If you use continuous positive airway pressure (CPAP) to treat your sleep apnea, you are likely quite familiar with the machine and its accompanying supplies. It may have a fixed place in your home next to your bed, but why might it be important to occasionally pack it up and bring it with you to see your doctor?
Whether you use CPAP, or other related treatments like bilevel, the machine is an integral part of your experience. Compliance to therapy is often dependent on having the right device, proper settings, and the related equipment to support your efforts. The supplies may include the mask interface, headgear, tubing (often heated), air filters, and even a chinstrap. These items can make or break your experience.
When you are just starting therapy, you may encounter specific problems. Perhaps the mask is not fitting properly. You may not know how to work all the bells and whistles of the machine. The humidifier and temperature settings may require some fine tuning. All of these issues can best be addressed by your sleep specialist or durable medical equipment provider, both with an expertise in managing these concerns.
As treatment continues, maintenance needs may also present themselves. The equipment may start to wear out and require replacement. There may be a funny noise that needs addressing. The humidifier may not be working as well as it once did. It is necessary to replace all the supplies on a regular basis. This requires a current prescription from your doctor, and this expires every 6 to 12 months. Moreover, your sleep specialist can help you to troubleshoot issues and point out equipment requiring replacement.
Therefore, whenever you go in to see your sleep doctor for routine follow up, it is best to bring your machine and equipment in as well. Don't forget the mask, tubing, and power cord. The doctor will download the usage data from the data card within the machine. Sometimes this card is corrupted, however, and by bringing in the machine the data stored on the device can be analyzed. If there are specific problems, the equipment can be inspected and the issues can be addressed. It is sometimes even helpful to have patients try on their masks or turn on the machine. In addition, if the settings need to be changed, this can be done easily in the office with the CPAP present.
Just like you wouldn't show up to your mechanic without your car, don't go to your sleep specialist without your CPAP machine and equipment. There are some providers who may not require you to bring everything in, but do it anyhow. This is the best way to address any issues that you might have with your therapy. You should see your sleep specialist at least once per year, and when you visit, always bring your CPAP.
My office is across from the station we use in our clinic to measure vital signs. When I leave my door open, I can overhear patients interact with the medical assistant as they are checked in. I am shocked by the number of patients, usually women, who refuse to have their weight measured as part of the intake process. This may have serious consequences.
As one of my professors taught us in medical school, vital signs are just that: vital. They are extremely important and each and every one can tell us much about the state of a patient's health. These vital signs include blood pressure, heart rate, respiratory rate, blood oxygen level, height, and weight. In my office, we also measure neck size as it can have implications for the risk of sleep apnea. Doctors use this information to direct their questioning and, ultimately, the therapy meant to improve your health.
Refusing weight checks is unwise. When patients are overweight or obese, there is often a psychological stigma associated with this assessment. These individuals may feel like they are a failure. It may be associated with intense shame. It may feel better not to even think about it. This is not healthy.
Visiting the doctor's office is a chance to check on your weight, even to discuss ways to lose weight. Ideally, weight would be checked daily at home on a scale. This would allow a more immediate accountability to the prior day's eating and exercise habits. It also provides positive reinforcement when the weight is gradually lost. Ignoring your weight, shuttering it away, and refusing to acknowledge the problem simply reinforces denial and deferment.
Don't refuse the weight check at your next doctor's visit. Your doctor may overlook the omission, but your weight problem won't go away. You may feel better not knowing, but as it wears on your health, even your sleep, you'll regret ignoring this important part of your examination.
In the trial of Kerry Kennedy, she recently disclosed in testimony her belief that she mistakenly took Ambien instead of her thyroid medication and that his contributed to an accident in 2012 in which she swerved and hit a tractor trailer. This raises important concerns about the effects of Ambien on driving, both when taken accidentally in the day or when its effects last into the morning.
Ambien is typically prescribed as a sleeping pill. It is sold under the generic name of zolpidem. It may come in an extended-release form called Ambien CR or as a lower dose to be taken in the middle of the night called Intermezzo. Once taken, users are advised to immediately go to bed. The reason for this becomes clear when considering how it affects the brain.
