Julie Vann FNP discusses the field of sleep medicine. She explains which sleep disorders are commonly seen in the sleep clinic. She explores sleep apnea, why it is so important to a person’s overall health that it is treated, and new treatment options for sleep disorders.
Finally, she offers basic sleep hygiene measures that are important for each of us to achieve a good night sleep
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Sleep Medicine
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Learn more about Julie Vann, FNP
Julie Vann, FNP
Julie Vann, FNP is a Nurse Practitioner in Sleep Clinic.Learn more about Julie Vann, FNP
Transcription:
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole, and I invite you to listen as we discuss the field of sleep medicine. Joining me is Julie Vann. She's a nurse practitioner in Sleep Clinic at the Carle Foundation Hospital,
Julie, thank you so much for being with us and what a burgeoning field this is now, sleep medicine. Start by telling us some of the health conditions that can result from poor sleep habits, and tell us a little bit about the sleep clinic at the Carle Foundation Hospital.
Julie Vann: Well, hello, thank you for having me today. Yes, in sleep medicine, we see a variety of disorders that affect a person's sleep. The most common disorders that we work with, sleep apnea is definitely the most common. We also work with patients who have insomnia, restless leg syndrome; parasomnia patients, these are the patients that are sleepwalking or have sleep-related eating disorders; dream enactment patients, or REM behavior disorder patients and narcolepsy. Narcolepsy is more rare, only about 20 patients in a hundred thousand have narcolepsy. So those are the most common disorders that we work with here.
Melanie Cole (Host): So, okay. Then, tell us a little bit about who notices sleep disorders. So, first of all, what would even send somebody to their physician? A lot of people snore. And we're going to talk a little bit about sleep apnea. Does that mean that you have apnea? Who notices sleep disorders? Are there some symptoms you can point to?
Julie Vann: Yeah. You know, a lot of patients don't realize they have a problem, especially with sleep apnea. It's usually their bed partner telling them that they're snoring incredibly loud or that they're breathing abnormally in the night or that they're having pauses in their breathing and it looked blatantly unhealthy. So we get a lot of referrals just based on the bed partner saying that their breathing is not normal in the night. A lot of patients also will feel that their sleep is incredibly disrupted. They wake up a lot through the night, they wake up feeling tired or they wake up with headaches or they just feel tired in the daytime and sluggish in the daytime. And so we get a lot of referrals from primary care providers based on just very poor sleep quality or if they have insomnia and they've struggled with that for a while. And then we also get a lot of referrals from outpatient procedures, especially when they're sedated, because the staff will notice that they're having apneas and pauses in their breathing when they're sedated, and so that's also a commonplace we get referrals. Or in cardiology, untreated sleep apnea is a big cause of irregular heart rhythms, like a AFib. Also, things like high blood pressure and congestive heart failure. So we also get a lot of referrals from cardiology, wanting to look and see if sleep apnea is contributing to their heart condition.
Melanie Cole (Host): What a good point you just made, that it's a lot of healthcare providers that sometimes are the ones that notice these. So tell us a little bit about sleep studies, what patients can expect. And for other providers, when they're counseling their patients saying, "You know, this is something you should look into," what does that mean? Tell us about the sleep studies in the clinic at Carle Foundation Hospital.
Julie Vann: Okay. Yeah. So the sleep studies are very overwhelming for patients. A lot of patients don't want to come here because they are scared to go through with a sleep study or they're scared about the treatments. We do have two kinds of sleep studies. We have an in-lab sleep study, which is the most common. That's what we prefer. There's also a home study. A small population do meet criteria for a home study, which is just a very simple device they wear at home one night and they bring it back to us the next day.
The home studies are a bit less sensitive. They do have a higher failure rate. About 20% of the home studies come back as inconclusive, and then we do an in-lab study. So most of the time, we do in-lab studies, they're much more accurate. And this involves the patient coming into the sleep lab in the evening time getting hooked up to sensors. They have an EEG to look at their brainwaves, which records the stages of sleep. They have EKG to look at their heart rhythm and they have oxygen sensors and sensors to look at leg movement. But the room is very comfortable. It looks like a hotel room. They have a private room, their own TV, their own bathroom. The bed is like a queen size bed. And so it is comfortable and most patients, honestly, they can sleep really well. We tell them to kind of wear themselves out that day, come tired, come ready to sleep. And most patients, I mean, it's kind of bothersome having wires on you at night, but it's just one night and it's really a wealth of information that the sleep studies give us because it's a huge part of our lives that's really not studied, otherwise. And so it really is a lot of great information that the studies give us.
