Monday, March 31, 2014

FAA to Check Obese Pilots for Sleep Apnea

FAA to Check Obese Pilots for Sleep Apnea

Posted by Frank Howard
Obese pilots and air traffic controllers will soon need to be screened over concerns that their weight is causing them to lose sleep and negatively affects work performance, according to the Federal Aviation Administration.
FAA flight surgeon Fred Tilton said Tuesday that under the new policy all pilots and air traffic controllers with a body mass index (BMI) over 40 or a neck measurement of more than 17 inches will have to be checked by a sleep specialist before they can get their medical certificate to work.
The issue, Tilton says, is obstructive sleep apnea, which “is almost universal in obese individuals.”
“Obstructive sleep apnea in obese patients is a common condition, and it results in lack of enough sleep or quality sleep. As a result they remain sleepy during the day,” said Dr. Gholam Motamedi, a neurologist at Georgetown University Medical Center.
Eventually, the plan will move to test all pilots and air traffic controllers with a BMI of 30. Body mass index calculates weight divided by height. That means a 6-foot tall man with a BMI of 40 would weigh nearly 300 pounds. With a BMI of 30, that same man would weigh 220 pounds.
This plan comes five years after two pilots aboard a Go Airlines flight between islands in Hawaii fell asleep and overshot the airport. The flight eventually landed without further incident but the National Transportation Safety Board launched an investigation.
The captain, according to the NTSB, was obese and later diagnosed with apnea.
Former fighter pilot and ABC News consultant Stephen Ganyard said lack of sleep or quality of sleep can affect a pilot’s ability.
“It really has the same physiological effects as drinking. And so you don’t want a drunk pilot flying your airplane any more than you would want a pilot who hasn’t had appropriate sleep flying your airplane,” Ganyard said.

Thursday, March 27, 2014

Tips on Using CPAP to Treat Your Sleep Apnea

Posted by Frank Howard, content courtesy of Frank Barnhill, M.D.

Continuous positive airway pressure (CPAP) has been used for years to help keep premature baby’s lungs inflated long enough to clear mucous and other fluids and improve blood oxygen levels. A constant amount of air pressure is provided by a pump in such a manner as to barely open collapsed lung air sacs making the work of breathing much easier. As the baby exhales, that air escapes through a vent on the CPAP mask to allow for loss of carbon dioxide and oxygen exchange.

CPAP works much the same way in adults. Since sleep apnea affects men more than women, most wives are grateful for a good night’s sleep, finally after all these years. So, It’s not always used to help remove fluid or mucus, but often helps make the work of breathing easier and provides a constant pressure to prevent or treat sleep apnea.

Sleep apnea is a condition in which a person literally stops breathing for 10 to 30 seconds several times an hour, resulting in low blood oxygen levels, daytime sleepiness and fatigue. It is often accompanied by very loud snoring and the affected person may awake with “air starvation” several times in a night. A lot of wives do refer to freight trains, chainsaws, and grizzly bears when describing their husbands sleep problem.
Sleep apnea can cause high blood pressure and damage to the heart, as well as dispose one to frequent accidents from sudden sleepiness. It can be a major cause of poor attention span in kids and adults, responsible for poor work and classroom performance, and disrupt marriages and family life. For more information please see our article "Snoring, chainsaws and sleep apnea".

CPAP is the treatment most persons with sleep apnea choose, since no surgery is involved. The unit consists of a vented plastic mask or nasal prongs attached by semi- flexible plastic tubing to a filtered air pump set at a pressure level determined by a sleep study. The mask either covers just the nose, or both nose and mouth, or nasal prongs are inserted just into the nose. The mask or prongs are worn at night or any time one goes to sleep. Most persons find discomfort in the fact that the mask must fit firmly and it’s difficult to lay on your stomach with either in place. Some persons can’t tolerate the feeling of claustrophobia they get when the mask is intact. I've had patients jerk the mask off in the middle of the night feeling smothered.
Since CPAP therapy is so important, let’s review these problems and look at a few solutions and tips on using CPAP.

Probably 60% of persons starting CPAP therapy have difficulty sleeping for the first four to five days. About 15% of these will continue having difficulty after ten days. For these patients, most doctors prescribe a mild sleeping pill for a few days or up to two weeks. This seems to decrease what I have termed “mask claustrophobia and anxiety” or the feeling of suffocation caused by the CPAP mask. Probably 90% of CPAP users adjust to the presence of the mask by the third week and most can go right to sleep. These patients often say it is often the best sleep they've had in years. They feel energetic the next day and have less daytime sleepiness.