Ambien is a hypnotic medication. It modestly increases total sleep time compared to baseline. It has profound effects on awareness and memory, however. Therefore, while the drug is in your system, consciousness may be clouded and memory absent. This can lead to one of the more common side effects: parasomnias. Parasomnias are sleep behaviors which might include sleepwalking, sleep eating, and, yes, even sleep driving. These elaborate behaviors are possible when the part of the brain that controls movement remains awake while the areas controlling memory and consciousness are turned off.
This can clearly impact daytime function if the medication is taken unintentionally, as may have occurred in Ms. Kennedy's case. The nighttime effects may also persist into the early morning hours if the blood levels remain high. Therefore, last year the U.S. Food and Drug Administration (FDA) recommended that women take lower doses of Ambien and Ambien CR. It was observed that the higher doses compromised driving ability in women in the morning.
Depending on metabolism, which is based on body mass as well as kidney or liver function, men may be similarly affected. Therefore, it is recommended that the lowest effective dose of Ambien be used. In addition, these medications should not be used for extended periods of time, beyond about 2 weeks. Instead, cognitive behavioral therapy for insomnia (CBTI) may be a more effective solution for chronic insomnia.
If you are interested in learning ways to discontinue Ambien, you may start by speaking to your doctor who can provide a referral to a sleep specialist.
More About Ambien:
- Can Ambien Affect Your Memory?
- Sleeping Pills Overview
- Ambien: Insomnia Treatment Option
- Intermezzo Targets Middle-of-the-Night Awakenings
- What Are Ambien's Side Effects?
Recent advances by Dr. Emmanuel Mignot's research group at Stanford University may move us closer to being able to diagnose narcolepsy with a blood test, as discussed in a recent piece on The Huffington Post.
Historically, narcolepsy has been difficult to diagnose and prior to the identification of its cause, was often dismissed as a psychiatric manifestation. The condition is relatively rare, affecting 1 in 2,000 people. It is characterized by excessive daytime sleepiness, hallucinations associated with sleep transitions, sleep paralysis, and often cataplexy. Cataplexy is weakness that may manifest as knee buckling or jaw slackness and that occurs in response to an emotional stimulus such as laughter, fright, or pleasure. Narcolepsy is now believed to be due to the autoimmune destruction of a population of cells within the brain that produce a neurotransmitter called hypocretin.
Beyond a clinical assessment, further testing includes the multiple sleep latency testing (MSLT). The ability to quickly fall asleep during naps spaced throughout the day, or the occurrence of REM sleep with these naps, is suggestive of narcolepsy. In addition, cerebrospinal fluid can be tested with a lumbar puncture for the absence of hypocretin, a strong indicator of the condition. Genetic testing can also occur, but it is less specific for the disorder. To this point, blood tests have not been available.
As some of the symptoms of narcolepsy may be difficult to quantify, and may overlap with other sleep disorders such as sleep apnea, the utility of a blood test cannot be understated. It may help many people to finally get the diagnosis that has eluded them and obtain the help that they need.
Learn More About Narcolepsy:
This month's articles include some important pieces on children's sleep and related testing. Review how a standard sleep study, called a polysomnogram, differs in children. On a related topic, also find out how multiple sleep latency testing (MSLT) is done in children and why. Consider 10 signs that your child may have a sleep problem. Learn how imipramine may be used to treat bedwetting in children. If you use CPAP to treat your sleep apnea, you may want to know some ways you can talk while wearing your mask. Reflect on some of the most important consequences of insomnia, a condition that plagues millions. Finally, learn how to use saline sprays to relieve snoring and allergies this spring.
- Polysomnography in Children
- MSLT in Children
- 10 Signs Your Child May Have a Sleep Problem
- Imipramine Treats Bedwetting in Children
- How Can I Talk with CPAP?
- What Are the Consequences of Insomnia?
