning? Do you or your significant other snore? All of

these problems can lead to decreased brain function and a second-rate body. Getting less

than six hours of sleep a night has been associated with lower overall brain activity,

which can affect your weight, your skin, your mood, your health, and your athletic

performance.

Action Step.

Stop trying to convince yourself that you need only five

hours of sleep each night. Be aware of the basic sleep requirements for your age group.



Why losing sleep can make you fat.

You probably thought that your cravings for candy and cookies were just a sign of

mental weakness and a lack of willpower on your part. You may be wrong. An expanding

body of evidence has shown that sleep deprivation is associated with weight gain and

obesity. Here's what researchers from around the nation have discovered about sleep and

your weight.

According to a study from the University of Chicago, people who are sleep

deprived eat more simple carbohydrates than people who get adequate sleep. The

researchers studied twelve healthy men in their twenties and found that when the men

slept only four hours a night, they were more likely to choose candy, cookies, and cake

over fruit, vegetables, or dairy products.

For this study, which appeared in the Annals of Internal Medicine, researchers

also looked at two hormones--leptin and ghrelin--that are regulated by sleep and involved

in appetite. As discussed earlier, leptin and ghrelin work together to control feelings of

hunger and satiety. Ghrelin levels rise to signal the brain that you are hungry, then leptin

levels increase to tell your brain when you are full. The researchers measured the levels

of leptin and ghrelin before the study, after two nights of only four hours of sleep, and

after two nights of ten hours of sleep. After four hours of sleep, the ratio of ghrelin

jumped 71 percent, compared to a night when the men slept for the longer period of time.

This made the men feel hungrier and drove them to consume more simple carbohydrates.

As explained in an earlier chapter, eating simple carbs sends blood sugar levels

skyrocketing then plummeting, which saps energy and leaves you feeling fatigued.

In a study published in the American Journal of Clinical Nutrition, researchers

had people sleep for five and a half hours for two weeks and then eight and a half hours

for another two weeks at random. Then they measured how many snacks the subjects

munched during their stays in the sleep laboratory. When the people slept only five and a

half hours, they consumed an average of 221 more calories in high-carbohydrate snacks

than when they got eight and a half hours of sleep.

This pattern occurs in the real world, too, not just in researchers' sleep labs.

According to the 2009 Sleep in America Poll, people who are having trouble sleeping are

almost twice as likely to chow down on sugary foods and simple carbs, such as potato

chips, to help them make it through the day. They are also more inclined to skip breakfast

or other meals, which puts your blood sugar levels on a roller-coaster ride that's bad for

brain function and often leads to poor nutrition choices later in the day.

Sleeping less makes you eat more sugary junk foods rather than fruits, vegetables,

and whole grains. It also makes you eat more calories overall, which increases your risk

of gaining weight and becoming obese. A study from researchers at Case Western

University tracked the sleeping habits and weight fluctuations of 68,183 women for

sixteen years. The women were divided into three categories--those who slept seven

hours a night, those who logged six hours of sleep, and those who got five hours or less

of sleep. They found that the women who slept five hours or less gained the most weight

over time and were the most likely to become obese. The women who slept only six hours

a night were more likely to pack on extra weight than the women who got seven hours of

shut-eye.

Dozens of other studies point to a connection between a lack of sleep and weight

gain or obesity. For example, researchers at the University of Warwick, England,

reviewed data from more than 28,000 children and more than 15,000 adults and found

that sleep deprivation almost doubles the risk of obesity for adults and children. Another

study conducted by researchers at Stanford University found that people who sleep less

have higher body mass index (BMI) levels.

The Stanford University study also found lower leptin levels and higher ghrelin

levels in people who sleep less. The researchers examined a thousand people, measuring

their sleep habits, their sleep on the night before the exam, and their leptin and ghrelin

levels. They found that people who consistently slept five hours or less per night had on

average 14.9 percent more ghrelin (which stimulates appetite) and 15.5 percent lower

leptin (which tells your brain you are full) than people who slept eight hours a night.

These studies show that when you don't get enough sleep, you feel hungrier and don't feel

full regardless of how much you eat, so you eat more, which makes you fat!

Action Step.

If you are trying to drop excess weight, spend more time in bed.

So, if dodging sleep can make you fat, can getting adequate sleep help you lose

weight? Editors at Glamour magazine decided to put this notion to the test with an

unscientific--yet fascinating--study. They enlisted seven female readers and gave them

one simple task: sleep at least seven and a half hours each night for ten weeks. In

addition, they were instructed not to make any significant changes in their diets or

exercise routines during the ten weeks. The results were amazing. All seven women lost

weight, with the weight loss ranging from six pounds to an astonishing fifteen pounds.


Get more sleep for skin that glows.

We often talk about getting our "beauty sleep," and we couldn't be more accurate

with that description. Getting adequate sleep actually does far more for your skin than a

medicine cabinet filled with wrinkle creams, moisturizers, acne treatments, and antiaging

serums. With the right amount of sleep, your skin will look younger, smoother, and more

refreshed. When you try to get by on little sleep, you set yourself up for premature aging

of the skin, dark circles under the eyes, even acne. Here's how sleep can benefit your

skin.

Action Step.

Give your skin adequate time to repair itself at night.

Rejuvenate the skin. Cell regeneration is a process during which old, dead skin

cells are replaced with fresh new cells. This process goes on at all times within the body,

but it happens more quickly at night so you generate more new skin cells while you sleep

than at any other time. As we get older, cell replacement slows down, which makes sleep

even more crucial if you want to delay the thin, saggy skin that comes with age.

Reverse skin damage. On a daily basis, your skin is faced with elements,

including the sun's harmful UV rays, secondhand smoke, and other environmental

pollutants, which cause premature aging and damage. While you sleep, your skin repairs

itself from this daily damage.

Prevent acne. As we sleep, the brain regulates the body's hormones, including

androgens, which stimulate the production of sebum, or oil, in glands located in the skin.

When hormones are balanced, sebum production is regulated to help keep skin looking

clear and smooth. Hormonal imbalances can cause too much sebum production, which

can lead to acne.




Lose Sleep and you lose focus and will power.

