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Allergies, Reflux and Sleep (A Better Night’s Sleep Podcast)


[Dr. Kinn] [music] This is A Better Night’s
Sleep. A podcast about sleep, sleep disorders and
evidence based treatment from military health sleep experts. I’m Dr. Julie Kinn with The Defense Health
Agency, and today I’m pleased to welcome back COL Brian Robertson, from Walter Reed Army
Medical Center. Welcome back, COL Robertson. [COL Robertson] I’m glad to be here. [Dr. Kinn] COL Robertson, we’ve asked you
back this time to ask about another area of your expertise, which is allergies. And from what I understand, allergies and
sleep disorders go hand in hand. [COL Robertson] Well, a little bit on my background. So I was an allergist and I practiced allergy
for years, and I actually got interested in sleep because of my allergic patients. It turns out that if you have allergic problems,
then you often have trouble sleeping. [Dr. Kinn] Well, could you give us a little
bit of a background into the type of allergies that we’re talking about here? [COL Robertson] So the first one, and the
one that we know the most about, is allergic rhinitis. Allergic rhinitis is a problem of nasal inflammation,
and that nasal inflammation manifests as several different symptoms. One, is nasal congestion, which is the most
important thing for people when it comes to sleep. You can have excess mucus production. Itching in your nose is another one. And then this thing called post nasal drip,
which is a lot of mucus going down the back of your throat, and it can lead to coughing. [Dr. Kinn] And that’s what gives you a sore
throat when you wake up, right? [COL Robertson] Right. So part of it. The other part is that when you have a lot
of nasal congestion you can’t breathe through your nose very well, and instead of not breathing
at all, we all choose to open our [laughter] mouth. We choose to open our mouth and breathe through
our mouth. And when you do that then it dries your mouth
out. So if you’ve ever had a cold, one of the things
that makes you miserable about it is that you’re almost forced to breathe through your
mouth all the time. It doesn’t feel comfortable. It can cause dryness in your mouth. And so when you wake up, that’s that super
dry throat that you get as part of having a cold. Well, the same thing can happen on a nightly
basis when you have allergies. [Dr. Kinn] It just strikes me that most people,
who experience this, would first chalk it up to, “Oh, I’ve got a bad cold. I’ll give it a few weeks. It’ll go away.” [COL Robertson] Right. So it’s the unremitting nature of it. Or, also, the other thing people notice is
that it happens seasonally. So if they’re allergic to grass, for instance,
they’ll have a lot of symptoms during the summer months, in particular. Or if they’re allergic to ragweed, it might
be something they experience a lot in the fall. There are indoor allergens, like dust mites,
and dogs and cat allergen. Those things will happen– if you have a dog
or a cat, they can happen year round. [Dr. Kinn] So how do you test for it to know
whether or not it’s an allergy, or a series of colds? [COL Robertson] So the test that we use the
most is a skin prick test. What we do is we take a small amount of an
extract from that particular allergen. So if it’s a pollen, for instance, what we’ll
do is extract the proteins that cause allergic diseases, or allergic symptoms, and we extract
it into this liquid. With this testing, the skin is pricked and
we introduce just a little tiny bit of that allergen underneath the skin. [Dr. Kinn] And then you look at the skin to
see where it’s inflamed? [COL Robertson] Right, right. So what will happen then is if you are allergic
to that thing, then you’ll have a little bit of a bump there. It will get very itchy and red. And we call it the wheal-and-flare reaction. And that is an indication that someone’s
having an allergic reaction to that particular extract from that pollen, or dog dander, or
cat dander, or whatever it’s from. [Dr. Kinn] Is it possible to experience this
for the first time as an adult? Or are these the kinds of symptoms you have
your whole life long? [COL Robertson] So I always think of allergies
as a childhood disease. It is pretty rare– it can happen, but it’s
pretty rare for adults to have sort of a sudden onset of allergic rhinitis. It usually is started in childhood. It may not be recognized, or tested, or diagnosed
in childhood, but most of the time when I see adults where I diagnosis them with new
allergic rhinitis, if I ask them enough questions I find out, yeah they have had a long history
of nasal congestion. [Dr. Kinn] Okay. So is this something that our listeners can
go to their general practitioner’s about? Or do they need to see an allergist, or another
specialist? [COL Robertson] Yeah, so generally allergists
are the ones that do this testing. So general practitioners often refer patients. That’s how we get our patients in the allergy
clinic, is a general practitioner’s will refer them, if they sound like they have allergic
diseases. [Dr. Kinn] Thanks for helping us understand
more about the kind of allergies we’re talking about here. It’s not so much food allergies. It’s really things that are going to affect
respiration and mucus production. How does that affect sleep? [COL Robertson] This is the nasal congestion
that’s the real problem. There’s a survey done a few years ago of thousands
and thousands of children– or their parent’s were answering these questions, nasal congestion
