Sleep Health with Dr Alison Bentley | Sleep Apnea

Hi, this is Dr. Addison Bentley on the Sleep Health Podcast in the Rastonic Power of Sleep Channel. Welcome to this podcast. What we're going to be covering today is Sleep Apnea, the basics of Sleep Apnea. What is it? I mean, is it that you stop breathing at night? Am I going to die in the middle of the night because I stop breathing? How does it actually create symptoms and what is this thing that we call apnea? So it's interesting. If you are somebody who sleeps with someone who has sleep apnea, what you're going to hear is lots of snoring, lots of noise, and then you're going to hear that snoring stop. And there's going to be a gap, and then the snoring is suddenly going to start again. So I'll demonstrate because I have demonstrated this often. So snoring. You're going to hear this noise that's when you breathe in that snoring. You're going to hear that noise and so it's going to go. And then there's going to be at the end of it. That's an apnea. So that quiet that you hear during the snoring, that's an apnea. And it's really all about moving air. It is not about that you stop breathing. So it sounds like that. And that's certainly because you're lying in the dark as the partner hearing this, hearing the noise, hearing the silence and going, it sounds like you stop breathing. But it is not that you stop breathing. So that implies stopping breathing implies that the brain has kind of just faltered on its mission. And its mission really, when you're asleep, is to keep your life till the next morning. And that means that the heart is going to keep going, that you're going to keep breathing, that's its mission. And it would imply that it's faltered on that. So in the vast majority of patients, 99.9% of patients, that is not what has happened. That if the brain stopped breathing for a short period, that would be called a central apnea and is incredibly rare that you would only have central apneas. So we're not going to talk about them because they're incredibly rare. Honestly, they don't present the same as obstructive sleep apnea. So obstructive sleep apnea is what we're talking about today as opposed to central. You can get centrals with obstruction, and we're going to talk about that a little bit later, but really we're talking about obstructive sleep apnea. Snoring, this gap that happens in snoring and this awakening that happens at the end of that. So if it's not about how common is snoring and sleep apnea, snoring, very common. We know most people of the age of 50 are actually going to snore in some circumstances, even if that's just lying on their back. But there's going to be some snoring. And that's to do with the changes that are happening in the throat. So think about the fact that if you've got wrinkles on the outside, you've got wrinkles on the inside as well. So you kind of have a floppy throat. Your nose may be a little bit blocked and so you may have some snoring. If you lie on your back because all the muscles relax around the jaw, the jaw on the tongue might move back a bit and that is why you're snoring. So snoring very common, 40% of patients. The data we have for South Africa when it comes to the prevalence or how many people have sleep apnea now, which does come from snoring. Provence of people who have sleep apnea if we look at moderate to severe apnea, which is a point at which we say you need treatment is about 23%. And that is whether you're a man, whether you're a woman between the ages of 39 and 69 is looking at about 23%. Snoring at least 40% of patients. So it's very common. It's in the medical scheme of diseases that is a very, very common disorder. Does everybody know about it? No. Do doctors know about it? Very often not. They do now. They think they know a lot more about it now than they used to. But the bottom line is that doctors are very, rarely trained in their undergraduates. So when they're training to be a doctor or in their specialisation, they're very, rarely trained on sleep apnea. It's kind of one of those side things. It doesn't belong to any specialties. So it's not an ENT thing or a psychiatry thing or a physician thing. It's all of them. And that's why it's not held by somebody who's kind of fighting and championing the cause in medical schools. So doctors often don't know about it. And so we do depend on patients to come to us and say, I think I have sleep apnea. So I'm hoping that if you do have sleep apnea or you suspect that your partner has sleep apnea, that this podcast will help you understand what it is and why it's important that something gets done about it. So what are the symptoms of sleep apnea? Obviously snoring. Snoring is the big symptom. So very rarely do people have sleep apnea without snoring. And so if you have somebody who's snoring, what snoring indicates? It's not, it's noise pollution. I