Expert Interview: Dr. Avram Gold

[sypark]

Please join me on Tuesday, March 22nd at 8 PM Eastern when I’ll interview Dr. Avran Gold, a pioneer in researching the link between upper airway resistance syndrome, chronic fatigue syndrome, and the functional somatic syndromes. Some of the topics will include:

- What are the functional somatic syndromes and how are they related to sleep-breathing disorders?
- What’s the relationship between central sensitivity syndrome and stress?
- How is sleep-disordered breathing related to stress?
- How is anxiety or depression related to functional somatic syndromes?
- How is chronic fatigue syndrome connected to the this condition?

Topic: Dr. Avram Gold on UARS, Chronic Fatigue & Functional Somatic Syndromes
Date: Tuesday, March 22, 8PM Eastern
Place: Teleseminar / Webinar

Click here to register: http://doctorstevenpark.com/?p=5798

[KatieW]

This was an interesting talk. Here is the article that Dr. Gold wrote:

The Symptoms and Signs of Upper Airway Resistance Syndrome—A Link to the Functional Somatic Syndromes

http://chestjournal.chestpubs.org/conte ... l.pdf+html

[Bright Choice]

Katie
What did you think of his comment that full face masks do not provide effective therapy?

[KatieW]

Katie
What did you think of his comment that full face masks do not provide effective therapy?

I didn't understand it. I wonder if he was just talking about UARS though. I wrote down what he said...."with FF mask, the pressure is in front and behind the tongue. With a nasal interface, the pressure is nasal, to get around the tongue." I guess that assumes you are also mouth breathing.

The other thing he said was that if you are not getting effective therapy for UARS, it's the FF mask, or you were improperly titrated--the pressure is too high and causing arousals. Usually it's 5-9 cm H2O for UARS.

Here's the link to the mp3:

https://www.dropbox.com/s/bms7pthhdvx7a ... m.Gold.mp3

And a link to the Fibromyalgia Newsletter:

https://www.dropbox.com/s/84ptx2rix8xuq ... r.Gold.pdf

[SleepingUgly]

This talk was excellent. A couple of points he made that I am sure will stimulate interesting debates are:

A full face mask is not an effective treatment for sleep apnea or UARS. There is pressure in front of the tongue and behind the tongue, and the most important job of CPAP is to move the tongue and soft palate forward, so it can't be applied to the mouth. If you're using a FFM, there's a good chance you're not adequately treated.

and

Titrate to eliminate flow limitations, whether they are associated with arousals or not. It is the snoring, whether audible or not, not the arousals, that causes the symptoms. You want CPAP titrated so throat doesn't collapse and there are no audible or inaudible inspiratory flow limitations. Don't count RERAs; look at the shape of the airflow trace. Get rid of inspiratory airflow in NREM sleep. You can still have some in REM and it doesn't seem to affect things.

[SleepingUgly]

I hope people will click on this thread and not just skip over it because it's about a talk that's past due. I can't wait for Roster to hear what Dr. Gold said about FFMs.... tee hee hee!

In any event, I think I'll stop fiddling around with the Quattro FX and, now that I'm back on nasal steroids for the first time since my surgery in June, I'll work with a nasal mask.

[SleepingUgly]

There are a lot of good reasons to optimize nasal breathing during sleep and to try to avoid oral breathing, or even mouth opening.

-SWS, where's that article I used to love to cite where they experimentally induced OSA by occluding the nose, but not by occluding the mouth? And the article that shows just opening your mouth facilitates airway collapse?

Why, oh why, can't I be organized in my links like Rested Gal?

[-SWS]

There are a lot of good reasons to optimize nasal breathing during sleep and to try to avoid oral breathing, or even mouth opening.

-SWS, where's that article I used to love to cite where they experimentally induced OSA by occluding the nose, but not by occluding the mouth? And the article that shows just opening your mouth facilitates airway collapse?

