What is a Sleep Center?
A Sleep Center is designed to diagnose and treat all types of sleep disorders. A Sleep Center must have a medical director that is board certified as a Specialist in Sleep Medicine. Our Sleep Center has been designed with your comfort in mind, providing a home like environment including private suites with private baths, queen size comfortable bedding, and flat panel televisions.
Sleep apnea – is it serious??
Sleep apnea is a serious disorder that interrupts a person's breathing during sleep, sometimes for several seconds and hundreds of times during the night. Sleep Apnea is characterized by pauses in breathing many times during sleep; these breathing pauses can last for as long as a minute. With each apnea event, the brain briefly rouses the sleeper in order for breathing to resume. As a result, sleep is fragmented and of poor quality. Common symptoms of sleep apnea include excessive daytime sleepiness and loud snoring, though everyone who snores does not have sleep apnea. Sleep apnea can trigger other, potentially fatal health problems including high blood pressure, cardiovascular disease, memory problems, impotence, and morning headaches. Sleep apnea can strike anyone at any age, including children and even athletes. Those at the highest risk are overweight and over 40.
There are 2 forms of sleep apnea – obstructive and central. Obstructive Sleep Apnea (OSA) is far more common, affecting up to 5% of the adult population. It is due to collapse of the airway. It is often related to obesity but may be seen in thin individuals as well. OSA results in repeated episodes of partially decreased airflow (hypopnea) or total loss of airflow (apnea) despite efforts to breathe. Central Sleep Apnea is uncommon and is not due to airway collapse. It is due to loss of effort to breathe. It is seen in congestive heart failure, neuromuscular disorders, severe strokes and sometimes no obvious cause can be found.
What exactly is Narcolepsy?
This is the classic pure sleep disorder. This is disease causing severe daytime drowsiness regardless of how much sleep is obtained. Irresistible daytime sleep episodes may cause severe problems working, going to school, driving, etc. It is a disorder of REM sleep regulation that results in normal REM phenomena (sleepiness, muscle paralysis/weakness, dreams) appearing when patients are fully awake. There are 4 symptoms:
1. Daytime Somnolence (Sleepiness) – this is present in all patients and can be severe
2. Sleep Paralysis – this is a frightening symptom. The patient will wake from sleep totally unable to move. This always resolves, usually in less than a minute. This symptom may be seen in normal individuals. Some studies have shown that up to 50% of the normal population may have this at least once in their lifetime.
3. Hypnogogic Hallucinations – These are dreams that break into the waking state. Like sleep paralysis, this occurs when awakening from sleep. The patient will report being fully awake but still having vivid dreams. Technically this would be termed a hallucination. It is not a sign of mental illness.
4. Cataplexy – this is an unusual symptom consisting of muscle weakness affecting parts or all of the body. This can lead to falls with injuries but this is unusual. These attacks often have a recognizable trigger, often laughing or being angry. If present, it is diagnostic of Narcolepsy.
The last 3 symptoms are not seen in all patients with narcolepsy. The only symptom seen in all patients is daytime sleepiness (which can be seen for numerous other reasons).
Treatment of drowsiness involves wake promoting medications such as Provigil or stimulants such as Ritalin, Adderall or Dexedrine or a new class of medication, Xyrem. The other symptoms, particularly cataplexy, can be treated with a variety of antidepressants or with Xyrem. Xyrem is the only medication known that can treat both the somnolence and the ancillary symptoms.
Insomnia – I just can’t sleep!!
Insomnia is very common. It is defined as a problem of either initiating or maintaining sleep. Virtually everyone has experienced a night where it is difficult to get to sleep or to stay asleep. It is estimated that up to 30% of the population in the US may have insomnia frequently enough that treatment should be considered. There are numerous reasons for insomnia including caffeine usage too late in the day, stress, snoring bed partners, medication effects, and pain problems. Some of the causes are not as obvious, such as Restless Legs Syndrome, mood disorders, nocturnal reflux and others.
The diagnosis and treatment of insomnia is a complex topic and an important one. A Sleep Medicine Specialist can be very helpful. A consultation with one of our doctors often leads to better sleep.
Sleep Studies - Tell me more….
There are several types of sleep studies. The primary and most commonly done study is a polysomnogram. This is usually done during a full night's sleep although it may be done during the day in a shift worker who normally sleeps during the day. During a sleep study, a number of physiologic variables are recorded. This usually includes 4 or more channels of EEG, a recording of air flow from the nose and mouth, an oxygen monitor on the finger or the ear lobe, EKG, belts that record movement of the chest and abdomen, muscle activity around the chin and the lower leg. These monitoring electrodes and transducers are placed by a polysomnography technician (sleep tech). This is a painless process that generally takes 30 - 45 minutes. This may take longer in children as we want to put the child’s fears at ease as much as possible. Parents are required to stay overnight with children under the age of 18. We provide bedding in the room with your child. Once the wires are in place, the patient is requested to turn out the lights and try to fall asleep. Once asleep, all the data is recorded by a computer for later analysis.
A titration study generally follows a positive polysomnography. It is a full night study very similar to the polysomnogram that is done in patients who have been diagnosed with sleep apnea. During a titration study, the patient is started on PAP therapy and the pressure is adjusted until normal breathing resumes. You’ll read more about PAP therapy later.
Another form of titration study is a split night study. Some patients with severe sleep apnea can be proven to have significant problems with breathing after only 2 or 3 hours of sleep. In that case, the sleep study may be stopped and then restarted with CPAP. In other words the study is ‘split' between a typical polysomnogram and a titration study.