If you have been using CPAP and notice a sudden unexplained decrease in your energy level, have started snoring again or experience “air hunger”, then your mask is not fitted properly, or the CPAP pressure is not set properly. You should contact your doctor or the technician who supplied the equipment. When choosing a supplier, you want someone who is knowledgeable and fits ten to twelve masks a week, not one or two a month.

Another common problem with CPAP is excessive drying of the nasal passages resulting in nighttime stuffiness or nosebleeds. This can be corrected by placing a cool mist humidifier in the line tubing ($50), at the bedside ($30) or using a two dollar treatment. For two or three dollars you can buy saline nasal gel at your local pharmacy and use a cotton tip swab to “paint” the inside of your nostrils with gel before applying your mask. The saline gel will slowly convert to salt water and moisturize your airway most of the night.
If you frequently awaken with a dry eye, red eye or a painful eye, your CPAP mask is leaking. The face seal may be damaged or fit poorly. I've cured many cases of pink eye by refitting a CPAP mask. Once again, discuss it with your supplier or doctor.

A common complaint is “Doc, I can't sleep on my back all the time!” “I just have to sleep on my stomach and when I roll over the stupid mask comes off.” This is a more difficult problem to solve, but not impossible. Special over the back of the head plastic tubing is available that doesn't cause a problem when lying on one cheek. This lets a person sleep on their stomach with the head turned to one side. Most CPAP users tend to sleep on their right or left side with their cheek at the edge of a very firm pillow. That allows the tubing to trail off to that side.

Another complaint is “Doc, sometimes I wake up in the middle of the night and my lungs feel so cold that my throats on fire.” The CPAP machine sucking in and delivering very cold air usually causes this problem. I advise these patients to place the machine on a nightstand at the same height as the top mattress. Air drawn from the floor under the bed tends to be much cooler. In addition, I find a lot of patients place as much of the delivery tubing as possible under the covers with them. This tends to preheat the air a little and lessen “freezer burn”.

If your mask is often pulled off or to the side when you roll over in bed, ask your supplier for a ten to twelve foot delivery tube. The extra length will give you room to roll and lessen the possibility you will experience frequent awakening.

Hopefully, these tips will help you while using CPAP in treating your sleep apnea. Keep in mind that overweight persons can significantly improve sleep apnea symptoms by losing 30 to 45 pounds. We'll discuss other treatments, such as surgery, in “Sleep Apnea Quick Fixes”. Here’s to a good night’s sleep!
If you have any tips on using CPAP, please share them.

Dr. Frank

After Your Sleep Study: CPAP and Sleep Apnea

Posted by Frank Howard

Dr. Helene A. Emsellem, director of the Center for Sleep and Wake Disorders in Chevy Chase, MD, answers common questions about CPAP.

I've just been diagnosed with sleep apnea. Can I expect my insurance or Medicaid to cover the CPAP (continuous positive airway pressure) machine?
Yes, most insurance policies cover CPAP. CPAP is considered to be durable medical equipment, and you can call your insurer to find out the specifics of your coverage. Deductibles and copayments for medical equipment may be different than what you pay for office visits or prescriptions. Medicaid does cover CPAP equipment, but it will need authorization. Supplies are covered separately, and the amount of coverage varies by state. Deductibles and copayments may apply depending on whether or not you have a secondary insurance.

What kind of mask should I get for my CPAP?

Nasal pillow systems, nasal masks and full face masks are available in all sizes, shapes and styles from a variety of vendors. They are all effective. The delivery system selection is very personal. On the night of a CPAP titration study (similar to the sleep study), we encourage patients to try on a variety of different types, guided by our experienced technologists. We ask patients to choose a first and second choice and to let us know if they are uncomfortable during the night so they can make a change. We find that even with maximal attention to mask/pillow fit prior to the first night, about 10-15% of the time patients may have an issue with irritation, air leaks or discomfort and may need to make a change over the first few weeks to optimize adaptation.

What should I do if my nose is runny or I have a dry mouth after using the CPAP?

