Joey Wahler (Host): They're common conditions that can affect our quality of life, so we're discussing sleep disorders. Our guest is Dr. Karl Fernandes. He's a Pulmonary Critical Care and Sleep Specialist for Wood County Hospital. This is Health Matters, Insights from WCH Medical Experts. Thanks for joining us. I'm Joey Wahler.

 Hi there, Doc. Great to have you aboard. So first, just how common would you say sleep disorders are? They affect a lot of people, right?

Karl Fernandes, MD, FCCP: Yeah, they sure do. Sleep disorders are very, very common, especially as you get older. People have problems falling asleep, maintaining sleep, sleep apnea, which is very, very common. It's as common as asthma, actually. And there are many factors that are probably going to increase it as the years go by, including our national health epidemic of obesity.

Host: Yeah, what's the connection between being overweight and having sleep issues?

Karl Fernandes, MD, FCCP: So there are two things. First of all, when you're overweight, you have a mechanical disadvantage in the abdomen, you know, pressing up on your, your lungs and it's harder for you to have that energy, extra energy to push up. And then also you have excessive tissue in the neck and in the upper airway. So that also causes a problem breathing at night. When we go to sleep during the day, we're fine, we're talking, no problem. But at nighttime, gravity takes over. And as we progress into middle age, unfortunately, everything sags, including our upper airway muscles. And by that, I mean your palate, your tonsils, if you still have them, your tongue, your base of your tongue.

So you're making an effort to breathe in and out, but it's basically, you know, either partially or completely shut off in the back of your throat.

Host: Well, you mentioned sleep apnea a moment ago. What are some of the other most common sleep disorders you treat?

Karl Fernandes, MD, FCCP: Probably the most common sleep disorder is insomnia, and insomnia can be due to various things. You know, drinking caffeinated products before you go to bed, having poor sleep hygiene, watching TV in bed, on their phone. So there are many reasons why people can stay awake, stress from job, home, situation, things like that.

So insomnia is probably the most common sleep disorder. And we hear commercials all the time advertising about quick fixes for insomnia.

Host: And there's also a condition in which your legs move a lot when you sleep. What is that and what causes it?

Karl Fernandes, MD, FCCP: Yeah, that's called restless leg syndrome, and it's thought to be a chemical imbalance in your brain and basically these chemicals are in your body and then they send passages to your legs and they kick at night. Sometimes they wake you up. Sometimes they don't. A lot of times people just the next day, just feel tired in their legs. And during the day, sometimes they'll feel creepy, crawly sensations. And always the, you can see them always trying to move around, move their legs around. It almost looks like a nervous habit. So. Restless legs at nighttime can also be caused by sleep apnea because when your airway closes off, your body says, Hey, breathe, and you move your whole body, including your legs.

Host: Gotcha. How about how often are sleep disorders hereditary?

Karl Fernandes, MD, FCCP: They're very much hereditary in things like sleep apnea. For example. It's one of the questions that we always ask is family history. And, I don't ask, do your parents have sleep apnea? I ask, did your parents snore? Do you remember them snoring? And they always say, oh yeah, mom and dad did, or uncle did this or that.

So it's definitely sleep apnea is hereditary. And part of that is genetics, obesity, upper airway structure, things like that. Insomnia is not usually hereditary. Restless leg can be hereditary, so.

Host: I want to ask you about kind of a misconception. Thinking sleep disorders only affect those that are overweight, as we touched on, or those that snore a lot, as you just touched on. That's not true, right? It affects them, but it affects others as well, yes?

Karl Fernandes, MD, FCCP: Well, first of all, you know, the overweight person with sleep apnea, while that's the stereotype, we see many people who are very thin who have sleep apnea because they have an abnormal upper airway. But when you're sleeping in bed, you're obviously affecting your sleep partner. For example, if I'm snoring like a freight train, my sleep partner is not going to get a good night's sleep. In fact, most of the times when we see patients, for example, sleep apnea, it's their partner that drags them in. That says, yeah, I have a problem with him snoring that I can't sleep. So that usually happens quite a bit.

Host: So this is often a family affair?

Karl Fernandes, MD, FCCP: Oh yeah, yeah, definitely. Or you know, heaven forbid if someone's not getting enough sleep and they're driving, they may get into a motor vehicle accident. That's a thing that we don't always think of, but can be a deadly event.

Host: Absolutely. So, for diagnosis, patients can have a sleep study done. We hear about these. What's involved in that?