- Use Saline Sprays to Relieve Snoring Caused by Allergies
You may have already noticed, but there is change afoot: your doctor is likely becoming more wired, further integrating technology and social media into the practice of medicine. How will this impact the health of patients?
As a younger physician, I have grown up with the explosion of computer technology. In grade school, I played Number Munchers and Oregon Trail on the Apple IIe computers that populated the computer labs of my school and the local library. When I was 8, we got our first Zenith computer at home. It couldn't do much, really. It didn't even run Windows. It did, however, have a Lotus word processing application. I began to write on it. I even learned a little about DOS commands.
Within five years, we had upgraded to a Gateway 2000 system. Its modem was shockingly slow by today's standards, a mere 2400 bps, but this connection opened up a world to me. I could access local bulletin board systems (BBS) to play turn-based games. We had AOL for email and early browsers to access the Internet. I could use Microsoft Encarta as an encyclopedia, listening to Martin Luther King, Jr. delivering his dreams. By the time I was attending courses at Oxford in 2000, I began to hear about a new search option called Google. As my education advanced, so did the technology that both supported and influenced it.
The transition continued into medical school. When I started, we relied heavily on syllabi constituting of 1000s of pages and books that accompanied them. When I began my clinical rotations in the 3rd year, we used paper charts. I would scribble down my notes, copying the important details from one day to the next. I would try to decipher the few sentences scrawled by a consulting surgeon or cardiologist. Countless hours were spent trying to track down the patient's chart. By the next year, the university and local hospitals were adopting Epic as an electronic medical record (EMR). This system would be used by half a dozen other hospitals that I trained at in the ensuing years of residency and fellowship. Other hospitals, including the Veterans Administration Medical Center, used different EMRs. I sat on the technology committee of the Oregon Medical Association, discussing how to prepare practices throughout the state for the change from paper to electronic records. With the passage of the Affordable Care Act in 2010, the mandate to transition to EMRs is now fully sweeping the country.
This adoption of technology within healthcare has not always gone smoothly. Having worked at multiple hospitals as the EMR comes online and the paper charts are filed away permanently, it's a little uncomfortable. Questions can become life and death, or just a nuisance: Where are those lab results? Why did my note just disappear? How do I admit this patient? When the providers - from the lab techs to the nurses to the physicians - are used to the old way, it's a little bumpy at first. I have seen older physicians choose to retire rather than start again from scratch. These changes occur behind the scenes, for the most part, and patients may be blissfully unaware. However, technology is starting to have a more visible influence on medicine, especially in how physicians engage broader issues of health beyond the limits of their exam rooms.
Enter social media. (I don't particularly care for the phrase; I think all media is social, really.) With the advent of Myspace, Facebook, Twitter, Google+, and countless other manifestations, your doctor is now very publicly online. With a reasonable mastery of privacy settings, doctors' private lives can stay private. Some more adventurous souls have started to forge new frontiers in this sphere by using the medium to advance health. There is a lot of misinformation out there on health matters, so why not allow medical experts be at the forefront to set people on the right path?
The word doctor comes from the Latin docere, which means "to teach". Doctors are healers, but they are also teachers. The Internet allows knowledge to be shared with millions. It also allows doctors to quickly access information. It is no longer necessary to trudge over to a medical library's basement to discern the cause of an unusual condition. With a few keystrokes, answers can be found. It requires a discerning mind, certainly, to separate the wheat from the chaff. For this purpose, doctors remain indispensable.
Wired doctors can exert a wider influence than ever before. Through blogs, online columns, tweets, and Facebook statuses, the wisdom and advice discerned through practice can be made accessible to the masses. This is both exciting and terrifying. There are good and bad doctors, the same as any other profession. The opportunity to share medical expertise based in science may be a profound benefit to others. It is important that we rely on those physicians with the training, credentials, and experience that make them a reliable and trustworthy source.
The future of medicine is exhilarating. Technology will continue to be intimately paired with the practice of medicine. It will allow us to provide health information to those who previously could not access it. As the healthcare system adopts to these changes, we can be assured that leaders in the field will continue to stay true to the roots of the profession, and use this new technology to teach patients wherever they might be found.