was the one symptom that caused the most disturbance in sleep during that survey. And I think in clinical practice we see that,
too. That’s the thing that people complain about. When you have a lot of nasal congestion, the
area– you think of your nose as a tube, and when you have inflammation that tube just
gets narrower and narrower. It’s harder to breathe through your nose,
and that can lead to mouth breathing, if it’s severe enough. But before that happens it actually leads
to upper airway resistance syndrome it’s called, where you have resistance to airflow through
your nose, and it makes it a little more difficult to breathe. And that leads to a thing called sleep apnea. [Dr. Kinn] Okay. Our listeners will remember sleep apnea from
a few episodes ago where we talked a little bit about it. But it’s always worth hearing more about it
and repetition is good for remembering. So could you refresh our memories about how
exactly sleep apnea affects us? [COL Robertson] Yeah, so I always explain
sleep apnea to patients as, it’s a problem of space. So you just don’t have enough space in your
upper airway to breathe. So the part of your airway from the back of
your nose down to your vocal cords, is a tube of muscle. It’s held open by muscle tone. And all those muscles relax when you fall
asleep. And that’s when we start seeing snoring. People that snore at night obviously don’t
snore while they’re awake, but when they fall asleep they do snore. And it’s because that airway is narrowing
a little bit. If it narrows enough, you get to a point where
you actually can’t move enough air in and out, comfortably, and it’s just not enough. It feels like you’re getting choked. Or if your airway closes enough then you won’t
breathe at all, and that’s called apnea. And in fact, you won’t breathe at all until
you wake up, which is exactly what happens is people wake up, typically after just a
few seconds of this. They feel like they’re getting choked and
they wake up. [COL Robertson] So sleep apnea disrupts sleep. It also has effects on your heart, in particular,
and also your blood vessels. There’s several effects that we see with sleep
apnea, but we’ll talk about just interrupting sleep for now. When you have nasal congestion– if you can
imagine having a– you’re drinking a milkshake, a strawberry milkshake [laughter], and you’re
drinking your milkshake– bare with me. So you have this milkshake and you’re drinking
it with a straw, and let’s say the straw’s made of steel, okay? So when you suck on it and then a strawberry
gets stuck in the end, and you’re trying to suck your milkshake up there and it just doesn’t
work, because you got the strawberry stuck in there. So actually when you’re sucking on it you
create a little bit of a vacuum inside that steel drinking straw that you have, and it
would collapse except that your tube is made of steel. [COL Robertson] Now, imagine that you have
a paper straw, and you’re doing the same thing. You’re drinking with your paper straw and
a strawberry gets stuck in the end of that tube, and you start sucking on it. What’s going to happen? It’ll collapse. And that’s what happens with your upper airway,
okay? So when your nose is– when you have nasal
congestion, you have increased nasal resistance. It makes it harder for your lungs to breathe
in that air. Because it’s harder to breathe in, your airway
tends to collapse. And that’s the mechanism– we call it the
Starling resistor model, after a doctor kind of described this model, but that’s the model
we use to describe how nasal congestion leads to worsened sleep apnea. [Dr. Kinn] And so when that plastic straw
is bending, and collapsing, it makes you wake up and it probably– depriving you of a little
bit of oxygen, which isn’t good for other parts of your body, but waking up repeatedly
throughout the night, it will leave you fatigued, even if you’re not aware that you’re waking. [COL Robertson] Exactly. So people are not aware. We call them these micro-arousals, is sometimes
the word we use for it. They only last a few seconds, and you’re not
really awake long enough to form a memory of that arousal. And so it’s just for a few seconds. It’s just enough to open up airway, you fall
right back to sleep, but it disrupts your sleep. It also has affects– I said earlier that
it has effects on your heart. So it raises your blood pressure. Your heart rate goes up because you feel like
you’re getting choked, and you want to fight off that thing that’s choking you. And that’s why people feel tired when they
wake up. They feel sweaty sometimes and then their
blood pressure is up, if we check it, their blood pressure is higher than it otherwise
would be. [Dr. Kinn] So for listeners with allergies
and sleep apnea, is it a combination of treatment? [COL Robertson] I prescribe medication for
chronic nasal congestion more than any other medication I prescribe in the sleep clinic. That is number one. Our treatment of choice is a nasal steroid. You can buy these over the counter now. Nasal steroids will decrease the nasal inflammation
that leads to that blockage that keeps you from breathing easily through your nose. So that is the medication we’d use. [Dr. Kinn] And then you probably see symptoms
of sleep apnea abate as well? [COL Robertson] Right. So I always tell our patients too, when we
start positive airway pressure machines, CPAP machines, right? You have to wear this mask, you have to breathe
in through your nose. Some of the masks fit over your mouth, too. But even if they fit over your mouth you really
