At The Forefront Live: Understanding Sleep Apnea
UChicago Medicine experts Babak Mokhlesi, MD, director of the University of Chicago Medicine's Sleep Disorder Center and colleagues Zhen Gooi, MD and Hemal Nayak, MD discuss sleep apnea, and the multidisciplinary approach to treatment.
The following is a paid program from UChicago Medicine.
Today on At the Forefront Live, we will discuss sleep apnea. A good night's sleep is as necessary to health and well-being as diet and exercise. Unfortunately, for more than half of all Americans, a good, refreshing sleep is difficult to obtain. On today's At the Forefront Live, we will take your questions for our sleep experts. That happens right now on At the Forefront Live.
And we have three experts with us today to talk about the importance of sleep and how you can get better rest. We have Dr. Mokhlesi, Dr. Gooi, and Dr. Nayak here to answer your questions. And welcome to all three of you.
Let's start the program. If you will, just tell us a little bit about yourselves and what you do here at UChicago Medicine. Dr. Mokhlesi, we'll start with you.
Well, I'm a professor of medicine in the Department of Medicine. And I direct the Sleep Disorder Center and the Sleep Training Program here at the University of Chicago.
I'm an assistant professor in the Division of Surgery. I have a special interest in head and neck cancer, and also surgery for sleep apnea.
And Dr. Nayak.
So I'm an associate professor of medicine. I'm a cardiac electrophysiologist. And I direct the Device Clinic and the Fellowship Program here at the University of Chicago.
Let's get right into our questions. But first, we want to remind our viewers that today's program is not designed to take the place of an actual visit with your physician. And Dr. Mokhlesi, we're going to start with you and just talk about general sleep first and how important that is. Because I think that's an area that people far underestimate what they need and how critical that is to their health and well-being.
Well, that's a great point because the average American and people living in the industrialized world don't get enough sleep for a variety of reasons-- television, tablets, work, other duties. Suffice it to say, the average American-- compared to 60, 70 years ago-- is sleeping an hour and a half or two hours less than what they need. So that, obviously, has important consequences-- daytime sleepiness impairs in quality of life, and it can even lead to increased risk of weight gain and obesity and heart disease or high blood pressure.
You mentioned health benefits to getting plenty of sleep. What exactly does this do to a person if they're not getting enough? Because, again, I think this is the kind of thing that can sneak up on people. But it can have a rather detrimental impact on them.
Correct. You know, insufficient sleep-- again insufficient for the amount of need that that individual has-- the consequences-- the main consequence is impacting mood, impacting daytime functioning, increasing risk of motor vehicle accidents or occupational accidents. And some data, as I mentioned earlier, suggests that it could be linked to weight gain, an increase in risk of high blood pressure, and ultimately some cardiac diseases.
But it's also important to point out that some of the more recent literature suggests that long duration of sleep-- beyond nine hours-- can also be associated with health detriments. So there seems to be a sweet spot.
That's interesting. And you mentioned the safety aspects in-- you know, when we think of distracted drivers out there. And, you know, a lot of us commute fairly significant distance here in the Chicagoland area. It's very important to get plenty of sleep before you get behind the wheel of the vehicle, as well.
For sure. And it's not just, you know, the variety of sleep disorders, obviously. One of the ones that is self-imposed in modern society is short sleep duration. But it's important to note that there are multiple medical conditions-- that we're going to delve into a little bit later, such as sleep apnea-- that can also lead to poor quality sleep, ultimately leading to daytime sleepiness. That's one important consequence.
And we have two other physicians on here with you today, as well. And they're going to speak to very specific areas of sleep disorders. What will they be talking about?
Well, I think many of our viewers and patients know about sleep apnea, or hopefully they'll learn about it. And most people identify or link sleep apnea with mask therapy, with CPAP-- continuous positive airway pressure. And it's important-- one of our jobs as providers is to educate our patients and their family members of their alternative therapy options for different types of sleep apnea.
And I think-- and my colleagues, Dr. Gooi and Dr. Nayak can discuss some of the new interventions that have become FDA approved for treatment of obstructive sleep apnea and central sleep apnea.
Great. Before we get to too deep into these areas, we're already getting questions from viewers. So I want to get to those in just a moment. But we have a video that we prepared earlier this week that I think gives a great snapshot of some of the work that you do and some of the things that happen here at UChicago Medicine. So let's play that video. We'll talk a little bit about that when we get out.