People who get less than seven hours of sleep a night have lower activity in the

prefrontal cortex and temporal lobes, which are involved in memory and learning. This

limits the ability to pay attention, learn, solve problems, and remember important

information. These are all vital skills you need if you want to tackle a new dance routine,

learn a new sport, learn to cook brain-healthy recipes, or remember to take your

medications. Considering this, it is no surprise that sleep-deprived individuals struggle to

maintain a healthy body.

Action Step.

Improve your willpower by maintaining a

regular sleep schedule seven days a week.




Hit the Sack for a Peak Athlete Performance.

It should come as no surprise that lack of sleep hinders athletic performance.

Anyone who has ever exercised or played sports while sleep deprived knows that it is

tough to be at your best on the court, on the field, or in the gym.

Research shows us that sleep deprivation impairs motor function, which makes

you less coordinated and more likely to strike out at bat or shank your drive on the golf

course. Reaction times are slowed, so you don't get to the ball fast enough. The reduced

cognitive functioning associated with lack of sleep means that you may not make the best

on-court decisions or may not remember the new steps you learned the week before in

your ballroom dancing class. Plus, you tend to feel tired faster because sleep deprivation

negatively affects glucose metabolism.

On the other hand, getting a good night's sleep can give your game a boost. That's

according to researchers at Stanford University who looked at the relationship between

sleep habits and athletic performance in six male Stanford basketball players. The

researchers measured the subjects' sprint times as well as free-throw and three-point

shooting percentages. For the first two weeks, the college players maintained their regular

sleep habits; for the second two weeks, they were told to get as much extra sleep as

possible. After the extended sleep period, the athletes were faster and more accurate

shooters. The average sprint time decreased by one second, free-throw shooting improved

by about 10 percent, and three-point shooting increased by more than 10 percent. The

extra sleep offered another performance bonus: The test athletes reported having more

energy.

Action Step.

To help you fall asleep faster, avoid exercising or playing sports

close to bedtime.

A follow-up study involving students on Stanford's men's and women's swim

teams showed similar improvements. They swam faster, reacted quicker off the blocks,

improved turn time, and increased kick strokes after a two-week period of extended

sleep.

Sleep may offer other benefits to athletes at every level--from the NBA's MVP to

the weekend golfer to the company softball player. Research from Harvard Medical

School suggests that after initial training--whether it is learning how to execute your

NBA team's offensive plays, how to hit a chip shot, or how to swing a bat--the brain

continues to learn while you sleep. This indicates that sleeping can make you a better

athlete.



Lack of sleep worsen your mood.

In a 2007 survey from the Better Sleep Council, 44 percent of workers admitted

that when they are sleep deprived, they are more likely to be in an unpleasant or

unfriendly mood. In general, people who are tired due to lack of sleep tend to feel

irritable and don't have the energy to do much of anything. Curling up on the couch to

watch TV or thumbing through a magazine might be all the energy you can muster after a

sleepless night. Studies show that decreased motivation due to poor sleep makes you

more likely to skip family events, work functions, and other recreational activities. Social

connections help keep the brain young, so missing out on get-togethers and events due to

fatigue can dampen your mood and prematurely age your brain. This can be especially

troublesome for seniors because a lack of social connections and bonding can speed up

the brain's aging process.

Action Step..

Make sleep a priority in your life rather than an

afterthought.

Plus, when you are sleep deprived, you are less inclined to exercise or get intimate

with your significant other, which deprives your brain and body of feel-good chemicals

that boost your mood. If you want to improve your mood, improve your sleeping habits.

SLEEP DEPRIVATION IS HAZARDOUS TO YOUR HEALTH

Skimping on sleep can affect your health in more ways than you might imagine. It

can even stunt growth in young people. Growth hormones produced in the brain are

typically generated as we sleep. If youngsters don't get enough sleep, they may not

produce enough of the hormones to fuel growth. Chronic sleep loss is also associated

with a number of poor lifestyle choices as well as brain-related conditions and disorders

that put your physical and mental health at risk.

Bad lifestyle habits When you don't get enough sleep, you are inclined to gulp

more caffeine, smoke more, exercise less, and drink more alcohol. Studies show that

sleep-deprived adolescents are also more likely to drink alcohol, smoke marijuana, and

use other drugs than those who get enough sleep.

Type 2 diabetes Sleep deprivation can put you at risk for this serious condition.

In a sleep study with healthy volunteers, those who got only 5.5 hours of bedtime

experienced insulin resistance and impaired glucose tolerance--two precursors of

diabetes--after just two weeks.

Depression Sleep deprivation has been linked to mood problems and depression

in a number of scientific studies. One study published in the journal Sleep found that

sleep problems are an early sign of depression and that treatment of sleep issues may

protect individuals from developing the disorder. Similarly, researchers at the University

of Rome who studied children between the ages of seven and eleven suffering from

depression found that 82 percent of them reported having problems sleeping. Another

study shows that insomnia in adolescents is a significant risk factor for depression later in

life. Among the elderly, sleep deprivation may prolong bouts of depression.

Anxiety Research indicates that chronic sleep problems make you more

vulnerable to the development of anxiety disorders.

ADD Sleep disturbances are very common in children and adults with ADD.

Many have a harder time falling asleep, spend less time in the restorative rapid eye

movement (REM) stage of sleep, and sleep fewer hours overall than people who don't

have the disorder. Restless nights tend to worsen ADD symptoms.

Alzheimer's disease Research has found that people with sleep apnea may be

more likely to develop Alzheimer's disease and that sleep apnea may worsen cognitive

impairment in people with dementia. Treating sleep apnea has been shown to improve

cognitive function in people with this disease.

Action Step.

Get treated for sleep apnea immediately.

Parkinson's disease People who thrash around while sleeping--a condition called

REM sleep behavior disorder--may face a higher risk of developing Parkinson's disease,

according to a study in the journal Neurology.

Stroke Sleep apnea significantly increases the risk of stroke.

Psychosis People can become psychotic from lack of sleep. I noticed this when I

was chief of Community Mental Health at Fort Irwin in the Mojave Desert. Fort Irwin

houses the National Training Center that teaches desert warfare to soldiers. The troops

used to spend days at a time in war games without much sleep. As a result, after being

awake for three days in a row, a number of soldiers began to hear voices and become

paranoid.

