How to sleep by Dr. Dewald

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:

  1. airway — If you can’t breathe, nothing else matters
  2. arousal – comes into play if you have a narrow airway
    1. Sluggish arousal mechanism with a narrow airway à“sleepy” people with moderate/severe obstructive sleep apnea
    2. 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.

Problem area: Solution:
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
-Anti-allergy meds

-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
Weight loss
Aerobic exercise — strengthens pharyngeal dilator muscles
Surgery/Tonsillectomy
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

http://www.cbtforinsomnia.com/

Circadian rhythm

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)
Pharmacological -decrease caffeine!!!

-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.