mean, let's be frank. It is noisy and we don't want it. But it's not just about noise pollution, what it means is that the airway, which is going from the nose, down into the lungs, that that airway has an obstruction in it. So think about if you switch on a tap. So when you switch on a tap and you get this nice smooth column of water coming out of the tap, if you put your finger in even slightly at the top of that, underneath that where your finger is, the column of water is not smooth anymore. It is turbulent. The water is changing. It's moving in all kinds of different directions. And that is what causes snoring. So normally you would have the smooth column of air going down through the nose into the lungs. If there's any obstruction in that pathway, that is going to cause turbulent air flow. Once the air flow is turbulent, it's going to attack the uvula. Now the uvula, if you look in the mouth, the uvula is that little tongue at the back of the throat. It's the end of the soft palate. And it's this little tongue that sits there. And it's in the way. If you have turbulent air flow, that is what's in the way. And the turbulent air is going to cause that little uvula to vibrate. And so you're going to get this noise. So that, I hope you can hear that vibration at the back of the throat. That is the uvula vibrating. And that is what causes snoring. So some obstruction in that whole pathway. And the important thing to recognize about snoring, therefore it's a partial obstruction. So that's partly obstructing the earway and you're notified because you can hear the noise. Now the difference between snoring and apnea is that everything that produces snoring just got worse and produces apnea. So snoring is a partial obstruction. Apnea is a total obstruction of the same thing. So it's really exactly the same thing. It just gets worse. And that's why we kind of go with it very unlikely that you have apnea if you don't snore because snoring is the entry drug for apnea. So I'm going to tell you about what could cause snoring and understand that everything that can cause snoring can cause apnea if it gets worse. Or if you just get older. So very often people snore for a while and then they hit 50 and they get over 50 and then they have apnea. So 50 years old seems to be a line at which people cross over from snoring to getting apnea. All right, so let's look at the kind of possible causes of obstruction. Obviously the earway itself. So anything that is, because anything that blocks or partially blocks the earway from the outside, so where the nose is, right the way through down to where the atom's apple is. Anything in that area that obstructs is going to cause snoring. So I'm going to list a couple of them. It's not a comprehensive, but a couple of things. So for example, a deviated septum. So that means your septum is skew. Generally means you got bashed on the nose at some point. So I mean, if you do boxing and rugby, well then you've always been bashed on the nose. But even if you slam into a door, even if you fall off the bed, you can bash your nose enough so that you wake up with bruises around your nose. But the inside of the nose, because it is cartilage, buckles. And so it bends. And then it fixes, it sits in that bent kind of phase. Now you have the inside of the nose on that is more towards one side than the other side. And so you basically have more air coming down one side of the nose than the other. So 30% is going down one side, 70% is going down the other side. Those two channels of your nose meet at the end of the hard palate, which is at the, and you can find the hard palate, but taking your tongue from the top inside of your top teeth, running it backwards and you feel hard bone. And then suddenly you feel a soft spot. That is the end of the hard palate. And the beginning of the soft palate, the end of the soft palate is the uvele. So gets to that point. Now you have a little bit of a tornado, because you've got 70% coming down one side and 30% coming down the other. And the air swirls around hits the uvele and you start snoring. But anything else can also cause that obstruction. So if you have the joeberg nose and every winter, it kind of gets, it's too, the air is too dry and we're too high and it's too cold and it's too polluted and your nose reacts to that. Understand if the lining of the nose reacts to anything, it can only swell inwards because it's stuck in bone. So swells inwards and it causes a narrowing of the airway. So congested nose, which will also happen in hay fever and colds and flu and anything like that is also going to cause congestion of your nose. Things like polyps in your nose, tonsils and adenoids. Now in my generation, you kind of had three episodes of tonsilitis and your parents instructed the EMT to take your tonsils and adenoids out because they were done with that. Right? And then