A Multiple Sleep Latency Test (MSLT) is also known as a nap study. This is done to document daytime sleepiness, typically in a patient thought to have Narcolepsy. This is usually started in the morning after an overnight sleep study. The patient has a number of recording electrodes but it differs from an overnight study in that air flow, rib belts, abdominal belts, EKG and oxygen are not recorded. The patient is asked to take a 20 minute nap every 2 hours through the day starting at 8:00 a.m. usually. There will be 4 or 5 naps depending on the results. The primary measures are the average length of time to fall asleep in the naps (less than 10 minutes is considered abnormal) and the presence of REM. Excessive REM sleep is seen with Narcolepsy (REM sleep in 2 or more of the naps). REM sleep normally is present in at most one nap during an MSLT. Patients are encouraged to bring in reading material and television is available.
PAP – ‘Positively’ Good Treatment for Apnea
The Sleep Center’s role is to ensure that after a positive sleep study, patients have adequate follow up and treatment. Sleep apnea patients being treated with PAP therapy in particular need follow up. The key to treatment is to make sure that patients are periodically seen by a doctor with expertise in the evaluation and treatment of sleep disorders.
CPAP – a continuous flow of air passess into the airway at a set pressure. The airflow is constant and holds the airway open at a set pressure when breathing in and out- imagine the air acting as a splint to hold the airway in place. The set pressure can vary from 4 – 25 depending on the amount of air required to hold open a person's airway and stop the obstructions that are occurring. This pressure is determined during your titration study.
BIPAP – Bi-level (or two level) is airflow that allowsfor a higher pressure when breathing in and a lower pressure when breathing out. Individuals who require a higher flow of air to maintain their open airway often will tolerate Bi-level therapy better.
AUTOPAP – The device will recognize if an obstruction occurs and will increase the pressure until the obstruction is corrected. This device is great for someone who needs a wide variation in pressure through the night (ex: needs higher pressure when lying on your back and lower pressure when on your side) or for someone that a definitive setting cannot be obtained in the lab.
Getting Comfortable with PAP therapy..
Some people find it very easy to use from the beginning. Others find a period of time is needed to become comfortable with the machine. Finding the correct mask for the user can often be a challenge. One mask does not work for everyone. Sometimes it takes sampling different types of masks to find the one that works best. Keeping in contact with the Durable Medical Equipment (DME) company that provides the machine and supplies is important. If a patient is having a problem, contacting the equipment company for assistance is essential.
If a patient is claustrophobic, the best solution is to use a mask that is less obtrusive. There are many newer masks on the market that do not have to be strapped to the patient's head tightly.
When you breathe, your nostrils and upper airway filter any dust or foreign particles from the air. The machine will come with filters that will act as your upper airway currently does. Replacement of these filters is very important. Secondly, your airway adds humidity to the air you breathe. The air pressure from the machine is bypassing the ability to add this humidity, therefore a humidifier is often ordered by the physician when the machine is prescribed.
Masks – What will work for me??
Nasal Mask – This is a placed over the nose only. The major advantage is that a seal is required over a relatively small area. The major disadvantage is that mouth breathers cannot use this type of mask. If the air from the CPAP is delivered through a nasal mask, the air will leak out of the mouth and will not effectively hold the airway open.
Full Face Mask - this mask type fits over the nose and the mouth. It is the only option for a mouth breather. Because it must seal over a larger area, it tends to leak more than a nasal mask.
Nasal Pillows - There are several varieties of masks that use nasal ‘pillows'. These masks have small prongs that are very soft and fit into both nostrils to deliver air directly in to the nose. These mask types are less bulky and easier to maintain a seal.
What problems should I be aware of?
1. Mask Leaks – Usually caused by a poor fitting of the mask. Call the Durable Medical Equipment / Home Health Company and inquire about being fitted with a better fitting mask. The mask may simply need to be adjusted differently. Over time, the mask will begin to age and mask leakage is an indication that a new mask is needed.
2. Nasal Dryness – PAP units blow air into your airway and dryness can occur. Heated humidification added to the unit can fix the problem. By increasing the heat on the humidifier, the humidity will be increased.
3. Nose Bleeds – Usually results from excessive dryness and should not persist more than two days. If persistent, contact your sleep physician's office.
4. Mask Removal at Night – This can be a normal response when becoming acquainted to the unit. This should stop after a short time. The pressure of the machine may need to be adjusted if it does not. Please contact your physician for help with this.
5. Mouth Opening – This problem can be solved by using a full face mask or using a chin strap. Contact your home healthcare provider.
6. Snoring – The pressure may be too high or too low on the machine. Mouth breathers may need a full face mask. Weight gain may also increase snoring. Schedule an appointment with your sleep physician.
7. Skin Irritation – A reaction to a new mask or problems with pressure on your face from a mask needs to be communicated to the equipment company first and if they cannot help, contact your sleep physician's office. You may need pharmaceutical treatment.
Cleaning Your Machine – VERY IMPORTANT!!
It is important to keep the PAP unit and the filters, hoses, humidifier, and mask clean. Daily cleaning with warm soapy water followed by rinse is recommended. Hanging the hoses and mask up will allow for complete drying. Upper respiratory infection can occur if the supplies and unit are not kept clean. Your DME company will provide you with instructions on how to properly clean and maintain your equipment.