The U.S. Food and Drug Administration (FDA) recently announced its intent to hold a meeting in late March to discuss changes in how it regulates over-the-counter drugs. Although this could be a welcome change, it is clear that a lack of federal oversight regarding other supplements continues to endanger lives.
The current review system for over-the-counter medications has been in place since 1972. It is painstakingly slow, with many products on the shelves that are still, technically, under FDA review. This process is nowhere near as strict as the guidelines and requirements in place for prescription medications. So-called dietary supplements, including herbal medications, are completely unregulated by the FDA. This can lead to significant problems.
Regulation of drugs is important to foremost ensure their safety. It is imperative that additives and fillers used in their manufacture not be harmful to the consumer. As an example, heavy metals like lead or mercury may contaminate some products.
Secondly, the active ingredient, the drug that is being paid for, should be of sufficient quality and quantity to have its intended effects. This depends on manufacturing standards. It can be checked with some simple chemistry, but only if someone is willing to do the quality control analysis. This is a key task for the FDA.
Moreover, many dietary supplements, herbal medications, vitamins, and innumerable "health products" are available that make claims that have not been substantiated through a rigorous scientific process. These unregulated supplements can proclaim their abilities to cure colds, ease pain, aid weight loss, or improve sleep - all without a shred of evidence supporting these assertions. They are not scrutinized by the FDA because they are not viewed as drugs. As a result, such claims by these supplements may be misleading or just simply false.
In the world of sleep medicine, there are countless pills and potions that are offered as a way to aid sleep. Although some may have modest effects, many may be of limited benefit. Some may even be harmful. Without regulation by the FDA, consumers are left to fend for themselves.
This is not a fair battle. Companies have slick marketing campaigns and shiny packages filled with promises of sleep, health, and wellness. Consumers may receive some guidance from doctors, but many simply don't have the access to the information that will help them.
The FDA should take a stronger role in the regulation of over-the-counter medications as well as those products classified as dietary supplements. Turning a blind eye to the fleecing of consumers with potentially harmful and impotent products that make dubious and unsubstantiated claims is an embarrassment. We deserve better.
As we welcome 2014, it is a great time to expand your knowledge of sleep apnea and the most common treatment, continuous positive airway pressure (CPAP). Take a few minutes to learn about the anatomy associated with the incidence of sleep apnea, as well as factors that might make it worse. Discover how menopause increases the risk of sleep apnea in women. If you are using CPAP, consider what might happen if you don't use it one night. Is it possible to travel with CPAP? Finally, if you are thinking about using CPAP, you might wonder what should be done if you consistently breathe through your mouth at night. Finally, expand your vocabulary by learning the definition of two new terms: hypoxemia and CWP. Get started with a click and learn something new today.
- The Anatomy of Sleep Apnea
- What Makes Sleep Apnea Worse?
- Menopause and the Risk of Sleep Apnea in Women
- What Happens If I Don't Use CPAP One Night?
- Can I Travel with CPAP?
- Can I Use CPAP If I Mouth Breathe?
- Definition of Hypoxemia
- Definition of CWP
This afternoon the latest chapter in the demise and subsequent saga of 13-year-old Jahi McMath has been started when a judge granted an extension of life support through Jan. 7. Since her surgery and subsequent cardiac arrest on Dec. 9, this case has become the topic of conversation throughout the nation. The unusual situation has attracted the commentary of medical providers, lawyers, ethicists, public relations agents, and religious figures. It has sparked an intense, emotional debate across water coolers and dining room tables. It deserves our considerate reflection for what it can teach us about medical science, the end of life, and the responsibility of physicians.
There is a paucity of known facts in this situation. The family and their lawyer have released few specific details. Oakland Children's Hospital, bound by the privacy restrictions of the Health Insurance Portability and Accountability Act (HIPAA), has offered even less. Jahi underwent three surgical procedures for the treatment of her sleep apnea. This included a tonsillectomy, uvulopalatopharyngoplasty (UPPP), and removal of nasal turbinates. Though initially described as a "routine tonsillectomy," this degree of surgery in children is not routine. It is extensive. When performed on a child, the risk is high. Bleeding and death can occur, as it did in her situation.