stopped happening because we realized that the tonsils and adenoids actually have an important function to do. They are the lymph nodes of your nose and your mouth and they have a good function and so they don't get taken out now. And the only reason really to take out tonsils and adenoids is obstruction. How do we know that there's obstruction because they're snoring? But what happens is now we don't recognize that if children snore, that that's not normal and we should be looking at that because children can have apnea as well. So children who snore is never normal. It's never normal for a child to snore and that should be investigated. How do you investigate that? As a parent, you go and sit in their room and listen to them sleeping. You can hear the apneas if they have them and then go to somebody and say, "My child has sleep apnea." Sleep apnea is likely to make them focus less at school, have attention deficits, all of that kind of stuff and so it's really important to find kids who snore and manage that. Adults, we usually don't get the same complications. So tonsils and adenoids. So you're likely, if you're a young adults or in your 30s or 40s, you're likely to still have your tonsils and adenoids and they may be causing an obstruction. Right. So the nose can be a whole issue. The nose and the throat can be a whole issue as far as obstruction is concerned. Then things like putting on weight. In men, particularly when men put on weight, they tend to put on weight around, I would always describe it as putting on weight between the jaw and the groin. So kind of tummy up to chest but up to neck. Woman tend to put on weight between the shoulders and the knees and so it's far away from the throat. But if you put on weight as a man, you know that your colors don't fit anymore or that your neck is bigger and understand if your neck is expanding, then it's also going into the spaces that are currently there. So when you put on weight, you can put weight on, I mean it's, I know it sounds gross, but you can put weight on in your tongues so your tongue gets bigger. Okay. And so it's going to close off that space at the back. But the whole throat can narrow down so that it's much narrower and therefore it's a smaller space. So putting on weight can do it. Lying on your back can do it. If you lying on your side, then generally your jaw is forward. But when you lie on your back, all the muscles that hold the jaw in place are relaxed during sleep. And so your jaw can kind of hinge backwards if that makes sense. So normally it's up near your top teeth and it just hinges backwards and it goes into that airway and closes off the airway. And that's the major reason why people snore on their back more than they do on their side. So the jaw can be a problem. Then reflex, heartburn can be a problem. When we're upright during the day, the only, often the only thing that keeps acid in our stomach is gravity. It just keeps it down there. But when we lie on our backs, that acid can creep up because there's no gravity, can creep up. If it gets into the area of the throat, it causes a swelling in the throat area. And that can cause snoring as well. So reflex can be a major cause of snoring and therefore of apnea. Then there is muscle tone, just the muscle tone that you have in the throat. And that's the major thing that changes when you get into your 50s or 60s. Muscle tone becomes less. And so it's more likely to flap in the breeze just because there's less this less tone there. Okay. And then there's something extra that's about your arousal threshold and the way that your brain operates with oxygen and carbon dioxide, which can influence whether you have apneas or not. But really, we're looking for can, is there any obstruction in that area of the throat that would be causing the snoring? So that's the major major reason, something that is sticking into the airflow that is creating this noise. So that is snoring. And as I say, many people have snoring. Generally, if you have snoring, it's about like which of those kind of things is the problem and what do I need to do about it? So if snoring is a big issue, then it would be going to see the ENT surgeon to have for him to have a look down in that area of the throat. What is obstructing there? If you are overweight, lose weight. I know it sounds easy to say that, but I'm just saying it is really important when it comes to snoring. Reflex, make sure that your dinner is at least three hours before you go to bed. Check if you have reflex. So these are things that you can look at quite, quite simply. If you're concerned that it might be the jaw and it's mainly when you lie on your back, well, that's where a whole lot of things can do about that. So you can hold your jaw forward by using a chin strap. You can do mouth taping. You can put a little ball on the side of your back, on the back