The University of Chicago has always been at the forefront of sleep. We have a very rich tradition, dating back decades. The main thing we focus on is helping patients improve their sleep and dealing with sleep disorders. They are one of the most common reasons that patients end up coming to the sleep laboratory at night as an outpatient is to get evaluated for presence and severity of obstructive sleep apnea or central sleep apnea.
Typically, we ask patients to come here after they have their dinner, you know, around 8:00 at night. Children naturally come a little bit earlier with their parents. We don't need eight hours of sleeping like a baby to make a diagnoses of a sleep disorder. For most sleep disorders, we can make a diagnosis after even two, three hours of sleep.
It's really truly a noninvasive test where patients get hooked up by a sleep technologist who has a lot of expertise doing this and to kind of make the patient feel comfortable about their surroundings. And these rooms are designed in such a way that they look more like hotel rooms, a small hotel room, as opposed to a typical hospital room to make the patient feel more at home.
At some point, we ask to turn off the TV, and turn off their mobiles, and turn off the light, and try to fall asleep. We monitor sleep based on brain activity. We monitor eye movements so we can pick up rapid eye movement sleep, which is a type of stage of sleep during which we dream typically.
We have a little cannula-- like an oxygen cannula-- but it's not delivering oxygen. It's just sitting there, measuring flow of air, the way we normally breathe. Naturally, we measure oxygen at the finger and limb movements. And, on top of that, one of the things we do-- all sleep labs do is to have an infrared video camera from which a sleep technologist is watching the patient throughout the sleep. Naturally, the patient knows that they're being recorded, and they sign consent for that. And the purpose of the recording is for us to verify body position and any unusual movements during sleep.
Once a sleep study is over-- typically around 6:00, 7:00 in the morning-- the patient is free to go. And then the next business day in our sleep laboratory, the sleep medicine experts review the sleep studies. And typically, our nurse from the laboratory calls the patient to briefly discuss what the sleep study shows and what's the next course of action.
Very interesting. So that gives you a really good snapshot into what people are doing when they're asleep or maybe not doing.
Correct. And one thing that is also important to point out is that in addition to doing sleep studies into sleep laboratory, we also do home sleep testing, which is a situation where an individual comes to either to the clinic or to the sleep lab and get trained on how to use a device. And they take home the device and return it the next day to us so that we can analyze their sleep patterns and to see if they have evidence of sleep apnea or breathing disorder during sleep.
So can we talk about sleep apnea in general at this point? Because I think that's a term we hear often. What exactly does that mean?
Well, sleep apnea, it comes in two major flavors, so to speak. One is-- the most common one is obstructive sleep apnea. And if you look at all patients who have some form of disordered breathing at night when they sleep, obstructive sleep apnea is the most common type. Typically, 85% to 90% of cases of sleep apnea are obstructive in nature.
And, essentially, as the name implies, in the back of their throat when the upper airway is, once they fall asleep, it intermittently collapses or narrows down significantly, making breathing more challenging and more difficult for the patient. And most patients don't even notice this. The bed partner may notice it by loud, disruptive snoring or periods where breathing actually pauses. And that's quite disconcerting for the bed partner.
And occasionally a patient may also wake up with nocturnal choking episodes. But most patients sleep through obstructive apneas and shallow breathing. And the way we monitor and notice it is it causes disturbance of the brain activity-- one of the reasons we monitor brain activity-- but without causing full awakening. So the patient may not be aware of it. And it also causes intermittent rise in blood pressure every time they experience one of these apneas. And their oxygen levels, at the fingertip, when we measure it in the sleep laboratory or at home with a home sleep test, it shows these intermittent drops in oxygen levels, which is detrimental.
And Dr. Gooi, that's one of the areas where you do work.
Tell us a little bit about what you do and how that works for the patient.
So there are a host of surgical options for the treatment of obstructive sleep apnea, which can range from simple to complex, depending on the sites of every obstruction, as well as the severity of the patient's obstructive sleep apnea.
One of the newer therapies that we have at our institution is the hypoglossal nerve stimulator, which essentially aims to relieve obstruction at the back of the tongue and the front part of the throat.
How does that work? How does that do that?
So it's surgery. So it involves an operation, usually three to four hours of surgery in experienced hands, which includes time to go to sleep, positioning, and time to wake up. We make three incisions-- one slightly beneath the jaw line, and two more on the chest, one on the front and on the side. We implant a nerve stimulator. So it senses the tongue-- parts of the tongue nerve which control tongue movement, specifically tongue protrusion.
