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Sleep Apnea
And
Chinese Medicine
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Sleep Apnea was first identified as a medical condition in 1965. The word Apnea is Greek, and
literally means "without breath." In all types of sleep apnea, the person stops breathing
repeatedly during their sleep. No matter what type of sleep apnea exists, the brain signals the
person to awaken briefly so that they may resume breathing. This sometimes happens an
astounding 20-30 times per hour and hundreds of times per night. The results are fragmented,
poor quality sleep, leaving sufferers of this condition unrefreshed in the morning and fatigued
during the day.
The individual with sleep apnea is rarely aware of having difficulty breathing or of being
awakened so many times. Sleep apnea is usually recognized as a problem by others witnessing
the individual during episodes, ie, a sleeping partner, or is suspected because of its effects on the
body. The person suffering from this syndrome may view daytime sleepiness and fatigue as
normal .
Sleep Apnea is categorized as three types:
Obstructive (most common): Obstructive sleep apnea (OSA) is caused by a blockage of the
airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep.
Individuals with decreased muscle tone, increased soft tissue around the airway (e.g., due to
obesity), and structural features that give rise to a narrowed airway are at high risk for
obstructive sleep apnea. Older people are more likely to have OSA than younger people. Men are
more typical sleep apnea sufferers, although the condition is not unusual in women or children.
Common symptoms include loud snoring, restless sleep, and sleepiness during the daytime.
Central : Central sleep apnea -- the airway is not blocked but the brain fails to signal the muscles
to breathe. The brain's respiratory control centers are imbalanced during sleep. Blood levels of
carbon dioxide, and the neurological feedback mechanism that monitors it do not react quickly
enough to maintain an even respiratory rate. The sleeper stops breathing, and then starts again.
There is no effort made to breathe during the pause in breathing: there are no chest movements
and no struggling. After the episode of apnea, breathing may be faster (hyperpnea) for a period
of time, a compensatory mechanism to blow off retained waste gases and absorb more oxygen.

Mixed and Complex: Some people with sleep apnea have a combination of both types. When
obstructive sleep apnea syndrome is severe and longstanding, episodes of central apnea
sometimes develop. Complex sleep apnea has recently been described by researchers as a novel
presentation of sleep apnea. Patients with complex sleep apnea exhibit Obstructive Sleep Apnea,
but upon application of positive airway pressure (through a device), the patient exhibits
persistent central sleep apnea.

Sleep apnea doesnt just lead to fatigue. It is a serious, potentially life-threatening condition and
may lead to hypertension, dysrhythmia, heart attack, and stroke. It is sometimes implicated in
sudden infant death syndrome (SIDS) and motor vehicle accidents. Sleep apnea may also lead to
poor memory, weight gain, headaches, impotence, and job impairment.
According to studies, over 12 million Americans suffer from sleep apnea. While anyone of any
age can develop this condition, risk factors include being male, overweight, and over 40 years of
age. Other risk factors include alcohol use, smoking, and ethnicity, with studies showing AfroAmericans, Pacific Islanders, and Mexicans being at greater risk than Anglo-Europeans.
Clinical symptoms: The presenting symptoms of sleep apnea are loud snoring, excessive
daytime sleepiness, high blood pressure or other cardiovascular disease, morning headaches,
memory problems, depression, reflux, choking sensations, nocturia (awakening from sleep at
night to pass urine), and impotence. While many people snore without having apnea, snoring is
almost a uniform finding in an individual with this syndrome. The loudness of the snoring is not
indicative of the severity of obstruction. If the upper airways are tremendously obstructed, there
may not be enough air movement to make much sound. The sign that is most suggestive of sleep
apneas occurs if snoring stops along with breath. When breathing starts again, there is typically
a deep gasp, and then the resumption of snoring.
Fifty percent of people with sleep apnea have high blood pressure. When high blood pressure is
caused by Obstructive Sleep Apnea, it is distinctive in that the readings do not drop significantly
when the individual is sleeping. Stroke is associated with obstructive sleep apnea. Sleep apnea
sufferers also have a 30% higher risk of heart attack or death than those unaffected

