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Good Night, Sleep Tight: Understanding the Importance of Sleep
 

Good Night, Sleep Tight: Understanding the Importance of Sleep

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By Dr. Elliott Lee, Sleep Specialist at The Royal as presented at our monthly lecture series, Conversations at The Royal.

By Dr. Elliott Lee, Sleep Specialist at The Royal as presented at our monthly lecture series, Conversations at The Royal.

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  • Cumulative Sleepiness, Mood Disturbance, And Psychomotor Vigilance Performance Decrements During A Week Of Sleep Restricted To 4-5 Hours Per Night *†‡David F. Dinges, ‡Frances Pack, ‡Katherine Williams, *Kelly A. Gillen, *John W. Powell, *Geoffrey E. Ott, *Caitlin Aptowicz and †‡§Allan I. Pack*Unit for Experimental Psychiatry, †Division of Sleep and Chronobiology, Department of Psychiatry, ‡Center for Sleep and Respiratory Neurobiology and §Pulmonary and Critical Care Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A.Volume : 20 Issue : 04 Pages : 267-277 •  View full text•  Email to a friendCumulative Sleepiness, Mood Disturbance, And Psychomotor Vigilance Performance Decrements During A Week Of Sleep Restricted To 4-5 Hours Per
  • To the Editor: It has become increasingly clear that insufficientsleep and disrupted circadian rhythms are a major publichealth problem. For instance, in 1988 the cost of sleeprelatedaccidents exceeded $56 billion and included 24,318deaths and 2,474,430 disabling injuries.1 Major disasters, includingthe nuclear accident at Chernobyl, the Exxon Valdez oilspill, and the destruction of the space shuttle Challenger, havebeen linked to insufficient sleep, disrupted circadian rhythms,or both on the part of involved supervisors and staff.2,3 It hasbeen suggested that as a society we are chronically sleepdeprived4and that small additional losses of sleep may haveconsequences for public and individual safety.2We can use noninvasive techniques to examine the effectsof minor disruptions of circadian rhythms on normal activitiesif w e take advantage of annual shifts in time keeping.More than 25 countries shift to daylight savings time eachspring and return to standard time in the fall. The spring shiftresults in the loss of one hour of sleep time (the equivalent interms of jet lag of traveling one time zone to the east), whereasthe fall shift permits an additional hour of sleep (the equivalentof traveling one time zone to the west). A lthough onehour’s change may seem like a minor disruption in the cycleof sleep and wakefulness, measurable changes in sleep patternpersist for up to five days after each time shift.5 This leads tothe prediction that the spring shift, involving a loss of anhour’s sleep, might lead to an increased number of “microsleeps,”or lapses of attention, during daily activities and thusmight cause an increase in the probability of accidents, especiallyin traffic. The additional hour of sleep gained in the fallmight then lead conversely to a reduction in accident rates.We used data from a tabulation of all traffic accidents inCanada as they were reported to the Canadian Ministry ofTransport for the years 1991 and 1992 by all 10 provinces. Atotal of 1,398,784 accidents were coded according to the dateof occurrence. Data for analysis were restricted to the Mondaypreceding the week of the change due to daylight savingstime , the Monday immediately a fter, a nd the Monday o neweek after the change, for both spring and fall time shifts.Data from the province of Saskatchewan were excluded becauseit does not observe daylight savings time. The analysisof the spring shift included 9593 accidents and that of the fallshift 12,010. The resulting data are shown in Figure 1.The loss of one hour’s sleep associated with the spring shiftto daylight savings time increased the risk of accidents. TheMonday immediately after the shift showed a relative risk of1.086 (95 percent confidence interval, 1.029 to 1.145; x29.01,1 df; P0.01). As compared with the accident rate a week later,the relative risk for the Monday immediately after the shift was1.070 (95 percent confidence interval, 1.015 to 1.129; x26.19,1 df; P0.05). Conversely, there was a reduction in the risk oftraffic accidents after the fall shift from daylight savings timewhen an hour of sleep was gained. In the fall, the relative riskon the Monday of the