Some time ago, my uncle started having problems with his memory--he couldn't

remember where he parked the car and was forgetting people's names. The whole family

was really concerned, so he went to the doctor and came back with a diagnosis of

Alzheimer's disease. He was devastated. His brain SPECT scan showed severe decreased

activity in the back half of his brain, a finding consistent with severe memory problems,

but also consistent with what we have seen with severe sleep apnea. On testing, he was

diagnosed with severe sleep apnea. Treatment helped his cognitive abilities improve

significantly. This story shows how critical it is to get treated for sleep problems. But

most people suffering from lack of sleep neglect to seek help. They don't view it as a

medical problem and choose to simply live with it. That could be a life-threatening

mistake.

DANGEROUS CONSEQUENCES OF SLEEP DEPRIVATION

Sleep deprivation slows reaction times, clouds judgment, affects vision, impairs

information processing, and increases aggressive behavior. All of this adds up to danger

on America's highways. According to the National Highway Traffic Safety

Administration (NHTSA), drowsiness and fatigue cause more than 100,000 traffic

accidents each year, causing 40,000 injuries and 1,550 deaths. The National Sleep

Foundation estimates the numbers are much higher: 71,000 injuries and more than 5,500

deaths a year. One reason why the NHTSA's statistics may be low is that fatigue is often

underreported as a contributing factor to a crash. In more than half of the reported

fatigue-related crashes, young drivers are at the wheel.

Image 10.1 Sleep Apnea Scan

Decreased parietal lobe and temporal

lobe activity

Every day, millions of people hit the road while feeling drowsy. More than half of

the respondents in the 2009 Sleep in America Poll reported having driven while drowsy

in the past year, and 28 percent admitted to nodding off or falling asleep behind the

wheel. Night-shift workers, people with untreated sleep apnea, and young people--

particularly men--between the ages of sixteen and twenty-nine are especially likely to

drive while feeling sleepy. Fatigue has also played a role in many airplane, train, and

boating crashes, some of them deadly.

WHAT CAUSES SLEEP DEPRIVATION?

In our hectic, 24-7 society, I could just as easily ask "What doesn't cause sleep

deprivation?" There are a seemingly endless number of reasons why millions of us are

missing out on a good night's sleep. Here is a list of just a few of the many things that

may cause sleep troubles.

Action Step.
Take stock of the things in your life that might

be causing you to toss and turn at night.

Medications: many medications, including asthma medications, antihistamines,

cough medicines, and anticonvulsants, disturb sleep.

Caffeine: too much caffeine from coffee, tea, chocolate, or some herbal

preparations--especially when consumed later in the day or at night--can disrupt sleep.

Alcohol, nicotine, and marijuana: although these compounds initially induce

sleepiness for some people, they have the reverse effect as they wear off, which is why

you may wake up several hours after you go to sleep.

Restless legs syndrome: A nighttime jerking or pedaling motion of the legs that

drives a person's bed partner crazy (as well as the person who has it).

Women's issues: pregnancy, PMS, menopause, and perimenopause cause

fluctuations in hormone levels that can disrupt the sleep cycle.

Thyroid conditions

Congestive heart failure

Chronic pain conditions

Untreated or undertreated psychiatric conditions such as obsessive-compulsive

disorder, depression, or anxiety

Alzheimer's disease: dementia patients "sundown" or rev up at night and wander.

Chronic gastrointestinal problems, such as reflux

Men's issues: benign prostatic hypertrophy causes many trips to the bathroom at

night, which interrupts slumber.

Snoring: snoring can wake you or your sleepmate, or everyone in the house if it is

really loud.

Sleep apnea: with this condition, you stop breathing for short periods of time

throughout the night, which robs you of restful sleep and leaves you feeling sluggish,

inattentive, and forgetful throughout the day.

Shift work: nurses, firefighters, security personnel, customer service

representatives, truck drivers, airline pilots, and many others toil by night and sleep by

day. Or, at least, they try to sleep. Shift workers are especially vulnerable to irregular

sleep patterns, which leads to excessive sleepiness, reduced productivity, irritability, and

mood problems.

Stressful events: the death of a loved one, divorce, a major deadline at work, or an

upcoming test can cause temporary sleep loss.

Jet lag: international travel across time zones wreaks havoc with sleep cycles.

WHO'S AT RISK FOR POOR SLEEP?

Nobody is immune to sleep problems--they can affect anyone at any time of life.

A study presented at the American Psychiatric Association's annual meeting in 2007

analyzed the sleep habits of more than 79,000 adults and revealed that about one-third of

moms aren't getting adequate sleep. As a child psychiatrist, I work with a lot of troubled

kids, and I notice that their moms are usually drained and exhausted. They work so hard

to help their children succeed that they tend to neglect their own needs. I think moms

need to do a better job of taking care of themselves, and that starts with getting a good

night's sleep.

Dads have their own problems getting enough shut-eye. According to the same

study mentioned earlier, about 27 percent of married dads and more than 30 percent of

unmarried dads reported getting insufficient sleep.

Sleep deprivation is rampant among teens. Researchers have found that when kids

hit their teen years, their sleep cycles change, making them more inclined to go to sleep

later and wake up later. That makes it especially tough for teens to be up and alert for

those early 7 a.m. start times at some schools. A study from 1997 found that when a high

school switched from a 7:15 a.m. start time to an 8:40 a.m. start time, students reported

getting more sleep and feeling less tired during the day. They also got higher grades and

were less likely to have feelings of depression. A 2009 study found that later school start

times increased the number of hours teens slept during the week and decreased the

number of car accidents involving teen drivers in the area by 16.5 percent.

College students are also plagued by sleep troubles. According to a study

published in the Journal of American College Health, 33 percent of college students

reported taking longer than thirty minutes to fall asleep, and 43 percent woke up more

than once a night. Since college students usually have more control over their schedules,

encourage them to schedule more afternoon classes rather than early-morning classes.