Melanie Cole (Host): So now tell us once you've diagnosed what the situation is. And we spoke a little bit before the podcast, and you mentioned you wanted to talk about apnea just a little bit. So tell us about some of the treatments, some of the advancements that are out there for general sleep disorders, but specifically apnea as well.
Julie Vann: In terms of sleep apnea, which is definitely the most common disorder we see here, there are two types of sleep apnea. Obstructive sleep apnea is the most common. And that is when a person sleeping, their tongue falls back, it relaxes too much and it falls back and blocks their airway. And then they stop breathing. their oxygen level drops. And once their oxygen level gets low enough, their brain recognizes that they're suffocating and their body sends a rush of adrenaline to wake them up to breathe again. And most patients don't fully wake up. It's more from a deep sleep to a light sleep. Most patients really have no idea it's happening. In order for it to be diagnosed as sleep apnea, they have to have at least five apneas per hour. And for patients that have severe sleep apnea, they're having at least 30 apneas an hour or more. And so patients potentially could be having hundreds of rushes of adrenaline every night just to keep them breathing and hundreds of these oxygen drops every night. And so over time, that is what gets so damaging to the body and greatly increases the chance of heart attack and stroke and other things like congestive heart failure, AFib, high blood pressure, insomnia, mood disorders. It's like sand, it gets into every aspect of the life.
Central sleep apnea is the other type of apnea. This is much less common, but central apnea is when the breathing center in the brain becomes depressed. And that causes pauses in the breathing at night. And this is usually caused from congestive heart failure, narcotic use, a history of stroke or alcohol use before bed. So those are the main types of sleep apnea.
In terms of treatment, there are different options. There's a stigma around treatment for sleep apnea. People think of the CPAP machine as being big and scary. But there are different options for treatment. Weight loss is an option for treatment of sleep apnea. Weight loss can cure apnea. For some ,patients it doesn't completely cure their apnea, but it does improve it. For patients that have more mild sleep apnea, an oral appliance also known as a mandibular advancement device could be a treatment. And this is basically a fancy bite guard fitted by a dentist that is worn at night and advances the lower jaw, which helps open up the airway.
The first line treatment is the CPAP machine. And the new CPAPs, they're very small, they're silent, they're lightweight, they're very easy to travel with. The masks are small. They're much more comfortable than they used to be. And, when a person wears a CPAP at night and their apnea is completely treated, most patients feel that it is completely life-changing. They feel so much better. They love their CPAP machines. And when the apnea is treated, a patient's risk of heart attack and stroke is significantly reduced. So it is very effective at keeping the body healthy.
There is a new treatment out though called the Inspire. It is recently approved by insurance and so they are airing commercials for it now, so patients are starting to see this, providers are starting to see this. And it's very interesting. It is an implanted device in the upper chest similar to a cardiac pacemaker. And internally, there are two sensors placed. One is placed at the base of the tongue and the other is placed on the rib. And it is turned on at night and when a person falls asleep, the ribs sensor senses the inspiration, which then sends a signal to the tongue stimulator to stimulate. And so that stimulates the tongue to prevent the apneas and the stimulation is synced with the person's breathing. And studies are very promising. The patients that fit the criteria for this, it is a smaller group that do, there's criteria for the Inspire. But for the patients who have the Inspire, the studies are showing it can reduce apneas by up to 79%. So it's a very effective treatment. The goal is that it's not meant to be felt at all at night. The patient should not feel that stimulation. And, at Carle, we just did our first two implantations a few weeks ago. So that's a very exciting, up and coming technology for sleep apnea.
Melanie Cole (Host): Wow. What a wealth of information you are. And you made so many good points. I'm glad you told us about Inspire. And I hope that you'll come back and tell us as you get more of these and how the outcomes and how much patients are loving them. And I'm glad that you mentioned weight loss and behavioral lifestyle modifications that can help with sleep disorders and certainly adherence to CPAP and telling us about those new CPAP machines, which are much easier and will increase that adherence. As we wrap up, tell us about sleep hygiene and some of those lifestyle modifications. How can somebody improve that? We've got our white lights and our blue lights and our phones. And everybody's so wrapped up in all of these things. It's about turning your mind off and the temperature. Tell us about sleep hygiene.