Diagnosis: The diagnosis of sleep apnea is not simple. Definitive diagnosis typically requires
polysomnography. This is a test which is done in a sleep laboratory or sleep clinic which
measures 16 different parameters during sleep, such as EEG, EKG, eye movements, chin
movements, chest movements, leg movements, airflow, etc. The Multiple Sleep Latency Test
(MSLT) measures the speed in which a person falls asleep during the day when ordinarily they
would be awake. For most people, it takes at least 10-20 minutes to fall asleep during the day.
Patients with sleep apnea commonly fall asleep in five minutes due to being so fatigued.
Treatment: Some typical medical treatments involve lifestyle changes, such as avoiding
alcohol , muscle relaxants or other medication that slows the respiration. Losing weight, and
quitting smoking are recommended. Many people benefit from sleeping at a 30 degree angle or
higher, as if in a recliner. This is especially true for back sleepers. Doing so helps prevent
gravity from collapsing the airway. Lateral positions (sleeping on your side) are also
recommended as a treatment for sleep apnea, largely because the airway-collapsing effect of
gravity is not as strong to collapse the airway. Some people benefit from various kinds of oral
appliances to keep the airway open during sleep. "Breathing machines" like the Continuous
Positive Airway Pressure (CPAP) may help. The most common treatment for sleep apnea is the
use of a positive airway pressure device (PAP), which 'splints' the patient's airway open during
sleep with a flow of pressurized air into the throat.
In addition, a dentist specializing in sleep disorders can prescribe Oral Appliance Therapy
(OAT). The oral appliance is a custom made mouthpiece that shifts the lower jaw forward which
opens up the airway. OAT is usually successful in patients with mild to moderate obstructive
sleep apnea. OAT is a relatively new treatment option for sleep apnea in the United States, but it
is much more common in Canada and Europe.
There are also surgical procedures to remove and tighten tissue and widen the airway.

Chinese Medicine & Sleep Apnea

We live in a complex world, where disease patterns are not uniform. The patient with Sleep
Apnea is probably not coming to your office for a diagnosis. They may not even recognize they
have this syndrome. The above information is so that you will be more aware if they have been
diagnosed with sleep apnea or if they have symptoms that make you believe that Sleep Apnea
could be a problem. As practitioners of Chinese Medicine, we would look for the root of the
problem and perhaps help them resolve some or all of their issues. In order to do that, we must
determine why there is a blockage in the airway causing snoring and choking and why there
might be a suspension of breathing. Something is inhibiting the qi mechanism is it qi
stagnation, phlegm dampness, blood stasis, external warm or cold ? Most will have some
element of phlegm is it hot or cold? There are always different theories, but according to Li
Dong-Yuans Treatise on the Spleen and Stomach -- "The spleen is the root of phlegm
engenderment, but the lungs are the place where phlegm is stored." Both the lungs and the heart
receive their qi from the spleen. It is important to keep the Spleen healthy because it is the
source for qi and blood production for the body. An important saying in Chinese medicine states,
"The Spleen hates cold and the Spleen hates dampness." Spleen vacuity occurs when the
process of transformation and transportation malfunctions, thus causing dampness to gather and
stagnate instead of transforming which further weakens T&T. Then a vicious cycle begins.
Spleen vacuity is a causative factor in all cases that have symptoms of fatigue. Treatment has
to be based on the patient's signs and symptoms. There is no one size fits all That type of
thinking is pharmaceutically based.
Published clinical trials suggest that cure rates of more than 80% and total amelioration rates of
over 90% are possible with Chinese medicinals prescribed based on pattern discrimination.

Herbal Treatments:
The following patterns have all been used in published treatments of patients with snoring and
Sleep Apnea in China. Most are classical formulas that are used to treat the pattern, however,
some are not listed in Formula texts, so I have listed the herbs so you can get an idea of intention.
These first two patterns come from studies on snoring:
1. Wind warm heat snoring (Wind-Heat disorder with a slight Yin Deficiency)
Wei Rui Tang aka Polygonum Odoratum Decoction
Release the Exterior ; Disperse Wind-Heat
Actions
Clears Heat
Releases the Exterior
Nourishes Yin.