Karl Fernandes, MD, FCCP: In the old days, you'd have to go to the hospital or outpatient sleep center, and they would hook you up with electrodes to monitor your brain waves, EKGlead to monitor your heart, oxygen probe, and, various other bands to monitor how you're breathing and your breathing pattern.

So what happens, we can tell what stage of sleep you are, how long it takes you to sleep with their infrared cameras. So you can see how they're moving in sleep. So we get a lot of information. Nowadays, in part due to better technology and in part due to pressure from insurance companies, people do home sleep studies.

And what that is is a basically a box that people take and they can give us some information. For example, how we're sleeping in terms of movement, oxygen level, and whether we stop breathing. It cannot give us, however, other important information like whether our legs kick.

It cannot give us our brainwaves, so we don't know, for example, if may be the seizure, you're having a seizure, or what stage of sleep you are when your oxygen level drops, so we don't get that information. But if someone has sleep apnea, pretty positive, you're gonna get that information.

Host: Are there ever instances in which you're able to do a diagnosis without a sleep study?

Karl Fernandes, MD, FCCP: Yeah, I mean, you can look at a person and say, I bet he has sleep apnea. In fact, sometimes when I'm walking in the malls, I say sleep apnea, sleep apnea, sleep apnea. Yeah. However, in order to get a formal medical diagnosis, you really have to do a sleep study, whether it's a home sleep study or in lab sleep study.

And the reason being is you have to establish a diagnosis. You want to make sure nothing else is going on. For example, some patients have emphysema and sleep apnea. And that's a pretty bad combination to have because your oxygen level will go down at night due to the emphysema and it may go down at night due to sleep apnea.

So, you want to get that diagnosis tied on and plus the treatment of sleep apnea, you have to have a diagnosis that is definite.

Host: I want to go back to what you touched on a moment ago when you mentioned just walking in the mall, being able to tell if someone has sleep apnea, what are you seeing or hearing that you're able to eyeball someone and make that determination?

Karl Fernandes, MD, FCCP: Yeah. So obesity is one of the things, but, for example, also neck size. If you're a man and you have a neck size over 17 inches, there's a high chance you have sleep apnea. If a woman, I think it's 16 inches, there's a high chance you have sleep apnea.

It correlates very well. Of course, the person in the mall who's falling asleep sitting down, and you know, you can just sort of tell their head nodding, and sometimes you can even hear them snoring. So, those are the things. But usually it's the obesity and the thick neck is the main tip off.

Host: I know sometimes I can fall asleep on a bench at the mall just from too much shopping by the person I'm with, but that's a story for another day.

Karl Fernandes, MD, FCCP: Yeah. And not, not all snoring is sleep apnea. You have to have not only snoring, but also obstruction of your airway and oxygen desaturation. So your oxygen level has to go down too. That's one of the criterias, which is in younger folks is a problem because they're healthy usually, and their lungs are healthy and they don't smoke.

And, so you may not see that oxygen desaturation. But what you do see is their brain is so sensitive that they're not getting the good night's sleep that they need to or not getting the deep sleep. So the next day they do feel tired and fatigued. But then it's sort of fighting with the insurance company to get approval for treatment.

Same thing with kids, they may have sleep apnea and in kids, when you don't get enough sleep, if you're a parent, you know what happens. The kids actually become hyperactive. And, a story one of my mentors told me is that this teacher wanted her student to be put on ADD medications because she was always hyperactive.

Well, over Christmas time, the mom took the student to the doctor. The doctor looked it in and the patient had huge tonsils. So they got the tonsils out and after a couple of weeks at the parent teacher conference, he said, well, thank you for putting your child on medications and mom said, I never did. So, that's the moral of the story. You gotta have a high suspicion index.

Host: Gotcha. Let's back up for just a second. What exactly is sleep apnea simply put in layman's terms and how is it most commonly treated?

Karl Fernandes, MD, FCCP: So, apnea is a Greek word, which means stop breathing. So, sleep apnea is stop breathing when you're sleeping. What happens is, you have upper airway collapse when you're sleeping or you're falling asleep and your airway either partially obstructs, which is called a hypopnea, or completely obstructs, which is called an apnea.

And that's detected on your sleep study. So when that happens, a couple of things are going on. Your oxygen level sometimes dips and your brain senses that, because it's not getting enough oxygen, sends receptors to the body, says, hey, wake up, or your spouse elbows you and says quit snoring. So when that happens, you wake up and by awake, I don't mean like completely from falling asleep.