shouldn’t breathe through your mouth with them. You really need to be breathing through your
nose. So our treatments depend on you being able
to breathe through your nose fairly easily. And the number one reason we see in our clinic
for people failing to use the CPAP, the medical reason, is nasal congestion. [Dr. Kinn] Right. If you can’t breathe through your nose–
[COL Robertson] Right. And it leads to a lot of feeling. So one thing that patient’s describe to me
is air hunger. Like they feel like they’re not getting enough
air. Well the machine’s actually supplying about
five or six times the amount of air that they breathe every minute. It’s supplying plenty of air. The problem is that they can’t breathe it
in because they have this nasal congestion. So absolutely one of the top reasons why we
have problems using CPAP. [Dr. Kinn] Okay. So then what’s your first stop? If you’re a listener, and you’re not sure
if you’ve got a cold, or an allergy– if we’re thinking a decision tree here. It sounds like your first stop is probably
your general practitioner to get a referral to your allergist to see, “Hey, do I have
allergies?” [COL Robertson] Yes. [Dr. Kinn] And then after working on allergies,
looking into sleep and sleep apnea? [COL Robertson] We really should address the
allergic problems first. Now, there’s a lot of people that don’t have
allergic diseases and they do have snoring. Their spouses have observed them stopping
their breathing during their sleep. Things like that, they probably should go
right to the sleep doctor. But if they’re having itchy, watery eyes,
runny nose, nasal congestion, that’s chronic and sort of unremitting, or is happening really
intensely during certain seasons, then an allergist should be the first stop. [Dr. Kinn] That makes sense. I would guess, also, if the listener is obese,
or has a very large neck size, or one of the other predictors of sleep apnea, then maybe
the sleep doc is the first stop. [COL Robertson] I agree, absolutely. [Dr. Kinn] So what other information, if any,
is there that we should offer to our listeners? What else would you like them to know about
allergies, and how their allergies might affect sleep? [COL Robertson] We didn’t really talk about
it earlier, but I wanted to mention asthma. So controlling asthma and controlling sleep
apnea tend to– you got to be able to control both of them, in order to control either one. We call it bi-directional relationships. So asthma tends to make sleep apnea worse,
and sleep apnea tends to make asthma worse. If we try to fix one, we tend to do better
controlling the other problem, too. And asthma is an allergic disease in many,
many people. If you have asthma and you have sleep apnea
it’s important that we treat both. [Dr. Kinn] So any other allergic diseases
we should know about that do affect sleep? [COL Robertson] Yes. So it’s not just your airway, it’s also how
your body feels, and one of the things that people with allergic diseases do sometimes
is they itch. So eczema, in particular, is a very important
problem for an allergist, and our patients itch. And sometimes they itch out of proportion
to how bad the rash looks. [Dr. Kinn] Really? [COL Robertson] Yeah, so it’s not really a
good gauge to just look at a rash and say, “That’s minor,” but the patient may be really
itching a whole lot. And itching keeps people up. So as an allergist you want to make sure you
control that, and we have a variety of ways to do that. I won’t go into detail on it right now, but
there are things that an allergist can do to help stop itching. [Dr. Kinn] Some of the take-home’s I’m getting
here are that if you’re experiencing symptoms of sleep apnea, or just other breathing problems
at night, there’s a lot of different factors that could be at play. It could be allergies. It could be seasonal allergies, or just allergies
to an environment, like dust mites, dogs, cats. Also, that eczema and asthma, all these things
are related, and they can all add up to make you have a bad night’s sleep. [COL Robertson] They can. They definitely can. And you have to remember, these problems are
related to each other. So asthma’s related to having allergic rhinitis,
having inflammation in your nose. These things are related to each other. They’re both related to sleep apnea. All these things kind of play off each other,
and so you can’t just try to fix just the allergic rhinitis. You have to fix the asthma, too. And you should really fix sleep apnea, if
you think it might be there. And that’s kind of our approach generally
with people when we see them in the allergy clinic. [Dr. Kinn] I really appreciate you adding
all this up for us. I’m hoping it encourages our listeners to
go see their GP, their general practitioner, or their allergist about it, because it’s
more than just experiencing itching, or watery eyes. It’s going to affect sleep, which effects
your resilience, and your readiness to perform on the job. [COL Robertson] Absolutely. [Dr. Kinn] Thank you so much, Colonel Robertson. It’s always a pleasure to speak with you. [music]
[COL Robertson] You’re welcome. I appreciate it. It was a lot of fun. [Dr. Kinn] A Better Night’s Sleep podcast
is produced by the Defense Health Agency. Please get in touch with us on Facebook and
Twitter @MilitaryHealth. Thank you so much for subscribing and rating
us on iTunes, or wherever you get podcasts. Be sure to check out our other resources and
free shows. We hope you have a better night’s sleep.

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