Why, oh why, can't I be organized in my links like Rested Gal?

Here are links to your fine nasal-breathing posts, SU:
search.php?keywords=superior+nasal+brea ... mit=Search

[tiredintenn]

I wasn't able to listen but did they discuss treatment options for UARS and if there was an optimal treatment? I have UARS (17 RERAs/hour, 0 AHI). I have tried a dental device and PAP therapy. Neither have provided me with any relief. I am now considering surgical options. Was any of this discussed?

[Jade]

Can someone have both UARS and OSA?

What's the differential diagnosis procedure, or rule-out to determine which a person has?

PS: Thanks for the links, Katie, I clicked on this post after the interview occurred.

[SleepingUgly]

You can download the whole talk at the link that Katie posted.

[M.D.Hosehead]

This talk was excellent. A couple of points he made that I am sure will stimulate interesting debates are:

A full face mask is not an effective treatment for sleep apnea or UARS. There is pressure in front of the tongue and behind the tongue, and the most important job of CPAP is to move the tongue and soft palate forward, so it can't be applied to the mouth. If you're using a FFM, there's a good chance you're not adequately treated.

and

Titrate to eliminate flow limitations, whether they are associated with arousals or not. It is the snoring, whether audible or not, not the arousals, that causes the symptoms. You want CPAP titrated so throat doesn't collapse and there are no audible or inaudible inspiratory flow limitations. Don't count RERAs; look at the shape of the airflow trace. Get rid of inspiratory airflow in NREM sleep. You can still have some in REM and it doesn't seem to affect things.

and

You can't titrate yourself at home with an auto machine, "That won't work."


...still waiting for the show to start.

[SleepingUgly]

You can't titrate yourself at home with an auto machine, "That won't work."

I was given an empiric trial of CPAP prior to my diagnosis and official titration. Here is my personal opinion based only on my experience: If you're titrating to minimize your AHI, and you easily adapt to CPAP, it's possible to titrate yourself on APAP/CPAP. If you're titrating to minimize symptoms, such as EDS, and you don't easily adapt to CPAP, may G-d be with you.

I spent months trying various masks and various combinations of pressures, straight pressures and pressure ranges, in conjunction with various C-flex/C-flex + settings. The masks clearly made it difficult as I couldn't log more than 13 days in a row without a mask hurting my nose too badly to proceed without a break. But besides that, there is night to night variability, and in variability in EDS, and when your outcome variable is a moving target, it's really tough to know what the "right" setting is. There are so many possible permutations between 6cm and 14cm (not to mention higher, and not counting comfort settings)! Add to that someone who has more of a REM-dependent OSA or positional OSA, and every portion of the night may yield different data! For all my efforts, I never got myself to the right pressure according to my official titration.

My personal opinion is that the best way to proceed is to get an in-lab titration, which gives you a starting point for tweaking the pressures at home.

[roster]

A full face mask is not an effective treatment for sleep apnea or UARS. There is pressure in front of the tongue and behind the tongue, and the most important job of CPAP is to move the tongue and soft palate forward, so it can't be applied to the mouth. If you're using a FFM, there's a good chance you're not adequately treated.

This statement standing alone is just not true and I am sure the good doctor did not mean it that way.

I have not listened to the interview or read the paper, however as KatieW nicely pointed out the doctor was surely talking about someone mouthbreathing/leaking while using a full face mask. The desirable way to use a full face mask (or a nasal interface) is with your mouth closed.

There are hundreds of posts on the forum with ideas (including surgery) for keeping the nasal passages open and breathing as much as possible through the nasal passages. There are also posts about how much healthier it is to breathe through the nose (whether using CPAP or not) - for one example see viewtopic.php?f=1&t=49494&p=453631&hili ... de#p453631. These posts were made to encourage the users of FFMs or nasal interfaces to minimize mouthbreathing.