Humidification of the air in your CPAP system can be extremely helpful in managing both dry mouth as well as a runny nose. Most current CPAP setups include humidification chambers. Studies have shown improved comfort and compliance when the humidity is used. The humidity setting may need to be adjusted, with a higher setting required in cold climates during the heating season. A persistently runny nose can be a problem and sometimes this is due to an allergy to the mask materials. Changing masks and brands is sometimes helpful. We have had to send some patients to see an allergist when a runny nose persists despite humidity and multiple mask changes.

What if I’m having trouble breathing?

Difficulty breathing with CPAP can be due to the newness of the experience or pressure problems. High prescribed pressures may be uncomfortable initially and low settings, such as 4 cm, may create a sensation of being “air starved.” Contact your homecare provider to check the accuracy of your equipment and discuss the problem with your sleep specialist so they can determine if a pressure adjustment is required.

How do I clean my CPAP?

You should receive specific cleaning/maintenance instructions from the homecare company that delivers your equipment. We recommend taking the mask, tubing and headgear in the shower with you once a week, rinsing it with a mild dish soap (odorless or with a smell you can tolerate), hanging it over the showerhead to dry and remembering to hook it back up the next night. Filters should generally be checked once a month, more often if the environment is dusty. The humidifier chamber should be rinsed daily, and the use of distilled water will keep it clean and free of mineral deposits.

How long do I have to wear my CPAP each night for it to be effective?

Studies show that at least 6 hours of CPAP usage per night is needed to reduce the long-term health risks of obstructive sleep apnea. We encourage our patients to put the CPAP on at lights out each night and to make every attempt to put it back on after nighttime awakenings. If there are frequent awakenings or if you are finding the mask on the floor in the morning, then pressure adjustment or a mask refitting may be necessary.

Who should I call if there’s a problem?

For technical problems with the equipment, check in with the homecare company. Your doctor/sleep lab should also provide troubleshooting services if the problem has to do with mask fit or pressure adjustments rather than the workings of the equipment itself.

What should I do if I am still tired or sleepy despite using my CPAP nightly?

The short answer here is that it is important to make an appointment to see your sleep doctor and go over the possible explanations. Persistent sleepiness may occur in a small percentage of patients with sleep apnea despite nightly use of the device for at least 7 hours. If sleepiness has not resolved after you have been fully adapted to the device for 4 to 6 weeks, then there are several possible explanations:
  • You may need more pressure. Speak to your healthcare professional about this. If changing the pressure is not helpful and other causes are ruled out, then a return to the sleep lab to confirm that your equipment is adequately managing the apnea is sometimes necessary.
  • If you have had longstanding severe sleep apnea , especially when there have been significant episodes of low oxygen levels at night, you may have a subtle injury to the brain’s alerting pathways that may take a much longer time to improve. The use of a wake-promoting agent to enhance daytime alertness may be indicated. These symptoms should be discussed with your sleep specialist. Daytime Multiple Sleep Latency Testing (MSLT) can be obtained to assess the extent of sleepiness and the need for intervention with medication.
  • You just might not be allocating enough time for sleep. CPAP will not make you feel great in the morning if you are getting less than the necessary 7 to 9 hours of sleep per night! CPAP does not substitute for adequate sleep.
  • Some individuals with obstructive sleep apnea may also have other underlying medical conditions. If an increase in CPAP pressure has not been helpful then further workup with a daytime Multiple Sleep Latency Test (MSLT) to assess the severity of your sleepiness may be helpful.
  • Other medical conditions may be present, such as thyroid dysfunction, thus a good check up with your primary care doctor is always helpful.
  • Depression can be a fairly common problem in patients with obstructive sleep apnea. If adjustments to the equipment are not effective or not indicated and the MSLT is normal then workup for a mood disorder may be necessary.
  • Inspection of the CPAP equipment including checking the tubing for pinholes or leaks is important to confirm that you are being treated with the prescribed pressure.