You may not get into that deep sleep that you need to. You may not be able to get into REM sleep, which is our dreaming sleep. You may just stay at stage one or stage two sleep. So the next day you're feeling tired. So you either can have a reduction in, in airflow or complete cessation of air flow, and you know, you stop breathing.

Host: How is that most commonly treated?

Karl Fernandes, MD, FCCP: So the mainstay of treatment is called positive pressure therapy, and there are two main types. One's called CPAP, which we've probably heard the term, which stands for continuous positive airway pressure. So, imagine if you will, the problem is a collapse of the upper airway. So, by putting positive pressure on a patient, in the form of a mask, that'll splint the airway open.

Another term you might hear is bilevel positive pressure, or the trade name is called biPAP. And what happens is when we breathe in, we need a higher force to keep that airway open than when we breathe out. So when you get to higher pressure, some people can't tolerate the continuous pressure and you need two levels of pressure, an inspiratory pressure, and when you, an expiratory pressure when you breathe out.

That's the mainstay of pressure, 98 percent effective. Other forms of therapy are surgery. There was an old therapy, I shouldn't say old, but it was practiced up until the 2000s where they would trim the soft palate, take out your tonsils, take out your uvea on that side.

You call the UP3 or uveal pharyngeoplasty. Well, they thought that would be successful, but it turns out it's only 15 percent curative. And the problem is that the airway obstruction can be in multiple places. So that's one thing. The other thing, there's more dramatic surgery where they actually fracture the upper and lower jaw and move the whole jaw forward.

And that actually has efficacy about 90 percent of the time, but you have to be in a specialized center to do that. Tracheostomy, where there's a hole here in the throat that completely bypasses the upper airway. But of course, that's reserved for very, very serious patients. We don't routine that.

And then, of course, the thing you might have seen on commercials is this new device called the Inspire device. It is basically a device that goes underneath the skin, and they take wires and they wire, through the back of your throat into the muscles. And basically what you do is when you're going to bed, you put the device on and it can sense, when your upper airway is collapsing and can give you impulses to keep your jaw open, move your tongue forward.

It works, according to the data, very well in mild to moderate sleep apnea, but it's only, it's been out maybe five to 10 years, so we're still gathering more information. But many centers are doing it now and many ear, nose, throat physicians are getting trained.

Host: And if untreated, what other medical problems can sleep apnea cause?

Karl Fernandes, MD, FCCP: That's a very good question, very important question. So there's what I describe as social and physiological problems. Now the physiological problems are due to the fact that sleep apnea can cause oxygen desaturation, where your oxygen level drops. We have seen sleep apnea associated, not necessarily the direct cause, but associated with high blood pressure, atrial fibrillation, which is an irregular heartbeat, stroke, and certain forms of heart disease.

 So those are the physical. Socially. Because you're tired all the time, you're not getting your sleep that you should, you might be irritable, might be forgetful, memory loss, four times more motor vehicle accidents, and decreased sexual drive, especially in men. So there are both physical and social things that why sleep apnea should be treated.

Host: And as you point out, a dramatically increased chance of getting into a car accident, which is obviously as good a reason as any to get it addressed. And so in summary here, Doctor, generally speaking, with all of the above, what can you tell those tuning in about having a sleep disorder, their chances for having it successfully addressed?

Karl Fernandes, MD, FCCP: So first thing I would tell them is you are not alone. It's a very common thing. It's not a mysterious disease. It's something that's important to your health and should be taken care of. The second thing is that there are various forms of treatment for sleep apnea. Patients are always discouraged. Oh, I'm never gonna wear that mask. It's too claustrophobic.

The masks have come a long way. They're much more comfortable. They're masks that fit over the nose just fit up like an oxygen over the nose and mouth. It's whatever mask you like is the mask that's gonna work for you. The machines are very quiet, you can barely hear them. They're humidified now, and they're really small.

They're about this big as opposed to when I started my career. And they're auto adjustable. So in other words, the machines now, the technology is such that it will sense where your airway is closing and what pressure you need, and it can adjust the pressure either upwards or downwards. So the technology has come a long way, even in the last five to ten years.

Host: Well, it sounds like it's promising indeed. Folks, we trust you're now more familiar with sleep disorders. Dr. Karl Fernandes, thanks so much again.

Karl Fernandes, MD, FCCP: It was a pleasure being on the show. Thank you very much for giving, giving me this opportunity to reach out.

Host: Oh, great to have you aboard. We hope we can do it again. And for more information or to schedule an appointment, please call Wood County Pulmonology at 419-728-0651 or visit woodcountyhospital.org. Now, if you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for being part of Health Matters, Insights from WCH Medical Experts.