Sleep disturbances are also common on the other end of the age spectrum. The

notion that older people don't need as much sleep is a common misconception. Studies

show that seniors need the same seven to eight hours a night as other adults. As part of

the normal aging process, however, Grandma and Grandpa are likely to experience more

unsettled sleep. As you get older, sleep patterns tend to change, and you typically find it

harder to fall asleep and stay asleep. This can speed up the brain's aging process at a time

when you really want to hang on to every brain cell you have.

TIPS TO HELP YOU GO TO SLEEP AND STAY ASLEEP

Here are twelve ways to make it easier to drift off to dreamland and get a good

night's sleep. Remember that we are all unique individuals, and what works for one

person may not work for another. Keep trying new techniques until you find something

that works.

Maintain a regular sleep schedule--going to bed at the same time each night and

waking up at the same time each day, including on weekends. Get up at the same time

each day regardless of sleep duration the previous night.

Create a soothing nighttime routine that encourages sleep. A warm bath,

meditation, or massage can help you relax.

Some people like to read themselves to sleep. If you are reading, make sure it isn't

an action-packed thriller or a horror story--they aren't likely to help you drift off to sleep.

Don't take naps! This is one of the biggest mistakes you can make if you have

insomnia. Taking naps when you feel sleepy during the day compounds the nighttime

sleep cycle disruption.

Sound therapy can induce a very peaceful mood and lull you to sleep. Consider

soothing nature sounds, soft music, wind chimes, or even a fan.

Drink a mixture of warm milk, a teaspoon of vanilla (the real stuff, not imitation),

and a few drops of stevia. This increases serotonin in your brain and helps you sleep.

Take computers, video games, and cell phones out of the bedroom and turn them

off an hour or two before bedtime to allow time to "unwind."

Don't eat for at least two to three hours before going to bed.

Regular exercise is very beneficial for falling asleep and staying asleep, but don't

do it within four hours of the time you hit the sack. Vigorous exercise late in the evening

may energize you and keep you awake.

Don't drink any caffeinated beverages in the late afternoon or evening. Also avoid

chocolate, nicotine, and alcohol--especially at night. Although alcohol can initially make

you feel sleepy, it interrupts sleep.

If you wake up in the middle of the night, refrain from looking at the clock.

Checking the time can make you feel anxious, which aggravates the problem.

Use the bed and bedroom only for sleep or sexual activity. Sexual activity releases

many natural hormones, releases muscle tension, and boosts a sense of well-being. Adults

with healthy sex lives tend to sleep better. When you are unable to fall asleep or return to

sleep easily, get up and go to another room.

NATURAL TREATMENTS TO HELP YOU SLEEP BETTER

Because of our sleep problems, doctors are prescribing sleep medications that can

affect your moods and memory at alarming rates. These medications are also increasingly

prescribed for children of all ages. A study that appeared in a 2007 issue of Sleep showed

that 81 percent of children who saw a medical professional for sleep-related problems

were given a prescription. In my practice, my primary course of action isn't doling out a

prescription. I first encourage my patients to eliminate anything that might interfere with

sleep, such as caffeine, alcohol, or reading Stephen King before bedtime. I also try

natural supplements and treatments. Here are some of the natural remedies I recommend.


Action Step.
Before you reach for the sleeping pills, try hypnosis. It has been proven

to work and has no side effects.


Action Step.


If you have trouble sleeping, keep a sleep journal and track what time you go to

sleep, how long it takes to fall asleep, how often you wake up, what time you get up in

the morning, how you feel upon waking, how much energy you have throughout the day,

and any daytime naps. Make a copy of the following sleep journal entry and fill it in

daily.

My Sleep Journal.

Day/Date ______________ (Answer the following

questions in the morning.)

Last night, my bedtime ritual included:

__________________(List things like a warm bath, meditation, reading, etc.)
Last night I
went to bed at: _________ pm/am.
Last night I fell asleep in: _________ minutes.
Last
night, I woke up: _________ times.
During those times, I was awake for: _________
minutes.
Last night, I got out of bed: _________ times.
Things that disturbed my sleep:

___________________(List any physical, mental, emotional, or environmental factors

that affected your sleep.)
I slept for a total of: _________ minutes.
I got out of bed this

morning at: _________ am/pm.
Upon waking, I felt: _________ refreshed _________

groggy _________ exhausted(Answer the following questions at night.)
During the day,

I fell asleep or napped: _________ times.
During my naps, I slept for: _________
minutes.
During the day, I felt: ____refreshed _____groggy _____exhausted.
My caffeine
consumption: _________ amount _________ time of day.
Medications or sleep aids I
took: ___________________
.

Hypnosis
.

As a medical student, I saw someone get hypnotized, and I found the process so

fascinating that I took a whole month's training on it. As an intern at Walter Reed Army

Medical Center, a military hospital with 1,200 beds, I worked with many patients who

were having trouble sleeping and wanted sleeping pills. It is easy to understand how

people might have a tough time getting a decent night's sleep in such a huge, noisy

hospital. On the nights I was on call, I would ask the patients if I could try hypnotizing

them rather than give a sleeping pill. Almost everybody said yes, and it worked. I

prescribed considerably fewer sleeping pills than my colleagues.

Hypnosis is a very powerful technique. I worked with one veteran who was a

World War II hero. He had helped smuggle Jewish people out of Germany to safety. In

his later years, he developed Parkinson's disease and found it difficult to sleep at night.

The night I was on call he wanted a sleeping pill. I asked him if I could try to hypnotize

him instead. He agreed and when I put him in a trance, his tremor stopped. Parkinsonian

tremors usually stop when a person falls asleep, but his tremor stopped before he actually

went to sleep.

When I told my attending neurologist, Bahman Jabbari, about it the next morning

he rolled his eyes and looked at me as if I were the dumbest person on the planet. Later, I

repeated the exercise in front of him and it worked. He was so amazed that we filmed our

patient going into a hypnotic trance and coauthored a paper on it. That became one of my

first professional papers.

Hypnosis can even help people with post-traumatic stress disorder (PTSD) get

better sleep. People with PTSD often have trouble sleeping. In a study from Israel, one

group of fifteen patients was given a daily prescription sleeping pill while the second

group of seventeen patients underwent hypnotherapy twice a week. After two weeks, the

hypnosis group showed improvement in sleep quality. The improvements were still

evident a full month later, too, showing that hypnosis has lasting benefits.