Julie Vann: So in the sleep clinic, we are big believers in sleep hygiene. And a lot of patients come to us and they've never heard of sleep hygiene. Really what it is, it's basically having a consistent routine at bedtime to signal to your brain that sleep is coming and it doesn't have to be a complicated routine. It's really basically that 30 to 60 minutes before bed, turning the lights in the house down low and doing something relaxing. Trying to avoid the cell phones and the TVs as much as possible, instead trying to do things like reading, journaling, making it to do list for the next day is a great way to kind of just dump your brain on paper so that you don't think about it when you get into bed. Taking a warm bath one to two hours before. And once you're in bed, trying to avoid the cell phones and the TVs. Don't watch the clock, trying to do like deep breathing exercises, mindfulness exercises. And then if you cannot fall asleep After 20 to 30 minutes, to get out of the bed and do something quiet to help you get drowsy, like reading or listening to quiet music or doing crossword puzzles. Don't allow yourself to just lay in bed for hours. If you can't fall asleep, get out of bed and do something to make yourself drowsy and then get back into bed and try again. Consistency is really the key here. The brain needs patterns, the brain loves patterns. And so when patients have a consistent routine they do every night, it just helps the brain know when to make melatonin, and so that makes sleep easier.
Other important sleep hygiene tips, keeping the bedroom cool and dark. Making sure the mattress and the pillow are comfortable, that's a big thing for us too. Having white noise also helps, like a fan, that provides like a little bit of background noise. Using the bed only for sleep, so don't hang out in the bed, don't watch TV in the bed, training your brain to know that the bed is only for sleep. And then another thing that I like to tell my patients if they're kind of struggling to fall asleep at night, listening to sleep stories. These can be found very easily on YouTube. And it's basically just a story, like a really relaxing story that a person's telling and the goal is to get the person listening to fall asleep and it actually really works. And so if people are struggling to fall asleep at night, they can put a sleep story on and those usually help too. But just that bedtime routine at night to help your brain know that sleep is coming, those are huge and those are often more effective than sleep medication.
Melanie Cole (Host): Wow. There are so many options. And as we said, what a burgeoning field. Thank you so much, Julie, for joining us and really telling us about the sleep clinic at Carle Foundation Hospital and all of the disorders and the treatments that are out there. So thank you so much again.
For more information and to get connected with one of our providers, please visit carle.org. Or for a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Thanks so much for listening
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole, and I invite you to listen as we discuss the field of sleep medicine. Joining me is Julie Vann. She's a nurse practitioner in Sleep Clinic at the Carle Foundation Hospital,
Julie, thank you so much for being with us and what a burgeoning field this is now, sleep medicine. Start by telling us some of the health conditions that can result from poor sleep habits, and tell us a little bit about the sleep clinic at the Carle Foundation Hospital.
Julie Vann: Well, hello, thank you for having me today. Yes, in sleep medicine, we see a variety of disorders that affect a person's sleep. The most common disorders that we work with, sleep apnea is definitely the most common. We also work with patients who have insomnia, restless leg syndrome; parasomnia patients, these are the patients that are sleepwalking or have sleep-related eating disorders; dream enactment patients, or REM behavior disorder patients and narcolepsy. Narcolepsy is more rare, only about 20 patients in a hundred thousand have narcolepsy. So those are the most common disorders that we work with here.
Melanie Cole (Host): So, okay. Then, tell us a little bit about who notices sleep disorders. So, first of all, what would even send somebody to their physician? A lot of people snore. And we're going to talk a little bit about sleep apnea. Does that mean that you have apnea? Who notices sleep disorders? Are there some symptoms you can point to?
Julie Vann: Yeah. You know, a lot of patients don't realize they have a problem, especially with sleep apnea. It's usually their bed partner telling them that they're snoring incredibly loud or that they're breathing abnormally in the night or that they're having pauses in their breathing and it looked blatantly unhealthy. So we get a lot of referrals just based on the bed partner saying that their breathing is not normal in the night. A lot of patients also will feel that their sleep is incredibly disrupted. They wake up a lot through the night, they wake up feeling tired or they wake up with headaches or they just feel tired in the daytime and sluggish in the daytime. And so we get a lot of referrals from primary care providers based on just very poor sleep quality or if they have insomnia and they've struggled with that for a while. And then we also get a lot of referrals from outpatient procedures, especially when they're sedated, because the staff will notice that they're having apneas and pauses in their breathing when they're sedated, and so that's also a commonplace we get referrals. Or in cardiology, untreated sleep apnea is a big cause of irregular heart rhythms, like a AFib. Also, things like high blood pressure and congestive heart failure. So we also get a lot of referrals from cardiology, wanting to look and see if sleep apnea is contributing to their heart condition.