There is a nerve-- there's a pacemaker-like device which is implanted into the front of the chest, which generates an electrical signal. And there is a sensing lead in the chest, which senses when the patient takes in a breath.
So we're getting some questions from viewers. And I want to get to some of these because I think they're appropriate for what we're-- this portion of the program. One is, my son just had an obstructive sleep apnea surgery. He does have a CPAP machine. Will he still need to use a CPAP machine long-term? Or can it be reduced in usage, eventually leading to removing it completely?
So following sleep surgery, we usually like to get a reassessment on what the severity of sleep apnea is, the absence or presence of sleep apnea. And the way that we verify this is with a repeat sleep study once the surgical sites are healed up.
So, Dr. Nayak, you specialize in a little bit of a different area and that's central sleep apnea. Is that correct? And I don't know if you could explain to us what that is a little bit and then how your work--
Sure. So central sleep apnea is the other major type of sleep apnea, as Babok was trying to explain. And so in central sleep apnea, the problem is that the brain doesn't tell the diaphragm to move. So, basically, you don't breathe at night. And you can imagine, if you don't breathe at night, the same issues are going to happen. Your blood pressure is going to go up. Your oxygen level is going to come down. And that can have a lot of bad effects on the body, especially on the heart.
So for patients who have moderate to severe central sleep apnea, what we plan to do or we hope to do is to provide this new therapy. It's called phrenic nerve stimulation. So the phrenic nerve is the nerve that goes from the brain to the diaphragm, which is the muscle that causes you to breathe. And in this technique, what we do is we place a device-- very similar to what a pacemaker would look like. And I think most people kind of understand what a pacemaker looks like.
We place it in the right upper chest region. And the device is placed underneath the skin. This procedure is done using moderate sedation. So you're half awake, half asleep for it. In fact, you don't need general anesthesia for this procedure. And, in fact, for a portion of the procedure, we actually want the patient be awake.
So what we do is we place the device underneath the skin in the right upper chest. We then access a vein that runs underneath the collarbone. And we place pacing leads and place them in two very special positions in the body. One is we thread a pacing lead down a small vein that runs on the surface of the heart that runs parallel to this phrenic nerve. And that's the pacing lead that's going to stimulate that phrenic nerve to then contract and cause the diaphragm to go up and down.
Then we place a second lead in a vein in the heart. And that senses how much breathing takes place. Once we have those leads in place, we attach the end of those two leads to the unit. We make a pocket for it underneath the skin. We sew patients up. And the procedure takes about two, two and 1/2 hours.
And, eventually, when we turn the device on, once the leads settle into place, the device turns on at night based on when the patient goes to sleep. So we ask the patient, hey, what time do you usually go to sleep? What time do you wake up? We program the device to sort of activate at that time.
And then the device just stimulates that phrenic nerve, causing it to contract, and allowing the heart-- the lungs to breathe. So that's a treatment for central sleep apnea, which is relatively new.
Interesting. And Dr. Mokhlesi, when people come to the sleep center, you can diagnose all of these different areas. Because I think most people, when they think of sleep problems, they just think of sleep apnea. But they're not-- they may not really know what's happening.
Correct. When a patient comes to the clinic, obviously we do a full assessment. And then together with the patient, we make decisions on what's the best course of action for making an appropriate diagnoses. As Dr. Gooi was referring earlier, the purpose of the sleep study is to understand what type of sleep apnea they have-- obstructive or central. Sometimes patients have both, a combination of both, and how severe it is.
And many times when they come to the sleep lab, if they have your typical garden variety severe obstructive sleep apnea, we can take advantage of their presence in the sleep lab on that same night, in the second half of the night, start treatment with CPAP and see if they-- that's the mask that goes on the nose or on the nose and mouth-- and pushes air. And it's just not oxygen. It's just regular air, pressurized, to open up the airway, so the patient can breathe on their own.
And some patients respond very well to that therapy. They like it. And they want to have it. And that's great. And they use it. And we prescribe it for them, and we monitor them.
Some other patients find it very difficult to tolerate. Or at the beginning, they're willing to accept it, and then later they find it difficult to tolerate. And those are the patients that we like to meet and go over other treatment options. But it's important to point out that when patients have multiple medical problems like heart failure, rhythm problems of the heart, or other conditions, sometimes doing home sleep tests may be more challenging.
And in those individuals-- particularly those that we suspect central sleep apnea-- the best course of action would be to get a sleep study in the laboratory where there tends to be a little bit more accuracy compared to the home sleep test.