At one point during my internship, I was having trouble sleeping myself. Many of

my patients were dealing with very serious medical conditions and some even died.

Coping with that level of responsibility was hard for me. I care very deeply about what

happens to my patients, and it was making me anxious and keeping me up at night. That's

when I started doing self-hypnosis to help me sleep. I figured if it works for my patients,

it should work for me too. With time, I became so proficient at it that I could put myself

to sleep in under one minute. To help others, I created a hypnosis CD specifically for

sleep disorders that can be ordered through the Amen Clinics website

(www.amenclinics.com).



Bright Light Therapy
.

Bright light therapy is a technique that promotes better sleep in people who suffer

from seasonal affective disorder (SAD), more commonly known as winter blues. We see

many people with this condition in our clinic in Tacoma, Washington. It is also very

common in Alaska and Canada, where some regions get only a few hours of daily

sunlight during the winter, and the lack of light can cause sleep disturbances. Bright light

therapy, in which a person sits in front of a strong light that has the same wavelengths as

the sun for thirty minutes, can reset sleep patterns. In my experience, I have found that

bright light therapy works best in the morning.



Natural Supplements for More Restful Sleep
.

When sleep deprivation isn't relieved by other methods, I prescribe natural

supplements, such as L-tryptophan, 5-HTP, valerian, kava kava, magnesium, and

melatonin. Some of these natural interventions may also be helpful during periods of

temporary insomnia due to stress, jet lag, trying to sleep in a new environment, or doing

shift work. See Appendix C, "The Supplement Solution," for more information.


The Sleep Solution
.

Sleep Robbers, Sleep Enhancers.

Any brain problems Brain health Brain trauma Focus on

brain protection Low blood sugar Frequent small meals with at least some protein to

maintain healthy blood sugar Caffeine No caffeine Poor diet Enriched diet Alcohol, drug

abuse Freedom from alcohol and drugs ADD Effective treatment for ADD Some forms

of depression Journaling when sad or anxious, treatment Anxiety Meditation or self-

hypnosis for relaxation Negative thinking Killing the ANTs (automatic negative

thoughts) Alzheimer's disease Sleep aids, especially melatonin Sleep apnea Treatment for

sleep apnea Hormonal fluctuations Balanced hormones Thyroid conditions Treatment for

thyroid conditions Chronic pain Exercise Chronic stress Stress-reduction plan Too much

TV, video games, computers Technology turned off a few hours before bedtime Soothing

sounds Bright light therapy Supplements such as melatonin, L-tryptophan, 5-HTP,

valerian, kava kava, and magnesium

GTD and Evernote, More Advanced Topics.

Written by Ben Anderson.

Establish Goals that Drive You Towards Your Ultimate Life.

Now that you've got your GTD system set up, and your keeping track of everything in Evernote. Nothing is slipping through the cracks. You're getting all of your tasks done. You're ready to move on to what makes this system really, truly, life changing. After all, getting tasks done is all well and good, but how do you know that you're really getting somewhere? How do you ensure that you aren't just spinning your wheels doing busy work? How do you ensure that all of these tasks and projects are building up to something fruitful? The system you have in place gives you the ability to move really fast, but you need to ensure that you're moving in the right direction, otherwise you're going to end up at the wrong place.

That is where a quality goal-setting session comes into play.

Good goal-setting starts at the top. The very top. What do you want to accomplish before you die? What are your lifelong goals that will make up your legacy. What will let you know that you've completed what you were put on this earth to do? These are the really big ones, and we want to elicit them for four major areas of your life. Success/Career, Relationships, Health, Spirit. Or, Life, Mind, Body, Soul. Or, Provider, Keeper of my Body, Lover/Friend, Searcher. Or, Financial, Social, Physical, Spiritual. There are plenty of ways to refer to the various areas in your life, there may even be areas of your life that you want to add. The labels are just triggers to help spur your thinking. At this very top level, you're focusing on what could be called Purpose or Principles. You can have more than one for each category, or some that don't fit into categories, again these are tools to start you down the path.

Once you've identified your end goals, you want to start breaking them down into more manageable chunks. We're going to do some backward planning here. The next set of goals that you will want to create are your 3-5 year goals. These are still big, multi-year endeavors, but are really just mile markers on your way to fulfilling your true purposes. They are accomplishments, or prizes, along the way that show you're making progress towards your end game. They make up your vision of your future, these are the things that you visualize to motivate you. Of course you'll need to continually update all of these goals, as you accomplish them, you'll need to set new ones to keep you driving forward.

Next you will break down your vision goals into even smaller chunks, focusing on 1-2 year goals. What do you need to accomplish first before you can get to your 3-5 year goals? These items will make up your big immediate projects. These are the things you'll be working directly on for the next foreseeable future. You can start to see things coming into your reach now, you can start to identify with some of these 1-2 year goals and actually envision accomplishing them. Some you might even get done early, within a year!

Next I like to think about a set of goals that aren't really goals, but more like Habits. Often times you'll find that as you elicit your major goals and what it will take to get there, you realize that you need to adjust your habits. These can be things like saving money, or managing your budget. They can be areas of study that you want to keep up on regularly. They can be adopting a healthier diet or a regular exercise program. These things aren't necessarily goals in the traditional sense, as they don't have an end date and then they're accomplished. They're accomplished regularly, and over time, and indefinitely onward. They make up an important part of what is going to help you successfully reach your goals however, so they are important to capture and track.

And on back to your goals, we need to identify our short-term projects. These are one year or less goals, things that may be small and only take you a month, or might take you the better part of a year. Again, the timeframes are flexible here, the idea is to identify a golden thread that leads from your lifelong goals, all the way down to the immediate projects and actions that you need to perform today. This is how you can crystallize your actions and be assured that they are moving you in the right direction. These projects and short term goals will land directly in your GTD system with a .Project tag.