of between your shoulder blades, so that you can't lie on your back. All of those kind of things can be used to correct the snoring. So that is snoring. Many, many reasons why you might have obstruction. But they're still breathing. And so some of my patients will describe it as deforestation that they do at night. So that sounds like they're soaring down trees. But the breathing is happening. If you're snoring, then there's an M, then air is moving and you're kind of safe. When it tips over into apnea, that's when it moves from snoring noise pollution into apnea medical condition. And that's why what we think snoring is important because it leads to apnea. And that's where doctors get involved is in the apnea kind of process. So what does apnea look like? What actually is an apnea? So what an apnea is as I've described is that the throat collapses in on itself. Now if you're old enough to remember the old paper drinking straws, not the cardboard stuff ones they have right now, but the old paper drinking straws, you'll remember if you left it in your cool drink and you came back and you tried to suck through that straw again, it would collapse in on itself. That is what's happening with an apnea. It is a very passive process and essentially what you're doing you're sucking too hard for that throat to stay open and it simply collapses. If you're an engineer or you've done physics and you're listening to this podcast, then it is the Venturi effect that's happening in the back of the throat. Now those of you who may be more cultured and drink wine and aerate wine, we use the Venturi effect to aerate wine. So if you've ever poured wine through a very long tube and the air comes in with the wine, then you're using the Venturi effect. So physics is fun guys, that just is fun. So that's what's happening in the middle of the night. So the throat is collapsing. So it is not that you stop breathing, but it is that you stop moving air. So you just stop moving air and that's why the snoring stops. So why is that a problem when that happens? Well firstly for the bed pod and it's terrifying because they think you're going to die. So firstly that. But secondly, there are consequences to that collapse of the airway and the consequences are that the brain and the body cannot open that airway while you're still asleep. The other consequence that happens is that the minute you close off that airway, that the oxygen level in your body and your blood starts to drop. And so those are two consequences that now move it into the medical kind of thing. So first consequence is the brain cannot and body cannot restart breathing and while you're still asleep. So what it does, brain wakes you up. It might be 15 seconds later, but it could be 45 seconds. So it could be 15 seconds later and that's the kind of gas that you will experience if you're the bed partner, that's what that is. Wake up and so you wake up. Most of the time you are not aware that you've woken. So please don't think that you are always aware of these wakeups, not at all. So you wake up and you go straight back to sleep again and if everything's exactly the same as it was before, you might have another one. So you could have lots of them in a row, but the consequences waking up. The second consequence is the oxygen starts dropping as soon as you wake up, the oxygen kicks right back to normal. So this is not the same as the oxygen dropping during COVID or if you have lung disease or anything like that. So if you have lung disease, the way that the oxygen drops in is the whole level of oxygen drops as a whole. So you might start of as 92% and you might drop to 87 percent and it stays at 87%. That is not what we're talking about here. Apnea has a very specific kind of oxygen drop, that oxygen drops and 15 seconds later it's back to normal and then drops again and 15 seconds later back to normal. So if you look at it over the night, it looks like a comb effect that's happened. Instead of a total drop of everything, it's just a sudden drop and a sudden return to normal. So it's different, but it still has consequences. The oxygen drop has consequences and the wake up has consequences. And those two things drive the symptoms about how do you know you have sleep apnea. So how do you know you have sleep apnea? It's tricky if you sleep alone. I'll be quite honest. It's really tricky because you don't know what's happening at night. You go to sleep, you might wake up the next morning and you go, I don't know what happened, but I slept, but I feel awful. I'm exhausted. I don't feel like I've slept at all. That is the the cardinal symptom of sleep apnea is that your quality of sleep is bad. And so you wake up feeling exhausted in the morning and then generally feel tired the whole day. Often feel very sleepy during the day and and and there are consequences to that. So often people have