So we're getting a lot of questions from viewers. And I want to get to as many of those as we possibly can. So I'm just going to throw these out there. And any of you that want to answer them can certainly do that. Here's one that I guess makes-- it's kind of a general question. Can one die from sleep apnea?
Yes. Sleep apnea increases the risk of death. The important thing for people to understand is that sleep apnea-- patients with sleep apnea typically do not die in their sleep because they stop breathing. You know, what happens is that when there is difficulty to breathe, that disturbs the brain, and the person has what we call an arousal. The brain becomes active. And that opens up the airway again. That's why they have very disrupted sleep.
The way sleep apnea can lead to earlier death would be through pathways that lead to cardiac disease, heart disease, abnormalities in metabolism, increasing risk of motor vehicle accident. But I always tell my patients that if you don't use CPAP or any treatment for one night, it's not like you're going to die. People don't usually die in their sleep because they can't breathe.
They may die because they have a bad rhythm of the heart or they may end up having heart disease down the road and get a stroke or heart attack, but not because they just simply stopped breathing.
I think that's a very important point I want to just raise to the audience because sleep apnea really affects cardiovascular health in many different ways. So sleep apnea has been associated with the development of heart failure. And congestive heart failure is a leading cause of death in the United States. Sleep apnea makes heart failure treatment more difficult. So patients don't respond to their medical therapy with heart failure if they have untreated sleep apnea, both central as well as obstructive forms.
Sleep apnea which is untreated has been linked to the development of atrial fibrillation, which is the most common arrhythmia affecting the patients in the United States, and, once again, can lead to patients not accepting or receiving benefit from the therapies that we have for atrial fibrillation. So just to reiterate the point that heart failure, sleep apnea, cardiovascular health are intimately linked.
So, Dr. Nayak, here's a question from a viewer that I believe is directed to you. I have a neuromuscular disease-- CMT-- that has affected my phrenic nerve, and have paralysis of the left diaphragm. Could the stimulator potentially work to get my diaphragm to function?
Well, that's a very good question. We don't have great data on using the phrenic nerve stimulator for those specific type of conditions. Because, right now, the phrenic nerve stimulator is used primarily to treat patients who have central sleep apnea as a formal diagnosis. But it's something I know that we wanted to explore and see if this type of therapy can be extended to those type of patients.
OK. And this can go out to any one of you. Can you please address REM sleep apnea and its role in atrial fib, and if a beta blocker medication helps or contributes to the apnea?
Well, REM sleep, or rapid eye movement sleep, in humans-- and least in adults-- occupies a quarter of our sleep. Typically, 20% of our sleep is rapid eye movement sleep, or REM sleep. And that's typically more concentrated in the early morning hours. So when you wake up from sleep and you remember your dream or you remember you were dreaming, you woke up from REM sleep.
And it comes in fragments throughout the night. And, in many patients, sleep apnea gets worse during REM sleep because the upper airway muscles become even more relaxed and more prone to collapse during that stage of sleep. Whether REM sleep apnea increases the risk of atrial fibrillation, you know, is not fully known. You know, there's some data that we published and looking at REM sleep apnea increasing risk of hypertension or high blood pressure. But I think the jury is still out as to whether REM sleep apnea increases the risk of atrial fibrillation.
And beta blockers-- maybe Dr. Nayak can comment on that-- but they don't-- beta blockers don't worsen sleep apnea per se. But it could be very effective medication for cardiac conditions.
Dr. Nayak, do you have any thoughts on that?
No. I absolutely-- I think beta blockers are a mainstay of therapy for most patients with atrial fibrillation. And they're very protective of the heart. So if your doctor has prescribed a beta blocker to treat atrial fibrillation, I think that's a good idea.
Another question-- how common is sleep apnea in children with Down syndrome?
Well, patients with Down syndrome, be it adult or children, their upper airway anatomy is a little bit different. And they have less upper airway space. So, with that said, it's quite common. We don't know exactly how common. But we definitely know it's more than the general population.
Some studies have reported 60%, 70%, 80%. So the probability of having sleep apnea in a child or an adult with Down syndrome is extremely high. Extremely, extremely high.
So here's one that's interesting. My dentist mentioned that grinding teeth is related to sleep apnea. Is that true? And, if so, is-- can you explain that?