Which of course brings us to each discrete action. This is the bottom of your goal elicitation chart. For each project you have identified a 'Next Action'. The very next, specific, thing that you need to do to move that project forward. Thereby moving the associated 1-2 year goal forward, which gets you closer to the 3-5 year vision, which puts you significantly closer to your life-long goals and callings. This way you can be sure that what you're spending time on today is aligned with what you want to accomplish in your life. This ensures you are moving in a straight line directly towards your goals and the life that you want.

Keep in mind as you're setting your goals. Goals that only exist in the future aren't ever going to do you any good. You need to create goals that inspire or motivate you today. Your goals should act on you in the present, they should cause you to do things differently right NOW. Otherwise, they'll stay in the future and never get accomplished. If your goal doesn't excite you and cause you to move towards it immediately by changing things in your life at the present moment, then it's not a goal worth having.

Sure, there will be plenty of actions and even projects that you work on that don't directly align with your higher purpose and goals, however the important thing is that we are tracking those things that do, and continually making progress. And while you're at it, it doesn't hurt to use these categorizations as tools to help you prioritize your actions. Which leads us to our next topic.

Prioritization - Accomplishing the Most Important Actions Every Time.

So you have a bunch of tasks, next actions, sitting in your context lists. You open even just one of those lists and you have 50 items to choose from. There's no way that you can get them all done today. You feel overwhelmed, you end up cherry picking the tasks that you think will be easiest or the most enjoyable. Over time you realize that some tasks are getting ignored, they're sitting on your lists for weeks at a time and not getting done. You're just picking the low hanging fruit over, and over again. How do you decide what you should be working on at any given time?

You should be doing work based on the resources that you have available, which means the right context. Luckily you have your actions divided up by context, so this is helpful. Your energy level needs to be taken into account as well. If you don't have the energy to perform a certain task, then making yourself do it isn't going to help anyone. Time, is another factor. How long to you have? You need to select actions that can be accomplished in the time you have to work on them. The choice should be intuitive as much as possible, we want to avoid spending a bunch of time creating an ordered list. Numbering your tasks from most important to least important takes time, and it changes constantly, and it doesn't take into account the previously mentioned factors. But you need some way to narrow down your choices, something to reduce the overwhelming feeling.

One definite thing to do is to make sure that everything on your next action lists is actually something that you want to get done. If it's only an idea, or something that doesn't need to be done in the immediate future, put it on the Someday/Maybe list. You're going to review this list weekly anyway, so you're not going to lose it forever, the task is still there. But if it's not important enough to get done this week, it might be better served out of sight until you have the time. The Someday/Maybe list is a lockbox for ideas that relieve your brain from being cluttered with them.

The next thing that might help is a "!CRITICAL" tag. This is an action that you've identified as an important task, something that absolutely needs to get done this week. We're not prioritizing all of our actions here, all we're doing is picking out the ones that stand above the rest. The ones that are clearly more aligned with our projects and goals. The things that are going to move you forward the most. The !CRITICAL tag will sort these items at the top of your list if you sort by Tags and will jump out at you, giving you that extra push you needed to help decide what tasks to pick of the list and accomplish.

One approach is to pick three actions that you want to get done each day. Choose them the night before and assign !CRITICAL tags. Then when you wake up in the morning, start with those three items before you do anything else. Focus your work there and ensure that those three things get done.

Project Prioritization - What is Most Important to You.

The same strategy can be applied to your projects. A certain school of thought indicates that if you're working on more than three projects at a time you're spreading yourself too thin and don't have a reasonable chance to progress on any of them. I personally think that's extreme, especially with the definition of 'project' that we've established. However, I think it's reasonable to focus on three primary projects at once. This allows you to align your thinking with the most important efforts you have going on at any particular time. It does help to cut through the clutter if you have a bunch of projects going.

The way I accomplished this in Evernote is by augmenting the Active Projects tag with an "Auxiliary Projects" tag. I use it the same way, with a single note representing the overview of the project itself, why I'm doing it and what I want to accomplish, that gets tagged with the Auxiliary Projects tag and makes up my project list. Then tagging it and the supporting notes with a .projectname tag so that all the supporting material stays associated with each project. Then I nest those .projectname tags underneath the Auxiliary Projects tag so that you can easily collapse them in your standard tag view. Then I move all of my projects except for the three most important to the Auxiliary Projects tag. I generally leave my Active Projects tag expanded so that those projects are sitting there staring me in the face all day long. This ends up being similar to using the !CRITICAL tag, but at a project level.

Adding these advanced tactics to your GTD/EN system will provide you with even more laser focus and will make you absolutely unstoppable in attaining your goals. With the addition of these tools, you've now expanded a simple task management system into a full dream-realization mechanism. And it's foolproof. With these techniques you can't help but drive forward on your goals and accomplish everything you set out to do.

If you haven't read the previous two articles on GTD and Evernote or need to review, you can find links to them below. If you like these ideas or have other ways that work for you, post them in the comments. Your additions may be the breakthrough for someone else!

GTD and Evernote - Tying It All Together

Written by Ben Anderson.

In the last article in my GTD and Evernote series, we'll explore the things that make the whole thing go smoothly week in and week out. These are best practices that you can implement to juice your system and make it work for you. By this time you should have a powerhouse GTD system that chugs along for you, driving you toward success in the things that you want to accomplish.

We're going to focusing mostly on the Weekly Review. This is the engine behind your ongoing care and feeding of your system. It ensures that nothing slips through the cracks and that each and every item gets attention and thought. When you are consistent with your weekly review, the rest falls into place.

We'll also talk a bit about physical space. While this is a paperless system and one that exists completely "in the cloud", you've still got to interface with it somehow. This can make a big impact on how effective it is for you.

Weekly Review.

Of course you need a time that is set aside for making such judgments as assigning the !CRITICAL tag, determining your top three projects, and for managing your system in general. The weekly review is one of the most powerful components of this system. This is where it all comes together into a giant life progressing engine. Once you add the weekly review, this system goes from an organizational system to a full fledged dream fulfilling machine!