to sit in meetings, they have to read or they're watching TV and they're falling asleep every time they're reading or watching TV. So the main symptoms are most common symptoms are waking up feeling exhausted in the morning and then feeling tired during the day. About 30% of men who have sleep apnea and of higher percentage of women who have sleep apnea are going to present within some near-instead. So with that wake up when that adrenaline surge happens, they're going to wake with that adrenaline surge. So they're going to, I mean, it sounds stupid, but they wake and they kind of go, I am awake awake, like super awake. It is not the same as just gradual wake up and gradual being able to go back to sleep. I am very awake and then it's difficult to go back to sleep again. So they can present within some near. Sleep apnea, and I don't say never, but pretty much never, stops you falling asleep. So that's not an apnea thing. The apnea thing is you do fall asleep and then you get woken up multiple times at night. So the symptoms are poor sleep, either poor quality sleep or insomnia and then tiredness during the day. So those are the main symptoms. But unfortunately, they're also the symptoms of other things. So often what happens is people who have sleep apnea and wake up tired in the morning go, I'm doing too much, it's work stress, I should be doing more exercise, I should be doing this and put it down to a lifestyle kind of problem as opposed to sleep apnea, which is what it is. If you have a bed partner, it's very likely that they have told you that you have apnea. So they've told you out the snoring, they've told you that you appear to stop breathing and so you get more information and you can work from that. So how do you know? What can you do to kind of go, do I have sleep apnea or not? So there are a couple of screening questionnaires that we use for sleep apnea. The easiest one is the stop bang. It's eight questions and you answer yes or no. And if you score four or five out of eight, 80% chance you've got sleep apnea. So here's the stop bang. So all of, it means we love mnemonics because that's the only way we can remember stuff. So the S stands for snoring and the car says, do you snore loudly enough that you can be heard of outside the room to snoring? Do you have bad snoring? The T is for tiredness during the day and that's, as I mentioned, for T sleepiness that you have during the day. The O stands for observed apneas has somebody told you that you stop breathing at night. It can also stand for have you ever woken up, gasping for breath, choking, feeling like you're not breathing ever. And this is like once or twice ever, then you've got it, right? Because there's nothing else that does that. The P stands for pressure and that's for high blood pressure. Do you have high blood pressure? So the stop snoring, tiredness, observed apnea, high pressure. Those that's the stop. The bang part of it is the BMI is your BMI over 30. So you need to calculate that to see if you're waiting to push your BMI over 30. The A is age over 50. The N is next circumference and for men, for men that's 43 and for women that's 41. If you don't know, get a tape measure, put around your neck. What does it measure? Is it over 43? Take yes. And the G is gender for male. So when we come to women, we do the calculation out of seven instead of out of eight. And so bang, we're going to go through them again, bang BMI, age over 50, next circumference over 43 and if you're male. So if you kind of look at it and you look at men who are over the age of 50 have put on some weight, they've already got three out of five. All they need to do is snoring and have high blood pressure, they probably got sleep apnea. So it's very common because of that because those are the the kind of the symptoms or the signs that we would look at to go, you're likely to have apnea. And I've spoken about the fact that the prevalence or the number of people who have apnea is about 23% of the adult population. But those numbers go a lot higher if you then have a medical condition because sleep apnea is much, if you do have sleep apnea, you're much more likely to get all of the big disorders. Again, it's about servicing the car. If you have sleep apnea and you're not sleeping well, then you are underservicing your car. And if you underservice the car, all of those diseases are going to happen earlier in life. And with sleep apnea, that bringing those diseases earlier is much hard. It happens much earlier and is much more severe compared to insomnia. So you're much more likely to have these things. So if you look at those patients, so if you, as a patient, have any of these diseases, you're much more likely to have sleep apnea. So the big ones are hypertension and atrial fibrillation or abnormal heartbeats. So if you have atrial fibrillation, the chances of you having sleep apnea is 60%. I mean, it's much, much higher than that 23%. If you have hypertension, particularly hypertension, that's difficult to manage. So you're on multiple medications. So two or three medications to manage the pressure is still not great. 