In recovery from surgery, about 30 minutes after its conclusion, it seems that she began to bleed profusely before she went into cardiac arrest. What may have triggered this? It has not been publicly disclosed, and it may not be fully known until autopsy. It is possible that she may have choked on her own blood and that this may have led to asphyxiation, depriving her brain of oxygen. Another equally plausible explanation would be that she lost such a volume of blood that her blood pressure dipped and, in a state of decreased blood flow to the brain, it was irreparably injured. Either scenario may be associated with a heart attack, as has been described. Regardless, the insult was fatal.
After she was stabilized, it is inevitable that a neurologist was called in to evaluate her. This is a position in which I have found myself many times. After cardiac arrest, a cooling protocol is often initiated. This is meant to preserve brain function by decreasing the metabolic demands of the damaged tissues. Once rewarming occurs, typically after a few days, the neurologist is summoned to perform a formal examination. This is done off of all sedation. This is a critical assessment because it can determine to what degree brain damage has occurred.
Neurologists, more than any other doctor, are specialists that rely on an elaborate and sophisticated examination. It is a skill that is learned over 4 years of residency and even among intelligent, capable physicians, it can be challenging to master. There are seven parts, or categories, to the examination: mental status, cranial nerves, motor, reflexes, sensory, coordination, and gait. In the setting of a comatose patient, it is simplified to include the components that can be tested without cooperation on the part of the patient.
When I examine a comatose patient, as I would have done in the case of Jahi, I start by evaluating the mental state. This relies on assessing the degree of responsiveness to stimuli. The patient's name may be spoken loudly and any response is carefully observed. Someone who is simply asleep or lethargic may startle, open her eyes, or even respond by speaking. Someone who is in a coma, by definition, will never open her eyes. Commands are often given: asking to wiggle toes, give a thumbs up, or open the eyes. The key is that with each command a clear action follows. This must be consistent and reproducible. "Open your eyes." Eyes open. "Close your eyes." Eyes close.
If verbal stimulation is insufficient, physical stimulation may be applied. This might be done by pinching the nailbeds of the hands or feet. Again, any response is monitored for, and someone who is partially conscious may cringe or pull away from the stimulus. This part can be a little tricky because some movements are reflexive and not purposeful.
People with severe brain damage or even brain death may still have reflexive movements that are mediated not by the brain or brainstem, but by the spinal cord. One example is called the triple flexion response. In squeezing the big toe, for example, the foot at the ankle, leg at the knee, and leg at the hip may all draw up. This is a reflex, similar to testing the stretch reflex of the patellar tendon at the knee. It is an action of the muscle, peripheral nerves, and spinal cord, and doesn't involve the brain. To sort out purposeful movements, rather than reflexive ones, the painful stimulus is often applied to the top of the foot. If the person is conscious, they will move the foot away from the stimulus to escape the pain. The reflex will draw the foot towards it. These subtleties, and there are many, require the expertise of the neurologist to differentiate.
In performing a brain death examination, the functions of the cranial nerves are also carefully evaluated. These trace to the brainstem, which is required to breathe, wake, and to even have sleep. In particular, the loss of pupillary restriction to light, blinking with touching of the cornea, conjugate movement of the eyes with head movement (oculocephalic reflex), and the gag reflex would occur in brain death. Further testing of these functions might occur with caloric testing, in which water is squirted on the eardrums to test for a reflexive movement of the eyes (vestibulocochlear reflex). Finally, apnea testing in which the ventilator is stopped and the levels of carbon dioxide are allowed to increase while monitoring for effort to breathe is also typically performed during a brain death assessment. Someone who is brain dead will not breathe off the ventilator, ever. These tests may be repeated once, sometimes by a different examiner or often by the same person the next day, to ensure that the findings are the same. Brain death assessments in children are especially careful given the gravity of the situation.