Melanie Cole (Host): What a good point you just made, that it's a lot of healthcare providers that sometimes are the ones that notice these. So tell us a little bit about sleep studies, what patients can expect. And for other providers, when they're counseling their patients saying, "You know, this is something you should look into," what does that mean? Tell us about the sleep studies in the clinic at Carle Foundation Hospital.
Julie Vann: Okay. Yeah. So the sleep studies are very overwhelming for patients. A lot of patients don't want to come here because they are scared to go through with a sleep study or they're scared about the treatments. We do have two kinds of sleep studies. We have an in-lab sleep study, which is the most common. That's what we prefer. There's also a home study. A small population do meet criteria for a home study, which is just a very simple device they wear at home one night and they bring it back to us the next day.
The home studies are a bit less sensitive. They do have a higher failure rate. About 20% of the home studies come back as inconclusive, and then we do an in-lab study. So most of the time, we do in-lab studies, they're much more accurate. And this involves the patient coming into the sleep lab in the evening time getting hooked up to sensors. They have an EEG to look at their brainwaves, which records the stages of sleep. They have EKG to look at their heart rhythm and they have oxygen sensors and sensors to look at leg movement. But the room is very comfortable. It looks like a hotel room. They have a private room, their own TV, their own bathroom. The bed is like a queen size bed. And so it is comfortable and most patients, honestly, they can sleep really well. We tell them to kind of wear themselves out that day, come tired, come ready to sleep. And most patients, I mean, it's kind of bothersome having wires on you at night, but it's just one night and it's really a wealth of information that the sleep studies give us because it's a huge part of our lives that's really not studied, otherwise. And so it really is a lot of great information that the studies give us.
Melanie Cole (Host): So now tell us once you've diagnosed what the situation is. And we spoke a little bit before the podcast, and you mentioned you wanted to talk about apnea just a little bit. So tell us about some of the treatments, some of the advancements that are out there for general sleep disorders, but specifically apnea as well.
Julie Vann: In terms of sleep apnea, which is definitely the most common disorder we see here, there are two types of sleep apnea. Obstructive sleep apnea is the most common. And that is when a person sleeping, their tongue falls back, it relaxes too much and it falls back and blocks their airway. And then they stop breathing. their oxygen level drops. And once their oxygen level gets low enough, their brain recognizes that they're suffocating and their body sends a rush of adrenaline to wake them up to breathe again. And most patients don't fully wake up. It's more from a deep sleep to a light sleep. Most patients really have no idea it's happening. In order for it to be diagnosed as sleep apnea, they have to have at least five apneas per hour. And for patients that have severe sleep apnea, they're having at least 30 apneas an hour or more. And so patients potentially could be having hundreds of rushes of adrenaline every night just to keep them breathing and hundreds of these oxygen drops every night. And so over time, that is what gets so damaging to the body and greatly increases the chance of heart attack and stroke and other things like congestive heart failure, AFib, high blood pressure, insomnia, mood disorders. It's like sand, it gets into every aspect of the life.
Central sleep apnea is the other type of apnea. This is much less common, but central apnea is when the breathing center in the brain becomes depressed. And that causes pauses in the breathing at night. And this is usually caused from congestive heart failure, narcotic use, a history of stroke or alcohol use before bed. So those are the main types of sleep apnea.
In terms of treatment, there are different options. There's a stigma around treatment for sleep apnea. People think of the CPAP machine as being big and scary. But there are different options for treatment. Weight loss is an option for treatment of sleep apnea. Weight loss can cure apnea. For some ,patients it doesn't completely cure their apnea, but it does improve it. For patients that have more mild sleep apnea, an oral appliance also known as a mandibular advancement device could be a treatment. And this is basically a fancy bite guard fitted by a dentist that is worn at night and advances the lower jaw, which helps open up the airway.
