Transcription:
Do You Have Sleep Apnea? A Sleep Study May Have the Answers

Melanie Cole (Host): If you're among the seventy million Americans who suffer from a sleep disorder, it's really important to know that an inability to get a good quality night's sleep not only impacts how you feel every day, but can also seriously affect your overall health. My guest today is Dr. Anita Bhola. She's the Medical Director of the Sleep Center of the Cornwall campus at St. Luke's Cornwall Hospital. Welcome, to the show, Dr. Bhola. Let's start with sleep apnea. Please explain for the listeners what it is and who is at most risk.

Dr. Anita Bhola, MD, FCCP, FAAS (Guest): Hi Melanie, and thanks for having me here today. So sleep apnea is a common name for obstructive sleep apnea. The other less common type of sleep apnea is also called central sleep apnea. Apnea is basically- it's Greek for absence of breathing, and so sleep apnea is a serious sleep disorder that occurs when a person's breathing is interrupted repeatedly during sleep. Sometimes over 100 times per hour of sleep. Each episode can last ten seconds or longer, and they can be pretty scary. These episodes reoccur night after night and they've been going on for several years before the patient becomes symptomatic and seeks evaluation. And sleep apnea occurs because of obstruction of the muscles of the back of the throat, what we call the upper airway. These muscles relax during sleep and the tissues tend to cave in, blocking the airway.

So as a result of this, the oxygen- the brain and the rest of the body may not get enough oxygen during the episodes, and fortunately these episodes are transient, but they do result in recurrent arousals and awakenings, and therefore fragment the sleep. So it's almost like you're sleeping eight hours, but it's eight hours of chopped up or fragmented sleep, where it's almost like somebody is poking you in the ribs multiple times at night, and when it occurs night after night, it creates a state of sleep deprivation. So there are two things that are important that happen.

One is that the oxygen level tends to transiently drop multiple times due to this blockage of the upper airway, and sleep tends to get fragmented causing a state of sleep deprivation even though you're sleeping a normal number of hours, which we know most Americans do not. We are a sleep deprived society in general, so that's sort of like a double whammy.

Now over twenty million Americans may have sleep apnea, the numbers just seem to be growing, and the estimates are that it's seen in about 4% of men and 2% of women, however in reality, the numbers can be as high as 24% of men and 15% of women. And what is most frightening is that this condition remains undiagnosed in 80% to 90% of people who have it, and a lot of these people are being treated for the end result or sequelae of untreated sleep apnea such as diabetes or high blood pressure or depression, et cetera.

Melanie: Who notices the symptoms, Dr. Bhola? Is it a loved one? You mentioned that people are feeling sleepy in the day, and you mentioned some of the symptoms, but generally when you see it, is it partners pushing their partners in saying, "You're snoring and you need to get in and get this checked out."

Dr. Bhola: Right, so the common symptoms of sleep apnea include snoring, breathing pauses also known as witnessed apneas. Witnessed apneas means they're witnessed by a bed partner or somebody else, and these can be quite frightening to the bed partner. Other symptoms include multiple awakenings during the night, often increased urination, sleep is restless, and patients wake up feeling fatigued and report daytime sleepiness in various sedentary situations. They often fall asleep at the wheel and could have motor vehicle accidents. In addition, patients may report poor concentration, memory, focusing problems, or sometimes even just a writer's block. If you're in one of those jobs that involves writing or concentrating on scripts. Patients often have morning headaches, they may develop personality changes, irritability, and often mood disorders such as depression and anxiety can set in.

Now it's important to note that women are less likely to have the classic symptoms of snoring and breathing pauses as we know the symptoms of sleep apnea. Women present less with these classic symptoms and tend to report more of daytime fatigue, and morning headaches, and depression, and women often are undiagnosed or underdiagnosed.

Now in terms of who notices the symptoms, well it's often the bed partner who first notices the symptoms of snoring and breathing pauses and encourages the patient to seek evaluation. Now since women have a lower threshold for symptom perception, I see in my practice that a lot more men are referred by their wife than the other way around. And I often tell men how lucky they are that they are being referred by their wife.

