Sleep Lab Put Problems To Rest

Posted: February 08, 1990

For Charles Capella, a long-distance truck driver, sleeping on the job could be a dangerous practice. The Bristol resident, 43, learned to cope with his chronic drowsiness by pulling off to the side of the road for a nap.

At home, he often dozed while watching television. Yet when he went to bed, he was restless. And when he slept, his snoring was so raucous that his wife had to move to another bedroom.

"I was getting disgusted with him," Sandy Capella, his wife of 15 years, recalled recently. "I was beginning to think he was lazy."

One day in early November, Charles Capella's truck broke down near St. Mary Hospital in Langhorne. Police arrived; traffic was snarled for miles.

Seeming oblivious to the drama, Capella was falling asleep on his feet. He began to sweat, and his heartbeat was irregular.

"They thought I was having a heart attack," he recalled.

He was admitted to St. Mary for observation. The medical staff noticed he barely slept at night. He tossed and turned and paced the floors.

Capella then was referred to the sleep disorders clinic at Lower Bucks Hospital in Bristol, where, finally, doctors discovered the reason for his behavior. He was diagnosed as having obstructive sleep apnea.

A relatively common disorder, sleep apnea is caused by an obstruction in the windpipe that blocks the flow of air into the body during sleep. Capella's case was so acute, he actually stopped breathing an average of 50 times an hour throughout the night.

"You literally wake up gasping for air," he said.

Each time he stopped breathing, the oxygen level in his blood dropped, straining his heart and lungs. Each episode also disrupted deep sleep, which left him drowsy all day.

"Sleep disorders not only affect the quality of sleep, but they also affect the quality of daytime function," said Howard J. Lee, a pulmonologist who helped establish Lower Bucks Hospital's sleep disorders clinic, the only one in Bucks County.

"There are millions of Americans out there who have sleep disorders," the doctor added. "It's an area of medicine that was neglected from the time of Hippocrates up until 15 years ago. It really is a new area of medicine."

Capella returned to the sleep lab several days after his diagnosis and spent the night hooked up to a small, portable air compressor that steadily blew air into his throat through a mask fitted over his nose. The mask was held in place by straps resembling a protective helmet.

The jet of air was designed to prevent soft tissue from collapsing and obstructing the airway. Doctors say about 90 percent of sleep apnea patients respond to this type of treatment, known as continuous positive airway

pressure, or CPAP.

With the CPAP unit humming beside his bed each night, Capella has embarked on a new life.

"He's living again," said Sandy Capella. "He sleeps like a baby. The big difference is during the day because he's wide awake and he doesn't want to sleep any more."

About 20 million Americans suffer from sleep apnea, according to the Alabama Society for Sleep Disorders, an information and referral service in Birmingham. Apnea means "absence of breathing" and refers to the intermittent stoppage of breathing that occurs to patients in their sleep.

People with sleep apnea rarely reach the deep REM (rapid eye movement) sleep stage because they are roused so many times, Lee said. It afflicts many men who are overweight, but researchers have not yet learned what causes the condition.

In the past, the condition was considered a nuisance, but that has changed. Recent research has linked sleep apnea with heart failure, Lee said.

"It's our belief that in severe cases, this can cause failure of the right side of the heart and can also cause sudden death," he said. "This can be potentially life-threatening."

Some in the medical community have speculated that sleep apnea contributes to a significant number of motor vehicle accidents.

Lee said new technology had played an important role in the growth of sleep labs. For example, it previously was impossible to measure the oxygen in a patient's blood without drawing a sample and analyzing it in a lab.

The development of the pulse oximeter, which reads oxygen saturation with a beam of light through a finger tip or ear, has enabled physicians and sleep lab technicians to determine the oxygen saturation level continuously.

Other essential monitoring tools include an electroencephalograph (EEG), which measures brain waves and depicts the various stages of sleep. Heart rhythms are measured with an electrocardiograph (EKG), while other electrodes determine eye movement, chin muscle tone and chest movement.