change was 0.937 (95 percent confidenceinterval, 0.897 to 0.980; x28.07, 1 df; P0.01) when comparedwith the preceding Monday and 0.896 (95 percent confidenceinterval, 0.858 to 0.937; x223.69; P0.001) whencompared with the Monday one week later. Thus, the springshift to daylight savings time, and the concomitant loss of onehour of sleep, resulted in an average increase in traffic accidentsof approximately 8 percent, whereas the fall shift resultedin a decrease in accidents of approximately the same magnitudeimmediately after the time shift.These data show that small changes in the amount of sleepthat people get can have major consequences in everyday activities.The loss of merely one hour of sleep can increase therisk of traffic accidents. It is likely that the effects are due tosleep loss rather than a nonspecific disruption in circadianrhythm, since gaining an additional hour of sleep at the falltime shift seems to decrease the risk of accidents.Vancouver, BC V6T 1Z4, STANLEY COREN, PH.D.Canada University of British Columbia
  • Anxiety we see all the time in the sleep lab – sleeping in a foreign environmentChances are 1-3 people here may struggle with RLS which may give people problems falling/staying asleep
  • To the question: In an economy that often demands 24/7 activity, shift work remains common both among men and women. Among the different types of shift work are rotating and evening shifts. Are women more likely or less likely to work rotating shifts and evening shifts?The correct answer is A: While proportionately fewer women work irregular shifts (25% vs. 35% for men), they are more likely to work rotating shifts (41% vs. 34%) or evening shifts (14% vs. 10%).Among full-time shift workers, women were more likely than men to work rotating or evening shiftsIn 2005, over 3 million full-time workers worked something other than a regular daytime schedule, with two-thirds of them working a rotating or irregular shift. Just as women’s share of full-time work has increased in the labour market in general, so too has their share of full-time shift work. In 2005, about 37% of full-time shift workers were women, up from about 33% in 1992. Some occupations are more commonly associated with shift work. Almost half of workers in health-related occupations and two-thirds of those in protective services worked shift.Among full-time shift workers, women were more likely than men to work rotating or evening shiftsIn 2005, over 3 million full-time workers worked something other than a regular daytime schedule, with two-thirds of them working a rotating or irregular shift. Just as women’s share of full-time work has increased in the labour market in general, so too has their share of full-time shift work. In 2005, about 37% of full-time shift workers  
  • The time between the photographsand Epworth scores obtained initially, and then againafter at least 2 months of successful CPAP use, was 5.8 ± 1.8months. The mean Epworth score was 13.5 ± 2.3 at baselineand 5.6 ± 2.7 after use of CPAP, resulting in a mean change of-7.0 ± 4.1 (paired T-test p < 0.0001). Adequate adherence withPAP was confirmed electronically for all but one subject whosedata card failed to function properly. Among the 30 nights justprior to the post-PAP images, the percent of nights that showed≥ 4 h of use ranged from 70% to 100% (mean 89% ± 10%).Mean hours of PAP use, on nights used, was 6.3 ± 0.6.
  • Jocelyn Wildenstein, a wealthy socialite featured in this photo montage is 71 years old. She has had numerous plastic surgeries done to her face to create a more “cat like look”. She has sometimes been referred to as “the Lion Queen” or the “Catwoman”.
  • Jocelyn Wildenstein, a wealthy socialite featured in this photo montage is 71 years old. She has had numerous plastic surgeries done to her face to create a more “cat like look”. She has sometimes been referred to as “the Lion Queen” or the “Catwoman”.
  • Jocelyn Wildenstein, a wealthy socialite featured in this photo montage is 71 years old. She has had numerous plastic surgeries done to her face to create a more “cat like look”. She has sometimes been referred to as “the Lion Queen” or the “Catwoman”.
  • Jocelyn Wildenstein, a wealthy socialite featured in this photo montage is 71 years old. She has had numerous plastic surgeries done to her face to create a more “cat like look”. She has sometimes been referred to as “the Lion Queen” or the “Catwoman”.