But occasionally patients will just self-awaken from these snoring episodes or gasping and choking during sleep, and they may bring in an audio recording of the snoring, or they may bring in a Fit Bit to show me multiple interruptions to their sleep. And most people just drag during the day and have daytime sleepiness.

Melanie: Dr. Bhola-

Dr. Bhola: Just one other thing.

Melanie: Okay, go on.

Dr. Bhola: I'm sorry.

Melanie: No, that's okay.

Dr. Bhola: Just one other thing I've noticed, that occasionally patients when they undergo let's say a procedure such as a colonoscopy under anesthesia or sedation, they may be told by the anesthesiologist that they stopped breathing, and they may possibly have sleep apnea. So that's another source where patients could be referred from.

Melanie: So now let's get into diagnosis. If they've got all these symptoms, if they've come in to see you, tell us a little bit about how you diagnosis sleep apnea. What is that sleep study like? Because people are afraid, they think, "I'm not going to get a good night's sleep with someone watching me." Tell them a little bit about it, and then let's get into some treatments in the time that we have left.

Dr. Bhola: Sure. So diagnosis begins with a careful history and physical exam along with sleeping questionnaires, and this could be done by your primary care physician or your primary care physician may refer you to a sleep specialist such as myself, and I do a thorough evaluation and physical exam. And then if I suspect sleep apnea, or if the physician suspects sleep apnea, they may refer the patient to a sleep center to undergo a formal sleep test, which is also known as a nocturnal polysomnogram. It's a recording of the nighttime events. The patient goes into the facility, also known as a sleep lab, and the technician will spend about an hour hooking up the patient with electrodes and monitors all over the body to analyze different physiological parameters such as the brain waves, the breathing, the respirations, and the heart rate, et cetera while the patient is sleeping. And this is a recording of the entire night, and sometimes in night shift workers we perform the study during the daytime.

So once the study is performed, the study is read, and the results are sent to the referring physician, and basically what we do is we calculate how many times the patient stops breathing per hour of sleep, and how long each episode is, and low does your oxygen level drop. So these are important parameters. And how low is your deep sleep, and REM sleep, et cetera.

So to officially diagnose sleep apnea, you need to have- you need to stop breathing either completely or partially for at least ten seconds or more for at least fifteen times per hour of sleep. But if you're symptomatic, meaning if you have daytime sleepiness, or if you have other medical conditions such as depression, insomnia, high blood pressure, that count can be as low as five. So if you stop breathing more than five times per hour of sleep, and you have other symptoms, that indicates that you have sleep apnea. Now snoring is also detected during the sleep study as well as other parameters such as leg movements, et cetera.

So that is how we diagnose sleep apnea, and we'll call the patient back to discuss the results of the sleep study, and then it's determined whether the patient- if the patient has sleep apnea, whether they go onto a second study known as a titration study.

Melanie: So now let's get into treatments, and I'd really like you to talk about CPAP and adherence, because that seems to be the compliance to even using one, seems to be one of the biggest things. So in just the minute that we have left, please just cover CPAP, and what it is, and why it's so important to adhere to your prescription.

Dr. Bhola: Right. So there are a number of conservative measures that we use to treat sleep apnea such as weight loss, positional therapy, and certain non-prescription devices such as Breathe Right strips, and nasal dilators, et cetera. But CPAP is the gold standard of treatment for all levels of sleep apnea. It stands for Continuous Positive Airway Pressure. It is basically a small device that acts as a pneumatic splint, and the patient sleeps with a mask on, and is connected via a hose to a machine which sits on the nightstand, and this pressurized air acts as a pneumatic splint opening up your airway so you don't stop breathing at night and your sleep is not interrupted.

So it is very efficacious in decreasing daytime sleepiness, improving the quality of sleep, decreasing the blood pressure, as well as the risk of cardiovascular disease, and works very effectively. Patients wake up feeling more refreshed and have more energy and are able to exercise and possibly even lose weight. Their blood pressure is under much better control. I've seen patients go from being on four blood pressure medications down to zero at times.