Well, I'm not convinced that it's entirely relate to that because people have what we call bruxism or grinding of the teeth for a variety of reasons. My dentist tells me that I grind my teeth and I don't-- I don't have sleep apnea. So common things happen commonly. And just because two conditions are common doesn't mean they're necessarily linked to each other.
Dr. Gooi, can we talk a little bit more about the procedure with the-- when you implant the device, is-- are there limitations that the patient will experience after that?
So usually we tell patients that for one month after surgery we ask them not to lift their arms higher than their shoulder. But, for the most part, we ask them to carry out most of the activities of daily living. We tell them not to lift up anything higher than 10 pounds for about two weeks. So it's not heavily restrictive procedure in terms of recovery.
Are there any significant risks to the procedure?
As with also injury, there's risk of infection, bleeding, and scarring. Low risk. In particular with the surgery, there's a very small risk of injury to the nerve of the lower lip, which we take particular precautions during the time of surgery to avoid.
More questions from viewers. I have a CPAP and have an HX-- I'm not sure exactly what that refers to, but you would know-- of PSVT. Since I've been using my CPAP, I wake up with many episodes of PSVT. I take 50 milligrams of low pressure daily. What do I do next?
I think what they mean is they have history of paroxysmal--
History. I got you.
Yeah. Sustained-- I think it's--
Yes. It's paroxysmal sustained supraventricular tachycardia. Yeah.
Well, I mean, sleep apnea has been associated with or linked with certain heart rhythm problems or abnormalities, as Dr. Nayak pointed out earlier. One of the most common ones we see is atrial fibrillation, just because atrial fibrillation is quite common, as well. So you can see that association showing up frequently in our practice.
But there's also a link between sleep apnea and other rhythm abnormalities. If a patient is using CPAP successfully and is treating their obstructive sleep apnea, and the rhythm problem persists, then-- and, you know, I would argue that maybe they're independent of each other. And one would have to discuss that with a heart rhythm specialist or cardiologist as to what's the best course of action for ongoing rhythm problem, if the sleep apnea treatment is adequate.
Another question from a viewer. Will AFib caused by sleep apnea correct itself once the CPAP is used?
That's a very good question. So we've seen in our own data here at the University of Chicago that, number one, patients with atrial fibrillation can develop or have coexisting sleep apnea, both central as well as obstructive forms. And one of the things that we do here at the University of Chicago is, if you get to-- if you see us for an atrial fibrillation consult, you will most likely have a sleep study ordered by us, if you haven't had one already.
Because it's-- we're going to try to hit the atrial fibrillation in many different ways. One is that if we uncover untreated and undiagnosed sleep apnea, we will treat that, as well as treating you with other medical therapy for atrial fibrillation. We realize that that combined approach gives us the best results.
Even when, for example, we refer or we do-- we send patients for catheter ablation, we know that our catheter ablation procedures, when we do those to treat atrial fibrillation, have a higher success rate if we're able to then treat the other comorbidities or diseases, like sleep apnea. So, like I said, they're linked together.
Another viewer question. In your experience, are patients able to better tolerate the implantable therapies versus the mask therapies?
Well, it's somewhat of a loaded question because patients who decide to undergo implantable therapies that we were discuss-- that Dr. Gooi was discussing, are typically patients who dislike CPAP. So, yes, the answer is, if you have difficulty tolerating CPAP, undoubtedly you will tolerate the-- either oral appliances that dentists make or these implantable devices much, much better.
Here's an interesting question from the viewer, which I actually thought about my myself the other day. How accurate are health trackers and the watches-- I've got the watch myself-- with tracking sleep data and quality?
Yeah. That's an interesting question. Because whatever answer I give now may not be applicable one year from now. Because this technology is evolving very quickly and is improving on a yearly basis. Thus far, the data suggests that the devices are relatively accurate in terms of assessing weight versus sleep.
But some of these devices, for example, try to estimate deep sleep versus light sleep and REM sleep, or dream sleep. And when it comes to that, I think it's a little bit shakier. I wouldn't rely too much on that information.
And, again, it's really hard to make a generalized comment because there are so many of these devices out there that I may not be familiar with them. But I think we are moving little by little to improving technologies. So I think we just have to wait and see.
I think is an exciting area. And, maybe over time, some of these technologies can also assess more complex measures of heart, heart rhythm, and oxygen levels in the blood, and so on and so forth.
All right. We actually went a little bit over time, but I wanted to get to as many questions as we possibly could. Thanks for being on the show. You guys did a fantastic job.
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This was a paid program from UChicago Medicine.