Symptoms
Breathing difficulty
Heaviness of the body
Sweating

2. Internal heat & external cold snoring

Qing Yan Li Ge Tang aka Clear the Throat and Benefit the Diaphragm Decoction
Clear Heat and Relieve Toxicity
Actions
Clears Heat and relieves toxicity
Regulates the Qi

Symptoms
Fever
Laryngitis
Sore throat
Sore throat
Swelling of the throat

These next patterns come from studies on Sleep Apnea:

Formulas 3, 4, 5, 6 all involve phlegm blocking and inhibiting the free flow of the throat :
3. Spleen vacuity damp heat with phlegm turbidity congesting and stagnating
Xiang Chang Ping Dan Tang (Agastaches & Acorus Level the Gallbladder Decoction):
Herba Agastachis Seu Pogostemi (Huo Xiang)
Radix Angelicae Dahuricae (Bai Zhi),
Rhizoma Acori Graminei (Shi Chang Pu)
Caulis Bambusae In Taeniis (Zhu Ru)
Rhizoma Pinelliae Ternatae (Ban Xia)
Fructus Citri Aurantii (Zhi Ke)

Cortex Magnoliae Officinalis (Hou Pa)

Scierotium Poriae Cocos (Fu Ling)
Rhizoma Atractylodis (Cang Zhu)
Semen Pruni Armeniacae (Xing Ren)
Fructus Cardamomi (Bai Dou Kou)
Medulla Tetrapanacis Papyriferi (Tong Cao)
Semen Coicis Lachryma-jobi (Yi Yi Ren),
Radix Salviae Miltiorrhizae (Dan Shen)

4. Yin vacuity & damp heat with phlegm confounding the heart orifices
Liu Huang Xing Shen Tang (Six Yellows Arouse the Spirit Decoction):

uncooked Radix Rehmanaiae (Sheng Di)

cooked Radix Rehmanniae (Shu Di)
Radix Scutellariae Baicalensis (Huang Qin)
Rhizoma Coptidis Chinensis (Huang Lian)
Cortex Phellodendri (Huang Bai)
Radix Astragali Membranacei (Huang Qi)

Radix Angelicae Sinensis (Dang Gui)

Rhizoma Atractylodis (Cang Zhu)
Radix Angelicae Dahuricae (Bai Zhi)
Caulis Bambusae In Taeniis (Zhu Ru)
Rhizoma Acori Graminei (Shi Chang Pu)

5. Phlegm dampness internally obstructing with qi stagnation & blood stasis

Jia Wei Xue Fu Zhu Yu Tang (Added Flavors Blood Mansion Dispel Stasis Decoction):

Rhizoma Acori Graminei (Shi Chang Pu)

Radix Angelicae Dahuricae (Bai Zhi)
Fructus Trichosanthis Kirlowii (Quan Gua
Lou)
Caulis Bambusae In Taeniis (Zhu Ru)
Radix Angelicae Sinensis (Dang Gui)
uncooked Radix Rehmanniae (Sheng Di)

Flos Carthami Tinctorii (Hong Hua)

Radix Cyathulae (Chuan Niu Xi)
Semen Pruni Persicae (Tao Ren)
Radix Bupleuri (Chai Hu)
Radix Glycyrrhizae (Gan Cao)
Radix Ligustici Wallichii (Chuan Xiong)
Radix Platycodi Grandiflori (Jie Geng)

6. Depressive heat & recalcitrant phlegm joining and binding, obstructing and blocking the qi
passageways
(Unnamed formula containing):
Pericarpium Citri Reticulatae (Chen Pi)
Rhizoma Pinelliae Ternatae (Ban Xia)
Radix Scutellariae Baicalensis (Huang Qin)
Caulis Bambusae In Taeniis (Zhu Ru)
Rhizoma Acori Graminei (Shi Chang Pu)
Semen Pruni Armeniacae (Xing Ren)
Herba Houttuyniae Cordatae Cum Radice (Yu
Xing Cao)

uncooked Lapis Micae Seu Chloriti (Meng Shi)