During the diagnosis, the patient's every sound and rhythm is recorded in the control room next door to the bed. Electrodes are glued to the head of the patient, who is fitted with abdominal and chest bands to measure breathing patterns. An electrode taped to the corner of each eye measures REM sleep. Other electrodes are attached to the patient's legs and chin to measure muscle action such as twitching.

It takes about one hour to hook the patient to the different wires and calibrate the equipment.

A video camera runs throughout the night, and a technician watches the patient's movements on a screen. The technician also studies the monitoring equipment, which displays colored graphs on a computer screen and spits out reams of paper. Hard copy for each sleep study fills a gift box.

A pulmonologist and a neurologist look for irregular patterns in tracings

from the patient's night in the lab. Apnea episodes are easy to spot because the line graphing the airway begins to go flat and then abruptly changes to up-and-down strokes as patients jolt themselves wake.

A fee of $900 is charged for every night spent in the sleep lab at Lower Bucks Hospital. CPAP units range in cost from about $865 to $1,300.

Most insurance companies reimburse for sleep studies and CPAP devices, Lee said.

Before the advent of the CPAP, some patients faced painful surgery and sometimes were forced to have a tracheotomy - an opening in the neck to breathe through.

"Usually the only people who had it done were people who were going to die if they didn't have something done," said Tim Flanagan, director of the sleep lab at Lower Bucks.

Nighttime symptoms of sleep apnea include loud and irregular snoring, snorting or gasping for breath, sudden body movements before the person starts to breathe again, excessive sweating during sleep and irregular pounding of the heart when gasping for breath.

During the day, the condition is characterized by excessive sleepiness, confusion or a brief memory, headaches, high blood pressure, impotence and personality changes. People with sleep apnea also might gain weight, sometimes to the point of obesity.

About 90 percent of sleep apnea referrals come from spouses. Sometimes, co- workers urge colleagues to seek help.

For example, one woman sought help at the Lower Bucks sleep lab to please her co-workers. The woman, who worked on an assembly line, would fall asleep while she worked, and her friends were afraid she would get hurt.

"In many cases, they don't recognize these daytime symptoms," Lee said.

A case in point was Elaine Neifeld of Cheltenham, who was diagnosed with obstructive sleep apnea last month.

"I could not keep awake, and I thought I was normal," she said in a recent interview.

Ask Edward Neifeld about his wife's former sleeping habits, and the Cheltenham businessman will throw up his hands in horror.

She would toss and turn all night and nap all day, he said in an interview. She would start snoring during orchestra concerts and had difficulty staying awake when the couple socialized with friends.

"It was very trying," he said.

Elaine Neifeld was equally frustrated but dismissed her problem as a family failing. Her father was a notorious snorer, and she joked that she inherited his worst genes.

Edward Neifeld wasn't so sure. He had learned a little about sleep disorders but didn't really expect a miracle when it came to treating the condition. But he became vitally interested after a business trip last year, when he struck up a conversation with a fellow traveler who carried a portable CPAP unit. The man bubbled with tales of restful sleep and energetic days.

Neifeld said he had begun to bug his wife about seeking treatment when he returned home from the trip. Elaine Neifeld agreed and discussed her problem with her physician, who referred her to Lower Bucks Hospital for diagnosis.

She presented a classic case of sleep apnea and began CPAP treatment Jan. 2, a move that marked the beginning of a new life for her and her husband.

"Oh, my God, I'm a new person," she said. "I just can't believe it."

With a chuckle, she gestured to her husband and added: "I don't snore. He can't get used to it."

Elaine Neifeld conceded that the nasal mask she wears to bed "isn't romantic," and she feels as if her husband "is going to bed with someone

from outer space."

But she added, "I'm willing to do that."

Another patient, Robert Kite of Levittown, 64, said he was less than enthusiastic about the CPAP unit when he was diagnosed with sleep apnea a little more that a year ago.

"You resist it," he said. "It's hard to admit that you have to sleep with the aid of a machine."

In the past, Kite's sleeping patterns baffled him. Sometimes he sank into a really deep sleep, but on other occasions he slept fitfully. One night, when his neighbor's home caught fire, he wasn't even awakened by several fire engines on the lawn outside his window.

