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INTELLIGENCER JOURNAL (Lancaster, Pa.)
Cover, Business Monday

The science of sleep
Are you often drowsy during the day? Cranky and cannot concentrate? Dozing at your desk, or worse at the wheel?

According to the National Sleep Foundation (NSF), an estimated 70 million Americans suffer from some kind of sleep disorder. Could you be one of these people?

Although there are dozens of chronic sleep disorders, sleep apnea is among the most common. Characterized by brief interruptions of breathing during sleep, this problem affects as many as 18 million Americans.

While sleep apnea is easy to treat, 90 percent of those affected don't know they have it. Untreated, the problem can be life threatening, putting individuals at risk for stroke, coronary heart disease, heart failure, or heart attacks.

LGH Sleep Disorder Clinic
Locally, sleep apnea can be diagnosed and treated at a number of locations, including the Sleep Disorder Center at Lancaster General Hospital (LGH). Administrative Director James O'Connor, said that the Center, which opened in 1982, is today a bustling hub of activity with more than 1,800 individuals receiving about 3,000 sleep studies each year.

At LGH, patients are served in comfortable accommodations either at the hospital in Lancaster, or at the new satellite location at the Kissel Hill Health Center in Lititz. There are a dozen bedroom suites between the two locations.

Individuals coming to the Center for an evaluation will meet with a physician, who performs a complete consultation and evaluation for an initial diagnosis. If the physician believes someone has sleep apnea, he invites that individual to spend an evening in the Sleep Center for a sleep study called a polysomnogram. After all testing is completed, the physician will make a final diagnosis and arrange a treatment plan.

While sleep disorders can affect individuals of any age, a 26-year old truck driver who recently came to the Center was a typical case, O'Connor said.

This young man was in bed by 7:00 p.m. each evening and got eight hours sleep before getting up at 3:00 a.m. to start his route. Still, he was very tired and worried that he might fall asleep while driving. He drank coffee continuously to try to stay awake.

"Interestingly, this man's wife complained that he was a loud snorer and often had periods of not breathing interspersed with loud snoring and grunting noises. These are the classic symptoms of sleep apnea.

"When we hear these symptoms, the red flag really goes up," O'Connor said, adding that other symptoms include high blood pressure, obesity, depression, irritability, and low energy.

O'Connor, a registered respiratory therapist and polysomnographic technologist, invited this young man to spend the night at the Center. Here, he was hooked up to a network of wires that monitor breathing and heart function through the five stages of sleep.

O'Connor calls these five stages the "Architecture of Sleep." People start with stage one, where they are semi-awake, through stage four, where they are in a sound sleep.

Then they move into another phase known as rapid-eye movement or REM sleep. REM cycles in every 90 minutes.

"We look to see whether people are getting the right amounts of each stage of sleep and whether someone stops breathing."

If an individual stops breathing because of sleep apnea, it is because there is no air going into the nose, throat, and lungs, O'Connor explained. Oxygen levels fall and carbon dioxide levels rise.

The brain responds to this by automatically arousing the patient, who may go from stage three or four to a level one, just enough of an arousal to stimulate the brain to breathe again.

These breathing irregularities cause sleep fragmentation that results in daytime drowsiness, which interferes with job performance and puts individuals at higher risk for accidents.

O'Connor actually measures these irregularities by calculating the total number of minutes an individual sleeps at each stage, then comparing the number of minutes in light sleep vs. the minutes in deep sleep.

"The sleep test confirms whether or not an individual has sleep apnea," O'Connor said. "It also lets us quantify how many times an individual stopped breathing at night.

"This truck driver's sleep study revealed that he stopped breathing more than 60 times per hour, with some episodes lasting almost 60 seconds! His oxygen saturation level also dropped to 41 percent from a normal level of 97 percent."

According to O'Connor, what generally happens with sleep apnea is that when you go to sleep, all the muscles in the body relax, including the muscles of our upper airway. Apnea is a complete collapse of that tube.