Sclerotium Poriae Cocos (Fu Ling)
Tuber Curcumae (Yu Jin)
Fructus Trichosanthis Kirlowii (Quan Gua Lou)
Pumice (Hai Fu Shi)
Fructus Amomi (Sha Ren)
Lignu Aquilariae Agallochae (Chen Xiang)

7. Heart-spleen yang vacuity with water dampness internally collecting

Wu Ling San aka Poria Five Powder or Hoelen 5 Powder

Eliminate Dampness, Diuretic, Tonifies the

Spleen, Warms Yang
Rhizoma Alismatis (Ze Xie)
stir-fried Rhizoma Atractylodis
Macrocephalae (Bai Zhu)

Sclerotium Poriae Cocos (Fu Ling)

Sclerotium Polypori Umbellati (Zhu Ling)
Ramulus Cinnamomi Cassiae (Gui Zhi)

8. Central qi downward falling

Bu Zhong Yi Qi Tang aka Ginseng and Astragalus Decoction or Supplement the Center & Boost
the Qi Decoction
Tonify , Tonify the Qi , Raises Qi and Yang
Tonifies the Qi of the Middle Burner

Radix Astragali Membranacei (Huang Qi)

Radix Angelicae Sinensis (Dang Gui)
Radix Panacis Ginseng (Ren Shen)
Rhizoma Atractylodis Macrocephalae (Bai
Zhu)
Radix Bupleuri (Chai Hit)

Rhizoma Cimicifugae (Sheng Ma)

Pericarpium Citri Reticulatae (Chen Pi)
Fructus Zizyphi Jujubae (Da Zao)
Radix Glycyrrhizae (Gan Cao)
dry Rhizoma Zingiberis (Gan Jiang)

Acupuncture Treatments:
In China, Huang Tie-qun has treated one case of spleen qi vacuity weakness and phlegm obstructing the
qi mechanism ( Obstructive Sleep Apnea) by needling:
Dan Zhong (CV 17),
Nei Guan (Per 6),
Bai Hui (GV 20),
Si Shen Cong extra points aka Gods Cleverness Four Spirit Ability
location 4 points, 1 cun to the front, back and sides of GV 20
Feng Long (St 40),
Tai Xi (Ki 3),
Lion Quan (CV 23).
Huang needled these seven points once each day, retaining the needles for 15-30 minutes each time. As
the condition became less severe, he needled less points each time. One month equaled one course of
such treatment. At the same time, Huang counseled the patient to restrict their diet and increase their
physical activity. After one month of therapy, night-time snoring and cessation of breathing and daytime
somnolence and fatigue had completely disappeared.