There are other ancillary tests that may be done that are not routinely required for the declaration of brain death. Nevertheless, they may be used according to some hospital protocols. In large part, this determination is made by a physician (usually a neurologist) after a careful clinical examination. Supporting tests might include an electroencephalogram (EEG) that shows absence of electrical brain activity, blood flow studies that show no blood entering the skull, or even imaging tests like a CT scan or MRI.
Once brain death has been determined, in most states (including California) the person is legally dead. Brain dead is dead. This situation becomes more complicated when there are preserved functions of the cranial nerves or a diminished, but not absent, level of responsiveness. These individuals are not brain dead but often develop persistent vegetative state and may not fully recover. When the brain is damaged, but not dead, this may allow for sleep-wake patterns, roving eye movements, and varying degrees of interaction with the environment. For the brain damaged, the spectrum can range from minimal responsiveness to (rarely) normal outcomes. However, the zero point on this spectrum - brain death - is not something that can be recovered from and there is no chance of any return to consciousness.
Can the body function with a dead brain? Yes. Modern life support machines used in the intensive care setting can keep blood circulating, a heart pumping, and lungs inflating. When the brain is dead, when there is no chance of recovering the person who has been lost, it is not ethical to keep the body's tissues alive artificially. Once the machine is turned off, the body functions will also cease. Therefore, the machines are understood to be sustaining the function of tissues that cannot now, or will not ever, sustain themselves independently. Much like blowing air into an empty paper sack, when the effort to inflate the sack ceases, it stills.
Therefore, medical doctors are legally and ethically obligated to discontinue medically futile care when brain death has been determined. In most cases, the family will be informed of the situation, given a chance to gather and say goodbye, and the machines will be turned off. This is the standard of care. This is what happens in intensive care units throughout the world. For some reason, which is not fully apparent, this is not what happened to Jahi McMath in Oakland.
The window of opportunity was left open and ignorance flooded in. Belief that she could recover defied medical reason. Even despite multiple physicians attesting to her brain death, her family clings to the hope that she will come back to them. No one with brain death has ever done so. Lawyers took the place of doctors. Decision-making by those with the expertise, the experience, the understanding of medicine was undermined by legal wrangling. Religious figures, dubious ethicists, and a parade of attention-seekers marched into view.
The death of Jahi McMath is extraordinarily sad. Such a complication occurs rarely, thankfully, but when it does it shatters a family's world. It is not uncaring, unfeeling, or unbelieving for her medical providers to assert the fact that she died. When so determined, their role was to promptly turn off the unnecessary machines. A moment of loss has been prolonged into an enduring tragedy. It was the responsibility of her doctors to put an end to it. By deferring the termination of her life support, her death can be denied and the law can struggle with making decisions that should never have been offered to it. Her doctors failed her, in that moment of greatest need, and we fail her still the longer we perpetuate her inevitable end.
As we close out 2013, check out some of the latest sleep articles from December. Review what your goal apnea-hypopnea index (AHI) should be when you use CPAP or BiPAP to treat sleep apnea. If you are new to using CPAP, you may want to learn about how much you are required to use the device so that insurance will pay for it. Learn how often you should replace each of your CPAP supplies, including the mask, headgear, tubing, filters, and humidifier tank. Discover how Zzoma Positional Therapy may help to treat mild to moderate sleep apnea and snoring. Expand your vocabulary by learning the definition of glutamate. Consider some of the most common causes of mouth dryness at night. If you have difficulty with insomnia, read about the role of naps in undermining sleep at night as well as the benefit of turning your alarm clock so you can't see it. Resolve to sleep your best in 2014. Happy New Year!
- What Is My Goal AHI with CPAP Treatment for Sleep Apnea?
- How Initial Use Determines Insurance Payment for CPAP
- How Often Should I Replace My CPAP Supplies?
- What Is Zzoma Positional Therapy for Sleep Apnea?
- Definition of Glutamate
- How Do Naps Affect Sleep at Night?
- Causes of Mouth Dryness at Night
- Turning the Alarm Clock May Help with Insomnia