The retired supervisor woke every morning with a headache and often fell asleep during the day. He chuckled as he recalled how the writing on some of his reports would fade to an illegible scribble.

"Apparently, I was dozing without realizing it," he said. "Sometimes it was scary. I would be driving the car, and it seemed that I was going off the road. I never knew when I went to sleep."

Kite has a respiratory problem that the apnea aggravated, and medical staff at Lower Bucks noticed that his oxygen saturation was extremely low at times. He uses supplemental oxygen at night.

Although Kite took some time to adjust to CPAP, he said, "It's done wonders for me."

Another Bucks County resident to benefit from diagnosis at the sleep lab is Jim Beers of Croydon, 70. He has been on CPAP for three years and still sings its praises.

Before his physician referred him to Lower Bucks, Beers said, he "would wake every hour on the hour." During the day, "I could doze off in seconds."

Lee noted that 80 percent of sleep apnea patients continue to use the CPAP device for at least one year after diagnosis.

One of the exceptions was Bristol businessman Louis Quattrocchi, who was diagnosed with sleep apnea in November. He said he knew CPAP would not work for him because he had difficulty breathing through his nose.

Quattrocchi had redundant membrane tissue in his nose, and the uvula at the back of his throat was unusually large, Lee said. He recommended surgery, and Quattrocchi had the operation in December.

Quattrocchi returned to the sleep lab last week and was re-evaluated. His apnea episodes had decreased 50 percent, and the remaining ones were shorter and less disruptive to his sleep.

"He requires no additional therapy," Lee said.

Surgery is recommended for only 2 percent of apnea patients, the doctor said. Other conditions that could be surgically corrected include unusually large tonsils and adenoids or nasal polyps.

Although sleep apnea is the most common sleep disorder, it is not the only one.

Others include narcolepsy, a genetic disorder that causes drowsiness, and nocturnal myoclonus, which causes jerking movements during sleep. These conditions can be treated with medication.

A fourth sleeping disorder, insomnia, prevents sleep. Insomnia is often caused by poor sleep habits, psychological problems, extended use of sleep medication such as tranquilizers and excessive consumption of alcohol.

About 40 percent of chronic insomnia is caused by physical problems such as apnea or constant pain from conditions such as arthritis, according to the Alabama Society for Sleep Disorders.

Sleep disorders were not identified as a medical condition until the early 1970s, but there were references to them much earlier. Charles Dickens described classic apnea symptoms in Little Joe and his family in the Pickwick Papers. As a result, chronic drowsiness was once referred to as a ''Pickwickean condition."

The first sleep labs were established in the mid-'70s at Stanford University; the Mayo Clinic in Rochester, Minn.; and Massachusetts General Hospital in Boston. Since then, clinics have sprung up in community hospitals and cosmopolitan teaching hospitals alike.

Aside from Lower Bucks Hospital, two other area hospitals operate sleep labs. They are Holy Redeemer Hospital in Huntingdon Valley and Abington Memorial Hospital.

Lee became interested in sleep disorders while he was doing his medical training at Boston University. When he set up practice in Langhorne three years ago, he noticed patients who showed symptoms of sleep disorders.

In fact, Lee and his partner, John Mahan, identified so many patients that they concluded there was "an obvious need" for a sleep disorders center. After negotiations with the administration at Lower Bucks Hospital, the sleep lab opened in November 1987.

Flanagan, a registered respiratory therapist and director of respiratory care at Lower Bucks, was appointed director of the sleep lab. Sam DeFrancesco, also a respiratory therapist, was assigned as sleep coordinator and went to the Alabama Society for Sleep Disorders for a two-week training session.

The hospital invested about $150,000 in computerized monitoring equipment and in renovations, including a bedroom fitted with a video camera.

Although the center has not actively marketed the service, its patient load has risen steadily and runs an average of two sleep studies per week.

"We did over 100 studies last year," Flanagan said.

Working the sleep lab has provided a source of satisfaction for the allied health staff and physicians at Lower Bucks Hospital.

Said Lee: "You really have the chance to effect dramatic change in a person's life."

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