A STUDY ON HOW ACUPUNCTURE IMPROVES SLEEP A recent study shows that acupuncture as a treatment for obstructive sleep apnea (OSA) has immediate effects in
reducing nocturnal respiratory events, sleep disruptions, and desaturations (low oxygen levels in the blood). The
researchers hypothesize that this improvement is due to acupunctures effects on serotonergic pathways and also
acupunctures anti-inflammatory effects. Both manual acupuncture and 10Hz electro-acupuncture techniques
were found effective. Both techniques produced superior clinical outcomes compared with 2Hz electroacupuncture.
Acupuncture Technique used by Acupuncturists
The researchers used classical acupuncture techniques and acupuncture points in their study. The acupuncture
points chosen for the study were: Lu6, Lu7, LI4, LI20, GV20, CV23, St36, St40, Sp6, K6, and extra point
Shanglianquan (located near the hyoid bone). Copper-handle 40 X 0.25mm needles were used and inserted to
traditional depths. Electro-acupuncture was applied to the neck points CV23 and Shanglianquan and a separate
pair were connected to LI4 and St36. Electro-acupuncture stimulation had wave pulses of 0.45 ms2 at 10Hz and
increased to an intensity of between 0.6 - 0.8 mA which produced a mild twitch. The manual acupuncture group
receive manual stimulation to the needle until deqi (sensation of heaviness or numbness) was achieved at each
acupuncture point. The needles were retained for 30 minutes.
Acupuncture Testing Procedures
Laboratory findings used electroencephalography, electromyography, and electrocardiography. This tested
respiration, mouth flow, and pulse oximetry with the use of an oximeter. Subjects were chosen for the study from
a randomized process. Blinded independent researchers followed four groups: manual acupuncture, electroacupuncture at 10Hz, electro-acupuncture at 2Hz, control group. The researchers note that the electro-acupuncture
was not tested for analgesia but rather for its effects on the lack of motor competence as a result of inflammation
and other mechanisms responsible for reducing the activity of airway muscles.
Discussion of Acupuncture and Airflow
The researchers note that the acupuncture points of the neck are of specific interest because they stimulate the
genioglossus muscle (secondarily, the mylohyoid muscle) on deep insertion. They note that stimulation of this
lingual muscle affects airflow dynamics and may be a key reason as to why acupuncture is effective for improving
the symptoms of patients with sleep apnea.
Reference:
Immediate effect of acupuncture on the sleep pattern of patients with obstructive sleep apnea, Anaflvia O Freire,
Gisele C M Sugai, Snia Maria Togeiro, Luiz Eugnio Mello, Srgio Tufik; Acupunct Med 2010;28:115-119.
Department of Physiology, Universidade Federal de Sao Paulo, Unifesp Rua Botucatu 862, 04023-062 So Paulo/SP,
Brazil. a.freire@unifesp.br
Abstract
BACKGROUND: Most patients with obstructive sleep apnea (OSA) do not tolerate treatment with nasal
continuous positive airway pressure, the 'gold standard' treatment for this condition. It was shown in a pilot study
that acupuncture was more effective than placebo treatment (sham acupuncture) in producing significant changes
in the respiratory events assessed by polysomnography (PSG).
OBJECTIVES: To investigate the immediate effect of manual acupuncture (MA) and electroacupuncture (EA)
on the sleep pattern of patients presenting with moderate OSA.
METHODS: 40 patients with an Apnea-Hypopnea Index (AHI) of 15-30/h were randomly allocated to MA
treatment (n=10), EA 10 Hz treatment (n=10), EA 2 Hz treatment (n=10) and a no-treatment control group
(n=10). The patients received MA or EA (2 or 10 Hz) just before the PSG study at 20:00.
RESULTS: The AHI (p=0.005; p=0.005), the Apnea Index (p=0.038; p=0.009) and the respiratory events
(p=0.039; p=0.014) decreased significantly in the MA and EA 10 Hz groups, respectively (AHI (21.9, 11.2),
Apnea Index (5.15, 0.7), respiratory events (120.5, 61.0) in the MA group before and after. AHI (20.6, 9.9),
Apnea Index (8.2, 0.3), respiratory events (117.0, 56.0) in the EA 10 Hz group before and after). The microarousals decreased only in the MA group (146.0 vs 88.5, p=0.0002). There were no significant changes in the EA
2 Hz group or in the control group.
CONCLUSION: A single session of either MA or EA 10 Hz had an acute effect in reducing the AHI as well as
the number of nocturnal respiratory events of patients presenting with moderate OSA.

Questions for Sleep Apnea course:

1. Sleep Apnea was first identified as a medical condition in __________________________

2. Apnea literally means _______________________________________________________
3. In all types of sleep apnea, the person ___________________________________________
_____________________________ during sleep.
4. How many types of sleep apnea are there? ________________________________________
5. The most common type of sleep apnea is__________________________________________
6. According to studies, over ___________________________________Americans suffer from
sleep apnea.
7. Risk factors include being male, ____________________________ and over ____________
years of age. Other risk factors include _____________________________________________
_____________________________________________________________________________
8. Fifty percent of people with sleep apnea have _______________________________________
9. Sleep apnea sufferers also have a 30% higher risk of _________________________________
______________________________________________ than those unaffected.
10. Definitive diagnosis typically requires a test which is done in a sleep laboratory or sleep
clinic. This test is a ____________________________________________________________

11. As a TCM practitioner, your diagnosis would be based on ___________________________

______________________________________________________________________________
12. Studies in China have shown that herbal treatments are effective in treating sleep apnea
when pattern discrimination is used.
TRUE

FALSE

Name _____________________________________ License # ____________

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