  • US winter olympic team – used these measures; apollo anton ohno Michael phelps swears by napping and getting as much sleep as he canhttp://sportsblog.projo.com/2008/08/michael-phelps.htmlhttp://health.usnews.com/blogs/on-fitness/2008/06/26/the-athletes-legal-performance-aid-sleep.html
  • Improved cycling time-trial performance after ingestion of a caffeine energy drink.Ivy JL, Kammer L, Ding Z, Wang B, Bernard JR, Liao YH, Hwang J.Department of Kinesiology and Health Education, University of Texas, Austin, TX 78712-0360, USA.CONTEXT: Not all athletic competitions lend themselves to supplementation during the actual event, underscoring the importance of preexercise supplementation to extend endurance and improve exercise performance. Energy drinks are composed of ingredients that have been found to increase endurance and improve physical performance. PURPOSE: The purpose of the study was to investigate the effects of a commercially available energy drink, ingested before exercise, on endurance performance. METHODS: The study was a double-blind, randomized, crossover design. After a 12-hr fast, 6 male and 6 female trained cyclists (mean age 27.3 +/- 1.7 yr, mass 68.9 +/- 3.2 kg, and VO2 54.9 +/- 2.3 ml x kg-1 x min-1) consumed 500 ml of either flavored placebo or Red Bull Energy Drink (ED; 2.0 g taurine, 1.2 g glucuronolactone, 160 mg caffeine, 54 g carbohydrate, 40 mg niacin, 10 mg pantothenic acid, 10 mg vitamin B6, and 10 microg vitamin B12) 40 min before a simulated cycling time trial. Performance was measured as time to complete a standardized amount of work equal to 1 hr of cycling at 70% Wmax. RESULTS: Performance improved with ED compared with placebo (3,690 +/- 64 s vs. 3,874 +/- 93 s, p < .01), but there was no difference in rating of perceived exertion between treatments. b-Endorphin levels increased during exercise, with the increase for ED approaching significance over placebo (p = .10). Substrate utilization, as measured by open-circuit spirometry, did not differ between treatments. CONCLUSION: These results demonstrate that consuming a commercially available ED before exercise can improve endurance performance and that this improvement might be in part the result of increased effort without a concomitant increase in perceived exertion.PMID: 19403954 [PubMed - indexed for MEDLINE]Related articlesFailure of protein to improve time trial performance when added to a sports drink.Med Sci Sports Exerc. 2006 Aug; 38(8):1476-83. [Med Sci Sports Exerc. 2006]Effects of microhydrin supplementation on endurance performance and metabolism in well-trained cyclists.Int J Sport NutrExercMetab. 2004 Oct; 14(5):560-73. [Int J Sport NutrExercMetab. 2004]Effect of Red Bull energy drink on repeated Wingate cycle performance and bench-press muscle endurance.Int J Sport NutrExercMetab. 2007 Oct; 17(5):433-44. [Int J Sport NutrExercMetab. 2007]Carbohydrate-electrolyte feedings improve 1 h time trial cycling performance.Int J Sports Med. 1997 Feb; 18(2):125-9. [Int J Sports Med. 1997]Review[The effects of energy drinks on cognitive performance]TijdschrPsychiatr. 2008; 50(5):273-81. [TijdschrPsychiatr. 2008]» See reviews... | » See all...Patient Drug InformationNiacin (Advicor® , Niacor® , Niaspan® ) Niacin is used with diet changes (restriction of cholesterol and fat intake) to reduce the amount of cholesterol and certain fatty substances in your blood. Niacin is also used to prevent and treat pellagra (niacin defic... Glipizide (Metaglip, Glucovance, Avandamet, ...) In patients with diabetes or hyperlipidemia, how do combination drugs compare in improving long-term health? Source: AHFS Consumer Medication Information

Good Night, Sleep Tight: Understanding the Importance of Sleep Good Night, Sleep Tight: Understanding the Importance of Sleep Presentation Transcript

  • Good Night, Sleep Tight: Understanding the Importance of Sleep Conversations at the Royal Elliott Lee MD, FRCP(C) D. ABPN Sleep Medicine, Addiction Psychiatry D. Amer Board of Sleep Medicine Assistant Professor, Royal Ottawa MHC December 19, 2013
  • Outline • Functions of sleep • Factors affecting sleep - Quantity - Quality - Timing • Is sleep an issue for you? • Obstructive sleep apnea, Narcolepsy • How to improve sleep
  • Arianna Huffington, Internet publishing pioneer President and Editor In Chief, Huffington Post Media Group
  •  Approximately what percentage of our (adult) lives will be spent sleeping? A) 20% B) 25% C) 33% D) 40% E) 50%
  •  Approximately what percentage of our (adult) lives will be spent sleeping? A) 20% B) 25% C) 33% D) 40% E) 50%
  • Why Study Sleep?  We spend 1/3 of our lives sleeping  Severe health consequences - DEATH!  Sleep deprivation costs $150 BILLION/yr in lost productivity (Nat’l Commission on Sleep Disorders, 2003)
  • Functions of Sleep  Body /brain repair - Increased resilience to stress/injury  Pain Reduction  Mood regulation  Diminished anxiety  Memory and learning  Immune competence
  • Sleep Characteristics by Stage  NREM - Stage N1 + N2 (light sleep) Motor skill learning? - Stage N3 slow wave (deep) Restorative function Memory  REM (rapid eye movement) - Dreaming (85%) - Memory ? - Mood regulation ?