In order to fully trust your system, you have to have a time where you can take a step back and work on the system itself. The weekly review is the time for performing clean-up on your lists, making sure your inbox is empty and processed, and reviewing the plans for your active projects. Everyone's weekly review process is different, and you will develop your own style and methodology, which I recommend you record as it evolves. Regardless, you should block out probably 2 hours a week for this purpose and this purpose only. During these two hours, you remove any distractions and simply perform your review. Often times a good time to do this is Friday afternoon, while everything from the week is still fresh in your head. Plus this allows you to get cleaned up and your mind emptied so that you can enjoy the weekend knowing that everything is in order.

Process Email - You want to make sure that your inbox is as close to zero as possible. That's not to say that you won't have action items that you still need to do, but that they're appropriately organized. This is also a good opportunity to follow up on any items that you're waiting for - this ensures a weekly check on any open items, which seems like a good frequency to bug people without annoying them.

Process Evernote Inbox (Untagged Notes) - you probably find that you do a lot of this throughout the week, since tagging notes is really not that time consuming, you likely tag as you go. However, if you've had a busy week and you haven't gotten around to tagging all of the notes in your inbox, this is a good time to do so. Again, this gives you the trust and knowledge that when something goes into your system, it gets acted on, and nothing gets tucked away in the corners and ignored.

Review Goals - This is the time to pull out your goals sheet that we worked on earlier, or whatever you're currently using to track your goals. (you DO need to have your goals written down somewhere). Read through all of your goals, evaluating which ones you're making good progress on, and which ones you need to focus on more. Do you have another project that you should start to move down the path towards achieving any of your goals? If so, add it to your goals sheet and add it to Evernote. Some of your goals may need to be updated as you progress or taken off the list altogether as you complete them. This is a great time to 'check in' with your long-term desires and re-motivate yourself - this also helps to keep your goals fresh in your mind. A little bit of visualization here never hurts...

Review Projects - Here you'll want to review all of your currently projects, and any new projects you just created. You want to make sure that you at least have a 'next action' identified for each project. You may plan out the next several steps, or you may not. As long as you have something that you can go out and do today that will move the project along. Here's where you can do some informal prioritization of your projects. Some people subscribe to the idea that you should have a top three projects that you are really focusing on each week. This is a good time to identify which of your projects are going to be your top three for next week. Where is your focus going to be and what is important to really drive forward? Items on these top three projects can be identified with a !CRITICAL tag, ensuring that they'll float to the top at the beginning of next week.

Review To Do Lists - You want to make sure that everything you completed got a Done tag. Read briefly over all of the tasks that you have open. See if any jump out at you as no longer relevant, or needing an update to keep it accurate. Part of this review includes reviewing any habits that you've been working on establishing. How did you do this week? Do you need to renew your efforts on any particular habit next week?

Review Someday/Maybe List - Again, the power of the Someday/Maybe list is knowing that it's not an idea graveyard, that it does actually get reviewed on a regular basis. This is when you do that review. Are there any items that you're ready to do now? Anything that needs to be moved into Active Projects? Are there maybe's on the list that you've decided to definitely not do that can be removed completely?

Review Calendar - Here you want to go back through the last week's calendar to jog your memory of any action items that you took from any meetings, any follow-up items that you discussed during an event. You will also want to review the upcoming week, identify when your downtime is going to be this upcoming week. Walk-through your week and ensure there aren't' any conflicts. Mentally prepare yourself for what you have upcoming and make sure there isn't anything you need to be doing in order to be prepared for each event.

Review Your Finances - While not directly related to this system, this is a good time to review your spending for the past week. Compare it to your budget, how are you trending? Do you need to scale back your spending next week to get back on track, or are you coming in low for the week? Most of us budget by the month, but it's not a bad idea to get a weekly touch-point to make sure that we're staying on track.

Review Your Diet - Have you been eating healthy? Did you slip and eat a bunch of junk food this week? You can get really detailed about this and track measurements and times for your eating habits, or you can just do this based on a loose recollection of your eating trends. Both are helpful for keeping you aware of what you're putting in your body and serves as a good checkpoint to make sure it's what you want.

Character Review OR Be Creative and Courageous - Did you do anything last week that went outside of your comfort zone? Did you push yourself to do something that made you uncomfortable? If you're not taking risks on a fairly regular basis you're going to get stagnate. To keep growing, you want to constantly be living on your edge. Some time reflecting about your edge, and how you've pushed it lately is healthy and can be a great prod to ensure that you're growing as a human being.

You may want to add other items to your weekly review. Please contribute your ideas in the comments.

Don't RUSH your weekly review. Set aside the time and be thorough. This is probably the most important part of the system as a whole. This allows you to have confidence that nothing will slip through the cracks, as well as raise out of the muck and the 'doing' to step back and to do some strategic planning. This allows you to stay on the course that you have chosen, so that you can be assured you'll end up at the goal you desire.

Physical Space.

This has made a big enough difference to me that I thought it worth mentioning in this guide. If at all possible, if you spend any significant amount of time in front of your computer, or use it for a good number of your tasks, I highly recommend getting a second monitor for your machine. Having two monitors side-by-side, hooked up to the same machine, has changed the way that I use the computer. It allows you to compare and contrast, to drag from one window to another with ease, to reference one document while working on another, and any number of other efficiencies that you'll find you gain. Specifically relevant to this topic, if you have your Evernote window open on your second monitor with your GTD system up on it, you have instant access to your target actions. You also have the ability to dump ideas in their proper place as soon as they come to you.

If you're in the middle of something, and you get distracted and feel the familiar pull to take a quick detour, simply hit CTRL-N, pop open a new note and jot down the idea that you just had. You can come back to it when you're finished with your current task. Don't let every little stray though derail your current flow. Jot down the note and get back to the task at hand. After a while your mind will become accustomed to this process and you'll find it much easier to stay focused. It's almost as if your subconscious will realize that you're serious, you won't be distracted, and will eventually give up.

Flat-panel monitors have come down so much lately in price that you really have nothing to lose by adding a second screen. If you use a laptop, you can use the laptop screen as one screen and then an external flat-screen sitting next to it for the auxiliary screen.

Conclusion.

We've reviewed the need for an organization and time management system. It's going to allow you to be more successful at reaching your goals. A good system will have the unique effect of lowering your stress levels and raising your productivity. You'll find you get more done without expending more effort. When you are properly organized you'll have that comforting feeling of knowing that everything is being taken care of. It allows you to relax completely when it's time to relax, and focus on what needs to be done when it's time to be productive.