Having a virus with some congestion a few weeks ago and experiencing some mouthbreathing due to the congestion, I reviewed my data carefully each morning. I can say there were no significant periods of apneas and hypopneas at any time and overall I was very happy to maintain my AHI below 2.0 which is as good as on those nights when there is no congestion. So if the doctor did indeed, as you claim, say "A full face mask is not an effective treatment for sleep apnea", there is at least one case where it is effective (and I believe many more).

The FLs my machine reports are quite low, however I do not trust its sensitivity to record all of these and could not claim that I know there is no UARs left untreated in my case.

But then the more important question, on which you did not report, is what does the doctor propose as an alternative? Using a nasal interface and suffering even less effective therapy while mouthbreathing/leaking?

Those of us who do use FFMs are certainly happy to have them when congestion or other conditions causes us to go through some mouthbreathing/leaking.

tee hee hee!

Less someone think otherwise of you, let me say you are surely not expressing glee at the idea (mistaken idea) that the population of full face mask users is receiving ineffective therapy!

And I know someone of your character will not do a big disservice to newbies who mouthbreathe/leak by going on a campaign in the forum of discouraging them about the use of a FFM.

Sorry you can't get your FFM to work and good luck with keeping your mouth shut while using your nasal interface.

[socknitster]

Rooster,

Before your feathers get all afluff, I'd like to say that you should take a listen. Its worth the time. I listened to the tele seminar last night. This Dr. Gold is focused a great deal on UARS. UARS is a syndrome of subtleties. I would say that when he was referring to the mask issue, he was specifically referring to UARS patients. If your optimum pressure is in the range of 5-9 cm water pressure and you are using a ff mask and opening your mouth, well, that is clearly going to make a big difference in your therapy. A good diagnosis and prescription for UARS is ELUSIVE for those of us unlucky enough to fall into this category. He is trying to help us eliminate the things that could stop us from achieving optimal treatment.

Now, what to do if you can't keep your mouth closed for a nasal-only interface? This good doctor will send you to an ENT for nasal surgery to open that airway up. And over and over during the broadcast the point was hammered home that SMALL MOUTHS MAKE FOR SMALL AIRWAYS. A horn you too like to toot, Roost!

The roof of your mouth is the floor of your nose, as I've heard it said. if your mouth is too narrow, cramped and small, so too will be the nasal airway. You can resect those turbinates all you want but it won't make those passageways any wider. The best possible solution? A time machine to your teen years when you can get rapid palatial expansion. If that isn't available, then there are the mandibular advancement devices (I'm not a big fan of those, but they clearly work for some--my mouth was too small to accommodate the one I paid for and cannot use), braces and other orthodontic techniques and oral surgery.

Neither physician speaking was an orthodontist so they didn't go into great detail, but I for one can speak to this issue since I got braces almost 6 months ago to try to permanently increase my oral volume. I went to a non-extraction orthodontist who uses self-ligating braces that work to expand the arches (traditional orthodontia extracts teeth and make the mouth smaller by bringing all the teeth in.)

I personally have been diagnosed with chronic fatigue syndrome and had heard that UARS and cfs could be linked but it was never explained so eloquently as Dr. Gold explained it. He addresses the topic of chronic stress and how this affects the body. He was very thorough and eloquent. I found it exciting and moving.

For the person who asked about the relationship between UARS and OSA and if they can coexist. The answer is both yes and no. These things are really a continuum or spectrum. UARS and snoring are at the low end of the airflow disturbance end of the spectrum and severe OSA is at the other end. You might experience both in your lifetime, like I have, or you might get one and not the other. But the person with UARS who gets the sequelae of one of the somatic syndromes is acutely sensitive. Their central nervous system is sensitized to these minute airflow obstructions that probably wouldn't bother most people. Listen to the broadcast. As I said, it is well worth the time. I took copious notes and will probably refer to them often. I'm grateful to the host, Dr. Steven Park for doing these programs. I'm a new and grateful listener.