  • SLEEP HYPNOGRAM W N2 1 N1 N3 REM 1 2 3 4 Hours 5 6 7
  • Sleep factors impacting performance Sleep Quantity Sleep Quality Sleep Timing (Sleep Inertia)
  •  What is the commonest cause of excessive daytime sleepiness in the community?
  •  What is the commonest cause of excessive daytime sleepiness in the community? Chronic Insufficient Sleep
  • Sleep QUANTITY
  • Sleep Deprivation  According to the most recent General Social Survey done by Statistics Canada (2010), 46% percent of Canadians will cut back on sleep in order to add time to their days.
  • Sleep Deprivation  There is a conflict between the biological imperative for sleep and the social demand for performance. This poses a fundamental question: What happens to performance when the pressure for sleep is increased?
  • Sleep Quantity  Too little – equivalent to functioning with 0.05 blood alcohol level (<6 hours)1  <7 hours – decrements can be seen in performance  Cognitive function > speed > accuracy2,3 1Williamson AM and Feyer AM. Occup Environ Med 2000; 57; 649-55 2Koslowsky M and Babkoff H. Chronobiol Intl. 1992; 9(2); 132-6 3Reilly T and Edwards B. Physiology and Behaviour. 2007; 90; 274-84
  • Sleep Disorders Socioeconomic Consequences  More than 100,000 motor vehicle accidents annually are sleep-related (US).  “Toronto syndrome”
  • Psychomotor Vigilance Task (PVT) errors with cumulative sleep deprivation Dinges et al Sleep, 1997; 20(4), 267-77
  •  Challenger Disaster  3 Mile Island  Chernobyl  Exxon Valdez  Medical Errors  Transportation Industry
  • Daylight Savings and Traffic Accidents Coren S. N Engl J Med. 1996 Apr 4; 334(14): 924
  • Sleep Deprivation and Wt gain?  Women who sleep <5 hours per night, gained 2.5 lbs, cf. to women sleeping 7 hours/night  Relative risk for obesity (BMI > 30 kg/m2) 5 hour sleepers = 1.15 cf. to 7+ hours  Studied >68 000 women (Nurses Health Study) for 16 years  Hormones? Basal metabolic rate?
  • Sleep Deprivation and Children  Not the same as adults  May be “hyperactive” - fidget - poor attention - cranky
  • Sleep QUALITY
  • Sleep Quality  Fragmented sleep consequences are similar to sleep deprivation - ↓ concentration - ↓ attention - moodiness/irritability - ↓ reaction time - memory impairments  Causes of fragmented sleep: - Temperature - Light* - Noise - Pain - Anxiety/Stress - Sleep disorder - Snoring/Apnea - PLMs/RLS
  • Sleep TIMING
  • Sleep Control Process S(leep) Process C(ircadian)
  • Process S(leep)  Homeostatic control  “The longer we’re awake, the more sleep debt we accumulate i.e. the sleepier we become”  The sleepier we are, the more deficits are seen  To date, there is no surrogate available for good quality sleep.
  • Process S(leep)  Homeostatic control  “The longer we’re awake, the more sleep debt we accumulate i.e. the sleepier we become”  The sleepier we are, the more deficits are seen  To date, there is no surrogate available for good quality sleep.
  • Process C(ircadian)  Sleep tendencies follow a circadian (daily) rhythm  This is controlled by a central “biological clock”  Several inputs also influence this clock, especially - Light - Melatonin
  • Sleep and Light 11 PM 7 AM SLEEP SLEEP SLEEP
  • Sleep and Light 11 PM SLEEP SLEEP SLEEP 7 AM
  • Sleep and Melatonin 11 PM SLEEP SLEEP SLEEP 7 AM
  • Consequences of Asynchronous Sleep  Impaired continuity of sleep  ↓ alertness  ↑cognitive errors  Like “hitting a tennis ball off the centre of the racquet” – sleep is not as efficient, and sleep architecture is disrupted  Jet lag, shift work
  •  Who is more likely to do rotating or evening shifts in Canada, men or women?