We've reviewed one example of an organizational system, based on GTD. This is the system that I'm using currently and it's working really well for me. When I find improvements that need to be made, I make tweaks to the system, that's the beauty of it. Share in the comments what you use for your organizational system and what tweaks you've made for efficiency. There are certainly multiple approaches that can be adopted.

This concludes my series on GTD and Evernote. If you haven't read the previous articles, I recommend starting at the beginning.

GTD and Evernote ,Advanced Topics.

Written by Ben Anderson.

Now that you have your Evernote application configured for your GTD system, its time to begin talking about some of the more advanced options that you have to play with. I'm going to dedicate the next several articles to this topic, by the time we're finished, you'll have a high-powered GTD implementation that's as flexible as it is powerful.

In this article we're going to talk about using different Notebooks in Evernote, how to separate your personal life from your professional life in GTD, and how to integrate your email inbox into your new shiny GTD system.

Notebooks.

So you may have noticed, as you were setting up your GTD system in Evernote, that you have the ability to set up multiple notebooks within your account. You probably also noticed that I didn't mention them in my setup. That is primarily because I don't use them in my configuration. I started out using them, thinking that I would keep my GTD stuff in one notebook, and my reference materials in another notebook, and even had a third special-use notebook. However, in the end I found that these notebooks cause more trouble than they were worth. You had to constantly ensure you were focused on the right notebook when performing searches, and that your newly created notes were going into the right place.

The thing about the notebooks is that they have a hard division, meaning that a note in a particular notebook cannot exist in any other notebook. This is in contrast to the tags, which can span across multiple notebooks. This can create blocks in an otherwise open system. I have found, that with a fully fleshed out tagging system, the notebooks are irrelevant.

Now, if you wanted to try to run two separate GTD systems, you could theoretically configure your saved searches to look in one notebook or the other. However, to me, that doesn't gain you anything as you are still going to be leveraging those searches or tags to find your information. The notebooks in themselves are not helpful organizational tools. They don't help you to find information on their own. Your notebooks will quickly grow too large to simply browse, you will be reliant on your tagging system - and since tags ignore notebook boundaries, they won't help.

In different systems, the notebooks might very well have a place, and I'm glad that the option to use them is available, I just think that in this particular configuration, they are redundant and do more harm than good. If any of you can come up with a viable use for having multiple notebooks in your GTD system, please note them in the comments.

Personal/Professional.

In a related topic, I wanted to talk a bit about separating your personal GTD from your professional GTD. This is a highly individualized topic and can be sliced and diced several different ways. Personally I have two completely separate GTD systems for personal and professional. I have quite a lot of moving parts going on in each one, and I prefer them to not become cross-linked. When I am at work, I am focused on work and need to have all of those open loops and actions clear and concise. When I'm not working, everything else should be separated. To me it's fairly simple to bounce back and forth between the two. Each gets it's own weekly review and it's own dedicated attention and upkeep.

A different approach to this that I've seen is to integrate Stephen Covey's Roles concepts. Basically the idea is to have a GTD system for each of the major roles that you have in your life: parent, friend, manager, artist, volunteer. Each of these functions of who you are, holding a separate system, it allows you to focus on each one separately. You could also implement this idea with much less hard lines by keeping them all together in the same GTD system, but simply using different notebooks in Evernote to separate out the various sets of information.

With the same flexible framework as a base, it's possible to customize your system to meet your specific needs. How are you using a variation of this system to your unique situation?

Integration With Your Email.

If you're like me, and a lot of people, you use your inbox for driving your actions as well. You have requests for you do to something that come into your email, you've got emails that you need to respond to, and you get tons of information that you want to review at some point. So you're asking yourself, how does this fit into the Evernote/GTD implementation? Well there are a couple of ways to approach this topic.

The first and most basic thing you can do is apply the GTD principles to your email. This means processing your inbox on a predetermined interval and making a decision about each piece of mail. Is it actionable? If not, trash it, or file it. If it is actionable, do it, delegate it, or defer it. In order to facilitate that process, I recommend creating a @Waiting and @Action folder in your inbox. This will allow you to drop anything that you've delegated and are waiting for (including receipts for things that are being shipped for you, responses from customer service departments, etc.) into this folder. Likewise, if it's something that you are going to do, but later, drop it into the @Action folder. I also recommend creating a folder for any projects that you get a lot of email correspondence on, this way you have a place to drop reference materials for those projects. This will allow you to get your inbox to zero. This is a pleasant place to be.

Now here's where you have several options. Depending on the size of your system and the amount of threads you have going on, this may be enough. You may just want to keep an eye on your @Action and @Waiting folders on a regular basis to make sure that you're working any tasks that are included in those folders. This works well for small implementations and low-stress type systems.

However, you may find that you would rather have all of your stuff in once place (i.e. Evernote). In this case you have several options. You can email those actionable messages straight to your Evernote address, this will create a new note out of them and dump them into your Evernote inbox for processing. Then you can assign the appropriate context tags, add a check box, and work them like any other task. You could even add another tag to identify the note as originating in email, if you wanted a marker to determine source. This works especially well when the task that you have to carry out doesn't necessarily happen in email. However, if the action is to simply respond to the email, I find it redundant to move it into a note in Evernote just to move back to email to respond.

For this reason, you may prefer to leave these items in email. I even took my email tags a little bit farther and created a @Read/Review folder in my email. This works great for me because I get a lot of things into my email that I want to read about. This allows me to set it off to the side and get right at it whenever I prefer. The downside being that you now have to check two places when you want to get caught up on your Read/Review items. Still, two places is not that bad.

A third option is to simply leave the emails in your email folders, and create a new note in Evernote for each actionable email or waiting email. This can be done quickly and provides you with a quick way to keep track of those items in email, without duplicating all of the information unnecessarily. Ultimately the system that you choose to adopt will be based on your comfort levels with the various tools and the inherent complexity of your system. You may want to mix and match, or might come up with another idea altogether. If you do, let us know in the comments.