A Rocket Scientist Explains How a Sleep Study Can Change Your Life

 Originally appeared in Forbes by David DiSalvo

Once upon a time, before medical science started nosing around your bedroom, snoring was a nocturnal annoyance and little more. Sawing logs in the wee hours, while the bane of spouses and significant others, wasn't a health concern – just cause for housemates to wear ear plugs.
But over the last couple of decades, science has pulled the covers off snoring, revealing that in many cases—far more than anyone expected—it’s not only irritating, but the symptom of a potentially lethal condition known as sleep apnea. People suffering from this condition experience limited breathing multiple times during the night, depriving their brain of oxygen and consequently increasing blood pressure and putting enormous strain on their organs, most notably their heart.
Studies linking sleep apnea to heart disease have been adding up, and the evidence is pointing to one inescapable conclusion: snoring could be your body’s alarm letting you know that something is wrong along the vital brain-heart highway. The best way to find out for sure is undergoing a sleep study.
Does it take a rocket scientist to explain what a sleep study is and why it’s important?  Probably not, but that didn't stop me from finding one. John Cunningham is a Registered Polysomnographic Technologist (RPSGT) who runs sleep studies for Total Sleep Management, Inc. In a previous life, he was, in fact, a rocket scientist, but over the course of time his engineering interests turned from the aeronautic to the biologic.
John ran a sleep study I took part in not too long ago, and is a walking wealth of knowledge on all things sleep. He graciously agreed to answer a few questions about what happens during a sleep study, what anyone thinking of having one can expect, and why doing it could improve your health and your life.
David: First, tell us what we're all wondering – do sleep techs laugh at what people do during the night?
John: You know, sleep is such a personal thing. Inherently personal. You've slept all your life without wires or a mask on your face. For some people coming to the lab is the first night they will spend away from their spouse in 20 years. No joke. Some people are creeped out by the cameras. They are being watched! But the truth is we are not staring at you all night. The cameras are just a tool and nothing to be worried about. So I'm not going to say we don’t sometimes see something funny when running the tape, but no, rest easy. We're not laughing.
Ok a few basics. If you snore, do you definitely have sleep apnea?
No. People can snore for many reasons, including anything from allergies to loose skin in the back of their throat. Snoring is a potential symptom of apnea but not an absolute one.  It’s important, though, to tell your doctor if you snore because it could be the starting place to eventually diagnose apnea.
And sleep apnea occurs when someone stops breathing while asleep?
They don't necessarily stop breathing altogether, but someone with apnea will experience limited breathing multiple times during any given night. That’s one of the main things we track during the study using polysomnography, the comprehensive diagnostic tool that shows us all the biophysical changes your body undergoes while you are asleep. Some people will experience limited breathing hundreds of times, and that’s extremely dangerous because oxygen flow is reduced each time. The chief mechanism by which apnea damages your body is oxygen crashing hard and fast in your blood.  You can still breathe in many cases, but not enough air gets through your partially or totally collapsed throat muscles.
So is apnea a disease?  
Apnea is a structural problem—not a disease or chemical imbalance—which is why you can’t treat it with a pill. As you relax in sleep, your throat and chest muscles relax (so you don’t act out your dreams – but that’s another topic). Your throat is pitted against gravity, which is why the primary cause of apnea is age; the older we get the looser our muscles become. Because your throat and chest muscles partially or fully collapse, your breath decreases significantly. In the majority of apnea cases, your chest muscles are still trying to take in air, but you can't get enough air to pass through and your blood-oxygen level crashes rapidly. That’s when the damage begins.
And what can happen if someone doesn’t have their sleep apnea treated?
The connection between apnea and cardiovascular disease is very strong. Your blood pressure increases and you are at far greater risk of stroke with untreated apnea. You'll also suffer from sleep deprivation, which has a number of negative consequences, including fatigue, mental exhaustion and reduced immune system response. Aside from dire health concerns, quality of life is simply lower with apnea. Plus, your snoring is probably annoying people you live with, but that’s not necessarily a health concern, unless they get really angry.
Give us a general sense of what someone can expect when their doctor orders up a sleep study and they arrive at your lab.
They aren't going to encounter anything alarming—a typical doctor’s office setting with rooms in the back—but everyone arrives with questions, which is of course natural. My explanation from when they come through the door right into and including the hook-up stage of the study—when we place wires on their body—has been honed by answering patients varied questions and concerns over the years I've been doing this. When I'm in the zone (and I'm not always there, but when I am), everything I say while hooking them up is to answer questions before they ask them. And by the way, it’s worth mentioning that the rooms patients sleep in are rather nice, like a decent hotel room – not a sterile, clinical cell that some people envision.
So the tech’s first job is to read people when they walk in and try to anticipate their concerns.
Yes, because contrary to the obvious assumption, my job is art. This is not research, strictly speaking; it’s human diagnostics, which always contains an element of the emotional, the erratic, the unpredictable. In short, the human.
With so much in the news lately about the dangers of apnea, are you finding people more informed when they arrive at the lab?