80% chance that you've got apnea that is driving that hypertension because it's a direct effect. If you have obstructive sleep apnea, you're likely to have high blood pressure because all of those wakeups at night are pushing up your blood pressure. So you're likely to have high blood pressure. So hypertension, atrial fibrillation, if you're overweight, you're more likely to have apnea. If you have diabetes, you're more likely to have apnea and so on and so on. You can literally pick any disorder you like. You're more likely to have sleep apnea. And so all of those kind of diseases, if you have many more of them, consider whether you might have sleep apnea, particularly if you're feeling tired. Now, let's look at this tiredness because that's also a symptom, right? So fatigue is listed at a symptom in pretty much every single medical disorder. So it doesn't discriminate often. But if you're waking up fatigued and you go, there's no reason why I should be this tired, okay? Don't buy this thing that, oh, I'm 50 and so I can be tired. No, you're not designed to be tired at 50. So really interrogate, am I more tired than I used to be five years ago? It's a subtle thing. It comes on gradually and it kind of normalizes. And what I mean by that is it becomes normal. So this is how tired I am. And this is just how tired I am. And you kind of go that that's normal. And it often takes something to push you over the edge to go, no, this is way too tired. I am now falling asleep in meetings at work. I'm now I'm having trouble when I drive home at five o'clock because I am the sleepy. That is not normal and you need to be alert to those kind of situations where the sleepiness might be making it dangerous for you in that situation. So there's tiredness fatigue and then there's sleepiness. Now, sleepiness during the day is not normal. If you have slept seven to eight hours at night, you should not be sleepy during the day. You shouldn't be falling asleep. It is not normal to fall asleep every time you watch TV. It is not normal. It is not normal for you to never see the credits of any movie because you fall asleep halfway through. That is not normal. If you're doing an 11 o'clock at night, that's a different situation. But if you're watching a movie at seven o'clock in the evening and you don't get past the first five minutes before falling asleep, that is not normal. Don't buy that it's normal. So what you can do is you can look up something called if you want to know if your sleepiness is normal or not, look up something on the internet. It's available on the internet called the epworth sleepiness scale. The epworth sleepiness scale, ESS for short. And it asks you a very simple question, how likely are you to doze off or fall asleep in the following situations? It gives you eight situations, slight no chance, slight moderate or high chance of falling asleep in those situations. And these are the situations, sitting reading, watching television, lying down to rest in the afternoon, passenger in a car for an hour without a break, driving a car, sitting around after lunch. Eight situations like that that it asks you how likely are you to fall asleep. If you score under 10 out of 24, the maximum score is 24, if you score under 10, that's okay. But if you score 11, 12, 13 or anything over 10, then you are too sleepy. And there's a reason why you're too sleepy and you need to find out what that is because even if it's not sleep apnea, all the sleep disorders can be treated. Okay, so you're sitting in a zone where you have a sleep disorder, but you may not know that you have and it can be treated and you could wake up in the morning feeling better and then not be falling asleep. I have patients who tell me that they don't fall asleep reading and I say, "Why is that?" And they say, "Because I never read." And I go, "Why don't you read?" And they go, "Because I fall asleep." I go, "Do you understand that that's a problem?" Right? You shouldn't be falling asleep when you're reading that you can't read because you fall asleep. That's abnormal. So there's the stop bang that you can do. There's the epitome sleepiness scale that you can do to indicate like, "Do I have sleep apnea? Do I need to go and see somebody?" And yes, you do. If you think you have sleep apnea, even if you go, "I'm sure it's very mild, I promise you don't know." I've done this for 40 years. I've spoken to hundreds, possibly thousand people who have sleep apnea. And I get it wrong all the time because the symptoms do not match the severity of apnea. So I will have patients come and see me and in my head, we're talking about