But adherence can be a problem, and there can be many barriers to adherence, which is why long-term follow-up of these patients is extremely important. It's important to understand that sleep apnea is a chronic condition and requires diligent long-term follow-up because even though the acceptance to CPAP is high, in subsequent years, the usage of CPAP declines and CPAPs end up sitting in closets.

So if you don't use your CPAP, your sleep apnea is basically back. And some of the psychological barriers would be that patients just don't like using the CPAP, they may have anxiety or claustrophobia to the pressure or the mask, and there could be other barriers such as the pressure is too high, or the mask leaks, or the mask is just not the right fit, or the airway may be too dry. Patients may also have co-existing insomnia along with the sleep apnea, and this can be especially challenging to manage. It's like saying, "I have difficulty sleeping anyway, and now you want me to sleep with something on my face?" So in those instances, we'll try and teach the patient some relaxation techniques, maybe even prescribe melatonin or a low dose sleeping pill to acclimatize the CPAP for a few weeks.

Behavioral interventions are extremely important when adherence is a problem and we teach patients how to desensitize to the CPAP and the mask. Sometimes we need to refer them to a cognitive behavioral therapist who's a psychologist who works with the patient on behavioral interventions to improve self-efficacy.

I also educate patients- in addition to doing a compliance download in our office, and troubleshooting wherever we can, I also educate patients in self-management tools and downloading a mobile app through which they can actually follow their usage and compliance, and educating the patients I've realized makes a huge difference in the compliance because when patients are able to be responsible for their own care, this helps in adherence.

Melanie: Absolutely great information, Dr. Bhola. So give us your best advice as a wrap-up on just sleep hygiene, and what do you want us to know about getting that good night's sleep that's so restorative and so important for our health?

Dr. Bhola: So you know, as you know Melanie, we spend one third of our lives sleeping, and our health during the other two thirds is impacted by how we sleep. So it's really, really important not only to have a qualitative- in other words the quality of your sleep needs to be good, but also the quantity of your sleep and your sleep hygiene and sleep habits need to be good. So especially in patients who have sleep apnea, it is extremely important that they sleep a certain number of hours, which for most adults is seven to nine hours per day. Your bedtime and rise time should be fairly consistent. The bed is only for sleep and sex. A lot of sleep apnea patients will fall asleep on the couch while watching television, and that's a no-no. Once they feel a little sleepy, they need to get up and go to their bedroom, put their CPAP on, and fall asleep with the CPAP, otherwise they'll wake up at 2:00 in the morning and find themselves on the couch without the machine.

No use of computers close to bedtime, no use of stimulants such as caffeine close to bedtime. Patients should also avoid alcohol close to bedtime because this is a muscle relaxant and can make sleep apnea worse. In addition, smoking close to bedtime is a no-no because this is an upper airway irritant and can make sleep apnea worse. I also tell patients to keep their bedroom cool, dark, and quiet, and avoid large meals within two to three hours of bedtime because a large meal close to bedtime can cause acid reflux and acid reflux is also a risk factor and can make sleep apnea worse.

But I think the most important advice for patients who've been diagnosed with sleep apnea is that you have a qualitative sleep defect, and I will be responsible for helping you manage that, but on your part, you need to make sure that you sleep a normal number of hours. The problem is that most people are sleep deprived and they don't even know that they're sleep deprived. So it's important for a patient with sleep apnea to at least give themselves the opportunity to sleep seven to nine hours. And once they get that burst of energy with using CPAP, that they should use that to their advantage to exercise and lose weight.

Melanie: Thank you so much, Dr. Bhola. What great information. You are absolutely so well-spoken, and we can hear your passion about a good quality night's sleep. Thank you so much for joining us today. This is Doc Talk presented by St. Luke's Cornwall Hospital. For more information please visit www.StLukesCornwallHospital.org. That's www.StLukesCornwallHospital.org. I'm Melanie Cole, thanks so much for listening.