March 24, 2016
How to sleep by Dr. Dewald
How to Sleep by Dr. Dewald
Dr. Dewald sleep paradigm: a systematic approach to sleep problems.
There are two critical determinants of sleep:
- airway — If you can’t breathe, nothing else matters
- arousal – comes into play if you have a narrow airway
- Sluggish arousal mechanism with a narrow airway à“sleepy” people with moderate/severe obstructive sleep apnea
- Hyperactive arousal mechanisms with a narrow airway à “tired” people with chronic insomnia/upper airway resistance syndrome/mild OSA
The most bang for your buck comes from ensuring that your airway is patent during sleep. 90% of arousals in chronic insomniacs in a sleep lab are preceded by respiratory events.[i] If you fix your airway, the relative importance of your level of arousal decreases significantly.
Approximately of 10% of respiratory events in chronic insomniacs lead to arousals.1 Even one respiratory event may ruin your night’s sleep if you can’t fall back asleep afterwards. If you have a hyperactive arousal mechanism, you may only get good sleep if your AHI approaches 0 (which may not be possible), but you can work on your arousal mechanisms to improve sleep by teaching yourself to fall back asleep.
|Airway||Goal is a secure airway à exclusive nasal breathing|
|Lower jaw and tongue falling into airway||Oral appliance (**takes care of jaw but may not take care of tongue)|
|Myofunctional therapy – keep tongue on roof of mouth, anchor jaw forward, correct swallow|
|Mouth taping—may be enough by itself, or may need to incorporate with mandibular advancement|
|Avoid sedating meds/alcohol/overexhaustion à more likely to occlude airway|
|Positional therapy – most people have more of a problem with this while lying on back – enforce side or stomach sleeping by using positioning device, eg. pillows/socks sewn into back of shirt/Rematee|
|Nasal CPAP – trains you to keep your mouth shut (utilizes reflex?) — but only 25% of people will use long term|
|Palate width/nasal resistance||Resistance increases by 1/r4 à à anything that you do to widen your airway will improve thing tremendously|
|Palate expansion – effective in children, but possible in adults?|
|Nose dilator strips if nasal dilators weak|
|Aerobic exercise with mouth closed to strengthen nasal dilator muscles|
-URI: short term nasal decongestions (<4d)/Buteyko nasal clearance or tissue wick followed by exclusive nasal breathing
-dairy effect on mucus?
|Surgery – tonsillectomy/adenoidectomy, relief of nasal obstruction (warning: surgery is forever)|
|Soft tissues of throat and oropharynx||Myofunctional therapy—correct tongue position and swallow|
|Aerobic exercise — strengthens pharyngeal dilator muscles|
|Avoid sedating meds/overexhaustion
Avoid food within 4 hours of sleep – gastroesophageal reflux
|CPAP – stent soft tissues open|
|Arousal – working with your reptilian brain||Learn how to manage the stress of repeated nightly waterboarding-like experience?|
|Sleep phobia||Understand what is going on and reassure yourself that you will wake up and not suffocate.|
|Avoid panic over waking up and lack of sleep||CBT for insomnia – Gregg Jacobs|
Go to bed and get up at same time every day
Sunshine exposure during the day
|Routine – sleep/relaxation triggers||Bedtime routine – bedtime stories/reading in bed
Associate bed with only sleep and sex
|Physical relaxation||**muscle relaxation is an ACTIVE process that requires ATP à exercise/blood flow is critical to relaxation. IF YOU CAN’T SLEEP, GET UP AND EXERCISE!
**breathing exercises – abdominal breathing
|Mental relaxation||-Have a notebook next to your bed so you can write things down to think about or do tomorrow
-Decrease clutter in bedroom
|Metabolic changes||-Eat real food, avoid sugar and processed food – sugar linked to increase arousals.
-Eat dinner 4hr before bedtime, try to get in 13-hour fast overnight
|Protect melatonin||Low blue lights (fire/candlelight wavelengths); yellow filter or f.lux|
|Dark room||Light blocking curtains/shades, eye shades (however, eye shades may cause discomfort)|
|Noise prevention||Ear plugs, fans, noise machines, double or triple paned windows|
|Physical disturbance prevention||Separate bed? Pets out of bedroom|
|Get TV out of bedroom||-Blue light destroys melatonin
-stimulation gets you out of sleep mode
-Commercials are designed to attract attention
|Comfort||Soft bed for side-lying, underwear seams, uncomfortable straps on eye shades, CPAP, earplugs, make bed so that sheets aren’t wrinkled, wash bedding frequently (same reason)|
-decreased stimulating medications: ADHD meds, steroids
-short term use of sleep meds, sedating antihistamines
[i] Krakow B et al., Prospective assessment of nocturnal awakenings in a case series of treatment-seeking chronic insomnia patients: a pilot study of subjective and objective causes. Sleep. 2012 Dec 1;35(12):1685-92.