the symptoms and in my head I'm going, "Yeah, it sounds like it's mild." And we do a sleep study and it comes back and I go, "Good grief, never thought it would be this bad." So if I can't get it right, I don't think many people can get it right. And so it's really important if you think you might have sleep apnea. Don't depend on your wife or your bed partner to tell you if it's severe or not. Please go and get it tested. It's as simple as a home test that you get for sleep apnea and then you know. Even if you know, it's not bad. You go, "Right, it's not bad." Maybe it's a snoring thing. Maybe I just go and see an ENT that at least you know. And the only way to know is to have a formal sleep test done. So please, go and get it tested, know what's wrong and then tackle it if it is a major problem. And there's multiple ways to treat sleep apnea, the gold standard if you, and let's talk a little bit about the numbers because I think that's important. Having up to five apneas per hour would be considered normal. And I know a lot of people think that's a big number and it can be. I mean, if you sleep for eight hours times five, it's 40 apneas a night, okay. But it's not a high number. Mild apnea is where you do it five to 15 times per hour. Moderate is 15 to 30 and severe is over 30 apneas per hour. That is 30 times per hour that your throat is collapsing, that your oxygen is going down and that your throat has to be opened again when you get woken up. So you can understand that if you do this 30 times per hour, then you are going to feel sleepy the next day, okay. Eight hours of sleep, 30 times per hour, it's 240 times you work up. So you are going to feel sleepy. But again, the numbers go much higher than the 30. So they don't stop at 30. Every week I'm writing reports for people in the 60s and the 70s per hour. Okay, so four to 500 times per night, they are waking up and being alerted to the fact that their airway has closed off. Now, that's really important that we treat that because there are consequences to that. We need to find those patients. We need to be able to treat them. So if you're concerned and if you think you forget that you fit into any of these categories, for goodness sake, have the study done. How do you get it done? You go to your general practitioner. Don't go to your GP and say I'm tired in the morning. Go to your GP and tell them, "Are you think you have sleep apnea?" Because then they know what to do. Tired in the morning is a hundred different things. Go and say, "I think I have sleep apnea. I've done this test. Take them the stop bang. Take them there. Put sleeping a scale. Then they don't have to do it." And they know exactly what to do with you. There's lots of people around South Africa who do home studies who will then be able to send that report to your GP and he can go right here as what we need to do. Okay, so don't ignore the snoring. Snoring can lead to sleep apnea. We've spoken about sleep apnea in adults. There is children do get sleep apnea. Please make sure that your child doesn't have sleep apnea. If it's snoring, then there's a lot that can be done. I've done a podcast on non-seapap treatment of sleep apnea, which is everything else apart from CPAP. Once you get into the 20s and the 30s or over 30 apneas per hour, CPAP is the recommended treatment. And we'd like patients to be treated and sort themselves out before they get to that level because it does just keep trucking. Every night is the same and it gradually gets worse and worse over time. So then you end up in a zone where it's 60 apneas per hour and you have no other treatment options apart from CPAP. So as mentioned, there is a podcast on non-seapap treatment. Please go and listen to that. There's another podcast on CPAP. Everything that's involved in CPAP patients are terrified. They don't want to be Darth Vader in the middle of the night. But I can tell you now that if you wake up feeling exhausted in the morning from apnea and you go on CPAP and you wake up feeling amazing, it is worth it. So please go and listen to those other podcasts. There's also podcasts on wait and sleep apnea and snoring and how wait is involved in that. So please go and get information that most important thing. If you're worried, test yourself. You've got these two questionnaires that you can use. They can they're just type them in on the on the internet and it'll give you them and then go and see somebody if you're concerned. Okay, so I hope that was useful about where sleep apnea comes from. What it actually is, what the causes are, how you can be alerted to the fact that you might have sleep apnea and that it is a serious medical condition. It's not something to just ignore. Please do something about it. I hope that was useful. Thank you again to Rastonic for sponsoring the podcast and we'll see you on the next episode of sleep health.