  •  Who is more likely to do rotating or evening shifts in Canada, men or women? WOMEN
  • Women are more likely to work rotating shifts or evening shifts Men Women Irregular 25% Other 13% Other 12% Evening 14% Irregular 35% Evening 10% Night 8% Night 8% Rotating 41% Rotating 34% Source: Williams C. Worklife Balance of Shift Workers, Stats Canada General Social Survey, 2005
  • Shift Work  International Agency on Research and Cancer (IRAC) classified shift work as a probable carcinogen in 2007.  40-50% increase in breast cancer risk with >20-30 years of shift work exposure.  Melatonin thought to play a key role; reduces estrogen levels and shown to have anticancer properties. Megdal et al. Eur J Cancer. 2005; 41: 2023-32 Grundy A et al. Occup Environ Med. 2013; 70: 831-8 Shernhammer ES and Hankinson SE. Cancer Epidemiol Biomarkers Prev 2009; 18: 74-9
  • Is sleep an issue for you?  Do you feel satisfied with the quality of your sleep?  Do you frequently fall asleep if given a sleep opportunity (a sleep opportunity is defined as a quiet, dark environment for at least 10 minutes)?  Do you usually need an alarm clock to wake you?  Do you tend to catch up on sleep during the weekends?  Once awake, do you feel tired most mornings?  Do you frequently take naps during the day?
  • Is sleep an issue for you?  When you can get it, do you consistently sleep more than 9.5 hours per night?  Do you feel lethargic or slow throughout the day?  Do you sleep longer during times of depression, anxiety and stress?  Do you snore?  Do your legs bother you at bedtime, interfering with your sleep?
  • What Happens at the Sleep Lab…  ROMHC: 5 bed clinical lab, 4 bed research lab STEPS: 1) → Referral 2) → Consultation with a Sleep Specialist 3) → Overnight Sleep Study 4) → Data is Analyzed by RPSGTs 5) → Results Appt with a Sleep Specialist
  • How Do We Measure Sleep in the Laboratory?  Electrophysiology  EEG – brainwaves (Central & Occipital Leads)  EOG – eye movements  EMG – muscle tone  EKG – heart  Breathing: 1)Airflow & 2) Effort: Thoracic & Abdominal  Blood oxygen saturation (SaO2)  Audio-visual recording
  • Obstructive Sleep Apnea (OSA)  Definition: The presence of abnormal breathing disruptions/cessations (apneas) during sleep  Sleep is disrupted temporarily, usually without recall. As a result, sleep deprivation and/or excessive daytime sleepiness occur, usually with snoring at night  Up to 25% of men and 9% of women are thought to be affected, with 90% of patients likely undiagnosed1  50% of snorers are thought to have OSA2  Strongly associated with cardiac disease 1Young et al. N Eng J Med, 1993; 328(17): 2Lugaresi et al. Sleep, 1980; 3(3-4): 221-4 1230-5
  • Fatal CV events and OSA Months Marin JM et al. Lancet, 2005
  • Nonfatal CV events and OSA Marin JM et al. Lancet, 2005
  • Motor vehicle accidents Hypertension OSA Consequences Impaired glucose control Irritability, mental illness e.g. depression Heart attack and stroke Memory problems
  • Treatments for OSA     **Weight loss - ↓ BMI = ↓ RDI Avoid alcohol consumption and sedative medications “Snoreball” technique / positional therapy Upper airway surgery     Tonsillectomy (pediatrics) Uvulopalatopharyngoplasty (UPPP) Maxillomandibular Advancement (MMA) Tracheostomy  Provent  Oral Appliances - Mandibular Repositioning Devices (MRDs), Tongue Retention Devices (TRDs)  **CPAP – Continuous Positive Airway Pressure
  • OSA and Attractiveness?  Treatment of OSA with CPAP has been shown to improve attractiveness  Perceived to be - More alert - More youthful - Less forehead creases Chervin R et al. J Clin Sleep Med, 2013; 9(9): 845-52
  • All of the following famous people suffer from a sleep disorder. Which of these famous people suffers from obstructive sleep apnea? (Choose all that apply): A B C D E