I've found that people have heard about it in general terms, but most of their practical information about apnea and its medical solutions come from the sleep technician.  Apnea is rising for two main reasons: age and weight. Arguably, more people over 50 are overweight than ever before. So amidst growing concerns about obesity, there’s no question that more information about the warning signs of snoring and the dangers of apnea is out there, but the technical specifics usually don’t hit home until someone comes to the lab.
How do you put someone as ease who seems a bit freaked out by the prospect of being hooked up to wires and sleeping in a strange place with cameras running all night?
Much like special effects in movies, a good tech can tailor and weave solutions to the subtle, often unspoken human needs of the patient without them even knowing it. The less they notice it, the better the movie, so to speak. All the while, I'm spouting beneficial technobabble, cleaning, scrubbing and slapping on pieces of technology to create the perfect sleep cyborg for analysis.
Sleep cyborg?
Just a term I use for describing what someone looks like once we have the technology hooked up, and to underscore the point that you can't forget, no matter how much technology is layered on, that this is a human. And it’s the human who follows through on treatment. Actually, better stated: it’s the human with the unanswered questions and the unaddressed fears that doesn't follow through with the treatment.
And if someone is diagnosed with sleep apnea, the treatment is a CPAP mask, correct?
CPAP is the gold standard solution. There are a few other options, but they are about 50/50 in effectiveness—surgery and mouth pieces. These remedies can become ineffective over time.  CPAP can change with you as your body changes (essentially by increasing the air pressure of the device), which is what makes it the preferred standard.

CPAP machine example; image credit: Wikipedia
Many of the concerns I try to answer are about the possibility of having to wear a CPAP mask (which stands for Continuous Positive Airway Pressure) if the diagnosis is apnea. The reality is wearing the mask is going to feel weird. Anyone who tells you differently is lying. But it’s totally doable, and with time it will become normal. Most importantly, will it help? Without a doubt. I genuinely believe CPAP helps people live better, longer lives.
I often tell patients the facts about wearing a CPAP straight up, and getting the simple facts out in the open can be very helpful. I often notice people will then lower their shoulders a bit and hit me with their more personal concerns, their real worries, almost as if I have given them permission to vent their anxieties.  I wear a CPAP mask myself and have been in the exact same chair they are in, having the same electrodes placed on my slightly itchy, recently scrubbed skin and had to wash the white goopy paste out of my hair the next morning.
What’s the most important thing someone facing having to wear a CPAP should keep in mind?
It’s simply this: find a mask that you like. From a technical point of view, whether a mask is big or small, they both do the exact same thing. A patient needs to find a mask that is comfortable. My technical opinion on this point doesn't matter – the truth is, if you like it, you’ll wear it. If you don’t like it, you won’t wear it, even if I tell you otherwise. It will be that dress behind that “gorgeous” polka dot number that a clerk sold you on but that you secretly don't believe makes you look good. Same with the CPAP mask. If it fits well and you like it, ditch the polka dots and choose the low cut tye-dye.
Ok, so let’s say someone undergoes a sleep study and is diagnosed with apnea. They select their CPAP mask. Then what?
Well first off, be realistic. It will take you two months to get used to it. You'll try it, you'll hate it, it’ll be weird, then it'll be great, then you'll hate it again.  It’s ok. This is all normal.  You may experience some nasal swelling, but it’s temporary so don't worry. You may wake up some mornings with the mask across the room. Again, normal, don't be discouraged.
On the plus side, the snoring will disappear. That’s huge for most people. And you'll likely experience REM rebound, because you'll begin enjoying deeper REM sleep. When you have apnea and stop breathing several times throughout the night, your sleep is fragmented, and good, solid REM is hard to come by. With the CPAP mask, that will change and you may find yourself dreaming for the first time in a long time.
What’s the big takeaway you'd like to leave with readers of this interview?
Don't fear the sleep lab.  Seriously, if you snore, tell your doctor and if he or she suggests going to a sleep lab to check for apnea, go ahead and do it. We're going t0 take good care of you and the results could change your life.