The first line treatment is the CPAP machine. And the new CPAPs, they're very small, they're silent, they're lightweight, they're very easy to travel with. The masks are small. They're much more comfortable than they used to be. And, when a person wears a CPAP at night and their apnea is completely treated, most patients feel that it is completely life-changing. They feel so much better. They love their CPAP machines. And when the apnea is treated, a patient's risk of heart attack and stroke is significantly reduced. So it is very effective at keeping the body healthy.
There is a new treatment out though called the Inspire. It is recently approved by insurance and so they are airing commercials for it now, so patients are starting to see this, providers are starting to see this. And it's very interesting. It is an implanted device in the upper chest similar to a cardiac pacemaker. And internally, there are two sensors placed. One is placed at the base of the tongue and the other is placed on the rib. And it is turned on at night and when a person falls asleep, the ribs sensor senses the inspiration, which then sends a signal to the tongue stimulator to stimulate. And so that stimulates the tongue to prevent the apneas and the stimulation is synced with the person's breathing. And studies are very promising. The patients that fit the criteria for this, it is a smaller group that do, there's criteria for the Inspire. But for the patients who have the Inspire, the studies are showing it can reduce apneas by up to 79%. So it's a very effective treatment. The goal is that it's not meant to be felt at all at night. The patient should not feel that stimulation. And, at Carle, we just did our first two implantations a few weeks ago. So that's a very exciting, up and coming technology for sleep apnea.
Melanie Cole (Host): Wow. What a wealth of information you are. And you made so many good points. I'm glad you told us about Inspire. And I hope that you'll come back and tell us as you get more of these and how the outcomes and how much patients are loving them. And I'm glad that you mentioned weight loss and behavioral lifestyle modifications that can help with sleep disorders and certainly adherence to CPAP and telling us about those new CPAP machines, which are much easier and will increase that adherence. As we wrap up, tell us about sleep hygiene and some of those lifestyle modifications. How can somebody improve that? We've got our white lights and our blue lights and our phones. And everybody's so wrapped up in all of these things. It's about turning your mind off and the temperature. Tell us about sleep hygiene.
Julie Vann: So in the sleep clinic, we are big believers in sleep hygiene. And a lot of patients come to us and they've never heard of sleep hygiene. Really what it is, it's basically having a consistent routine at bedtime to signal to your brain that sleep is coming and it doesn't have to be a complicated routine. It's really basically that 30 to 60 minutes before bed, turning the lights in the house down low and doing something relaxing. Trying to avoid the cell phones and the TVs as much as possible, instead trying to do things like reading, journaling, making it to do list for the next day is a great way to kind of just dump your brain on paper so that you don't think about it when you get into bed. Taking a warm bath one to two hours before. And once you're in bed, trying to avoid the cell phones and the TVs. Don't watch the clock, trying to do like deep breathing exercises, mindfulness exercises. And then if you cannot fall asleep After 20 to 30 minutes, to get out of the bed and do something quiet to help you get drowsy, like reading or listening to quiet music or doing crossword puzzles. Don't allow yourself to just lay in bed for hours. If you can't fall asleep, get out of bed and do something to make yourself drowsy and then get back into bed and try again. Consistency is really the key here. The brain needs patterns, the brain loves patterns. And so when patients have a consistent routine they do every night, it just helps the brain know when to make melatonin, and so that makes sleep easier.
Other important sleep hygiene tips, keeping the bedroom cool and dark. Making sure the mattress and the pillow are comfortable, that's a big thing for us too. Having white noise also helps, like a fan, that provides like a little bit of background noise. Using the bed only for sleep, so don't hang out in the bed, don't watch TV in the bed, training your brain to know that the bed is only for sleep. And then another thing that I like to tell my patients if they're kind of struggling to fall asleep at night, listening to sleep stories. These can be found very easily on YouTube. And it's basically just a story, like a really relaxing story that a person's telling and the goal is to get the person listening to fall asleep and it actually really works. And so if people are struggling to fall asleep at night, they can put a sleep story on and those usually help too. But just that bedtime routine at night to help your brain know that sleep is coming, those are huge and those are often more effective than sleep medication.
Melanie Cole (Host): Wow. There are so many options. And as we said, what a burgeoning field. Thank you so much, Julie, for joining us and really telling us about the sleep clinic at Carle Foundation Hospital and all of the disorders and the treatments that are out there. So thank you so much again.
For more information and to get connected with one of our providers, please visit carle.org. Or for a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Thanks so much for listening