  • All of the following famous people suffer from a sleep disorder. Which of these famous people suffers from obstructive sleep apnea? (Choose all that apply): A B C D E
  • Narcolepsy  A pathologic disorder of sleepiness during the day – key symptom – sleepiness  May have insomnia at nighttime  Affects about 1/2000 people  Very underdiagnosed; difficult to recognize  80% may have cataplexy, a REM sleep intrusion phenomenon on wakefulness  Related to cerebrospinal fluid deficiency of hypocretin (orexin)
  • Narcolepsy Treatment SLEEPINESS: – Stimulants d-amphetamine (Dexedrine), methylphenidate (Ritalin) Novel - modafinil (Alertec / Provigil). - armodafinil CATAPLEXY: – Antidepressants – e.g. venlafaxine – Sodium oxybate (Xyrem)
  • All of the following famous people suffer from a sleep disorder. Which of these famous people suffers from narcolepsy? A B C D E
  • All of the following famous people suffer from a sleep disorder. Which of these famous people suffers from narcolepsy? A B C D E
  • How to Improve Sleep  Get adequate quantity of sleep (7.5-8.5 hrs)  Regular sleep/wake times – timing/routine important  Develop a relaxing pre sleep ritual - relaxation exercises can be helpful - avoid stressful/stimulating activities prior to sleep  Avoiding prolonged naps* in the day  Bed – only for sleep (and romance!)  Avoid clock watching  Rule out sleep disorder, psychiatric disorder
  • How to Improve Sleep  Sleep Environment - Avoid environmental disturbances - Partner/Children - Roommate - External noises – phones, texting, external (white noise generator may drown out) - Avoid bright light in evenings - Temperature – slightly cooler (<21-22oC) is better. drop in temperature facilitates sleep onset - Bed should be comfortable – consider memory foam mattresses/pillows; queen or king size beds Quiet. Dark. Cool. Comfortable.
  • Detriments to Sleep  Light (evening) - cell phones, computer  Stress (cortisol - steroid)  Caffeine  Nicotine  Alcohol  Marijuana  Drugs (Amphetamines, cocaine, opioids*)
  •  Which of the following substances has the highest amount of caffeine? A) Red Bull, 250 mL B) Coca Cola, 1 L C) Starbucks Coffee, Grande (360 mL) D) Green Tea, 300 mL E) Caffeine pill, (200 mg tab)
  •  Which of the following substances has the highest amount of caffeine? A) Red Bull, 250 mL B) Coca Cola, 1 L C) Starbucks Coffee, Grande (360 mL) D) Green Tea, 300 mL E) Caffeine pill, (200 mg tab)
  • Caffeine – a Canadian Love Affair Starbucks coffee(20 oz) 400 mg Second Cup coffee (20 oz) 400 mg Tim Horton’s coffee (20 oz) 270 mg Instant coffee (8 oz)* 95 mg Tea (leaf or bag, 8 oz) 50 mg Mountain Dew (12 oz) 55 mg Coca Cola (12 oz) 45 mg Red Bull (250 ml) 80 mg Sources: National Coffee Association, National Soft Drink Association, Tea Council of the USA, and information provided by food, beverage, and pharmaceutical companies and J.J. Barone, H.R. Roberts (1996) "Caffeine Consumption." Food Chemistry and Toxicology, vol. 34, pp. 119-129.
  • Summary  Sleep is important to consider for performance  Good sleep can improve performance - Cognition/memory - Accuracy - Speed - Health/Decrease sick days (immune competence) - Improve mood, anxiety, resilience  Sleep variables to consider: Quantity, Quality, Timing  Rule out sleep disorder  Details are important; BALANCE – key to success
  • When the time to perform has come, the time to prepare has past. Bob Bowman, coach of Michael Phelps
  • Thank You! Questions?
  • Severe OSA, treated with CPAP 10 PM 12 AM 2 AM 4 AM 6 AM
  • Video courtesy of Joe Santos, IOSleep Med
  • Video courtesy of Dr. Viozzi, Mayo Clinic
  • Maxillomandibular Advancement 5 mm 5 mm +8 mm
  • Mandibular Repositioning Devices (MRDs) Klearway- Silencer- Great Lakes Orthodontics Johns Dental Labs