"So we say, gee, this person's airway is collapsing. Let's find a way to keep that airway open. That solution is a Nasal Continuous Positive Airway Pressure (NCPAP) device, which keeps the airway open."

When someone is diagnosed with sleep apnea, the individual is invited to return for a second night and is given a NCPAP device. This small gadget (about the size of a six-pack) is connected to a mask that the patient wears over the nose.

This little machine continually blows in air. The airway remains open. O'Connor and his team adjust the pressure to ensure that the patient's sleeping is normal and that sleep quality has been restored.

"Because the truck driver's sleep study was so abnormal, NCPAP was added partway through the first night," O'Connor said. "The NCPAP apparatus eliminated all of his irregular breathing and abolished all of his snoring."

A month later, the patient said he was delighted with the results. He no longer worries about falling asleep while driving his truck.

"I cannot believe how much better I feel," he told O'Connor. "I never need to nap anymore and I have so much energy. I never want to be without my NCPAP mask!"

While some patients are reluctant to sleep with a mask at first, O'Connor said, anyone who has been sleep deprived soon comes to value the NCPAP device. "It's the best thing since sliced bread," they say.

What is sleep?
According to Lee M. Duke, M.D., Acting Medical Director of the LGH Sleep Disorder Center, "Sleep is an active biochemical process during which time the body replenishes a menu of key brain chemicals.

"Sleep is not simply the absence of stimuli," he added. "If you are deprived of sleep on a regular basis, it will affect your health."

Duke, who is board certified in sleep medicine, pulmonary critical care, and internal medicine, explained that some of the brain hormones that are restored or changed with sleep include serotonin and dopamine, which play a key role in many biochemical processes.

"There are extreme behavioral consequences when humans are deprived of sleep," he said. "Animal studies have even shown that without sleep for a prolonged period of time, animals will die."

Safety issues
Approved by the U.S. Food and Drug Administration (FDA) the NCPAP device has been used in treating sleep apnea since the condition was first recognized in the early 1980s. "The device is very safe," Duke said.

Individuals with chronic sinus or ear disease or a perforated eardrum should not use this device, because a sinus or ear block could develop, but this is extremely rare.

In fact, it's much more dangerous not to use this device, than to use it, if you have sleep apnea, Duke said.

For example, a sleep apnea patient who stops breathing for long periods of time may have a heart attack, because oxygen levels are so low. Indeed, the most common time of death is 5:00 a.m.

Untreated sleep apnea can also increase the risk of diabetes and the risk for work-related injuries.

In fact, NCPAP devices have lots of advantages. In restoring sleep, other medical conditions such as depression often improve. And unlike medication, there are no side effects to worry about.

Sleepiness affects others too, O'Connor pointed out, quoting from the National Highway Traffic Safety Administration, which estimates that drowsy drivers cause 100,000 motor vehicle crashes each year.

These accidents result in more than 1,500 fatalities and 71,000 injuries, so drivers are killing themselves as well as innocent bystanders. In fact, people with sleep apnea are seven times more likely to have an accident, O'Connor said.

"I tell my kids that they have to be home by midnight," he added. "The risk of bad drivers goes up after midnight both because of intoxication and tiredness."

Sleep apnea disrupts family, social, and professional relationships. Duke and O'Connor encourage readers who suspect they may have sleep apnea, to get a diagnosis.

"There are very good treatments available that can offer a significant improvement in your health and in your lifestyle," Duke said.

"What drives us is helping people," he added. "Seeing people who have been miserable and offering them treatment that makes them feel better is very gratifying."


Learn more about sleep disorders:
--Lancaster General Sleep Disorders Center: (717) 544-5910
http://www.lancastergeneral.org/content/Sleep_Disorders_Center.asp
http://www.lancastergeneral.org/content/kisselhill_outpt.asp

--National Institutes of Health: http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html

--American Sleep Apnea Association: http://www.sleepapnea.org/

--Alertness Matters: http://www.alertnessmatters.com